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13452145-RR-48

## EXAMINATION: CT CHEST W/O CONTRAST ## INDICATION: w/ ESRD (HD MWF), CABG ( ), HTN, HLD, DM2, HFrEF (30%; sev MR), PAF (coum), bioMVR c/b R empyema s/p decortication presents from rehab w/ SOB, ADHF requiring BIPAP.// Evaluation of worsening pulmonary opacities, fluid vs infection. ## DOSE: Acquisition sequence: 1) Spiral Acquisition 2.5 s, 39.7 cm; CTDIvol = 15.8 mGy (Body) DLP = 628.2 mGy-cm. Total DLP (Body) = 628 mGy-cm. ## FINDINGS: Thyroid is unremarkable. Right subclavian line terminates in the SVC. No pathologically enlarged lymph node is identified in the supraclavicular, axillary, and mediastinal regions. Thoracic aorta is normal caliber. Main pulmonary artery is top normal size. Severe coronary artery calcifications are present. Prosthetic mitral valve is noted. Partially imaged transesophageal tube enters the stomach. Small loculated pleural effusion is identified bilaterally. Multiple small pockets of air is present in the right posterior loculated pocket of pleural effusion. Several small foci of air is also noted in the right lower lateral aspect of pleural space. Mild pulmonary emphysema is present. Small dense airspace opacities and larger area of ground-glass opacities in right middle lobe and left upper lobe lingula are new. Limited evaluation of the upper abdomen demonstrates right renal cyst, partially imaged. Sternotomy wires are intact. No suspicious bone lesion is identified. Nondisplaced right lateral 8th rib fracture is newly apparent since . ## IMPRESSION: 1. Small loculated bilateral pleural effusions are demonstrated. Right posterior lower pocket of pleural fluid contains multiple foci of air, may reflect bronchopleural fistula in the absence of recent intervention into the pleural space. Compared to , the right pleural air is new and the left loculated pleural effusion is increased. 2. Small dense airspace opacities and larger area of ground-glass opacities in right middle lobe and left upper lobe lingula are new and may reflect pneumonia. 3. Mild pulmonary emphysema.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13452145", "visit_id": "21151088", "time": "2186-06-05 21:14:00"}

18548923-AR-15

## ADDENDUM: 1. The area of washout and peripheral rim enhancement in the liver adjacent to the RFA site appears to have tubular, branching appearance and might correspond to the tumor thrombus in the left hepatic or portal vein branches. 2. Further noted is oval filling defect adjacent to the interventricular septum in the right ventricle (9:8) measuring approximately 1.9 x 2.9 cm. This lesion appears to enhance on the post-contrast imaging and is concerning for cardiac tumor deposit. Further evaluation can be performed by cardiac echo or dedicated cardiac MRI. These findings were discussed at the multidisciplinary liver tumor conference on .

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18548923", "visit_id": "N/A", "time": "2182-05-12 11:46:00"}

18769077-RR-27

## INDICATION: female with left adnexal cyst seen on previous scan. ## FINDINGS: Transabdominal and transvaginal ultrasound images of the pelvis were obtained, the latter for further evaluation of the endometrium and adnexa. The uterus measures 8.1 x 4.3 x 6.1 cm. There are multiple masses consistent with fibroids. The largest fibroid is fundal, anterior and intramural measuring 1.5 x 0.8 x 1.3 cm. There are scattered myometrial cysts. The endometrium measures 4 mm, within normal limits. The right ovary is normal in appearance. There is resolution of the simple left adnexal cyst. Again seen is a 5.1 x 2.2 x 2.8 cm tubular left adnexal structure containing low-level echoes. The differential for this lesion remains hematosalpinx or an endometrioma. There is no free fluid in the posterior cul-de-sac. ## IMPRESSION: 1. A 5.1 x 2.2 x 2.8 cm tubular structure within the left adnexa, stable in size when compared to the previous examination, and is likely hematosalpinx. Endometrioma is also considered. 2. Fibroid uterus.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18769077", "visit_id": "N/A", "time": "2150-12-11 07:02:00"}

15947916-RR-83

## INDICATION: woman with pancreatic cancer and now with abdominal distention and vomiting. ## SUPINE AND ERECT ABDOMINAL RADIOGRAPHS: The biliary drain and feeding tube are unchanged in position from prior study. Mildly dilated loops of small bowel within the pelvis are noted. There is gas within the colon. Cannot exclude early mild partial small bowel obstruction. Followup is recommended. ## IMPRESSION: Mildly dilated pelvic loops of small bowel with gas in the colon raises the question of partial small bowel obstruction. Dr. was notified of the results at 12:47 p.m. on .

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15947916", "visit_id": "22046967", "time": "2134-09-23 11:34:00"}

11245423-RR-14

## INDICATION: female with history of left sternoclavicular joint effusion, presenting with neck pain for two days. ## FINDINGS: There is apparent superior displacement of the medial left clavicle without significant joint effusion. There is no evidence of inflammation or abscess. There is a small subchondral cyst along the left clavicular head near the sternoclavicular joint, likely related to degenerative change. The right clavicle is superiorly displaced distally with evidence of remote fracture and/or acromioclavicular separation with evidence of healing, consistent with chronic injury. There is no abnormal fluid collection in this region. There is diffuse multilevel cervical spine degenerative disease with disc space narrowing, spondylosis and endplate sclerosis. Multilevel discogenic disease is present. Uncovertebral disease is present exacerbating multilevel mild neural foraminal narrowing. There is no critical canal stenosis. Intrathecal evaluation is better on MRI. Paranasal sinuses and mastoid air cells are well aerated. There is severe left TMJ degenerative change. Vascular calcifications are seen in the cavernous carotid arteries and cervical carotid bifurcations. The nasopharyngeal and oropharyngeal soft tissues are symmetric. The salivary glands appear unremarkable. There is no lymphadenopathy by size criteria. Vascular structures appear patent. There is no focal thyroid lesion. Lung apices demonstrate severe right greater than left centrilobular emphysema. ## IMPRESSION: 1. No fluid collection about the sternoclavicular joints or evidence of inflammation. 2. Remote right distal clavicular fracture/AC separation. Mild superior displacement of left clavicular head. 3. Multilevel cervical degenerative disease. 4. Left TMJ degerative disease. 5. Emphysema.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11245423", "visit_id": "22208859", "time": "2115-03-25 22:12:00"}

13395801-DS-16

## ALLERGIES: No Known Allergies / Adverse Drug Reactions ## MAJOR SURGICAL OR INVASIVE PROCEDURE: Primary low transverse C-section, exploratory laparotomy, packing of liver, exploratory laparotomy with secondary washout and unpacking of liver laceration and complex abdominal closure ## HISTORY OF PRESENT ILLNESS: Ms. is a yo G3P1 at 38w3d presenting as a transfer from with HELLP syndrome. She reports initially beginning to feel "off" this past , when she noticed she was unusually fatigued. She continued to feel fatigued over the next few days, and today began to note upper abdominal pain that increased in severity throughout the day. She also today began to notice regular contractions that have increased in intensity throughout the day. She reported feeling decreased fetal movement as well. She was therefore instructed by her physician to come in for evaluation. At , she was diagnosed with HELLP based on LFTs in the 200s and platelets in the . She had a BPP done that was , but initially had fetal tachycardia that improved with fluid hydration. She was then transferred here for further evaluation and management. Patient denies chest pain, SOB, VB, LOF. Of note, patient was noted to have proteinuria on urine dipsticks during pregnancy, and had a 24 hour urine protein of 1017mg last week. She had normal PIH labs last week, and has had normal blood pressures throughout pregnancy. ## PNC: - by - Labs Rh pos/Abs neg/Rub I/RPR NR/HBsAg neg/HIV neg/GBS neg - FFS wnl - GLT - + early gdm screening -> GDMA1 - U/S - U/S for monitoring for single uterine artery notable for 7lb1oz - Issues - gdma1 - followed for single umbilical artery - uterine fibroid 2.5cmx2.4cm - anemia on iron - subchorionic hemorrhage trimester, now resolved ## GYNHX: - Hx of abnormal paps, repeat negative - no h/o Gyn surgery, STIs ## ABD: soft, gravid, epigastric and RUQ TTP, no rebound/guarding EFW 7 by ## SVE: FT/L/P Toco FHT 160/moderate varability/+accels/-decels (upon discharge) ## VS: afebrile, HR 88, BP 103-132/76-88, RR ## ABD: soft, nontender, FF 2cm below U. no RUQ tenderness ## PERTINENT RESULTS: WBC-10.3 RBC-4.28 Hgb-12.5 Hct-36.0 MCV-84 Plt-80 WBC-8.9 RBC-4.19 Hgb-12.2 Hct-35.8 MCV-85 Plt-70 WBC-8.0 RBC-3.71 Hgb-10.9 Hct-32.0 MCV-86 Plt-53 WBC-10.0 RBC-3.53 Hgb-10.1 Hct-30.3 MCV-86 Plt-60 WBC-7.6 RBC-3.13 Hgb-9.2 Hct-26.6 MCV-85 Plt-48 WBC-8.6 RBC-2.84 Hgb-8.2 Hct-24.1 MCV-85 Plt-57 WBC-9.4 RBC-3.63 Hgb-10.6 Hct-31.0 MCV-85 Plt-57 WBC-9.1 RBC-4.04 Hgb-11.9 Hct-34.3 MCV-85 Plt-63 WBC-10.1 RBC-3.59 Hgb-11.1 Hct-30.6 MCV-85 Plt-70 WBC-9.6 RBC-3.51 Hgb-10.8 Hct-29.8 MCV-85 Plt-72 WBC-9.1 RBC-3.42 Hgb-10.4 Hct-29.2 MCV-85 Plt-67 WBC-9.4 RBC-3.17 Hgb-9.2 Hct-27.4 MCV-86 Plt-91 WBC-10.9 RBC-3.12 Hgb-9.1 Hct-27.2 MCV-87 Plt-103 WBC-10.2 RBC-3.28 Hgb-9.6 Hct-28.9 MCV-88 Plt-132 PTT-26.9 PTT-26.7 PTT-27.9 PTT-25.8 PTT-25.3 PTT-20.2 PTT-21.2 PTT-24.7 PTT-24.3 Glu-132 BUN-4 Cre-0.4 Na-134 K-4.4 Cl-101 HCO3-19 Glu-113 BUN-6 Cre-0.6 Na-135 K-4.8 Cl-99 HCO3-22 Glu-94 BUN-7 Cre-0.6 Na-134 K-4.3 Cl-101 HCO3-23 Glu-120 BUN-8 Cre-0.5 Na-133 K-4.4 Cl-100 HCO3-20 Glu-148 BUN-8 Cre-0.4 Na-132 K-4.2 Cl-100 HCO3-21 Glu-148 BUN-8 Cre-0.4 Na-132 K-4.2 Cl-100 HCO3-21 Glu-155 BUN-7 Cre-0.4 Na-133 K-4.0 Cl-99 HCO3-25 Glu-127 BUN-11 Cre-0.4 Na-131 K-4.2 Cl-98 HCO3-25 Glu-123 BUN-10 Cre-0.4 Na-132 K-3.9 Cl-96 HCO3-26 Glu-97 BUN-7 Cre-0.4 Na-135 K-3.8 Cl-102 HCO3-24 ALT-353 AST-324 LD(LDH)-386 Amylase-46 ALT-417 AST-385 ALT-471 AST-419 ALT-238 AST-218 LD( )-321 AlkPhos-101 Amylase-33 TBili-2.4 ALT-181 AST-151 AlkPhos-78 TotBili-7.4 ALT-163 AST-135 LDH-403 APhos-69 TBili-6.8 DBili-4.2 IBili-2.6 ALT-245 AST-210 AlkPhos-90 TotBili-4.4 ALT-252 AST-188 AlkPhos-98 TotBili-3.8 ALT-232 AST-146 AlkPhos-82 TotBili-3.1 ALT-225 AST-127 LD(LDH)-281 AlkPhos-84 TotBili-2.5 DirBili-1.4 IndBili-1.1 ALT-215 AST-113 LD(LDH)-268 AlkPhos-84 TotBili-2.1 ALT-194 AST-86 LD(LDH)-215 AlkPhos-79 TotBili-1.5 ALT-193 AST-95 AlkPhos-91 TotBili-1.2 UricAcd-6.1 Albumin-2.4 Calcium-7.3 Phos-3.9 Mg-4.2 Iron-238 Calcium-7.1 Phos-3.9 Mg-6.0 Calcium-6.5 Phos-5.0* Mg-5.5 Calcium-8.0 Phos-3.0 Mg-2.3 Calcium-7.8 Phos-3.4 Mg-2.1 Calcium-7.7 Calcium-7.9 Phos-3.4 Mg-1.9 calTIBC-270 Ferritn-355 TRF-208 01:50AM BLOOD Hapto-<10 12:49AM BLOOD Hapto-<10 11:28PM BLOOD Hapto-38 TSH-3.4 T4-6.1 BLOOD Type-ART pO2-99 pCO2-44 pH-7.24 calTCO2-20 Base XS--8 BLOOD Type-ART pO2-374 pCO2-43 pH-7.34 calTCO2-24 Base XS--2 BLOOD Type-ART pO2-181 pCO2-46 pH-7.33 calTCO2-25 Base XS--1 BLOOD Type-ART pO2-165 pCO2-33 pH-7.45 calTCO2-24 Base XS-0 BLOOD Type-ART pO2-118 pCO2-38 pH-7.41 calTCO2-25 Base XS-0 BLOOD pH-7.36 BLOOD Type-ART pO2-72 pCO2-34 pH-7.38 calTCO2-21 Base XS-- yo G3P1 transferred at 38w3d presenting as a transfer from with preeclampsia/HELLP syndrome. On arrival, her blood pressures were stable and fetal testing was reassuring. Her transaminitis was worsening, platelets had decreased to 80, and LDH/haptoglobin confirmed hemolysis. She reported some RUQ discomfort which improved with Dilaudid. Induction of labor was initiated and she was started on Magnesium sulfate for seizure prophylaxis. Serial labs were followed and she was closely monitored. During her induction, she had a nonreassuring fetal tracing remote from delivery and underwent a primary LTCS on and delivered a liveborn female weighing 3235 grams with Agpars of 7 and 8. Intra-operative, a 400-500cc hemoperitoneum was noted upon entry into the abdomen. After delivery of the baby, inspection of the RUQ revealed active bleeding with a large hematoma on the surface of the liver. The RUQ as immediately packed, the massive transfusion protocol was initiated, and trauma surgery was consulted urgently. She was converted to general anesthesia as well. The hysterotomy was closed and trauma surgery scrubbed in to further evaluate the abdomen and liver. The liver hematoma was stabilized and packed. Intraoperatively, she was transfused 4 units of PRBCs and 2 units of FFP. Her abdomen was left open with 2 JP drains and she was transferred to the Trauma SICU. Please see operative reports for details. . Ms underwent close hemodynamic monitoring in the TSICU. Her coagulopathy improved. She received an additional 2 units of packed RBCs on POD#1. She was continued on Magnesium for 24 hours postpartum and her blood pressures were stable. On , she returned to the operating room for exploratory laparotomy with washout, unpacking of liver laceration, and complex abdominal closure. The procedure was uncomplicated with only 100cc EBL. She returned to the TSICU for further monitoring. On , she underwent a CTA of the chest/abdomen/pelvis after she developed tachycardia and hypoxia. No intra-abdominal extravasation or PE was identified. CXR was concerning for pulmonary edema. She diuresed appropriately after 40mg of Lasix. Echocardiogram on was unremarkable with an EF 60%. She was extubated and transferred to the postpartum floor. Her pain was controlled with a Dilaudid PCA. She continued to have tachycardia to the 130s and was closely monitored. Her blood pressures were well controlled on po Labetolol 200mg bid. Her labs remained stable. On , her foley was removed. She was tolerating a regular diet and transitioned to po pain medication. Her Labetolol was discontinued on . Also, a stitch was placed at the JP site on the right due to a moderate amount of serosanguinous drainage. Her incision was well approximated with staples without any surrounding erythema. She was discharged to home in stable condition on and will have close outpatient follow up. ## DISCHARGE MEDICATIONS: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 2. Ibuprofen 600 mg PO Q6H:PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*1 3. OxyCODONE (Immediate Release) mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 ## DISCHARGE DIAGNOSIS: 38 week gestation, HELLP syndrome, liver rupture ## DISCHARGE INSTRUCTIONS: Nothing in the vagina for 6 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks Do not drive while taking narcotics (i.e. Oxycodone, Percocet) Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns.

mimic

{"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13395801", "visit_id": "25479837", "time": "2149-07-18 00:00:00"}

17681159-RR-35

## MR RIGHT FEMUR: Within the right proximal femoral diaphysis, there is abnormal signal within the intramedullary cavity, spanning approximately 12 cm (CC). The abnormal signal is isointense to muscle on T1-weighted images and hyperintense to muscle on T2- and STIR-weighted images. Following the administration of intravenous Gadovist, there is heterogeneous enhancement. There is mild extension into the soft tissues medially, with the largest soft tissue component measuring 18 (AP) x 6 (TV) mm (10:19). There is mild scalloping of the cortex. No fracture line is identified. There is periosteal edema as before. Within the right ischium, there is an additional 2.0 (AP) x 2.0 (TV) cm metastatic lesion with surrounding edema. Right inguinal lymph nodes measure up to 7 mm. There is faint, somewhat nodular enhancement within the right adductor magnus muscle ( ) which may reflect vasculature as no abnormal FDG avidity was noted within this region. ## IMPRESSION: 1. Metastatic lesion within the right proximal femur with small soft tissue component and mild cortical thinning. Surrounding periosteal edema, but no discrete fracture line appreciated. 2. Right ischial tuberosity lesion. 3. Faint foci of enhancement within the right adductor magnus muscle, which could relate to vasculature, but to which attention can be paid on followup.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17681159", "visit_id": "N/A", "time": "2165-06-10 11:58:00"}

16896683-RR-33

## HISTORY: female with past medical history of sclerosing cholangitis and primary biliary cirrhosis now presenting with right upper quadrant/flank pain. ## CT PELVIS WITH INTRAVENOUS CONTRAST: There are scattered sigmoid diverticuli, though no signs of acute inflammation or obstruction. The bladder is mildly distended and appears normal. The uterus and adnexa are not visualized, likely secondary to prior surgical resection. There is no pelvic free fluid. No pathologically enlarged mesenteric, retroperitoneal, pelvic, or inguinal lymph nodes are identified. ## BONES AND SOFT TISSUES: No bone destructive lesion or acute fracture is identified. ## IMPRESSION: 1. Unchanged intra- and extrahepatic pneumobilia, likely related to prior sphincterotomy. 2. Stable periampullary duodenal diverticulum. 3. Pectus excavatum deformity. 4. Sigmoid diverticulosis without signs of acute diverticulitis.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16896683", "visit_id": "N/A", "time": "2153-01-29 21:26:00"}

12042461-DS-8

## ALLERGIES: All allergies / adverse drug reactions previously recorded have been deleted ## MAJOR SURGICAL OR INVASIVE PROCEDURE: Paracentesis Pigtail catheter placement in right thorax Flexible Bronchoscopy ## HISTORY OF PRESENT ILLNESS: Mr. is a year old male with history of MDS, hypercalcemia, and complicated pneumonia admitted with abdominal distention worsening oxygen demands at rehab. He was recently discharged from . He was treated for pneumonia and paraneumonic effusion. During admission he had hypercalcemia, and definitive cause was not determined. Per report from pt and family, he was at in and was having worsening shortness of breath as well as an increased O2 demand over the past several days and pt was sent to ED for concern for recurrance of PNA. . Pt reports that he has been slightly short of breath but denies any fever or chills, no night sweats, no cough. He also complains of feeling very gassy and has had worsening abdominal distention. He complains of occassional nausea, but no diarrhea or constipation. . Of note, pt reports a 70 lb weight loss over the past year. His wife reports that he has been bleeding easily as well but he has not had any brbpr, melena. . In ED vitals were 98.4 81 131/71 18 98% 4L. Lactate was 4.5 and he was given 2L fluid and improved to 3.0. Guaiac was negative, no leukocytosis but noted to have monocytosis and abnormal lymphocytes. CTA chest and abdomen revealed some cavitation in RLL as well as large right sided effusion. Abdominal CT showed diffuse ascites and splenomegaly. When taken off of O2 he was desating to the low . Pt was given vanc and zosyn. ## PAST MEDICAL HISTORY: BPH Anemia Dyspepsia Weight Loss Atrial flutter diagnosed in , s/p ablation in Vitamin D Deficiency DMII MDS Colonic adenomas h/o Sigmoid diverticulitis. h/o Basal cell carcinoma. h/o Left hip fracture, status post ORIF in . ## FAMILY HISTORY: Maternal aunt with diabetes. There is no family history of premature coronary artery disease, arrhythmias, or sudden death. ## GENERAL: Alert, oriented, no acute distress ## HEENT: Sclera anicteric, MMM, oropharynx clear ## NECK: supple, JVP not elevated, no bruits, 2cm hard fixed nontender lymph node on L upper anterior cervical chain ## LUNGS: R side lung sounds < L scattered crackles on right. Dull to percussion on right side up. ## CV: Regular rate and rhythm, normal S1 + S2, systolic murmur of RUSB ## ABDOMEN: Soft, grossly distended, some spider angiomoas on abdomen and chest. No hepatomegaly. dull to percussion throughout. Nontender, no rebound or guarding. ## EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema ## NEURO: CNs2-12 intact, motor function grossly normal ## HEENT: Sclera anicteric, oropharynx clear, dry MM with cracked lips ## NECK: no enlarged thyroid, enlarged lymph node no longer felt, JVP not elevated, no bruits ## COR: RRR, nl s1 and s2, no murmurs ## LUNGS: CTAB with diminished breath sounds at bilateral bases R>L, good air movement bilaterally ## ABD: +BS, nontender, distended with + fluid wave and shifting dullness that has increased, no hepatosplenomegaly felt ## SKIN: right hip bed sore and right arm bed sore. patient has many scabs and scratches from easy bleeding ## EXT: warm, well-perfused, no edema ## HIV: 07:35PM BLOOD HIV Ab-NEGATIVE ## SPEP/UPEP: 06:09AM BLOOD PEP-POLYCLONAL b2micro-14.8* IgG-2394* IgA-849* IgM-52 IFE-NO MONOCLO 07:30PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO Infectious disease labs: Test Result Reference Range/Units HISTOPLASMA ANTIGEN URINE <2.0 < 2.0 EIA Units Test Result Reference Range/Units QN 141 83-199 mg/dL HISTOPLASMA ANTIBODY (BY CF AND ID) Test Result Reference Range/Units YEAST PHASE ANTIBODY <1:8 MYCELIAL PHASE ANTIBODY <1:8 <1:8 ## INTERPRETIVE CRITERIA: <1:8 - Antibody Not Detected > or = 1:8 - Antibody Detected 07:50 B-GLUCAN Test ----- Fungitell (tm) Assay for (1,3)-B-D-Glucans Results Reference Ranges ----- ----- 56 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL HEPATITIS C - RIBA Test Name In Range Out of Range Reference Range ----- ----- ----- ----- HCV AB, RIBA Negative Negative BAND PATTERN Nonreactive Nonreactive (p)/cl00 (p) c33c Nonreactive Nonreactive c22p Nonreactive Nonreactive NS5 Nonreactive Nonreactive hSOD Nonreactive Nonreactive ## HIT WORK-UP: HEPARIN DEPENDENT ANTIBODIES NEGATIVE ## COMMENT: NEGATIVE PF4 HEPARIN ANTIBODY BY HEPARIN DEPENDENT ANTIBODIES Equivocal ## IMPRESSION: 1. Multifocal pneumonia with dense consolidation in the right lower lobe containing a central area of hypodensity and gas concerning for necrotizing pneumonia/abscess. Loculated right parapneumonic effusion without evidence of pleural enhancement to suggest empyema. 2. No evidence of pulmonary embolism. 3. Increased ascites. Splenomegaly. Slight nodular contour of the liver raises the question of cirrhosis. Clinical correlation recommended. 4. Known L1 fracture demonstrates no significant interval healing with slight distraction of the fracture fragments, however, no retropulsion into the spinal canal. ## IMPRESSION: 1. Multifocal pneumonia with dense consolidation in the right lower lobe containing a central area of hypodensity and gas concerning for necrotizing pneumonia/abscess. Loculated right parapneumonic effusion without evidence of pleural enhancement to suggest empyema. 2. No evidence of pulmonary embolism. 3. Increased ascites. Splenomegaly. Slight nodular contour of the liver raises the question of cirrhosis. Clinical correlation recommended. 4. Known L1 fracture demonstrates no significant interval healing with slight distraction of the fracture fragments, however, no retropulsion into the spinal canal. ## TTE : The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. ## IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild mitral regurgitation with normal valve morphology. Mild pulmonary artery systolic hypertension. Dilated ascending aorta. ## IMPRESSION: 1. Worsening left upper lobe opacification anteriorly concerning for continued spread of infection. 2. Stable cavitary abscess in the short interval since . A radiograph performed concurrent with this CT is recommended as a reference for future evaluation. 3. Centrilobular emphysema is severe in the upper lobes. 4. Axillary and mediastinal lymphadenopathy is stable in the shorter term from , though progressed since . 5. Slight increase moderate, layering, nonhemorrhagic right pleural effusion, whether this is empyema or exudate can only be reliably excluded by sampling. ## IMPRESSION: 1. Tiny right thyroid cyst; however, no new dominant nodule is seen within the thyroid gland. 2. Prominent lymph node with relatively normal morphology seen at level III of the left neck. This lymph node may represent a reactive process; while it has a fatty hilum it is somewhat prominant. Correlate with location of symptoms. ## PERITONEAL FLUID : NEGATIVE FOR MALIGNANT CELLS. ## PLEURAL FLUID : ATYPICAL. Rare atypical epithelioid cell. ## PLEURAL FLUID FLOW CYTOMETRY : INTERPRETATION Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by leukemia/lymphoma are not seen in specimen. Correlation with clinical findings and morphology (see Cytology) is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. ## IMPRESSION: 1. Patent portal, hepatic, and caval venous systems with normal hepatic arterial waveforms. 2. Cholelithiasis without evidence of acute cholecystitis. Gallbladder wall thickening likely relates to moderate ascites. No biliary dilatation. 3. Massive splenomegaly. ## IMPRESSION: 1. FDG avidity corresponding to areas of known pulmonary opacification, likely infectious in etiology 2. No FDG-avid lymphadenopathy or other concerning focus of FDG avidity 3. Diffuse bony FDG uptake, likely related to know MDS 4. Moderate right pleural effusion, large ascites and anasarca. ## MICRO: Bronchoalveolar lavage, right lower lobe : NEGATIVE FOR MALIGNANT CELLS. Alveolar macrophages and neutrophils. No fungal organisms or viral cytopathic effect identified. Bronchial brushings, right lower lobe : NEGATIVE FOR MALIGNANT CELLS. 4:00 pm SPUTUM Site: INDUCED Source: Induced. GRAM STAIN (Final : >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final : TEST CANCELLED, PATIENT CREDITED. LEGIONELLA CULTURE (Final : NO LEGIONELLA ISOLATED. ACID FAST SMEAR (Final : NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ## ACID FAST CULTURE (PRELIMINARY): NO MYCOBACTERIA ISOLATED. 2:13 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final : 2+ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final : NO GROWTH. ANAEROBIC CULTURE (Final : NO GROWTH. FUNGAL CULTURE (Final : NO FUNGUS ISOLATED. ACID FAST SMEAR (Final : NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ## ACID FAST CULTURE (PRELIMINARY): NO MYCOBACTERIA ISOLATED. 6:35 pm PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final : NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final : NO GROWTH. ANAEROBIC CULTURE (Final : NO GROWTH. ## FUNGAL CULTURE (PRELIMINARY): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final : NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ## ACID FAST CULTURE (PRELIMINARY): NO MYCOBACTERIA ISOLATED. 3:25 pm BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE BAL. LCU,NCU ADDED ON AT . GRAM STAIN (Final : 2+ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final : Commensal Respiratory Flora Absent. YEAST. 10,000-100,000 ORGANISMS/ML.. ACID FAST SMEAR (Final : NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ## FUNGAL CULTURE (PRELIMINARY): ALBICANS. ID AND FLUCONAZOLE TESTING REQUESTED BY # , ON . Fluconazole SENSITIVE. sensitivity testing performed by . This test has not been FDA approved but has been verified following Clinical and Laboratory Standards Institute guidelines by Clinical Laboratory.. POTASSIUM HYDROXIDE PREPARATION (Final : Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory ( ). LEGIONELLA CULTURE (Final : NO LEGIONELLA ISOLATED. ## NOCARDIA CULTURE (PRELIMINARY): NO NOCARDIA ISOLATED. 3:38 pm BRONCHIAL BRUSH RIGHT LOWER LOBE BRUSHING. GRAM STAIN (Final : NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final : NO GROWTH, <100 CFU/ml. ACID FAST SMEAR (Final : NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ## FUNGAL CULTURE (PRELIMINARY): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final : Test cancelled by laboratory. PATIENT CREDITED. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory ( ). ## PRIMARY REASON FOR ADMISSION: Mr. is a year old male with MDS, hypercalcemia and recent hospitalization for multifocal pneumonia, re-admitted with worsening O2 requirement and abdominal distension, treated for RLL necrotizing pneumonia and ascites, now with ascites and transaminitis of unknown etiology. ## # MALIGNANCY WORK-UP: Patient's history of 70-lb weight loss, anemia, uptrending LFTs, lymphomatous-appearing nodularity of liver, and overall clinical picture is concerning for malignancy. All cytologies (pleural, ascites, bronchial) have been negative for malignant cells, and flow cytometry if pleural fluid was negative for malignant pattern as well. PET/CT showed no evidnece of malignancy; again seen is bone marrow signal likely related to underlying MDS or drug effect. Further work-up of a malignancy would require tissue sampling, either an ultrasound-guided biopsy of a cervical lymph node (considered low yield because lymph node has fatty hilum and appears reactive), a transbronchial biopsy of a mediastinal node (considered high risk because patient bleeds disproportionally to his plts and INR, raising concern of platelet dysfunction), or a laparoscopic biopsy of a mesenteric node. A family meeting was held to discuss goals of care and how aggressively dignosis should be pursued, and it was concluded that even if a diagnosis could be made, patient was unlikely to tolerate extensive therapy, thus a focus should be made on providing comfort. The patient was made DNR/DNI, trending towards CMO (but not yet CMOO), and was discharged home with hospice. ## # MULTIFOCAL PNEUMONIA: Patient was recently hospitalized with complicated pneumonia with parapneumonic effusion with admission from to . During his last admission, he was treated with 9 days of vanc/zosyn/levo with clinical improvement. On CT, effusion has reaccumulated and some evidence of cavitation and enlarged mediastinal lymph nodes. Multifocal pneumonia is still present, as well as evidence of emphysema. Patient is afebrile with no leukocytosis. Differential dx includes multifocal pneumonia with necrotizing pneumonia vs. TB vs. malignant lesion. AFB cultures were negative. IP was consulted and chest tube was inserted on to drain the effusion. A bronchoscopy was also performed and BAL was sent for culture and cytology, both of which returned negative. Repeat CT chest shows worsening of RUL pneumonia and slight worsening of effusions; could not definitively rule out empyema. Antibiotics were broadened from zosyn to meropenem on as patient clinically looked worse. Pleural fluid cultures were negative for growth, cytology negative for malignant cells, and flow cytometry of pleural fluid was negtive for malignancy. All ID labs from have returned negative. Patient has completed a 14 day course of vancommycin, and a 12 day course of meropenem (thus patient has exceeded the 8 day course previously planned). He was continued on O2 by nasal cannula, eventually weaned from to . ## # HISTORY OF HYPERCALCEMIA: Patient was noted to be hypercalcemic last admission and was given palendronate with improvement. During that admission, no evidence of malignancy was found on skeletal survey or PET scan. Patient did not experience hypercalcemia until two weeks into this admission when Calcium trended up to 10.5-11.2. He again shows no evidence of thoracic malignancy on CT chest, and mediastinal lymphadenopathy can be reactive from pneumonia. Most likely cause of hypercalcemia is bone turnover, but no clear source despite thorough workup. During last admission, PTH was appropriately low, PTHrp was low, and VitD1,25 was low as well. SPEP and UPEP again both negative for MM. IgG was again measured this admission and is again polyclonal (as it was last admission). Patient was given gentle IVF to bring down calcium, but his ascites was monitored, as he tends to accumulate fluid in his abdomen. He was encouraged to increase PO intake. ## # TRANSAMINITIS/ASCITES: Patient has ascites, nodular liver on imaging, and splenomegaly. He has transaminitis with AST>ALT, elevated alk phos but normal Tbili. No SBP by tap, SAAG>1.1 with low protein. Does have some spiders on abdomen, but no other signs of liver disease. Differential diagnosis includes cirrhosis, portal vein thrombosis or other portal vein obstruction, or malignancy. No evidence of portal vein thrombosis seen on CTA. Spleen was also enlarged on abd US and all portal vasculature were patent. Under the guidance of a hepatology consult, labs were sent for hepatitis serologies, disease, hemachromatosis (iron studies), autoimmune hepatitis, all of which returned negative. TTG was negative. IgG and IgA are elevated; IgM normal. AMA, and antitrypsin negtive. Per liver, positive 1:80 Anti-smooth muscle antibodies is not high enough of a titer to be concerning. A week into his hospitalization, his LFTs began to rise. There were no recent changes to his medications, and all nonessential medications were discontinued. Pravastatin was also discontinued. Per hepatology team, this clinical and laboratory picture may be consistent with lymphomatous infiltration of the liver, which can produce the type of nodularity seen by imaging. Hepatology team would need tranjugular liver biopsy for further workup, but as patient was transitioning toward hospice care, further work-up was not pursued. # Afib: Patient was noted to be in afib on telemetry overnight during first week of admission. Patient has no hx of afib, although has hx of aflutter s/p ablation. He has had difficulty with anticoagulation in the past with bleeding after a tooth extraction. CHADS2 score is 2 (htn, DMII). Patient's heart rate has been fine in the . Patient was initially monitored on telemetry but preferred not to be on telemetry. As he did not have a fast heart rate despite being intermittently in afib, his telemetry was discontinued and he was maintaed on q4h vital checks. He was not anticoagulated, given his current clinical state and high risk for hemorrhage. ## # THROMBOCYTOPENIA: Patient's platelets started trending down a week into admission, from 218 to 99 over a course of five days. Differential diagnosis for thrombocytopenia included decreased production (known MDS, marrow suppression from vanc which has been supratherapeutic and zosyn), increased destruction (HIT - current T4 score is 5 intermediate risk, DIC because also slightly more anemic, ITP) and splenic sequestration. Peripheral smear shows no evidence of microangiopathic disease. First heparin dependent antibody test was equivocal, but second returned negative. However, patient may have had type 2 HIT. Despite negative PF4, given patient's ease of bleeding, and the uptrend of his plt count off of heparin, heparin sq was held for the rest of his admission. ## # MDS: His MDS has been followed by outpatient hematologist, who has thought about his case extensively for years and is uncertain why he has experienced such significant weight loss and severe anemia. It appears that his MDS is not severe enough to cause such severe anemia, and no evidence of GI bleeding was ever discovered. Based on current labs and smears, patient still does not have severe MDS and malignant transformation seems very unlikely. Patient had a few premature myelocytes on his diff, which can also be seen in the setting of infection. Thus, his cell lines were monitored throughout hospitalization and he received a total of 2 transfusions when his hct ws 22, to help with his symptoms of fatigue/dyspnea. ## # HTN: Patient's SBP was in the 100s on home lisinopril regimen, but then began to trend down to when patient was becoming more ill with pneumonia, so held lisinopril at that point and remained held for the remainder of his hospitalization. His SBP stayed in the 100s-110s throughout hospitalization. ## CODE: DNR/DNI (GOING HOME WITH HOSPICE CARE) ## (DAUGHTER): PCP be contact person for hospice. ## MEDICATIONS ON ADMISSION: 1. miconazole nitrate 2 % Powder Sig: One (1) application Topical three times a day: Apply to buttocks. 2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 3. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 6. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 7. dextromethorphan-guaifenesin mg/5 mL Syrup Sig: Five (5) ml PO every six (6) hours as needed for cough or chest congestion. 8. Fleet Enema gram/118 mL Enema Sig: One (1) enema Rectal once a day as needed for constipation. 9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection three times a day. 10. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for ## NEBULIZATION SIG: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. 11. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day: Apply to L1-L2 area. 12 hours on, 12 hours off. 12. pamidronate 60 mg/10 mL (6 mg/mL) Solution Sig: Sixty (60) mg Intravenous once a month: Last given . 13. aluminum-magnesium hydroxide 200-200 mg/5 mL Suspension Sig: Five (5) mL PO four times a day as needed for indigestion. 14. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. ## DISCHARGE MEDICATIONS: 1. hospice Admit to hospice 2. sodium chloride 0.65 % Aerosol, Spray Sig: Sprays Nasal QID (4 times a day) as needed for nasal dryness . Disp:*1 bottle* Refills:*3* 3. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Disp:*120 Tablet(s)* Refills:*2* 4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) powder package PO DAILY (Daily). Disp:*30 powder package* Refills:*2* 5. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 6. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every six (6) hours as needed for nausea. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* ## DISCHARGE DIAGNOSIS: Multifocal pneumonia/necrotizing pneumonia Ascites Anemia Weight Loss Myelodysplastic Syndrome ## ACTIVITY STATUS: Ambulatory - requires assistance or aid (walker or cane). ## DISCHARGE INSTRUCTIONS: Dear Mr. , It was a pleasure taking care of you here at . You were admitted with increasing trouble breathing and a distended abdomen. While you were here, we found you had a multifocal pneumonia with a necrotizing cavitary lesion. You also had a pocket of fluid around your lung, which we drained with a chest tube. We also found you had some liver problems with elevated enzymes and your blood level was low. We tried to find a unifying diagnosis for your problems and you received a few CTs, ultrasounds, and PET CTs in the process. Based on discussions with you and your family, we agreed that you think it is more important for you to be at home and with your family, than to find a definitive diagnosis for your current disease. Therefore, we helped you control your symptoms. We supported your breathing with oxygen and we gave you pain medication for your chronic pain. In keeping with your wishes to go home with a focus on comfort and symptom management, we have arranged for home hospice services to support you and your family. Please note that the following are the medications you should take: - Sodium chloride 0.65% Nasal Spray Sprays 4 times a day as needed for nasal dryness - Oxycodone 10mg PO every six hours - Polyethylene glycol 3350 17 gram/dose PO daily - Prochlorperazine 5mg PO every 6 hours as needed for nausea - Zofran ODT 8mg PO every six hours as needed for nausea - Oxygen therapy up to 2L by nasal cannula as needed

mimic

{"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12042461", "visit_id": "27750880", "time": "2123-02-28 00:00:00"}

10246643-RR-9

## : Cardiology Staff: , MD ## GENDER: Male Radiology Staff: , MD ## RACE: Other Technologist: , RT ## STATUS: Outpatient Nursing Support: , RN ## WEIGHT (LBS): 189 Injection Site: right hand vein ## RHYTHM: Sinus rhythm Creatinine (mg/dl): 0.9 ## CMR MEASUREMENTS: Measurement Normal Range Left Ventricle LV End-Diastolic Dimension (mm) 57 <62 LV End-Diastolic Dimension Index (mm/m2) 28 <32 LV End-Systolic Dimension (mm) 36 LV End-Diastolic Volume (ml) 184 <196 LV End-Diastolic Volume Index (ml/m2) 91 <95 LV End-Systolic Volume (ml) 76 LV Stroke Volume (ml) 108 LV Stroke Volume Index (ml/m2) 53 LV Ejection Fraction (%) 59 >=54 LV Mass (g) 86 LV Mass Index (g/m2) 42 <80 Basal wall thickness (mm) 8 <12 Basal infero-lateral wall thickness (mm) 6 <11 Q-Flow Aortic Net Forward Stroke Volume (ml) 96 Q-Flow Aortic Total Stroke Volume (ml) 98 Q-Flow Aortic Cardiac Output (l/min) 4.1 Q-Flow Aortic Cardiac Index (l/min/m2) 2 LV Effective Forward Ejection Fraction (%) *52 >=54 Right Ventricle RV End-Diastolic Volume (ml) 166 RV End-Diastolic Volume Index (ml/m2) 82 58-114 RV End-Systolic Volume (ml) 80 RV Stroke Volume (ml) 86 RV Stroke Volume Index (ml/m2) 42 RV Ejection Fraction (%) 52 >=46 Q-Flow Pulmonary Net Forward Stroke Volume (ml) 71 Q-Flow Pulmonary Total Stroke Volume (ml) 80 Qp/Qs 0.74 0.8-1.2 Atria Left Atrial Dimension (Axial) (mm) 36 <40 Left Atrial Length (4-Chamber) (mm) **61 <52 Right Atrial Dimension (4-Chamber) (mm) 46 <50 Coronary Sinus Diameter (mm) 13 <15 Great Vessels Ascending Aorta Diameter (mm) 30 <39 Ascending Aorta Diameter Index (mm/m2) 15 <20 Transverse Aorta Diameter (mm) 24 Transverse Aorta Diameter Index (mm/m2) 12 Descending Aorta Diameter (mm) 24 <28 Descending Aorta Index (mm/m2) 12 <14 Abdominal Aorta Diameter (mm) 24 Abdominal Aorta Diameter Index (mm/m2) 12 Main Pulmonary Artery Diameter (mm) 26 <29 Main Pulmonary Artery Diameter Index (mm/m2) 13 <15 Pulmonary Veins Number of Left Pulmonary Veins 1 Number of Right Pulmonary Veins 2 Left Common PV Dimension (mm) 28 x 11 Left Common PV Cross-Sectional Area (mm2) 264 Left Common PV Late Gadolinium Enhancement Positive Left Common PV Visual Apperance Normal Right Upper PV Dimension (mm) 21 x 16 Right Upper PV Cross-Sectional Area (mm2) 255 Right Upper PV Late Gadolinium Enhancement Positive Right Upper PV Visual Appearance Normal Right Lower PV Dimension (mm) 20 x 18 Right Lower PV Cross-Sectional Area (mm2) 339 Right Lower PV Late Gadolinium Enhancement Positive Right Lower PV Visual Appearance Normal Valves Aortic Valve Morphology Trileaflet Aortic Valve Excursion Normal Aortic Valve Area (cm2) 4.4 >=2 Aortic Valve Area Index (cm2/m2) 2.2 Aortic Valve Regurgitation (Visual) None present Aortic Valve Regurgitant Volume (ml) 2 Aortic Valve Regurgitant Fraction (%) 2 <5 Mitral Valve Regurgitation (Visual) Present Mitral Valve Regurgitant Volume (ml) 10 Mitral Valve Regurgitant Fraction (%) *9 <5 Pulmonary Valve Regurgitation (Visual) None present Pulmonary Valve Regurgitant Volume (ml) 9 Pulmonary Valve Regurgitant Fraction (%) *11 <5 Tricuspid Valve Regurgitation (Visual) Present Tricuspid Valve Regurgitant Volume (ml) 6 Tricuspid Valve Regurgitant Fraction (%) *7 <5 Pericardium Pericardial Thickness (mm) 2 <4 Pericardial Effusion Trace * Mildly abnormal | ** Moderately abnormal | *** Severely abnormal ## STRUCTURE " T1-WEIGHTED (BLACK BLOOD): Dual-inversion T1-weighted fast spin echo images were acquired in 5-mm contiguous axial slices to evaluate cardiac and vascular anatomy. ## FUNCTION " CINE SSFP: Breath-hold SSFP cine images were acquired in 8-mm slices in the 4-chamber, 3-chamber, 2-chamber, and short axis orientations. " Cine SSFP (Additional Aortic Valve Views): A short-axis series was acquired at the level of the aortic valve. ## FLOW " AORTIC VALVE FLOW: Phase-contrast cine images were acquired transverse to the proximal ascending aorta to quantify through-plane flow. " Pulmonary Valve Flow: Phase-contrast cine images were acquired transverse to the main pulmonary artery to quantify through-plane flow. Viability " LGE of the Pulmonary Veins: Late gadolinium enhancement (LGE) images of the left atrium and pulmonary veins were acquired using a navigator-gated 3D ultrafast gradient echo inversion-recovery sequence with spectral fat saturation pre-pulses 15 minutes after injection of a total of 0.1 mmol/kg (15 mL) Gd-BOPTA (Multihance). MRA " MRA of the Pulmonary Veins: First-pass magnetic resonance angiography (MRA) images of the pulmonary veins were acquired after administration of a bolus of 0.1 mmol/kg (15 mL) Gd-BOPTA (Multihance). Multiplanar reconstructions of the pulmonary arteries were generated and analyzed on a workstation. ## LEFT VENTRICLE " LV CAVITY SIZE: Normal " LV ejection fraction: Normal " LV mass: Normal ## RIGHT VENTRICLE " RV CAVITY SIZE: Normal " RV ejection fraction: Normal " Intra-cardiac shunt: None present ## ATRIA " LA SIZE: Moderately enlarged " RA size: Normal ## GREAT VESSELS " ASCENDING AORTIC DIAMETER: Normal " Main pulmonary artery diameter: Normal Pulmonary Veins " Number of Left Pulmonary Veins: 1 " Number of Right Pulmonary Veins: 2 " Late gadolinium enhancement of the left common pulmonary vein: Positive " Late gadolinium enhancement of the right upper pulmonary vein: Positive " Late gadolinium enhancement of the right lower pulmonary vein: Positive ## VALVES " AORTIC VALVE MORPHOLOGY: Trileaflet " Aortic stenosis: No " Aortic regurgitation jet: None present " Mitral regurgitation jet: Present " Mitral regurgitation: Mild " Pulmonary regurgitation jet: None present " Pulmonary regurgitation: Mild " Tricuspid regurgitation jet: Present " Tricuspid regurgitation: Mild ## PERICARDIUM " PERICARDIAL THICKNESS: Normal " Pericardial effusion: Trace ## ADDITIONAL INFORMATION/FINDINGS: None. ## NON-CARDIAC FINDINGS: Bilateral axillary lymphadenopathy, as seen previously. Clinical correlation is recommended, likely related to CLL. ## IMPRESSION: Moderately enlarged left atrium. Normal right atrium. Normal left ventricular wall thicknesses with normal cavity size and normal regional and global left ventricular systolic function. Normal right ventricular size and systolic function. Normal ascending aorta, descending aorta, and main pulmonary artery diameters. Mild mitral regurgitation. Mild tricuspid regurgitation. Normal size and orientation of the pulmonary veins (two right sided and one common left sided) without evidence of anomalous pulmonary venous return or pulmonary vein stenosis. Late gadolinium enhancement of the posterior left atrial wall and ostia of all pulmonary veins, consistent with prior ablation. Trace pericardial effusion. Compared to prior study dated , the left ventricular cavity size is now normal and there is evidence of mild tricuspid regurgitation. The pulmonary veins are mildly reduced in size compared to the prior study in the absence of focal stenosis.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10246643", "visit_id": "N/A", "time": "2170-07-16 15:51:00"}

17287581-RR-43

## HISTORY: female presenting with abdominal pain after recent surgery. Assess for subdiaphragmatic free air. ## PA AND LATERAL CHEST RADIOGRAPH: Linear opacities within the lung bases, left greater than right, correspond with atelectasis seen on concurrent CT. No confluent opacity is identified to suggest pneumonia. There is no pulmonary edema or pleural effusions. No pneumothorax is evident. Mediastinal and hilar contours are within normal limits. Mild enlargement of the cardiac silhouette is unchanged. There is no subdiaphragmatic free air. ## IMPRESSION: 1. Minimal bibasilar atelectasis. 2. Unchanged mild cardiomegaly.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17287581", "visit_id": "N/A", "time": "2181-09-19 23:35:00"}

16845903-RR-21

## HISTORY: with IgG lambda monoclonal gammopathy and inflammatory myopathy. Evaluation for bone lesions or plasmacytoma. ## SKULL: Lateral view shows no abnormal lesions. Paranasal sinuses and mastoid air cells are clear. ## CERVICAL SPINE: No lytic or destructive bone lesions or pathologic fracture. Paravertebral soft tissues are within normal limits. ## THORACIC SPINE: AP and lateral views show no destructive bone lesion or pathologic fracture. ## LUMBAR SPINE: AP and lateral views demonstrates the destructive bone lesions or pathologic fractures. Mild degenerative disease involving the lower lumbar spine. ## LONG BONES: The bilateral humeri, proximal aspects of the bilateral radius and ulnar, bilateral femurs, and bilateral proximal tibia show no lytic lesions or destructive bony mass. ## PELVIS: There is scattered enthesopathy at tendinous insertions. No lytic lesion seen, allowing for limitations of overlying bowel gas. The visualized lungs and mediastinal structures are within normal limits. Intra-abdominal structures are within normal limits. ## IMPRESSION: No evidence of myelomatous lesions or fractures.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16845903", "visit_id": "N/A", "time": "2165-06-24 12:20:00"}

10540520-RR-23

## INDICATION: year old man s/p brain stem cavernoma resection, evaluate for post-operative change ## FINDINGS: The examination is markedly limited by motion. The patient is status post right frontotemporal craniotomy and resection of the mass in the midbrain. The small extra-axial hematoma, underlying the craniotomy site in the right frontal lobe, and right frontotemporal scalp edema as well as subcutaneous emphysema are similar in appearance to the CT brain . There are small subdural fluid collections diffusely over the hemispheres and along the falx. This is a common postoperative finding. The pneumocephalus in the bilateral frontal lobes has decreased from the prior examination. There is hemorrhage and slow diffusion in the resection cavity. Hyperintensity in the midbrain on the FLAIR images appears similar to, or slightly decreased since, the brain MRI of No abnormal enhancement is identified. Hemorrhage layers dependently in the occipital horns of the bilateral ventricles. The prior ventriculostomy tract in the right frontal lobe is unchanged. There is no evidence of infarction or midline shift. The ventricles are unchanged in size. ## IMPRESSION: Postsurgical changes status post right frontotemporal craniotomy and resection of the mass in the inter pedicular midbrain with blood products at thepostsurgical bed and no abnormal enhancement.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10540520", "visit_id": "29199993", "time": "2147-07-25 00:33:00"}

13714286-RR-77

## EXAMINATION: CT CHEST W/O CONTRAST ## INDICATION: year old man with resp failure, PNA, pulm edema// pna pna ## DOSE: Acquisition sequence: 1) Spiral Acquisition 2.3 s, 36.2 cm; CTDIvol = 13.2 mGy (Body) DLP = 478.0 mGy-cm. Total DLP (Body) = 478 mGy-cm. ## THORACIC INLET: ET tube projects approximately 4 cm from the carina. NG tube projects below the left hemidiaphragm. There is a right IJ line which projects to the SVC. There is a right-sided PICC line with its tip in the SVC. ## BREAST AND AXILLA: There are no enlarged axillary lymph nodes ## MEDIASTINUM: There are multiple enlarged mediastinal bilateral hilar lymph nodes with evidence of wall calcification. There is moderate cardiomegaly. There is moderate coronary artery calcification. There is no pericardial effusion. ## PLEURA: There are moderate bilateral pleural effusions right greater than left. ## LUNG: Consolidative opacity in the right lower lobe and left lower lobe is unchanged there is diffuse bilateral ground-glass opacification superimposed over emphysema and several scattered nodules which most likely represents pulmonary edema. Evaluation of lung parenchyma is somewhat limited by respiratory motion. There is a right upper lobe nodule measuring 15 mm. ## BONES AND CHEST WALL: Review of bones shows degenerative changes involving the thoracic spine. ## UPPER ABDOMEN: Limited sections through the upper abdomen are unremarkable. ## IMPRESSION: Moderate bilateral pleural effusions right greater than left. Consolidative opacities in both lower lobes most likely represent atelectasis. Pulmonary edema. Superimposed over emphysema. Several scattered bilateral pulmonary nodules the largest in the right upper lobe measuring 15 mm ETT, NG tube, right IJ line and right PICC line in acceptable position. Mediastinal bilateral hilar lymph nodes some of which are calcified, could be related to sarcoidosis.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13714286", "visit_id": "25156580", "time": "2175-09-08 15:54:00"}

10245522-RR-34

## EXAMINATION: CT abdomen and pelvis with IV contrast. ## INDICATION: with abdominal wall pus draining. eval for abscess. Chart review notes that patient had a gastrostomy tube placed in in head and anterior abdominal wall infection in seventeen which was treated with antibiotics. Now presenting with several days of increasing redness, swelling, and purulent drainage. ## LOWER CHEST: There is mild dependent atelectasis in the bilateral lower lobes. Linear opacity in the left lower lobe likely represents scarring is unchanged from CT abdomen pelvis . There is a partially calcified right posterior pleural plaque, unchanged from . Epicardial pacing wires are again noted. ## HEPATOBILIARY: The liver is grossly unremarkable aside from mild periportal edema, unchanged from . There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. Small amount of pericholecystic fluid is unchanged from . ## PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. ## SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ## ADRENALS: The right and left adrenal glands are normal in size and shape. ## URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. ## GASTROINTESTINAL: Gastrostomy tube terminates within the stomach. The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not visualized but there are no secondary signs of acute appendicitis. ## PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. ## REPRODUCTIVE ORGANS: The prostate is not enlarged. ## LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. ## VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. ## BONES: There is no evidence of worrisome osseous lesions or acute fracture. Moderate degenerative changes the lumbar spine are noted. ## SOFT TISSUES: In the anterior abdominal wall near the course of the epicardial pacing wires and inferolateral to the course of the gastrostomy tube, there is a hyperattenuating area measuring 3.0 x 1.4 cm (02:30), mildly decreased in size from CTA . There is a lipoma in the anterior subcutaneous tissues of the upper abdomen (02:20) ## IMPRESSION: At the level of the left upper anterior abdomen inferolateral to the percutaneous gastrostomy tube is a hyperattenuating focus measuring 3.0 x 1.4 cm with associated skin thickening. This is nonspecific and may represent a phlegmon given the provided clinical history. No evidence of drainable fluid collection.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10245522", "visit_id": "26710066", "time": "2169-12-09 10:43:00"}

18032895-RR-45

## INDICATION: woman with pancreatic cancer and liver metastases. Evaluate for metastatic disease in the thorax. ## DOSE: Found no primary dose record and no dose record stored with the sibling of a split exam. !If this Fluency report was activated before the completion of the dose transmission, please reinsert the token called CT DLP Dose to load new data. ## FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: 5 mm calcified nodule is seen in the right thyroid lobe, unchanged from previous study (2:4). Supraclavicular and axillary nodes are not enlarged, largest node in the left axilla measuring 9 mm (302:61). Specifically excluding the breasts which require mammography for evaluation, there are no soft tissue abnormalities elsewhere in the chest wall concerning for malignancy. ## UPPER ABDOMEN: Findings below the diaphragm will be reported separately. ## MEDIASTINUM: No mediastinal mass or lymphadenopathy. ## HILA: No hilar mass or lymphadenopathy. ## HEART AND PERICARDIUM: Tip of right anterior chest wall port is at the cavoatrial junction. Heart is normal size. Coronary arteries are not calcified. No pericardial effusion. ## PLEURA: No pleural effusion or pneumothorax. ## 1. PARENCHYMA: There is no consolidation. No suspicious pulmonary nodules. ## 2. AIRWAYS: Tracheobronchial tree is patent to the subsegmental level. ## 3. VESSELS: The aorta and pulmonary artery are normal caliber. ## CHEST CAGE: No pathologic or compression fractures or destructive bone lesions. Although there are no bone lesions in the imaged chest cage suspicious for malignancy or infection, it should be noted that radionuclide bone and FDG PET scanning are more sensitive in detecting early osseous pathology than chest CT scanning. ## IMPRESSION: No evidence of metastatic disease in the chest.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18032895", "visit_id": "N/A", "time": "2138-12-07 09:45:00"}

10705949-RR-43

RADIOGRAPHS OF THE CERVICAL SPINE ## HISTORY: Left-sided neck pain with one month of atraumatic radiculopathy. ## FINDINGS: The C5-C6 interspace is mildly narrowed with moderate-sized anterior osteophyte formation. The C6-C7 and C7-T1 levels are somewhat difficult to visualize due to overlapping bony structures. On the left, the neural foramina appear widely patent without clear evidence for substantial degenerative change along facet joints. Minimal rightward convex curvature makes the right-sided neural foramina difficult to assess, but there is potentially moderate neural foraminal narrowing on the right at C4-C5 with striking osteophytes. ## IMPRESSION: Mild-to-moderate degenerative changes, particularly noting facet joint degenerative changes at C4-C5.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10705949", "visit_id": "N/A", "time": "2131-09-29 15:05:00"}

16625434-RR-79

## STUDY: man with syndrome and has had prior renal transplant, and right ankle pain. ## FINDINGS: No prior studies of the ankle available for a direct comparison. There is a sclerotic lesion in the distal tibia which has peripheral calcification and is compatible with a bone infarct. There is no cortical destruction or pathologic fracture at this location. Additionally, there is an area of cystic change in the talar dome measuring 2.4 cm which extends to the joint surface. This likely represents sequela from avascular necrosis. There is no gross articular collapse at this time. However, imaging with MRI may better characterize this abnormality. The ankle mortise is preserved. There is no discrete fracture. There is some mild soft tissue swelling. ## IMPRESSION: 1. Cystic area within the talar dome, extending to the articular surface, likely due to avascular necrosis. This could be further evaluated with MRI imaging. 2. Bone infarct within the distal tibial metaphysis.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16625434", "visit_id": "28760088", "time": "2135-10-28 18:02:00"}

15370183-RR-47

## INDICATION: Cirrhosis, status post antrectomy, Roux-en-Y gastrojejunostomy for bleeding ulcer with duodenal stump leak, now concern for sepsis. and ## CT ABDOMEN: The visualized lung bases demonstrate mild bibasilar atelectasis. There is no pleural or pericardial effusion. Nodularity of the liver with left hepatic lobe and caudate hypertrophy are consistent with known cirrhosis. A 9-mm hypodensity in the hepatic dome (2:7) is too small to characterize but is unchanged from . No other focal lesions are seen in the liver. The gallbladder is surgically absent. Splenomegaly is unchanged with the spleen measuring 15.1 cm. varices are unchanged. Bilateral adrenal glands are normal. The kidneys enhance symmetrically and excrete contrast promptly without hydronephrosis. A 1.3 x 2.3cm fluid collection anterior to right kidney is decreased from , when it measured 1.9 x 2.7cm. Small perihepatic and perisplenic ascites is stable, with a drain ending near the hepatic dome, unchanged in position from . The patient is status post Roux-en-Y gastrojejunostomy and oral contrast follows the expected post-surgical course. There is no extravasation of oral contrast at the anastomotic site to suggest a leak. The bowel is of normal caliber without obstruction. There is pancolonic bowel wall thickening, most pronounced in the ascending and transverse colons. A small amount of stranding surrounding the descending colon is improved from . Mild atherosclerotic calcifications are seen throughout the aorta without aneurysmal dilation. The main portal vein, splenic vein, and SMV are patent. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are present. ## CT PELVIS: Minimal bowel wall thickening is noted in the rectum and sigmoid colons. The bladder, and prostate are normal. There is no free fluid and no pelvic or inguinal lymphadenopathy. ## BONE WINDOWS: No bone finding suspicious for malignancy or infection is seen. ## IMPRESSION: 1. Status post Roux-en-Y gastrojejunostomy without evidence of leak. 2. Colonic wall thickening, predominantly in the ascending and transverse colons, with a small amount of surrouding stranding in the descending colon. Findings consistent with colitis of unknown acuity, but the CT appearance is improved from . 3. Interval decrease in size of small fluid collection anterior to right kidney. Initial findings discussed with 10:42am . Revised findings discussed with Dr. by phone .

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15370183", "visit_id": "20543489", "time": "2149-06-03 09:38:00"}

17509096-RR-57

## EXAMINATION: COMPLETE GU U.S. (BLADDER AND RENAL) ## INDICATION: year old man with hx gross hematuria, radiation for prostate cancer and renal failure with diabetes // r/o masses, hydro, tumors status post penile implant ## FINDINGS: The right kidney measures 10.1 cm. The right renal cortex is thinned and echogenic consistent with atrophy. Several simple cysts are evident. The largest is in the upper pole measuring 11.4 x 8.3 x 12.5 cm. The left kidney measures 11.8 cm. The left renal cortex appeared thinned and echogenic consistent with atrophy. There are several simple cyst demonstrated in the kidney. The largest measures 17 x 7 x 15 cm. There is no hydronephrosis bilaterally. The bladder remained empty during the exam. The penile implant reservoir was identified. ## IMPRESSION: 1. Bilateral renal atrophy. Large simple cysts bilaterally. 2. Empty urinary bladder throughout exam.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17509096", "visit_id": "N/A", "time": "2140-09-30 13:00:00"}

17784861-RR-75

## EXAMINATION: MR KNEE W/O CONTRAST RIGHT ## INDICATION: year old woman R knee pain and locking. Evaluation for meniscal tear. ## MEDIAL MENISCUS: There is redemonstration of a vertically oriented longitudinal tear involving the anterior horn of the medial meniscus, similar in appearance to prior study. There is medial extrusion of the meniscus measuring up to 3 mm. A small parameniscal cyst is again noted (05:11). Lateral meniscus: Intact. ## ANTERIOR CRUCIATE LIGAMENT: Intact. Posterior cruciate ligament: Intact. ## MEDIAL COLLATERAL LIGAMENT: Intact. Increased edema located along the posteromedial joint line, posterior to the MCL, which could be seen in the setting of meniscocapsular separation. Mild tendinosis of semimembranosus Lateral collateral ligamentous complex: Intact. ## EXTENSOR MECHANISM: The quadriceps and patellar tendons are intact. ## CYST: None. Joint effusion: None. Articular cartilage ## MEDIAL: Few areas of partial and full-thickness cartilage loss involving the medial femoral condyle and medial tibial plateau with associated subchondral marrow edema, increased from prior study. ## BONE MARROW: Increased subchondral marrow edema involving the anterior aspect of the medial tibial plateau, with small subchondral cyst measuring up to 7 mm (05:12). ## ADDITIONAL: Small amount of edema noted surrounding the semimembranosus muscle. ## IMPRESSION: 1. Overall similar appearance of a vertically oriented longitudinal tear involving the anterior horn of the medial meniscus, with an adjacent parameniscal cyst. There is mild medial extrusion of the meniscal body 2. Interval progression of degenerative change within the medial compartment, including few areas of partial and full-thickness cartilage loss involving the medial femoral condyle and medial tibial plateau with associated underlying subchondral marrow edema and subchondral cyst formation. 3. Intact appearance of the MCL with increased edema located posteriorly, which can be seen in the setting of meniscocapsular separation.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17784861", "visit_id": "N/A", "time": "2195-05-21 12:57:00"}

12612379-RR-119

## HISTORY: Shortness of breath, hypoxia. ## FINDINGS: The lungs are hyperinflated. The heart size is normal. Mediastinal and hilar contours are unchanged. Small right pleural effusion has increased in size compared to the prior study. Re- demonstrated is scarring with bronchiectasis and ill-defined nodular small opacities in the right middle lobe with coarse calcifications of the right breast. Right basilar patchy opacity likely reflects atelectasis. Pulmonary vasculature is not engorged. There is no pneumothorax. ## IMPRESSION: Slight interval increase in size of small right pleural effusion with right basilar atelectasis. Chronic bronchiectasis, scarring, and nodular opacities in the right middle lobe.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12612379", "visit_id": "29670447", "time": "2195-10-10 11:42:00"}

11685699-RR-35

## INDICATION: Status post aortofemoral bypass with abdominal and retroperitoneal abscess after drain fell out with spiking fevers. ## OSSEOUS STRUCTURES: No suspicious intraosseous lesions are present. There is multilevel degenerative disease and mild loss of vertebral body height at T12, unchanged. ## IMPRESSION: 1. Interval increase in the size of multiloculated retroperitoneal abscess with locules of air which could be due to gas forming organisms, however fistulous communication with bowel is not excluded. 2. Unchanged mild right hydroureteronephrosis likely due to mass effect from the retroperitoneal abscess. 3. Subcentimeter right renal cyst, too small to characterize, unchanged. 4. Mild pericholecystic fat stranding, acalculous cholecystitis is not excluded, and clinical correlation is recommended. Discussed with . 5. Bilateral pleural effusions, right greater than left, and bibasilar atelectasis.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11685699", "visit_id": "26579183", "time": "2186-06-28 10:24:00"}

16625180-RR-29

## EXAMINATION: HAND (PA,LAT AND OBLIQUE) RIGHT ## INDICATION: year old woman with right hand pain// right hand pain ## FINDINGS: There is a mildly comminuted mildly displaced intra-articular fracture of the fifth metacarpal base. There are scattered mild interphalangeal joint degenerative changes. There is moderate to severe first CMC joint osteoarthritis with joint space narrowing, osteophytosis, subchondral sclerosis. Minimal degenerative changes are present at the second and third MCP joints. There is minimal degenerative change at the triscaphe joint. No chondrocalcinosis. No erosion. No embedded radiopaque foreign body. ## IMPRESSION: Mildly comminuted and displaced intra-articular fracture of the fifth metacarpal base. Degenerative changes, most marked at the first CMC joint. ## NOTIFICATION: The impression and recommendation above was entered by Dr. on at 08:44 into the Department of Radiology critical communications system for direct communication to the referring provider.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16625180", "visit_id": "N/A", "time": "2143-07-14 08:21:00"}

15854896-RR-28

## HISTORY: male with hepatitis C and elevated LFTs. ## COMPLETE ABDOMINAL ULTRASOUND: The liver demonstrates homogeneous echogenicity without suspicious focal lesion. The main portal vein is patent with hepatopetal flow. Scattered subcentimeter hepatic cysts are identified, however, there are no suspicious hepatic lesions. There is a small amount of perihepatic ascites and a right pleural effusion. The gallbladder is filled with stones, however, demonstrates no secondary signs of acute cholecystitis. The common bile duct measures 3 mm and is not dilated. The right kidney measures 10.1 cm and the left kidney measures 9.1 cm. There is no hydronephrosis or suspicious renal mass. A 5-mm non-obstructing calculus is identified in the mid pole of the left kidney. The pancreas is well visualized and is normal in appearance. The spleen is normal measuring 7.6 cm. Evaluation of the distal aorta is limited due to overlying bowel gas; however, the proximal and mid aorta are normal in caliber. The visualized portions of the inferior vena cava are normal. ## IMPRESSION: 1. Normal echogenicity of the liver without suspicious focal lesion. Small hepatic cysts. 2. Small right pleural effusion and perihepatic ascites. 3. Cholelithiasis without evidence of acute cholecystitis.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15854896", "visit_id": "26243099", "time": "2182-09-11 15:06:00"}

14322627-RR-31

## EXAMINATION: MRA NECK WANDW/O CONTRAST T9716 MR NECK ## INDICATION: female with probable myeloproliferative neoplasm incidentally found to have circumferential thickening of left common carotid artery.// Evaluate left common carotid artery. ## FINDINGS: The common, internal and external carotid arteries appear normal. There is no evidence of stenosis by NASCET criteria. The origins of the great vessels, subclavian, and vertebral arteries appear normal bilaterally. The common carotid bifurcations appear normal. ## IMPRESSION: 1. Normal MRA neck. Specifically, no left common carotid narrowing.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14322627", "visit_id": "29780437", "time": "2136-09-27 12:24:00"}

16877638-RR-40

## EXAMINATION: CTA ABD AND PELVIS ## INDICATION: year old woman with right breast cancer planning for flap breast reconstruction. Has previous abdominal surgery. Please evaluate vessels// Please evaluate vessels for planning reconstructive surgery ## ABDOMEN AND PELVIS CTA: Non-contrast and multiphasic post-contrCast images were acquired through the abdomen and pelvis. Oral contrast was not administered. MIP reconstructions were performed on independent workstation and reviewed on PACS. ## DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 8.8 mGy (Body) DLP = 1.8 mGy-cm. 2) Stationary Acquisition 11.9 s, 0.2 cm; CTDIvol = 189.6 mGy (Body) DLP = 37.9 mGy-cm. 3) Spiral Acquisition 8.1 s, 52.6 cm; CTDIvol = 6.0 mGy (Body) DLP = 309.3 mGy-cm. Total DLP (Body) = 349 mGy-cm. ## FINDINGS: The inferior epigastric arteries are patent bilaterally from the external iliac artery to the perforator branches. There are 3 dominant perforators identified: ## LEFT: Branching pattern: Type 2 ## PERFORATORS: 2.5 mm, 22 mm to the left at the level of the umbilicus (series 10, image 52) 2.1 mm, 66 mm to the left at the level of the umbilicus (series 10, image 52) ## RIGHT: Branching pattern: Type 2 ## PERFORATORS: 3.3 mm, 39 mm to the right and 31 mm below the umbilicus (series 10, image 57) ## VASCULAR: There is no abdominal aortic aneurysm. The right hepatic artery is replaced to the SMA. The left hepatic artery is replaced to the left gastric artery. There is duplication of the IVC below the level of the renal veins. ## LOWER CHEST: The imaged lung bases are clear. There is no pleural or pericardial effusion. ## HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits, without stones or gallbladder wall thickening. ## PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. ## SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ## ADRENALS: The right adrenal gland appears normal. The left adrenal gland has a solitary limb. ## URINARY: The left kidney is congenitally absent. The right kidney is malrotated but is normal in size with no evidence of stones, solid renal lesions, or hydronephrosis. There is no perinephric abnormality. ## GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. ## RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. ## PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. ## REPRODUCTIVE ORGANS: There is a bicornuate uterus. The adnexa are normal in appearance. ## BONES: There is no evidence of worrisome osseous lesions or acute fracture. Interpeduncular screws are noted at L3-L5. ## SOFT TISSUES: The abdominal and pelvic wall is within normal limits. ## IMPRESSION: 1. 3 dominant vessels as detailed above. 2. Incidental congenitally absent left kidney and bicornuate uterus, duplication of the infrarenal IVC, left adrenal hypoplasia and replaced right and left hepatic arteries.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16877638", "visit_id": "N/A", "time": "2125-05-11 07:49:00"}

12117907-DS-24

## ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Tetracycline ## CHIEF COMPLAINT: fall and right shoulder pain ## HISTORY OF PRESENT ILLNESS: yo M with RML lung adenocarcinoma, right pleural effusion (s/p chest tube and pleureX), and mets to brain, liver, bone, with h/o malignant pleural effusion s/p pleurex removal presents after a fall with right shoulder pain. Note pt was recently admitted right rib fracture noted. Pain regimen of oxycontin was increased and lidocaine patch and gabapentin were added. He went home with plan to bridge to hospice. He also noted pain in the right shoulder worse than before which was attributed to 6th rib fracture. His course was complicated by chronic hyponatremia attributed to SIADH which improved w/ fluid restriction. He was noted to have a right sided pleural effusion and a chest tube was placed followed by a pleurex. Regarding his known malignant pleural effusion he is s/p R tunneled pleural catheter placement (h/o loculated empyema), with replacement of a second pleurX on the right given further accumulation of fluid. Original right pleurex was removed . He was seen in clinic on at which time he was feeling better from respiratory standpoint with decreased cough and noted very minimal drainage from the pleurex. Accordingly the pleurex was removed at that visit. Today he states that he was getting a snack in the kitchen and slipped. Note he recently fell which prompted his last admission as above, however he states he is not using alcohol and he had a purely mechanical slip. He did not feel dizzy. He hit the front of his head but no pain in that area now and no LOC. Fall witnessed by his girlfriend who wanted him to come to the hospital last night but he finally came today due to worsening pain in the right shoulder/scapular region which is where he landed during the fall. He denies chest pain, shortness of breath, cough, or fevers. Denies headaches, dizziness, palpitations. Pain poorly controlled at home wiht his usual dose of oxycontin/oxycodone so he came to the ED. ED Course (labs, imaging, interventions, consults): ## - INITIAL VITALS/TRIGGER: + Triage 115 133/91 20 98% - EKG: ST @105, NANI, no STE - CT cspine showed unchanged T2 and T3 lytic metastatic lesions with superior endplate compressions and focal lucency through right pedicle of T2 (cortical erosion from tumor but fracture not excluded) all stable from prior. - CXR showed removal of a chest tube, volume loss in right hemithorax and oval opacity suggesting loculated pleural collection, persistent infection not excluded but the only change from prior was slightly improved aeration in right mid lung. Nondisplaced but recent right sided rib fractures of and 5th ribs which appear unchanged. - head CT: stable known mets with surrounding edema; no bleed - new right posterior fourth rib fracture was seen on XR and again today. On the floor he is comfortable but reports continued pain in the right shoulder/scapula. ## PAST ONCOLOGIC HISTORY: Right shoulder pain started after a fall t showed RML mass SOB started ED visit for worsening SOB Chest CT showed RML mass, LAD, right effusion, right 5th rib fracture Chest tube placement ## CYTOLOGY: adenocarcinoma Admission with fatigue, hyponatremia and ARF Brain MRI showed many lesions FDG-PET Admission for SOB - WBR-C2 5x4 Gy by Dr. Pleurodesis did not receive chemo due to complicated hospital admission Brain MRI stable see HPI for recent hospital admission ## PAST MEDICAL HISTORY: 1. Lung mass, and brain lesions 2. Subdural bleed , craniotomy 3. Hypertension 4. Osteoporosis 5. Pancreatitis 6. Pancreatic duct stricture 7. H. pylori gastritis 8. Diverticular disease 9. Dyslipidemia ## FAMILY HISTORY: Of his three brothers, one died at with complications of an infection, and the others are healthy. His mother died in her with complications of diabetes, and his father is alive. He quit smoking years ago. ## GENERAL: NAD resting in bed ## HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly ## CV: RR, NL S1S2 no S3S4 MRG ## PULM: coarse breath sounds throughout but dullness at right base, no wheezing ## ABD: BS+, soft, NTND, no masses or hepatosplenomegaly ## LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy ## SKIN: No rashes, pt does have stage I decubitus ulcer over sacrum/right buttock but only 1-2cm in diameter ## NEURO: Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is of the proximal and distal upper and lower extremities; reflexes are 2+ of the biceps, triceps, patellar, and Achilles tendons, toes are down bilaterally; intact coorindation. Fully oriented x3 DISCHARGE PHYSICAL EXAM ## GENERAL: Pleasant man lying in bed, AAOx3, in mild distress due to pain ## HEENT: MMM, no OP lesions ## CV: RR, sinus tachycardia, normal S1/S2, no murmurs/rubs/gallps ## PULM: Coarse breath sounds throughout but dullness at right base, very coarse rumbling heard over all L lung fields, no wheezing ## ABD: BS+, soft, NTND, no masses or hepatosplenomegaly ## LIMBS: Tender to palpation over R shoulder, back and lateral chest, but has full ROM in both UEs bilaterally. No edema, clubbing, tremors, or asterixis ## SKIN: No rashes, pt does have stage I decubitus ulcer over sacrum/right buttock but only 1-2cm in diameter ## NEURO: CN exam grossly intact, some cognitive dysfunction noted although AOx3 ## SCAPULAR X-RAY: No scapular fracture. Right rib fractures as seen on chest x-ray. ## FINDINGS: A chest tube was removed. There is similar volume loss in the right hemithorax with an oval opacity suggesting a loculated pleural collection as well as the possibility of a small more free-flowing type of pleural effusion at the base of the right chest as well as areas of scarring and atelectasis. Findings associated with a known malignancy are not optimally assessed with radiographs and persistent infection is not excluded; however, the only change is slightly improved aeration in the right mid lung since the more recent of the comparison studies. Non-displaced but recent right-sided rib fractures involving the fourth and fifth ribs appear unchanged. ## CT C-SPINE: 1. No cervical spine fracture or malalignment. Degenerative changes as above. 2. Unchanged appearance of T2 and T3 with lytic metastatic lesions with superior endplate compressions, unchanged. Focal lucency through the right pedicle of T2, potentially due to cortical erosion from tumor although prior fracture is not entirely excluded. ## CT HEAD: 1. No evidence of new intracranial hemorrhage. No evidence of fracture. 2. Known intracranial metastases with surrounding edema are again demonstrated and unchanged in appearance from . ## BRIEF HOSPITAL COURSE: yo M with metastatic lung adenocarcinoma (to brain, liver, bone), malignant right pleural effusion (s/p chest tube and pleureX removed , presents after a fall with persistent right shoulder pain. # RIGHT SHOULDER PAIN AND RIB FX: Per shoulder and chest XR in ED, pt has a right sided fourth rib fracture now in addition to the known 6th rib fracture. However, that was present on XR that he had done for clinic visit, which seems to predate the fall, so likely this was a new pathologic fracture. He also may have some irritation from loculated pleural effusion (see below). Pt has full range of motion and no fevers, nothing to suggest an infectious etiology or more serious trauma to the joint in addition to the rib fractures. He recieved pamidronate 60mg x1 as this is helpful for pathologic fractures in metastatic disease but also will help with pain in that setting, doesn't appear pt has received this before. Per Palliative Care recs, giving home oxycontin, increased to 60/60/60 (as of due to increased pain requirements), home gabapentin increased to , and home oxycodone and lidocaine patch. His pain was better controlled and he was stable for discharge. ## # FALLS: History not c/w syncope, seems clearly mechanical. However pt has had two falls prompting hospital admission with fractures in the last 2 weeks which raises concerns for underlying pathology. Known brain lesions and last MRI showed small cerebellar mets which could be progressing. ## # PLEURAL EFFUSION: S/p pleurex removal . On CXR seems loculated. No fevers or imaging to suggest infectious process. Pt has h/o empyema. Will likely need a chest CT to characterize loculated effusions however given clinical stability this is not warranted urgently, will discuss with primary oncologist ## # BRAIN METS: C/b seizure previously. No signs of progression on CT, but last MRI showed small cerebellar mets. No changes in neuro exam from last admission. We continued home keppra for seizure prophylaxis, dexamethasone for cerebral edema, and atovaquone/acyclovir ppx while on dexamethasone ## # METASTATIC LUNG ADENOCARCINOMA: Pt has not received chemo yet. His outpatietn oncologists were informed of his admission and he has multidisipinary follow-up 2 days after discharge. Note pt had been DCd with bridge to hospice so DNR/DNI discussion should take place, however family deferring until one of his sons can get here. ## # T2/T3 ENDPLATE COMPRESSIONS: Apparently stable. No signs on imaging or clinical exam of cord compression. Doesn't appear to be causing much back pain. ## TRANSITIONAL ISSUES: ==================== - S/p a second mechanical fall in 2 weeks, seen on imaging to have two pathologic fractures in and 6th ribs causing severe R sided shoulder/chest wall pain - Adjusted pain med regimen to oxycontin 60/60/60, oxycodone 15 prn, gabapentin . At f/u, should consider adding fentanyl patch as pt sometimes gets behind on pain management upon waking in the morning; may also require increase in oxycontin schedule - evaluation for repeat falls, recommended placement in rehab after discharge, family amenable - Put on lovenox injections for DVT prophylaxis while admitted, which should be continued at rehab facility until pt is out of bed and ambulating - Has multidisciplinary oncology appt on w/ Dr. , has been made aware of this admission - Pt and family have elected to defer changing code status from "full" after pt's brother can get in from overseas on AM of - Will likely need a chest CT to characterize loculated effusions at some point in the future, however given clinical stability this was not warranted urgently. Should f/u w/ primary oncologist Dr. - followed by Palliative Care , NP), has previously been resistant to discussions about code status/hospice care/goals of care/end of life issues but seemed more open to these topics on this admission. Conversation on these topics should be continued at f/u oncology appts ## CODE STATUS: Full for now, addressed w/ pt and pt's daughter/HCP, who would like to defer decision until her brother gets here later this week. ## MEDICATIONS ON ADMISSION: The Preadmission Medication list is accurate and complete. 1. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H 2. OxycoDONE (Immediate Release) 15 mg PO Q2H:PRN pain 3. LeVETiracetam 1500 mg PO BID 4. Atovaquone Suspension 1500 mg PO DAILY 5. Dexamethasone 4 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Gabapentin 100 mg PO TID 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Lorazepam 0.5 mg PO Q4H:PRN SOB/anxiety 10. Omeprazole 40 mg PO DAILY 11. Docusate Sodium 100 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation ## DISCHARGE MEDICATIONS: 1. Atovaquone Suspension 1500 mg PO DAILY 2. Dexamethasone 4 mg PO DAILY 3. Docusate Sodium 100 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Gabapentin 100 mg PO BID RX *gabapentin 100 mg capsule(s) by mouth every 8 hours Disp #*20 Capsule Refills:*0 6. Gabapentin 300 mg PO HS Gabapentin 100 @ 8am Gabapentin 100 @ 4pm Gabapentin 300 @ 12am 7. LeVETiracetam 1500 mg PO BID 8. Lidocaine 5% Patch 2 PTCH TD QAM RX *lidocaine [Lidoderm] 5 % (700 mg/patch) apply 2 patches to skin over area of pain every morning Disp #*8 Patch Refills:*0 9. Lorazepam 0.5 mg PO Q4H:PRN SOB/anxiety RX *lorazepam 0.5 mg 1 tablet by mouth every 4 hours Disp #*24 ## TABLET REFILLS: *0 10. Omeprazole 40 mg PO DAILY 11. OxycoDONE (Immediate Release) 15 mg PO Q2H:PRN pain RX *oxycodone 15 mg 1 tablet(s) by mouth every 2 hours Disp #*48 ## TABLET REFILLS: *0 12. OxyCODONE SR (OxyconTIN) 60 mg PO TID RX *oxycodone [OxyContin] 60 mg 1 tablet(s) by mouth every 8 hours Disp #*12 Tablet Refills:*0 13. Polyethylene Glycol 17 g PO DAILY:PRN constipation 14. Acetaminophen 1000 mg PO Q8H 15. Enoxaparin Sodium 40 mg SC Q12H ## TODAY - , FIRST DOSE: Next Routine Administration Time Continue until pt OOB and ambulating. RX *enoxaparin 40 mg/0.4 mL 1 syringe SC daily Disp #*4 Syringe ## DISCHARGE DIAGNOSIS: Metastatic Lung Adenocarcinoma Pathologic Rib Fractures Chronic Pain Repeated Falls ## ACTIVITY STATUS: Ambulatory - requires assistance or aid (walker or cane). ## DISCHARGE INSTRUCTIONS: Dear Mr. , It was a pleasure taking care of at . came to us after suffered from an accidental fall, and had an increase in your chronic right shoulder pain. Your pain is likely from spread of your cancer into the bones of your right shoulder and chest, so we gave a shot to help strengthen your bones and worked with your pain medication regimen to try to get your pain under better control. also were evaluated by , who feels would do best after discharge at a rehabilitation facility where could consider getting more . Please note the medication changes and follow-up appointments scheduled for , as detailed below.

mimic

{"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12117907", "visit_id": "29427469", "time": "2151-10-30 00:00:00"}

17326187-RR-22

## INDICATION: year old man with atrial fibrillation for evaluation of pulmonary veins prior to pulmonary vein isolation procedure. ## RHYTHM: atrial fibrillation CMR Measurements Measurement Male Normal Range LV End-Diastolic Dimension (mm) 58 <62 LV End-Diastolic Dimension Index (mm/m2) 28 <32 LV End-Systolic Dimension (mm) 43 LV End-Diastolic Volume (ml) 135 <196 LV End-Diastolic Volume Index (ml/m2) 66 <95 LV End-Systolic Volume (ml) 58 LV Stroke Volume (ml) 77 LV Ejection Fraction (%) 57 >54 LV Anteroseptal Wall Thickness (mm) 7 <12 LV Inferolateral Wall Thickness (mm) 4 <11 LV Mass (g) 85 LV Mass Index (g/m2) 41 <80 RV End-Diastolic Volume (ml) 160 RV End-Diastolic Volume Index (ml/m2) 78 <114 RV End-Systolic Volume (ml) 83 RV Stroke Volume (ml) 77 RV Ejection Fraction (%) 48 >46 Aortic Valve Area (2-D) (cm2) 4.4 >3.0 Aortic Valve Area Index (cm2/m2) 2.1 Ascending Aorta diameter (mm) 33 <39 Ascending Aorta diameter Index (mm/m2) 16 <20 Transverse Aorta diameter (mm) 23 <31 Descending Aorta diameter (mm) 23 <28 Descending Aorta Index (mm/m2) 11 <14 Main Pulmonary Artery diameter (mm) 21 <29 Main Pulmonary Artery diameter Index (mm/m2) 10 <15 Left Atrium (Parasternal Long Axis) (mm) **52 <40 Left Atrium Length (4-Chamber) (mm) ***72 <52 Right Atrium (4-Chamber) (mm) ***72 <50 Pericardial Thickness (mm) 3 <4 Coronary Sinus diameter (mm) 9 <15 Pulmonary Vein Left Common (mm) 41x9 Right Lower (mm) 21x14 Right Upper (mm) 34x25 PV Cross-Sectional Area Left Common (mm2) 337 Right Lower (mm2) 248 Right Upper (mm2) 667 * = Mildly abnormal, ** =moderately abnormal, *** = severely abnormal ## EGFR: >60 ml/min1.73m2 based on creatinine 0.76 mg/dl on Total Gd-DTPA (Magnevist ) contrast: 35 ml (0.2 mmol/kg) Injection site: Right cephalic vein ## 1) STRUCTURE: Axial dual-inversion T1-weighted images of the myocardium were obtained without spectral fat saturation pre-pulses in 5-mm contiguous slices. 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. Breath- hold real time SSFP images were acquired in the left ventricular 2-chamber, 4- chamber, and mid-papillary short axis slices. 3) Pulmonary Vein MRA: First pass angiography of the pulmonary veins (PV) was obtained after administration of a bolus of gadopentetate dimeglumine 0.2 mmol/kg (24 ml Magnevist solution). Multiplanar reconstructions of the pulmonary veins were generated and assessed on a workstation. 4) : Late gadolinium enhancement (LGE) images were obtained using a 3D free-breathing ECG-gated segmented inversion-recovery TFE acquisition in the axial plane 20 minutes after injection of a total of 0.2 mmol/kg gadopentetate dimeglumine (24 ml Magnevist solution) with spectral fat saturation pre-pulses. ## FINDINGS: Structure and Function There was normal epicardial fat distribution. The pericardial thickness was normal. There were no pericardial or pleural effusions. The origins of the left main and right coronary arteries were identified in their customary positions. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. The left atrial AP dimension was moderately increased. The right and left atrial lengths in the 4-chamber view were severely increased. The coronary sinus diameter was normal. The left ventricular end-diastolic dimension index was normal. The end- diastolic volume index was normal. The calculated left ventricular ejection fraction was normal at 57% with normal regional systolic function. The anteroseptal and inferolateral wall thicknesses were normal. The left ventricular mass index was normal. The right ventricular end-diastolic volume index was normal. The calculated right ventricular ejection fraction was normal at 48%, with normal free wall motion. The aortic valve was tri-leaflet with normal valve area. Pulmonary Vein MR Two right-sided pulmonary veins and one (common) left-sided pulmonary vein were identified, all entering the left atrium and free of focal stenoses listed above). The multiplanar reconstructions confirmed the above findings. Left Atrial Fibrosis High-resolution late gadolinium enhancement images of left atrium demonstrated no focal enhancement of the atrial wall or ostia of the pulmonary veins. Non-Cardiac Findings There was a focus in the liver, which likely represents a cyst or hemangioma. There were also anterior compression deformities in the mid to lower thoracic spine and thoraco-lumbar junction and a small hiatal hernia. ## IMPRESSION: 1. Normal left ventricular cavity size with normal regional left ventricular systolic function. The LVEF was normal at 57%. 2. Normal right ventricular cavity size and systolic function. The RVEF was normal at 48%. 3. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. 4. Severe biatrial enlargement. 5. Normal size and orientation of the pulmonary veins without MR evidence of anomalous pulmonary venous return or pulmonary vein stenosis. 6. Liver focus, which likely represents a cyst or hemangioma. Anterior compression deformities in the mid to lower thoracic spine and thoraco-lumbar junction. Small hiatal hernia. The images were reviewed by Drs. , and .

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17326187", "visit_id": "N/A", "time": "2171-01-21 08:16:00"}

11754710-RR-17

## FINDINGS: Six radiographs in this series of both feet, and 3 radiographs of each knee were obtained. ## RIGHT FOOT: Joint spaces are preserved. There is no acute fracture. Mild second DIP subluxation is noted.There is mild tibiotalar degerative osteophyte formation. An os peroneum is incidentally noted. ## LEFT FOOT: There is no acute fracture. Mild first MTP osteoarthritis is noted. Alignment is satisfactory. ## RIGHT KNEE: Minimal sharpening of the tibial spines and patellar osteophyte formation is seen. No effusion, fracture or malalignment. ## LEFT KNEE: Minimal sharpening of the tibial spines and mild patellar osteophyte formation. No effusion, malalignment or fracture. ## IMPRESSION: No erosions in either foot to suggest gouty arthropathy. Early bilateral knee patelofemoral osetoarthritis.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11754710", "visit_id": "N/A", "time": "2130-06-24 10:09:00"}

13039821-RR-19

## INDICATION: woman with necrotizing fasciitis and septic shock, assess for infectious process. ## DOSE: Found no primary dose record and no dose record stored with the sibling of a split exam. !If this Fluency report was activated before the completion of the dose transmission, please reinsert the token called CT DLP Dose to load new data. ## FINDINGS: The study is somewhat limited due to motion artifact. An ET tube is in place, terminating approximately 2 cm above the carina. An enteric tube is in place, terminating below the diaphragm. A right IJ catheter terminates in the mid SVC. ## NECK, THORACIC INLET, AXILLAE: The visualized thyroid is normal. Supraclavicular and axillary lymph nodes are not enlarged. Soft tissue defect and subcutaneous emphysema in the left supraclavicular soft tissues is consistent with recent surgical intervention. ## MEDIASTINUM: Mediastinal lymph nodes are not enlarged. ## HILA: Hilar lymph nodes are not enlarged. ## HEART: The heart is not enlarged and there is no coronary arterial calcification. There is no pericardial effusion. ## VESSELS: Vascular configuration is conventional. Aortic caliber is normal. The main, right, and left pulmonary arteries are normal caliber. ## PULMONARY PARENCHYMA AND PLEURA: There are bilateral basilar atelectasis with associated small bilateral pleural effusions. There is no emphysema. ## AIRWAYS: The airways are patent to the subsegmental level bilaterally. ## CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion. Multilevel degenerative changes are mild. ## UPPER ABDOMEN: Please see separately submitted Abdomen and Pelvis CT report for subdiaphragmatic findings. ## IMPRESSION: 1. Bilateral compressive atelectasis with associated small bilateral pleural effusions. 2. No intrathoracic infectious source is identified. 3. Subcutaneous emphysema in the left supraclavicular soft tissue is consistent with recent surgical intervention. 4. Please refer to separate report of Abdomen and Pelvis CT performed same day for subdiaphragmatic findings.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13039821", "visit_id": "22851533", "time": "2163-02-25 14:55:00"}

11263908-RR-6

## INDICATION: female with chest pain and tortuous aorta on chest radiograph. ## CT THORAX: The thyroid gland is within normal limits. The airways are patent to the subsegmental level but show mild wall thickening, probably inflammatory, also accompanied by mild mosaic appearance of lung attenuation. There is no mediastinal, hilar, or axillary lymph node enlargement by CT size criteria. The heart, pericardium and great vessels are within normal limits. No esophageal abnormality is identified. No pleural effusion or pneumothorax is present. There has been mastectomy with a saline implant on the left. Within the inferior aspect of the left lower lobe, there is a 4 mm nodule noted (5:158). An additional left lower lobe nodule measures 3 mm (3:199). Lastly, a nodule at the left lung apex measures 2 mm in diameter (3:42). ## CTA THORAX: The upper descending aorta is very mildly ectatic measuring up to 29 mm in diameter although doubtful in significance with slight unfolding. The pulmonary arteries are opacified to the subsegmental level. There is no filling defect to suggest pulmonary embolism. The examination not tailored for evaluation of solid diaphragmatic officer, limited evaluation demonstrates a 1.9 x 1.9 cm hypodensity within the left hepatic lobe (2:96) consistent with a simple benign cyst. There are no suspicious bone lesions. ## IMPRESSION: 1. Very mild ectasia of the proximal descending aorta (28 mm in diameter). Minimally tortuous. 2. No evidence of pulmonary embolism. 3. Left hepatic cyst which appears simple and benign. 4. Few small left lung nodules measuring up to 5 mm. Although scattered incidental nodules are common, but close follow-up is recommended in three months with chest CT given history of known malignancy.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11263908", "visit_id": "27979925", "time": "2160-07-20 21:35:00"}

12432545-RR-36

## EXAMINATION: CHEST (PA AND LAT) ## INDICATION: man with Coronary artery disease and presenting with cough. Evaluate for pneumonia or congestive heart failure. ## FINDINGS: The lungs are well-expanded. The opacity in the region of the left upper hemithorax is increased in size from the prior exam. No focal consolidation to suggest pneumonia. No pleural effusion, pneumothorax, or pulmonary edema. The cardiomediastinal silhouette is unchanged. Stable tortuosity of thoracic aorta. The leftward deviation of the trachea with associated narrowing of the lumen appears stable and is consistent with a thyroid goiter. Stable appearance of the hila. ## IMPRESSION: 1. No acute cardiopulmonary process. 2. Interval increase in the left upper hemithorax opacity, which may be intraparenchymal or a pleural plaque. Recommend further evaluation with a chest CT. 3. Stable leftward deviation of the trachea, likely from thyroid goiter. When the chest CT is performed for the left upper lung opacity, this could be simultaneously evaluated. ## NOTIFICATION: The findings were discussed by Dr. with Dr. , the referring provider requesting wet read, on the telephone on at 4:42 , 2 minutes after discovery of the findings.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12432545", "visit_id": "N/A", "time": "2117-08-26 15:15:00"}

19634412-RR-40

## TYPE OF EXAMINATION: Chest AP portable single view. ## INDICATION: female patient with questionable pneumonia. Evaluate. ## FINDINGS: AP single view of the chest has been obtained with patient in sitting upright position. Analysis is performed in direct comparison with the next preceding PA and lateral chest examination of . On the previous examination the findings were considerably within normal limits. On the present single view examination the heart shadow is moderately larger. No typical configurational abnormalities identified and the pulmonary vasculature is not congested. There is crowded vasculature on the bases but no conclusive evidence of acute parenchymal infiltrates can be identified and the lateral pleural sinuses are free. No pneumothorax is present. Comparison with the previous normal chest examination demonstrates the limitations of this portable examination as the patient made a very shallow inspirational effort with crowded pulmonary vasculature. To exclude a possible local infiltrate is limited on this single examination and a routine PA lateral chest examination is recommended considering the questionable pneumonia as indicated on the requisition.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19634412", "visit_id": "20170715", "time": "2146-09-01 11:22:00"}

16495075-RR-20

## HISTORY: woman with left upper quadrant pain for two days. The patient is status post laparoscopic band. ## IMPRESSION: 1. Laparoscopic band surrounding the cardia of the stomach, just below the gastroesophageal junction. Oral contrast passes through the laparoscopic band into the body of the stomach. 2. Bilateral ovarian cysts. Further evaluation with pelvic ultrasound in 6 weeks is recommended. This finding was emailed to the ED QA nurses on .

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16495075", "visit_id": "N/A", "time": "2122-08-12 22:35:00"}

10581673-RR-45

## INDICATION: year old woman with scoliosis // Please eval scoliosis***PLEASE DO: AP/LAT VIEWS*** ## FINDINGS: Redemonstrated is a severe compression deformity at L1 with associated severe kyphosis at the thoracolumbar junction. Posterior stabilization hardware is unchanged in appearance when compared to the prior study. Kyphoplasty cement at L1 and L2, unchanged from the prior. Again seen are superior endplate irregularities of T11, T12 and L2.. There is dextroscoliosis at the thoracolumbar junction similar to with mild positive coronal imbalance seen. The visualized lung fields are clear. ## IMPRESSION: Redemonstrated postsurgical changes of posterior stabilization at the thoracolumbar junction, for L1 compression fracture, in unchanged alignment and without further height loss seen. Mild dextroscoliosis at the thoracolumbar junction .

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10581673", "visit_id": "N/A", "time": "2131-10-30 14:05:00"}

10433099-RR-135

## REASON FOR EXAMINATION: Followup of the patient with respiratory failure after pulseless electrical activity arrest. Portable AP chest radiograph was compared to . ET tube tip is approximately 6.5 cm above the carina. The right PICC line tip is at the level of low SVC. The NG tube tip passes below the diaphragm, most likely terminating in the stomach. Cardiomediastinal silhouette is stable. Lungs are essentially clear. There is interval improvement of the right upper lobe opacity seen on the prior study obtained yesterday at 05:10 a.m. There is no evidence of failure. There is no increase in pleural effusion and there is also no pneumothorax demonstrated on the current study.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10433099", "visit_id": "28593361", "time": "2149-01-09 04:23:00"}

17083316-RR-12

## EXAMINATION: MRI of the left calf. ## INDICATION: year old woman with history of repeat trauma to her left shin with open wound and ultrasound showing fluid collection. Orthopedics requesting MRI to better evaluate abscess vs. hematoma and extent of muscle involvement// ? hematoma vs. abscess, question muscle involvement. Wound is anterior shin/tibia ## SOFT TISSUE: There is a mildly T1 hyperintense STIR hyperintense rim enhancing collection within the anterior aspect of the left leg measuring approximately 8.5 x 1.8 x 7.7 cm within its maximal dimension that could represent an organized hematoma, however superimposed infection cannot be excluded. A skin defect is noted within the anterior aspect of the midportion of the leg, which is contiguous with the collection. ## MUSCLES: Fatty atrophy of the medial gastrocnemius muscle is likely from old injury. Otherwise, normal signal intensity. ## BONE MARROW: No signal abnormality to suggest osteomyelitis. Mild subchondral edema is noted within the bilateral tibial plateau secondary to degenerative changes. ## IMPRESSION: 8.5 x 1.8 x 7 collection within the subcutaneous tissue of the anterior aspect of the left leg could represent an organized hematoma, however superimposed infection cannot be excluded. No evidence of muscle or bony involvement.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17083316", "visit_id": "20596397", "time": "2140-08-21 14:37:00"}

12166185-RR-118

## EXAMINATION: BILATERAL DIGITAL 2D AND 3D TOMOSYNTHESIS DIAGNOSTIC MAMMOGRAM INTERPRETED WITH CAD ## INDICATION: woman with history of bilateral breast cancer status post breast conservation therapy. ## TISSUE DENSITY: C- The breast tissue is heterogeneously dense which may obscure detection of small masses. Stable postoperative changes are visualized within the bilateral breasts. There is no suspicious dominant mass, unexplained architectural distortion, or grouped microcalcifications in either breast. ## IMPRESSION: No specific mammographic evidence of malignancy. ## RECOMMENDATION(S): Age and risk appropriate screening. ## NOTIFICATION: Findings reviewed with the patient at the completion of the study.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12166185", "visit_id": "N/A", "time": "2200-02-27 09:12:00"}

15447353-RR-41

## INDICATION: year old woman with metastatic RCC, dyspnea, tachycardia and signs of heart strain// eval for PE ## DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8 mGy-cm. 2) Stationary Acquisition 2.1 s, 0.2 cm; CTDIvol = 34.6 mGy (Body) DLP = 6.9 mGy-cm. 3) Spiral Acquisition 4.9 s, 31.8 cm; CTDIvol = 6.9 mGy (Body) DLP = 206.2 mGy-cm. Total DLP (Body) = 215 mGy-cm. ## FINDINGS: Apparent hypodensity located at the junction of left atrium and posterior left pulmonary vein (4:75). Otherwise, the aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. Central filling defect within the right lower lobe subsegmental artery and possibly within subsegmental lingular branches in the left lung. The remainder of the pulmonary arteries are well opacified to the subsegmental level.The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid gland appears unremarkable. Multiple enlarged paraesophageal lymph nodes, the largest of which measures up to 14 mm (04:53) Small to moderate left lower lobe of pleural effusion. Patchy left lower lobe consolidation with air bronchograms, concerning for pneumonia in the appropriate clinical setting. The airways are patent to the subsegmental level. Limited images of the upper abdomen demonstrates innumerable hepatic, mesenteric and pelvic metastatic nodules in this patient with known history of RCC. These have increased in size in number in comparison to the prior CT chest dated , most notably throughout the liver. No lytic or blastic osseous lesion suspicious for malignancy is identified. ## IMPRESSION: 1. Right lower lobe segmental pulmonary embolism. No central pulmonary embolism or evidence of right heart strain. 2. Apparent hypodensity located at the junction of left atrium and posterior left pulmonary vein. Correlation with echocardiogram is recommended to exclude thrombus. 3. Patchy left lower lobe consolidation with air bronchograms, concerning for pneumonia in the appropriate clinical setting. 4. Interval progression of widespread metastatic to the liver and mesentery, increased since . 5. Paraesophageal lymphadenopathy measuring up to 14 mm. ## NOTIFICATION: The findings were discussed with Dr. by Dr. , . on the telephone on at 9:08 pm, 2 minutes after discovery of the findings.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15447353", "visit_id": "24378498", "time": "2122-08-16 21:27:00"}

14729260-RR-68

## INDICATION: A woman with lymphoma. New onset dizziness. ## FINDINGS: There is no evidence of infarct. There is a 6-mm focus of susceptibility artifact in the posterior right pons at the level of the middle cerebellar peduncle; on T2 it is centrally bright with a rim of dark signal. There is no associated FLAIR signal abnormality. There is possible minimal associated linear enhancement after gadolinium. Review of CT neck from demonstrates no calcifications in this location. There is no mass effect or enhancing mass. There are nonspecific T2/FLAIR hyperintensities in the periventricular and deep white matter, which are nonenhancing. The signal within the bone marrow is within normal limits. The paranasal sinuses are clear. ## IMPRESSION: 1. 6-mm focus of susceptibility artifact in the posterior right pons likely represents a cavernoma; questionable associated developemental venous anomaly. 2. No evidence of enhancing mass or mass effect. 3. Nonspecific nonenhancing T2/FLAIR hyperintensities in the periventricular white matter may reflect chronic small vessel ischemic disease in this age group.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14729260", "visit_id": "N/A", "time": "2197-04-03 12:51:00"}

19457519-DS-6

## ALLERGIES: Patient recorded as having No Known Allergies to Drugs ## MAJOR SURGICAL OR INVASIVE PROCEDURE: Left medial knee mass resection and MCL reconstruction ## HISTORY OF PRESENT ILLNESS: is a cooperative gentleman who complaints of pain and stiffness, left knee since . He was apparently alright before that time when he met with an accident in . He was hit by a jeep and the bumper hit him around the knee, left side. After that he was taken to the emergency room at where he was diagnosed with sprain in the knee and was discharged after painkillers and x-ray. After that he developed a swelling in the left knee, medial aspect. The swelling has been present there constantly since then and has not increased in size as per patient. As per patient, his knee swelling and pain is present since after the trauma and he had no joint pain before that. The pain is constantly present and about in intensity, but it becomes more and more when the patient starts walking on it and when the patient does activity. The pain becomes in intensity after walking a couple of blocks and then he has to sit and take rest and only after taking rest, he can walk further distance. The knee also gets stiff on prolonged sitting and he has to move around the knee before he can even start walking. His range of movement of the knee has also been affected slowly and gradually since that time. His knee gave way in of this year when he was taken to the BI Emergency where an x-ray was done. He was then sent to under the care of Dr. took an x-ray and an MRI and then the patient was referred here to our service. The range of movement and stiffness of the knee has been present there since , but has increased presently in the past six months. He seems to be in considerable distress and emotional trauma due to this pain and stiffness. There is no history of any fever or discharge from that site. There is no history of patient being hospitalized for that trauma. There is no history of any other joint pain. There is no history of any surgery being done on the patient. ## FAMILY HISTORY: There is history of cancer in both father and grandfather with prostate cancer. There is history of heart disease and diabetes in the family as well. ## LLE: -Incision without drainage or erythema -Hip flex, knee flex/ext, ankle DF/PF, intact -New decreased sensation around the knee. Baseline decreased sensation in the foot. -Palpable pulse ## BRIEF HOSPITAL COURSE: The patient was admitted following surgery. He worked with POD 1 and performed very well. His block wore off over the remainder of the day and he had increasing pain. The pain was tolerable. He was seen by the Hospitalist service as advised by anesthesia regarding his HTN. He was recommended to follow up with his PCP for further blood pressure management control. POD 2 he worked once again with and his dressing was changed and his drain removed. His incision was benign. POD 3 he was deemed medically stable for DC to home and had cleared for a safe discharge to home. He was provided a prescription for outpatient and pain medications. ## MEDICATIONS ON ADMISSION: Lisinopril 20mg once daily Bupropion 100mg twice daily ## DISCHARGE MEDICATIONS: 1. Docusate Sodium 100 mg Capsule Sig: Capsules PO BID (2 times a day) as needed for constipation. Disp:*40 Capsule(s)* Refills:*1* 2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily) for 2 weeks. Disp:*14 * Refills:*0* 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Hydromorphone 2 mg Tablet Sig: Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 6. Outpatient Physical Therapy Please work on endurance, gait, and gaining extension. Patient has baseline 20 degree knee flexion contracture. ROM for knee should be degrees. He is weight bearing as tolerated. 7. Walker ## DISCHARGE INSTRUCTIONS: You had a left medial knee mass resected and medial collateral ligament reconstruction. You should keep your incision dry for 5 days. After that you may get it wet in the shower but you may not soak it for 3 weeks. You should change your dressing daily for the week following surgery with a dry sterile dressing. Leave the steristrips in place (white pieces of tape). Watch for signs of infection. These include increasing pain, drainage and increasing redness surrounding your incision. You are allowing to put all of your weight on your left leg but do not bend you knee past 50 degrees.

mimic

{"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19457519", "visit_id": "24492140", "time": "2130-04-14 00:00:00"}

18841180-DS-19

## HISTORY OF PRESENT ILLNESS: yo M with no significant PMH presents with worsening right shin swelling and redness that started on . He does not remember any trauma or insect bite to the area but noticed a small area roughly the size of a pinhead that was red with black center. Pt relates accompanying pain and notes that the initial area of 'bite' increased as well as the erythema extending around the focal area with streaking up his right leg to his groin. Pt tried topical Bendryl and peroxide as well as manually compressing the area to expel fluid or pus but none of the methods were helpful. Pt denies any fever, chills, nausea, or vomiting. He says that he has pain in his right shin with ambulation and not with rest. In the ED, initial VS were: 98.8 86 139/87 16 100. Patient was given IV vancomycin. Pt experienced shortness of breath with vancomycin administration and it was stopped. This AM, lymphangitic streaking was still visible into right groin. Remained afeb, VS on transfer 97.6 117/85 71 16 100% on RA. On the floor, pt says that the area 'looks worse than it ever has before'. He still related pain but did not feel it warranted pain medication. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. ## PAST MEDICAL HISTORY: - Acid reflux - Hemorrhoids ## FAMILY HISTORY: - High cholesterol both sides of family ## HEENT: Sclera anicteric, MMM, oropharynx clear ## NECK: Supple, no JVD elevation ## LUNGS: No wheezing, crackles, rales ## CV: RRR, S1S2, no murmurs/rubs/gallops ## ABDOMEN: soft, NT, ND, bowel sounds present ## EXT: R leg +1 edema. Warm, well perfused, 2+ pulses ## SKIN: R anterior shin ~1cm focal red blister with fluid inside. Right erythematous with streaking of inner leg to groind. Palpable lymph node at groin. R shin edematous and warm to touch. No open lesions. Pulses b/l . ## NEURO: CN II-XII intact. Protective sensations intact. ## BRIEF HOSPITAL COURSE: # RLE Cellulitis - Pt received x2 doses of Linezolid while in-house. Following abx administration, lymphangitic streaking as well as erythema and edema of his right lower extremity began to improve in appearance. Pt remained afebrile while in-house and did not require any pain management during the duration of his stay. On discharge from the hospital, pt denied any pain and was given prescriptions for oral antibiotics (Keflex and Bactrim) for a linical appearance of RLE cellulitis was much improved from initial presentation. Blood cultures and MRSA screening were pending on his discharge. Pt was given x1 dose of Vancomycin in ED; he experienced shortness of breath and itchiness following administration. Allergy to Vancomycin has been documented in OMR and POE and related to the pt. # Acid reflux - Pt was asymptomatic while in-house. He continued his home regimen of Omeprazole. ## DISCHARGE MEDICATIONS: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Bactrim DS 800-160 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days. Disp:*28 Tablet(s)* Refills:*0* ## 3. KEFLEX MG CAPSULE SIG: One (1) Capsule PO every six (6) hours for 7 days. Disp:*28 Capsule(s)* Refills:*0* ## PRIMARY: Right lower extremity cellulitis ## DISCHARGE INSTRUCTIONS: You were admitted to the hospital with right leg swelling and pain. While you were at the hospital, you were given iv antibiotics and the streaking up your right leg as well as the infection in your right leg improved. You remained afebrile while in-house. You may have an allergy to Vancomycin. You should avoid using this antibiotic in the future. Changes in Medication: - You should take 2 tabs Bactrim DS orally twice a day for 7 days total. - You should take 1 tab orally Keflex every 6 hours for 7 days total. - Take can take Tylenol if you experience any pain. - If the blister on your right leg deroofs, you should gently wash the area with warm water and soap. Let the area air dry and then cover with dry dressings. If you develop any of the symptoms listed below or anything else concerning to you contact your PCP or go to your nearest emergency room. Please keep all follow up appointments.

mimic

{"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "18841180", "visit_id": "25741502", "time": "2172-02-10 00:00:00"}

18662708-RR-141

## REASON FOR EXAM: Follow up pulmonary nodules seen in prior PET-CT. PET-CT was performed on . and CT from ## FINDINGS: A subpleural rounded opacity in the right upper lobe measures 5 mm (4, 51) could be an area of atelectasis, new from prior study. There is diffuse mild air trapping. A ground-glass nodular opacity in the left lower lobe measuring 12 mm (4, 185) is likely an area of atelectasis, but attention on followup studies is recommended. 4-mm nodule in the left lower lobe (4, 113) is stable since . Right lower lobe atelectasis is unchanged. The airways are patent to the subsegmental level. There is no large mediastinal, hilar, or axillary lymph node, though evaluation of a small hilar lymphadenopathy is limited due to the lack of IV contrast. The main pulmonary artery is dilated as before measuring 4 cm, suggesting pulmonary hypertension. There is mild cardiomegaly. The aorta is normal in caliber. There is no pleural or pericardial effusion. This examination is not tailored for subdiaphragmatic evaluation. The patient is status post cholecystectomy. The right hemidiaphragm is elevated as before. There are no bone findings of malignancy. ## IMPRESSION: Stable left lower lobe lung nodule, no further followup is recommended. Peripheral opacity and ground-glass opacity in the right upper lobe and left lower lobe are most likely atelectasis. Small airways disease Dilated main pulmonary artery suggesting pulmonary hypertension.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18662708", "visit_id": "N/A", "time": "2203-04-21 10:52:00"}

14258949-RR-149

## INDICATION: M with multiple myeloma, admitted s/p fall with L hip fracture now s/p ORIF, admission CT with PNA, now with worsening hypoxia// eval for interval change ## FINDINGS: Lungs are well expanded. Small bilateral left greater than right pleural effusions and atelectasis are re-demonstrated. No new consolidations are identified. There is no pneumothorax. Cardiomediastinal silhouette appears stable, accounting for patient rotation. ## IMPRESSION: Small bilateral left greater than right pleural effusions, re-demonstrated. Superimposed pneumonia at the right lung base cannot be excluded.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14258949", "visit_id": "21506603", "time": "2183-11-26 11:34:00"}

19861402-RR-5

## EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) ## HISTORY: with painless jaundice// eval for dilated common bile duct ## LIVER: The hepatic parenchyma appears coarsened. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is trace ascites in the right lower quadrant. ## BILE DUCTS: There is no intrahepatic biliary dilation. The distal common bile duct is not visualized. ## GALLBLADDER: The gallbladder is mildly distended with small amount of sludge, but without evidence of wall edema or sonographic sign. ## PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. ## KIDNEYS: Limited views of the kidneys show no hydronephrosis. Right kidney: 12.1 cm Left kidney: 11.7 cm ## RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. ## IMPRESSION: 1. Dilated CBD up to 8 mm, with the distal portion is not well assessed. Findings are new compared to prior CT abdomen pelvis performed and further evaluation with dedicated MRCP is recommended. 2. Mildly distended gallbladder containing sludge without specific sonographic findings to suggest acute cholecystitis. 3. Coarsened hepatic parenchyma without evidence of focal liver lesion. There is probable underlying cirrhosis with evidence of portal hypertension including trace ascites and splenomegaly.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19861402", "visit_id": "27840398", "time": "2163-09-20 21:41:00"}

10606601-RR-12

## INDICATION: One day of worsening right lower quadrant pain. No comparison studies available. ## FINDINGS: Included views of the lung bases are clear. There is no pericardial or pleural effusion. The heart size is normal. The liver, gallbladder, spleen, pancreas, adrenal glands, kidneys, stomach, and intra-abdominal loops of small and large bowel are normal. There is no mesenteric or retroperitoneal lymphadenopathy, and no free air or free fluid. The appendix measures 6 mm in diameter, with a focus of air in the proximal segment (104B:63), with no neighboring stranding. Intrapelvic loops of small and large bowel are normal. There is no intrapelvic free fluid or lymphadenopathy. The uterus, adnexa, and urinary bladder are normal. ## OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or lytic lesions are identified. ## IMPRESSION: No acute intra-abdominal or intra-pelvic process.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10606601", "visit_id": "N/A", "time": "2122-01-12 20:57:00"}

13564061-RR-23

## EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) ## INDICATION: Evidence of biliary obstruction vs infection, metastasis. Pl ## LIVER: The liver echotexture is homogeneous. No focal suspicious liver lesions are identified. There is no ascites. Multiple hypoechoic lesions are seen adjacent to the porta hepatis and in the abdomen, which likely represent enlarged lymph nodes, measuring up to 2.2 cm in short axis. Additional hypoechoic structure in the mid abdomen noted, measuring 5.1 x 4.4 x 6.7 cm of uncertain significance. ## BILE DUCTS: There is no intrahepatic biliary dilatation. The CBD measures 3 mm. ## LIVER DOPPLER: The main, right, and left portal veins are patent with normal color Doppler and appropriate hepatopetal flow. The right, middle, and left hepatic veins are patent with appropriate hepatofugal flow. The main hepatic artery is patent with normal spectral Doppler waveforms. The patient is status post splenectomy and left nephrectomy. Limited evaluation of the right kidney shows multiple hypoechoic lesions, compatible with cysts. A 1.6 x 1.7 x 1.6 cm heterogeneously hypoechoic lesion in the right kidney shows internal echoes and is not consistent with a simple cyst. ## IMPRESSION: Normal hepatic vasculature. Normal gallbladder. Multiple hypoechoic lesions seen in the porta hepatis likely reflect adenopathy. Additional indeterminate hypoechoic process in the mid abdomen could reflect additional mass, less likely prominent bowel loop. 1.7 cm hypoechoic lesion in the midpole of the right kidney shows internal echoes and is not consistent with a simple cyst. Consider contrast enhanced CT for further evaluation when clinically appropriate. ## RECOMMENDATION: CT Torso to assess for adenopathy. When possible, a multi phase renal CT or MRI could also be performed to assess the indeterminate interpolar right renal lesion.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13564061", "visit_id": "26530519", "time": "2168-03-10 02:54:00"}

19923383-RR-41

## CHEST: Frontal and lateral views ## INDICATION: History: with chest pain// Eval for ptx, pna ## FINDINGS: The lungs remain relatively hyperinflated. There is bibasilar atelectasis. Streaky bibasilar opacities are most likely due to atelectasis and overlapping vascular structures, although developing pneumonia is difficult to exclude in the appropriate clinical setting. Biapical pleural thickening again seen. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. ## IMPRESSION: Streaky bibasilar opacities are most likely due to atelectasis and overlying vascular structures, but pneumonia is difficult to exclude in the appropriate clinical setting.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19923383", "visit_id": "26021355", "time": "2111-12-04 18:11:00"}

10354034-RR-25

MRI OF THE CERVICAL AND LUMBAR SPINES. ## HISTORY: A male patient status post fall with ongoing back pain. ## MRI CERVICAL SPINE: The cervical spine vertebral bodies are aligned. The vertebral body height is maintained. The craniocervical junction appears to be within normal limits. There is no cord signal abnormality seen. There is a small amount of fluid seen in the prevertebral soft tissues from approximately the C3 vertebral body to the level of the C5 vertebral body. However, no definite evidence of ligamentous injury is identified. At the C3/C4 level, there are disc osteophyte complexes eccentric to the right side causing moderate right-sided neural foraminal stenosis. There is mild left-sided neural foraminal stenosis. There is no high-grade spinal canal stenosis. At the C4/C5 level, there are also anterior and posterior spondylytic ridges with uncovertebral joint hypertrophy bilaterally causing moderate bilateral neural foraminal stenosis. There is no high-grade spinal canal stenosis. At the C5/C6 level, there are also disc osteophyte complexes with anterior and posterior spondylytic ridging more prominent anteriorly. There is no spinal canal stenosis. There is, however, bilateral moderate neural foraminal stenosis. At the C6/C7 level, there are endplate degenerative changes with anterior- posterior spondylytic ridges. There are disc osteophyte complexes. No high- grade spinal canal stenosis is seen. There is moderate neural foraminal stenosis. At the C7/T1 level, there are very minimal posterior spondylytic ridges without neural foraminal narrowing or spinal canal stenosis. ## IMPRESSION: 1. Small amount of prevertebral edema. However, no evidence of gross ligamentous injury. 2. Degenerative changes throughout the cervical spine as described above. No high-grade spinal canal stenosis. No cord signal abnormality. ## LUMBAR SPINE: The lumbar spine vertebral bodies are aligned. The vertebral body height is maintained. The conus terminates at the level of the L1 vertebral body. At the T12/L1, L1/L2, and L2/L3 levels, there is no disc herniation, spinal canal stenosis, or neural foraminal stenosis. There is a bright T1 and T2 lesion in the L2 vertebral body, which could represent a focal fatty change or a fat-containing hemangioma. At the L3/L4 level, there is mild disc bulging slightly eccentric to the left side causing mild left-sided neural foraminal narrowing without deformity of the exiting nerve root. There is no spinal canal stenosis. There is mild disc desiccation. At the L4/L5 level, there is minimal disc bulging. There is a small posterior annular tear. There is no spinal canal stenosis or neural foraminal stenosis. At the L5/S1 level, there is minimal central protrusion without spinal canal stenosis or neural foraminal stenosis. There is, however, a focal area of increased signal on the STIR images along the S2 and S3 vertebral bodies without significant deformity, which is of concern for a fracture of the sacrum. There is a Tarlov cyst in the sacral spinal canal. ## IMPRESSION: 1. Abnormal STIR signal on the S2 and S3 vertebral bodies, which are of concern for a non-displaced fracture of the sacrum. There is a small amount of presacral edema. 2. Mild degenerative changes in the lumbar spine.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10354034", "visit_id": "22521066", "time": "2170-10-08 13:20:00"}

18483037-RR-17

## INDICATION: Metastatic prostate cancer, followup ## FINDINGS: Diffuse enlargement of the thyroid gland is unchanged. Dilatation of the distal portion of the aortic arch with extensive atherosclerotic disease is unchanged. The rest of the descending aorta is distended but stable. Heart size is enlarged particular left ventricle. Severe calcifications of the aortic valve are re-demonstrated. There is no pericardial or pleural effusion. At the level of the hiatus there is continues presence of the extensive thrombus with progression of penetrating ulcer, series 2, image 49, 50. A adjacent low-density structure, series 2, image 49 measuring 28 Hounsfield units in diameter is stable in appearance, 1.9 cm. Image portion of the upper abdomen will be reviewed separately as part of the CT abdomen and pelvis in corresponding report will be issued Airways are patent to the subsegmental level bilaterally. Centrilobular emphysema is moderate. Pleural calcifications are similar to previous examinations consistent with prior asbestos exposure minimal atelectasis in the lingula is present. Extensive degenerative disease involving the thoracic spine. No definitive lytic or sclerotic lesions within the thorax demonstrated. ## IMPRESSION: Evidence of extensive atherosclerotic disease involving aorta including progressing ulcerating plaque at the level of the aortic hiatus, coronary calcifications and dilated heart. Asbestos exposure seen as pleural calcified plaques No evidence of intrathoracic metastatic disease.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18483037", "visit_id": "N/A", "time": "2169-10-15 09:15:00"}

14288592-RR-25

## HISTORY: Pain. PA and lateral radiographs of the lumbar spine demonstrate multilevel degenerative endplate change and marginal osteophyte formation. No spondylolisthesis is evident. There is sclerosis along the superior endplate of the L4 vertebral body and associated mild loss of height of the L4 vertebral body. The findings represent a subtle compression fracture accounting for less than 25% of normal vertebral body height. There is equivocal evidence of a small retropulsed fragment. There is densely atherosclerotic calcification. Moderate-to-severe degenerative change involves the bilateral hip joints, worse on the left than the right. The sacroiliac joints are unremarkable as is the symphysis pubis. Surgical staples are in the right upper quadrant. ## IMPRESSION: Lumbar spondylosis. L4 vertebral body compression fracture accounting for less than 25% of normal vertebral body height. The finding is of uncertain chronicity. Findings were entered into the critical results dashboard at the time of initial image interpretation.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14288592", "visit_id": "N/A", "time": "2200-02-17 10:37:00"}

10833304-RR-36

## EXAMINATION: BILATERAL DIGITAL DIAGNOSTIC MAMMOGRAM INTERPRETED WITH CAD AND LEFT BREAST ULTRASOUND ## INDICATION: Palpable lump felt by the patient's physician in the left breast at 12 o'clock near the areola is seen a mobile 2-3 cm mass. Patient does not feel any lumps. ## TISSUE DENSITY: C - The breast tissue is heterogeneously dense which may obscure detection of small masses. There is a cluster of linear branching microcalcifications spanning a 7 mm area in the right upper outer mid breast. These warrant a biopsy. There are no spiculated masses or areas of architectural distortion. A 9 mm asymmetry in the left upper breast appears consistent with an intramammary lymph node is stable dating back to . There are no spiculated masses or areas of architectural distortion. ## LEFT BREAST ULTRASOUND: Targeted ultrasound of the left breast was performed. The left breast was scanned from o'clock. A definite mass was not identified in the left breast at 12 o'clock. In the left breast at 11 o'clock ; 5 cm from the nipple is a fairly well-circumscribed hypoechoic lobulated mass measuring 0.8 x 0.7 x 0.5 cm, it shows some posterior acoustic enhancement and no vascularity. ## IMPRESSION: 1) Suspicious microcalcifications in the right breast. Stereotactic core biopsy of these recommended. 2) Lobulated mass in the left breast at the 11 o'clock. Though this could present a fibroadenoma and ultrasound-guided core biopsies recommended for definitive diagnosis. ## NOTIFICATION: Findings reviewed with the patient at the completion of the study. ## BI-RADS: 4B Suspicious - moderate suspicion for malignancy.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10833304", "visit_id": "N/A", "time": "2191-10-07 12:43:00"}

14430186-DS-4

## MAJOR SURGICAL OR INVASIVE PROCEDURE: : s/p Hemiarthroplasty, right hip. ## HISTORY OF PRESENT ILLNESS: year old female s/p fall on resulting in a right hip fracture requiring surgical management. ## FAMILY HISTORY: several aunts and uncles with cancer, no history of DM or heart disease ## HEENT: Normocephalic, atraumatic C-spine nontender to palpation and clinically clear ## CARDIOVASCULAR: Regular Rate and Rhythm, Normal first and second heart sounds ## EXTR/BACK: Good peripheral pulses. Pain with any motion of the right hip. System otherwise intact. ## NEURO: Speech fluent, moves all 4 extremities though motion of the right lower extremity limited secondary to pain. CSM is otherwise intact. ## PSYCH: Normal mood, Normal mentation ## BRIEF HOSPITAL COURSE: Ms. was admitted to the Orthopedic service on for a right hip fracture. On she underwent hemiarthroplasty of the right hip without complication. On she was started on Ciprofloxacin for an urinary tract infection. On she developed hypoxia. A chest xray was performed that showed pneumonia. She was started on Ceftriaxone and Azithromycin. The medical service was consulted for recommendations for antimicrobial therapy for the UTI and pneumonia. The morning of AM patient triggered for desat to 86% on 3L NC. This improved with repositioning, facemask oxygen, and nebulization treatment. ABG was obtained and was reassuring. Since then, saturations continued to improve. On her antibiotic therapy was changed to Levaquin and Cefpodoxime for treatment of her pneumonia and urinary tract infection. Oxygen has been weaned to 2L NC. Patient is discharged back to . ## MEDICATIONS ON ADMISSION: 1. Mirtazapine 15 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Tablets PO Q6H (every 6 hours) as needed for pain. 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. ## DISCHARGE MEDICATIONS: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous Q HS () for 4 weeks. 4. amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q 12H (Every 12 Hours). ## 13. MULTIVITAMIN TABLET SIG: One (1) Cap PO DAILY (Daily). 14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. 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. 16. ipratropium bromide 0.02 % Solution ## SIG: One (1) neb Inhalation Q4H (every 4 hours) as needed for SOB. 17. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days: Stop date . 18. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days: Stop date . 19. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 20. oxycodone 5 mg Tablet Sig: Tablets PO Q4H (every 4 hours) as needed for pain. 21. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 22. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as needed for insomnia. 24. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal ## SIG: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 25. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day) as needed for indigestion. 26. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 27. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily). ## DISCHARGE DIAGNOSIS: Right hip fracture. Hypoxia. Urinary Tract Infection. Pneumonia. Post operative hypokalemia. ## ACTIVITY STATUS: Ambulatory - requires assistance or aid (walker or cane). ## WOUND CARE: -Keep Incision dry. -Do not soak the incision in a bath or pool. ## ACTIVITY: -Continue to be full weight bearing on your right leg. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. If you have questions, concerns or experience any of the below danger signs then please call your doctor at or go to your local emergency room ## ACTIVITY AS TOLERATED RIGHT LOWER EXTREMITY: Full weight bearing Left lower extremity: Full weight bearing Encourage turn, cough and deep breathe q2h when awake ## TREATMENTS FREQUENCY: Remove staples 14 days from date of surgery. Continue to wean oxygen therapy. Patient is not on oxygen at baseline.

mimic

{"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14430186", "visit_id": "25125176", "time": "2145-04-22 00:00:00"}

13549117-RR-25

## INDICATION: year old man with cirrhosis and psoas abscess with drain in place, with persistent drainage evaluation of size of abscess // Evaluation of known psoas abscess ## DOSE: Acquisition sequence: 1) Spiral Acquisition 4.7 s, 51.9 cm; CTDIvol = 16.5 mGy (Body) DLP = 855.4 mGy-cm. Total DLP (Body) = 855 mGy-cm. ## LOWER CHEST: Minimal dependent atelectasis within the lung bases. There is no pleural or pericardial effusion. Moderate esophageal varices are noted. ## HEPATOBILIARY: Cirrhotic liver. A hypodense lesion is appreciated in segment 6 measuring 1.5 cm, unchanged compared to previous. No intrahepatic or extrahepatic biliary ductal dilatation. Cholelithiasis without evidence of cholecystitis. ## PANCREAS: The pancreas is mildly atrophic diffusely. The main pancreatic duct is not dilated. ## SPLEEN: Splenomegaly measuring up to 18.3 cm unchanged. Large splenic varices are noted. ## ADRENALS: The right and left adrenal glands are normal in size and shape. Nodular appearance of the adrenal glands is favored to be secondary to adjacent varices. ## URINARY: Normal appearance the right kidney. No renal calculi. No evidence of hydronephrosis. Unremarkable appearance of the left kidney, with no evidence of renal calculi or hydronephrosis. Mild perinephric stranding is appreciated, reactive to the left retroperitoneal process. The bladder is unremarkable. A few central prostatic calcifications are appreciated. ## GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. The colon and rectum are within normal limits. The appendix is normal. There is a left inguinal hernia, containing fat and fluid. ## RETROPERITONEUM: Appropriate position of the pigtail catheter is again appreciated in the left posterior para renal space, anterior to the psoas muscle. There is stable to minimally decreased size of the retroperitoneal collection, currently measuring 2.5 x 6.2 x 22 cm, compared to prior measurement of 1.9 x 6.9 x 22 cm. There is surrounding stranding, as well as a few locules of air. There is extension of the retroperitoneal fluid through the left inguinal hernia. No new collections are noted. ## LYMPH NODES: There are multiple mildly enlarged retroperitoneal and pelvic lymph nodes, likely reactive. There are bilateral mildly enlarged inguinal lymph nodes. The largest lymph nodes measure up to 1.3 cm in the left inguinal space. ## VASCULAR: Moderate esophageal and gastric varices, as well as splenic varices noted. IVC filter in situ. There is a background of moderate atherosclerosis. ## BONES: There is no evidence of worrisome osseous lesions or acute fracture. There has been prior spinal instrumentation at L4-S1, with compression and fragmentation of the L5 vertebral body, and mild retropulsion of the bony fragments, unchanged compared to previous. Background moderate multilevel degenerative changes within the spine. Old left healed rib fractures. ## IMPRESSION: 1. Stable to minimally decreased size of the left retroperitoneal collection, which herniates through the right inguinal canal into the scrotum. The pigtail catheter is in appropriate position. 2. Similar appearance of a hypodense lesion within hepatic segment 6, incompletely characterized. 3. Cirrhotic liver. Splenomegaly. Multiple varices. No ascites.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13549117", "visit_id": "26853673", "time": "2117-03-08 13:35:00"}

12030855-RR-17

## HISTORY: woman with fall and head strike and loss of consciousness. ## FINDINGS: The alignment of the cervical spine is preserved. There is no prevertebral soft tissue edema. The vertebral body height is preserved. There are mild multilevel degenerative changes in the cervical spine with small disk-osteophyte complexes indenting the thecal sac at C5/6 and C6/7 levels. Anterior and inferior to vertebral body of C5 there is a small osseous fragment, 401B:20. Lung apices appear normal. Hypodensity in the left thyroid lobe, 3:52, appears stable since . ## IMPRESSION: 1. Tiny osseous fragment anterior and inferior to vertebral body of C5, could be a small osteophyte. Correlate with point tenderness and flexion-extension views. 2. Small hypodensity in the left thyroid lobe, stable since . Thyroid ultrasound can be done in a nonurgent setting to evaluate further.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12030855", "visit_id": "20269491", "time": "2181-11-10 04:24:00"}

15574754-RR-93

## INDICATION: year old man with heart failure now with ischemic bowel and comfort focused care // Venting g-tube for symptomatic management of ischemic bowel ## OPERATORS: Dr. radiology fellow) and Dr. radiology attending) performed the procedure. The attending, Dr. was present and supervising throughout the procedure. Dr. radiologist, personally supervised the trainee during the key components of the procedure and reviewed and agreed with the trainee's findings. ## ANESTHESIA: Moderate sedation was provided by administrating divided doses of 1 mg of morphine and 0.5 mg of midazolam throughout the total intra-service time of 55 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. ## CONTRAST: 20 ml of Optiray contrast. ## PROCEDURE: 1. Flouroscopically-placed gastrostomy tube. ## PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per protocol. The abdomen was prepped and draped in the usual sterile fashion. A scout image of the abdomen was obtained. A 5 Kumpe catheter was advanced through the right nare and into the stomach to be used for insufflation. The stomach was then insufflated through the Kumpe catheter. Using a marker, the skin was marked using palpation to feel the costal margins and the liver edge was marked using ultrasound. Permanent ultrasound images were not stored. Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed in a triangular position elevating the stomach to the anterior abdominal wall. Intra-gastric position was confirmed with aspiration of air and injection of contrast. A 19 gauge needle was introduced under fluoroscopic guidance and position confirmed using an injection of dilute contrast. A wire was introduced into the stomach. A small skin incision was made along the needle and the needle was removed. After sequential dilation using 8, 10, and 12 dilators, a gastrostomy catheter was advanced over the wire into position. The metal stiffener and wire were removed. The catheter was secured by forming the retaining loop in the stomach after confirming the position of the catheter with a contrast injection. The catheter was then flushed, capped and secured to the skin with 0-silk sutures. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate complications. ## FINDINGS: 1. Successful placement of a gastrostomy tube. ## IMPRESSION: Successful placement of a 12 Wills gastrostomy tube. The catheter should not be used for 24 hours.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15574754", "visit_id": "27546909", "time": "2153-08-19 10:13:00"}

17181069-RR-69

## PREVIOUS SCAN DATE: . Transabdominal and transvaginal sonography were performed, the latter to better evaluate the uterus, endometrium, and adnexa. The uterus measures 10.5 x 5.7 x 6.5 cm. The uterus is heterogeneous in echotexture consistent with fibroids. The largest fibroid measures 2 cm. The endometrium measures 1.7 cm in thickness. No focal endometrial lesion is seen. There are some mobile blood products seen within the endometrial cavity. The ovaries are normal with a hemorrhagic left corpus luteal cyst. There is small amount of free fluid, within physiologic range. ## IMPRESSION: 1) Slightly enlarged uterus with small fibroids. Ovaries within normal limits with follicular activity. 2) 17 mm heterogeneous endometrium without focal lesion seen. Appearances could be due to stage of menstrual cycle. If there is a continued concern for endometrial pathology, follow up ultrasound in four to six weeks at the early part of the patient's next menstrual cycle, and/or sonohysterography could be considered.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17181069", "visit_id": "N/A", "time": "2168-01-10 14:39:00"}

17208152-RR-68

PA AND LATERAL CHEST, AT HOURS. ## FINDINGS: The lungs are clear without consolidation or edema. A double barrel port is again present from a right subclavian approach stable in course and position. The mediastinum is otherwise unremarkable. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is seen. A slight levoconcave curvature of the thoracic spine is again identified. Otherwise, the visualized osseous structures are unremarkable. ## IMPRESSION: No acute pulmonary process. Please note the numerous pulmonary nodules seen on recent chest CT remain radiographically occult.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17208152", "visit_id": "26343930", "time": "2141-08-22 19:33:00"}

13834826-RR-5

## REASON FOR EXAM: female with hypertension and right basal ganglia hemorrhage. ## NON-CONTRAST CT OF THE HEAD: Again seen, there is a 1.5 x 1.0 cm area of hemorrhage likely in the pulvinar of the right thalamus extending to the posterior limb of internal capsule with surrounding edema, grossly unchanged since prior exam. There is no midline shift. Basal cisterns and suprasellar cistern are patent. Mild prominence of the ventricles and cerebral sulci are consistent with age-appropriate atrophy. A focal low-density area in the right inferior basal ganglia, image #14, series 2, may represent a dilated Virchow- space vs. lacunar infarct. Multiple periventricular and subcortical areas of white matter hypodensity likely represent sequelae of chronic small vessel ischemic disease. Atherosclerotic calcification of bilateral carotid arteries, left middle cerebral artery is noted. There is no fracture. The visualized mastoid air cells and paranasal sinuses are grossly unremarkable. The visualized orbits are grossly unremarkable. The patient is likely status post right cataract surgery. ## IMPRESSION: 1. Stable right Pulvinar hemorrhage. 2. Areas of subcortical and periventricular hypodensity likely representing sequelae of small vessel ischemic disease.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13834826", "visit_id": "24324634", "time": "2135-05-07 11:23:00"}

10786539-DS-19

## HISTORY OF PRESENT ILLNESS: hx APLA syndrome with hx of multiple thromboembolic events, CAD s/p STEMI and large area of LV hypokinesis with associated thrombus, AICD. He initially presented to earlier today with of worsening L flank pain. It has been constant, worsening, and not similar in character to his prior kidney stones. It started on on the L, gradually worsened on that side, and then progressed to the R. It became so severe that he could not sleep, and then that he was vomiting. He presented to for eval. By report CTAP was obtained there showing suggestion of subtle stranding in L perirenal space, which they postulated might represent pancreatitis or pyelonephritis (has been over-read by our radiologists -- see below). His labs were notable for plt . He was given IVFs, IV Cipro, IV Morphine and Fentanlyl; his VS on transfer were BP 198/104, HR 75, RR 20, Sa 98% on RA. In the ED, initial vital signs were: 97.6 80 184/86 20 100% RA - Exam was notable for: none recorded in dash. - Labs were notable for: Na 146, K 4.6, glucose 119, plt 64. Coags showed 16.8, PTT 69.6, INR 1.5. UA with large blood, 100 prot, >182 RBCs, 18 WBCs. - Imaging: Reviewed pt's LifeImage CT scan with ED Radiology PGY4 on call. Per her read, there is no evidence of pancreatitis or nephrolithiasis. There is an area of periadrenal abnormality centered on the L adrenal gland that is suspicious for adrenal hemorrhage; additionally, neither adrenal gland attenuates appropriately relative to his prior CT in our system. She has received our request for formal opinion and will over-read the scan tonight. - The patient was given: 01:40IVMorphine Sulfate 4 mg 01:40IVOndansetron 4 mg 01:41IVF1000 mL NS 1000 mL 02:11IVMorphine Sulfate 4 mg 02:14IVF1000 mL NS 1000 mL 02:47IVMorphine Sulfate 4 mg 03:35IVF1000 mL NS 1000 mL 03:35IVKetorolac 15 ## VITALS PRIOR TO TRANSFER WERE: 98.4 85 177/102 22 98% RA Given bilateral attenuation of the adrenal glands, coagulopathy on labs, and plts 75K -> 64k, I was concerned for early onset of catastrophic APLA syndrome and consulted Heme Onc prior to patient arriving on the floor from the ED. Discussed with on-call Heme Onc fellow - will get peripheral smear, repeat labs, and tbw Heme Onc. ## REVIEW OF ATRIUS RECORDS: patient frequently subtherapeutic on INR. There are mentions of socioeconomic difficulties - lost job, house, etc and being unable to obtain meds. Upon arrival to the floor, patient continues to have severe bilateral flank pain and associated nausea. =========================== ## REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes, pharyngitis, rhinorrhea, nasal congestion, cough, fevers, chills, sweats, weight loss, dyspnea, chest pain, abdominal pain, diarrhea, constipation, hematochezia, dysuria, rash, paresthesias, and weakness. ## PAST MEDICAL HISTORY: -stroke in with no residual deficits, possible TIA years ago -antiphospholipid antibody syndrome -AICD placement -MI in -aborted STEMI in , LAD thrombus treated with bare metal stent -LV dysfunction -large mural left ventricular apical thrombus on echo -HTN -hand surgery year ago work accident ## FAMILY HISTORY: -- Mother with disease and hypothyroidism, maternal cousin with lupus, grandmother with "heart problems from an early age" -- patient's wife does not recall the details. Father died of kidney failure, patient's wife does not recall the cause of the renal failure. ## PHYSICAL EXAM: EXAM ON ADMISSION ========================= ## HEENT: no icterus, PERRLA, MMM, no OP lesion. Superficial quarter-sized lump on back of head, which is chronic per patient. Scar on forehead ## NECK: no JVP, no LAD ## COR: tachycardic, regular rhythm, no NMRG ## PULM: exam limited by pain with deep breathing, CTAB ## ABD: soft, mildly tender in epigastric area, nondistended ## BACK: Moderate-severe pain with palpation over kidneys bilaterally. Diffuse erythematous, non pruritic papular rash. ## NEURO: AOx3, no focal sensory or motor deficits in bilat ## MSK: without edema, 2+ distal pulses EXAM ON DISCHARGE ========================= ## GENL: appears comfortable, laying in bed, NAD ## HEENT: no icterus, PERRLA, MMM, no OP lesion. Superficial quarter-sized lump on back of head, which is chronic per patient. Scar on forehead ## COR: RRR, normal S1,S2, no NMRG ## ABD: soft, mild tenderness in left lower quadrant ## NEURO: AOx3, no focal sensory or motor deficits in bilat ## MSK: without edema, 2+ distal pulses ## IMAGING/STUDIES =========================== CTA CHEST: 1. Left ventricular filling defect concerning for left ventricular thrombus. Correlate with echocardiogram findings. 2. No pulmonary embolus or acute aortic abnormality. OSH CT abdomen w/ contrast read at : ## IMPRESSION: 1. Uniform thickening associated with diffuse hypoenhancement of the adrenal glands with surrounding stranding is suspicious for adrenal infarcts. No hemorrhage or hematoma is visualized. This examination was not protocoled for evaluation of adrenal vein thrombosis. 2. Left ventricular wall calcification with thrombus is not significantly changed from priorexam and may be monitored by ECHO. ## TTE : The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with mid to distal anterior/anterospetal and apical akinesis. A large thrombus is seen in the left ventricular apex. There is no ventricular septal defect. The diameters of aorta at the sinus, ascending and arch levels are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of , an apical LV thrombus is now seen. ## IMPRESSION: No evidence of obstruction. ## BRIEF HOSPITAL COURSE: Mr. is a year old man with APLA syndrome with hx of multiple thromboembolic events, CAD s/p STEMI and large area of LV hypokinesis with associated thrombus, AICD, who presented with bilateral flank pain and imaging concerning for adrenal infarcts. ## #APLP SYNDROME: #ADRENAL THROMBI + ISCHEMIA: Patient presented with adrenal thrombi secondary to APLP syndrome and having not taken coumadin for a week because he ran out of the prescription. Hematology was consulted. Patient was systemically anticoagulated first with a heparin gtt and then with lovenox. He was bridged back to coumadin for a goal INR . He also had a CTA chest to rule out PE, and it was negative. His AM cortisol was WNL while in the hospital and one was pending on discharge. Pt should be observed for signs of adrenal insufficiency on discharge. He was discharged on oxycodone. Pt was advised on the risks of narcotic use and notified of option for partial fill. ## #LV THROMBUS: Pt has a history of an LV thrombus, and CT abd/pelvis at outside hospital was concerning for one. A CTA chest and TTE were done, confirming an LV thrombus. Of note, TTE also showed an EF of 35-40% found on echo. Patient will have cardiology follow up. ## #THOMBOCYTOPENIA: Patient with thrombocytopenia upon hospitalization, likely in setting of thrombosis. Platelets were improved with systemic anticoagulation. ## # ALCOHOL USE: Patient had reported vague alcohol use upon admission, but would not give further details. He was initially placed on CIWA and was minimally scoring. ## TRANSITIONAL ISSUES: - Patient discharged on Coumadin 10 mg daily, goal INR - F/u anticardiolipin and anti Beta-2-Glycoprotein 1 Antibodies, cortisol - Patient discharged with mirtazapine for appetite stimulation, can consider discontinuing if appetite improves as pain resolves - TTE with 35-40% EF and new LV thrombus which will be followed up as an outpatient by cardiology ## MEDICATIONS ON ADMISSION: The Preadmission Medication list is accurate and complete. 1. Clopidogrel 75 mg PO DAILY 2. Warfarin 12.5 mg PO DAILY16 3. Cialis (tadalafil) 10 mg oral DAILY:PRN ED 4. Gabapentin 600 mg PO TID ## DISCHARGE MEDICATIONS: 1. Clopidogrel 75 mg PO DAILY 2. Warfarin 10 mg PO DAILY16 RX *warfarin [Coumadin] 10 mg 1 tablet(s) by mouth daily Disp #*30 ## TABLET REFILLS: *0 3. Mirtazapine 15 mg PO QHS RX *mirtazapine 15 mg 1 tablet(s) by mouth every night Disp #*30 Tablet ## REFILLS: *0 4. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet ## REFILLS: *0 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 6. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 7. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain RX *oxycodone 10 mg 1 tablet(s) by mouth q6h prn Disp #*25 ## TABLET REFILLS: *0 8. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills:*0 9. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Cialis (tadalafil) 10 mg oral DAILY:PRN ED 11. Gabapentin 600 mg PO TID ## PRIMARY DIAGNOSES: - Catastrophic antiphospholipid antibody syndrome - Bilateral adrenal thrombosis - Left ventricular thrombus Secondary Diagnoses - Previous stroke - Previous MI with AICD placement - Hypertension - Alcohol withdrawal ## DISCHARGE INSTRUCTIONS: Dear Mr. , It was a pleasure taking care of you during your hospitalization at the . You were admitted with back pain, which is from blood clots in your adrenal glands, which are organs that sit on top of the kidney. You were also found to have a blood clot in your heart. You were started on a blood thinner, and started to get better. You have been transitioned back to warfarin, and it is important that you get your INR checked regularly. Your next appointment is , and you should have your INR checked then. As you know, it is very important to keep taking the blood thinners at home. If you are having any difficulty with obtaining these medications, please talk to your doctor about finding alternative options. Please see below for additional information about your medications and followup appointments. It was very nice to meet you and we wish you the very best! Sincerely, Your Care Team

mimic

{"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10786539", "visit_id": "23065569", "time": "2135-07-18 00:00:00"}

16919532-RR-7

## EXAMINATION: CT ORBITS, SELLA AND IAC W/ CONTRAST Q1215 CT HEADSUB ## INDICATION: year old woman with right optic neuropathy, ? unable to obtain MRI due to old surgical clips ? enhancement of the right optic nerve- please perform thin, post-contrast, coronal cuts through the orbits. ## DOSE: The doses with CT angiography. ## FINDINGS: Postsurgical changes of bilateral lens replacement. Surgical material is seen within the left medial orbit. The extraocular muscles are symmetric. The retrobulbar fat is maintained. There is no evidence of intraconal or extraconal hemorrhage or mass. The optic nerve sheaths are symmetric. No fractures are identified. There is no evidence of facial swelling. There is mild mucosal thickening of the paranasal sinuses. No air-fluid levels are identified. There is no evidence of abnormal fluid collections. There is moderate opacification of the visualized mastoid air cells.. Mild arthrosis of the left temporomandibular joint. ## IMPRESSION: 1. No evidence of abnormal enhancement of the optic pathway. No perineural soft tissue abnormalities or enhancement seen. 2. Symmetric appearance of the optic nerve sheaths 3. Preserved intraconal and extraconal fat planes.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16919532", "visit_id": "N/A", "time": "2112-09-13 07:08:00"}

11882807-RR-38

## CLINICAL HISTORY: man with kidney and pancreas transplant. Increased LFT and ongoing abdominal pain. ## LUNG BASES: Lung bases are included and are clear. No suspicious pulmonary nodules or pleural effusions are seen. ## ABDOMEN: Numerous subcutaneous collaterals are identified in the anterior abdominal wall, no significant change from the prior study. The liver and spleen are normal in size. No focal hepatic lesions are identified on this unenhanced CT study. The gallbladder and adrenals are unremarkable. The pancreas is atrophic, unchanged from the prior study. Both kidneys are also significantly decreased in size. No suspicious renal lesions are identified on this unenhanced CT study. There are no enlarged retroperitoneal or mesenteric lymph nodes. ## PELVIS: The small and large bowel is unremarkable. A transplant kidney is identified in the left iliac fossa. No focal renal lesions are seen. There is no evidence of hydronephrosis. A pancreatic transplant is identified in the right iliac fossa, also appearing unremarkable. There is no peripancreatic fat stranding. The graft is normal in diameter. There is no pelvic or inguinal lymphadenopathy. The urinary bladder is decompressed. The seminal vesicles and prostate are normal in size for the age of the patient. Review of images on bone window does not show any suspicious bony lesions. ## IMPRESSION: 1. Status post pancreas and renal transplant. The grafts appear unremarkable. 2. The liver appears normal. The absence of intravenous contrast administration limits the evaluation of focal hepatic lesions, but no lesions are identified on the unenhanced images. 3. Atrophic native pancreas and kidneys bilaterally. ## DOSE REPORT: The total DLP of the exam is 1678.80 mGy-cm.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11882807", "visit_id": "N/A", "time": "2131-03-11 09:49:00"}

17708119-RR-54

## DOSE: DLP: given in abdominal CT report. ## FINDINGS: No incidental thyroid findings. No supraclavicular, infraclavicular or axillary lymphadenopathy. All visible lymph nodes in the mediastinum (2, 13) Are normal in size. No abnormalities are noted in the mediastinum. Mild cardiomegaly. No substantial coronary or valvular calcifications. No pericardial effusion. Moderate tortuosity of the descending aorta. Small hiatal hernia. The upper abdomen is reported in detail in the dedicated abdominal CT report, including the left renal cyst and the calcified gallstone (304, 114). No osteolytic lesions at the level of the ribs, the sternum, and the vertebral bodies. Moderate degenerative vertebral disease. No vertebral compression fractures. Mild respiratory motion. No pleural thickening, no pleural effusions. No diffuse lung disease. No suspicious pulmonary nodules or masses. The airways are patent. ## IMPRESSION: No evidence of metastatic disease to the thorax.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17708119", "visit_id": "N/A", "time": "2189-05-27 17:07:00"}

13823519-DS-10

## ALLERGIES: No Known Allergies / Adverse Drug Reactions ## MAJOR SURGICAL OR INVASIVE PROCEDURE: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, resection right-sided pelvic mass, infracolic omentectomy, bilateral pelvic and para-aortic lymph node dissection, cystoscopy. ## HISTORY OF PRESENT ILLNESS: Ms. is a female who presented with worsening back pain. An MRI on incidentally noted a pelvic mass. Patient complained of worsening abdominal pain and distention and was admitted to . During that admission she underwent a paracentesis confirming adenocarcinoma, with staining suggestive of gynecological origin. A CT scan was done which revealed small bilateral pleural effusions, moderate to large hiatal hernia and a large amount of ascites throughout the abdomen and pelvis. There was a large 10.4 cm irregular mass within the right adnexa, and CA-125 was 297. She presented to the gynecology-oncology service for surgical management. ## PAST MEDICAL HISTORY: lupus, new onset dementia, back pain, spinal stenosis, osteoporosis ## OBGYN HISTORY: G2P2, SVD x 2, metastatic ovarian cancer ## FAMILY HISTORY: Mother who was diagnosed with breast cancer in her . No other GYN related malignancies. ## PHYSICAL EXAM: On the day of discharge: Afebrile, vital signs stable ## GEN: well-appearing, no acute distress ## CV: regular rate and rhythm ## PULM: clear to auscultation bilaterally ## ABD: soft, non-distended, minimal tenderness to palpation, no rebound or guarding; incision with staples clean/dry/intact; no erythema or drainage; normoactive bowel sounds ## EXT: warm and well perfused, no edema, no calf tenderness ## GU: no spotting on pad ## PATHOLOGIC DIAGNOSIS: 1. and fallopian tube, right (1A-1FS1): Ovarian carcinosarcoma, see synoptic report. 2. Uterus, cervix, left fallopian tube and (2A-2J): Uterine serosa and left involved by metastatic carcinosarcoma. Uterine leiomyoma (3.6 cm), atrophic endometrium. 3. Omentum (3A-3G): Metastatic carcinosarcoma in adipose tissue (macroscopic nodule <2 cm, Block 3B).Metastatic carcinosarcoma in 1 of 1 lymph node. 4. Lymph ndes, right pelvic (4A-4H): Metastatic carcinosarcoma in 1 of 11 lymph nodes ( ). 5. Lymph nodes, left pelvic (5A-5G): Metastatic carcinosarcoma in 1 of 10 lymph nodes ( ). 6. "Fat nodule", sigmoid (6A-6B): No malignancy identified, fibroadipose tissue. 7. Lymph node, right paraortic (7A-7C): Metastatic carcinosarcoma in 1 of 2 lymph nodes ( ). 8. Lymph node, left paraortic (8A-8B) Metastatic carcinosarcoma in 4 of 4 lymph nodes ( ). ## NOTE: The tumor is poorly differentiated with foci consistent with high-grade Mullerian/serous carcinoma. The less differentiated component likely represents carcinosarcoma. Nodal metastases are composed of the carcinoma component. Synopsis Staging according to Joint Committee on Cancer Staging Manual -- Edition, Macroscopic ## SPECIMEN TYPE: Right salpingo-oophorectomyLeft salpingo-oophorectomyHysterectomy Tumor Site ## RIGHT: not applicable (distal tube not separately identified) ## OMENTUM: Implant (<2 cm) Extent of Invasion ## PT3B (IIIB): Macroscopic peritoneal metastasis beyond pelvis 2 cm or less in greatest dimension ## PN1: Regional lymph node metastasis ## BRIEF HOSPITAL COURSE: Ms. was admitted to the gynecology oncology service after undergoing exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, resection of right-sided pelvic mass, infracolic omentectomy, bilateral pelvic and para-aortic lymph node dissection, and cystoscopy. Please see the operative report for full details. Her immediate post-operative course was complicated by hypotension, likely secondary to her epidural anesthesia in addition to a low baseline and exacerbated by pre-operative bowel prep. She required phenylephrine in the OR and immediately post-operatively in the PACU. She remained asymptomatic in the PACU. She was found to be anemic with a hematocrit of 26.1, attributed to intra-operative blood loss. She received 1 unit of packed red blood cells in the PACU. Her blood pressure stabilized but remained low after IV fluid resuscitation and albumin transfusion. On the evening of post-operative day #0, her epidural came out unintentionally as she was getting out of bed without assistance. Subsequently, her blood pressure gradually improved and remained normal with systolic ranges 100-120s for the remainder of her hospitalization. For pain management, she was started on a Dilaudid PCA and IV Acetaminophen once her epidural came out. On post-operative day #2, she was transitioned to oral pain medications (Percocet, Motrin). An adjustable abdominal binder was provided for support. On post-operative day #1, she was noted to have intermittent borderline low urine output. She also was noted to be fluid positive after extensive IVF resuscitation secondary to hypotension immediately post-operatively. Her sodium level demonstrated hyponatremia to 129, likely secondary to the above. Her urine output and fluid balance improved after being given one dose of IV lasix. Her IVF were minimized and she was given a low maintenance dose of normal saline of 50 cc/hr until she was tolerating a regular diet. Her sodium level gradually increased and was noted to be 133 on the day of discharge. On post-operative day #3, her urine output was adequate and she was ambulating independently, so her Foley catheter was removed and she voided spontaneously. Her blood counts continued to be monitored post-operatively and remained low to a nadir of 26, felt to reflect equilibration after acute blood loss anemia secondary to surgery. She received a total transfusion of 3 units of packed red blood cells, including one immediately post-operatively in the PACU. She remained asymptomatic from an anemia standpoint. Her post-operative course was also notable for intermittent confusion and forgetfulness notable during interactions, which was consistent with her baseline status of recently diagnosed new onset dementia, likely exacerbated by post-anesthesia and medication side effects as well as disorientation while being hospitalized. Her mental status improved and returned to baseline by post-operative day #2. On post-operative day #2, her diet was gradually advanced and by day 3 she was tolerating a regular diet. She was continued on her home medications: baclofen for lupus and back pain, clonazepam as needed for insomnia, colace and senna for constipation, and pantoprazole for GERD. She received kefzol for infectious prophylaxis and lovenox for DVT prophylaxis post-operatively. By post-operative day #3, she was meeting discharge milestones -- tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. ## MEDICATIONS ON ADMISSION: -Clonazepam 0.5mg, one tablet at bedtime -Magnesium oxide 400mg tablet, once a day -Pantoprazole 40mg, once daily -Senna 8.6mg PO twice daily -Baclofen 20mg, once daily -Alendronate 70mg weekly -Methotrexate 2.5mg 5 pills weekly -Leucovorin 5mg biweekly -Multivitamin -Oxycodone, as needed for pain ## DISCHARGE MEDICATIONS: 1. Baclofen 20 mg PO DAILY 2. ClonazePAM 0.5 mg PO QHS:PRN insomnia, anxiety 3. Docusate Sodium 100 mg PO BID Hold for loose stools. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills:*2 4. Ibuprofen 600 mg PO Q8H:PRN pain Take with food to avoid GI upset. RX *ibuprofen 600 mg 1 tablet(s) by mouth up to every 8 hours. Disp #*60 Tablet Refills:*0 5. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN back pain 6. Oxycodone-Acetaminophen (5mg-325mg) TAB PO Q4H:PRN pain Do not drive or combine with alcohol. Do not take >4000mg acetaminophen in 24hrs. RX *oxycodone-acetaminophen 5 mg-325 mg tablet(s) by mouth every hours Disp #*50 Tablet Refills:*0 7. Pantoprazole 40 mg PO Q24H 8. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp #*60 Tablet Refills:*2 9. Methotrexate 2.5 mg PO 5X/WEEK ( ) 10. Leucovorin Calcium 5 mg PO 2X/WEEK (WE,SA) 11. Alendronate Sodium 70 mg PO QWEEK 12. Magnesium Oxide 400 mg PO DAILY ## DISCHARGE INSTRUCTIONS: Dear Ms. , You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * Your staples will be removed at your follow-up visit on . . To reach medical records to get the records from this hospitalization sent to your doctor at home, call .

mimic

{"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13823519", "visit_id": "27251670", "time": "2127-01-02 00:00:00"}

13777050-RR-226

## FINDINGS: Contrast is seen traversing a left upper quadrant tube into the left upper quadrant with borders most representative of stomach rugae in the gastric fundus. The tip of the catheter is likely within the stomach. Degenerative changes of the spine are severe. There is no evidence of bowel obstruction. ## IMPRESSION: Tip of tube likely within the stomach, level of the fundus.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13777050", "visit_id": "28694742", "time": "2142-12-15 17:56:00"}

15775667-RR-24

## INDICATION: History of foot pain and mild shortness of breath. Please evaluate for pneumonia. Please evaluate for pleural effusions or pneumonia. ## FINDINGS: The heart size is top normal. The hilar and mediastinal contours are normal. The lung volumes are low. Interval increase in diffuse opacification throughout the lungs bilaterally, compared to the exam from , is likely secondary to mild pulmonary edema. There is no large pleural effusion or pneumothorax. Partially visualized is a gastrostomy tube in place. The visualized osseous structures are unremakable. ## IMPRESSION: Mild diffuse opacification throughout the lungs bilaterally is likely secondary to pulmonary edema. Updated findings were d/w Dr. by Dr. by phone at 8:30a on .

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15775667", "visit_id": "28197635", "time": "2114-12-05 02:11:00"}

10946421-RR-20

## INDICATION: with PMH hypothyroidism, hypertension, compression fracture, who presented with abdominal pain, lipase > 7000, and CT consistent with acute pancreatitis. Also with new onset iron deficiency anemia, please eval for evidence of ampullary mass or evidence of ductal abnormality ## FINDINGS: Limited examination secondary to non breath hold technique. ## LOWER THORAX: There is moderate bibasilar atelectasis with associated pleural effusions. ## LIVER: The liver is normal in morphology and signal intensity. No focal liver lesions are seen. There is small volume ascites. ## BILIARY: Gallbladder is unremarkable without evidence of stones. No intra or extrahepatic biliary duct dilation is seen. ## PANCREAS: The pancreas is enlarged and edematous with surrounding peripancreatic and fluid. No focal pancreatic mass is seen. There are multiple acute peripancreatic collections with the largest located inferior to the distal pancreatic body measuring 2.8 x 3.1 x 2.1 cm. Additional acute peripancreatic collection is noted adjacent to the pancreatic tail measuring 2.4 x 3.9 x 2.3 cm. Pancreatic parenchyma demonstrates diffuse low T1 signal but enhances normally. There is no evidence of pancreatic necrosis. Note is made of pancreas divisum. ## SPLEEN: The spleen is normal in size and signal intensity. ## ADRENAL GLANDS: The right and left adrenal glands are thickened but without discrete nodularity. ## KIDNEYS: The kidneys are mildly atrophic. There are bilateral peripelvic renal cysts. No suspicious focal renal lesion is seen. ## GASTROINTESTINAL TRACT: There is a moderate hiatal hernia. Note is made of a small duodenal diverticulum. ## LYMPH NODES: There are no enlarged mesenteric or retroperitoneal lymph nodes. ## VASCULATURE: There is no abdominal aortic aneurysm. There is no gross vascular abnormality within the limitations of a non breath hold examination. ## OSSEOUS AND SOFT TISSUE STRUCTURES: There are no suspicious bony lesions. There is no superficial soft tissue abnormality. ## IMPRESSION: 1. Acute interstitial pancreatitis with multiple small acute peripancreatic fluid collections. No evidence of necrosis. 2. Limited study due to non breath hold technique, with no underlying mass identified. 3. Bilateral pleural effusions with associated atelectasis.

mimic

{"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10946421", "visit_id": "24266393", "time": "2196-07-17 09:59:00"}