Synthetic Mention Corpora for Disease Entity Recognition and Normalization 1.0.0
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| C2348412 | sig: one (1) tablet po qd. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. <1CUI> stable multiple myeloma or plasma cell leukemia </1CUI> 2. diabetes mellitus type ii 3. hypertension 4. hypercholesterolemia 5. hyperlipidemia 6. gout discharge condition: good discharge instructions: you will need to have blood drawn in the morning every two weeks. you will need to return to [**hospital 2062**] for a follow up appointment with [**last name (stitle) **] in two weeks. please call [**telephone/fax (2) 2942**] if you have any questions or concerns. you should be taking your blood pressure medication as prescribed. you should be taking your blood thinner medication as prescribed. you should be taking your cholesterol medication as prescribed. you should be taking |
| C2348517 | 4. pml. 5. <1CUI> favorable hodgkin lymphoma </1CUI> . 6. cmv. social history: she is a former smoker, who quit in [**2010-03-04**]. she works as a nurse and has two children. family history: non-contributory. physical exam: vs: t 99.5, bp 120/80, rr 18, hr 76, o2 sats 98%/ra. general: well-appearing woman in no acute distress. heent: perrla, anicteric sclerae, mmm, no mass, no lesions, no lad. neck: supple, no lymphadenopathy, no thyromegaly. chest: lungs cta, no rales or rhonchi. card: rrr, s1, s2, no murmurs. abd: soft, nontender, nondist |
| C2348639 | <1CUI> t waves biphasic </1CUI> . p waves: normal. qt (qtc): 365. cxr: [**2012-09-10**]: no evidence of pneumothorax. ct abdomen: impression: no evidence of bowel obstruction or hematoma. no evidence of active bleeding. ct head: impression: no evidence of acute intracranial hemorrhage. ekg [**2012-09-10**]: t waves biphasic. catheterization: a 7 french j-tip catheter was placed in the right femoral artery. conclusion: 1. the patient was stabilized with vasopressors and was transferred to the [**doctor last name 60**] for further management. 2. the patient was transferred to the [**doctor last name 60**] for further management of the bleed. 3. the patient was stabilized |
| C2348499 | she was started on hydroxyurea, cyclosporine, and steroids for cytoreduction. she was transferred to the [**hospital unit name 40**] for further management. past medical history: 1. chronic myelogenous leukemia 2. <1CUI> flt3 internal tandem duplication </1CUI> 3. essential hypertension 4. hyperlipidemia 5. gerd social history: she is a non-smoker, drinks occasionally, and denies illicit drug use. family history: non-contributory. physical exam: on admission, the patient was afebrile, tachycardic, and tachypneic. she had a left-sided chest tubes. she had a palpable spleen, liver, and lymphadenopathy. pertinent results: [**2015-05-27**] 04:10am blood wbc-2.4 rbc-2.64* hgb-7.4* h |
| C2348501 | 6. cytogenic abnormalities: 10/10 metaphases examined. 7. <1CUI> flt3-tkd mutation </1CUI> : 10/10 metaphases examined. 8. mll (ki-67): 100% of metaphases examined. 9. cdkn2a (p16): 100% of metaphases examined. 10. tp53: 100% of metaphases examined. 11. cdkn1a (p21): 100% of metaphases examined. 12. histone h3 family 31 (h3f3a): 100% of metaphases examined. 13. histone h3 family 31 (h3f3a): 100% of metaphases examined. 14. mll (histone h4): 100% of metaphases examined. 15. calr |
| C2348517 | he was admitted to the [**hospital unit name 42**] for observation and management of his condition. the patient was started on chemotherapy for his <1CUI> favorable hodgkin lymphoma </1CUI> . the patient's condition improved and he was discharged to home on [**2013-04-04**]. 2. favorable hodgkin lymphoma: the patient was diagnosed with favorable hodgkin lymphoma in [**2012-08-02**]. he received chemotherapy and was in remission. 3. hepatitis c: the patient was diagnosed with hepatitis c in [**2012-08-02**]. he was treated with interferon and ribavirin. 4. chronic obstructive pulmonary disease: the patient had a history of chronic obstructive pulmonary disease. 5. hypertension: the patient had a history of hypertension. 6. hyperlipidemia: the patient had a |
| C2348639 | the patient's cardiac rhythm was regular at rate of 60-70. the patient's electrocardiogram showed a normal sinus rhythm with <1CUI> t waves biphasic </1CUI> . the patient's cardiac enzymes were within normal limits. 2. the patient's white blood cell count was 12.4 with a neutrophil predominance. the patient's blood cultures were negative. 3. the patient's chest x-ray showed a right upper lobe infiltrate with consolidation of the right lower lobe. the patient's chest x-ray was read as likely viral pneumonia. 4. the patient was started on ceftriaxone and vancomycin for a possible bacterial pneumonia. 5. the patient's fever and cough resolved with the antibiotics. 6. the patient's electrocardiogram showed a normal sinus rhythm with t waves biphasic. 7. the patient's cardiac enzymes were within normal limits. 8. |
| C2348499 | 3. myeloid lineage mutations: - <1CUI> flt3 internal tandem duplication </1CUI> (<1cui> flt3 itd <1cui>). - npm1c. - cebpa mutation. - mll mutation. - kras mutation. - egfrviii mutation. - p53 mutation. - braf mutation. - idh1 mutation. - idh2 mutation. - jak2v617f mutation. - mpl w515k mutation. - calr mutation. - met exon 14 mutation. - pik3ca mutation. - akt1 mutation. - pten mutation. - stat3 mutation. - map3k5/asxl1 mutation. - tet2 mutation. - idh1/2 r132h mutation. - idh1/2 r140q mutation. - idh1/2 r172h |
| C2348501 | she had a right inguinal hernia repair in [**2014-04-15**]. she was started on prednisone 10mg daily for her rash in [**2015-05-07**]. her rash has resolved and she is now on 5mg of prednisone daily. she was started on 20mg of levofloxacin for her right inguinal hernia repair. her <1CUI> flt3-tkd mutation </1CUI> was positive and she was started on 60mg of dasatinib. she was started on 1000mg of azathioprine for her [**last name (un) 1739**]-lymphocytosis. she was started on 500mg of methotrexate for her acute lymphoblastic leukemia. she was started on 10mg of melphalan for her acute lymphoblastic leukemia. she was started on 2000mg of cyclosporine for |
| C2348509 | 3. rheumatoid arthritis. 4. hypercholesterolemia. 5. hypertension. 6. hypothyroidism. 7. cervical stenosis. 8. [**2013-03-26**] lumbar fusion. 9. [**2013-03-26**] carotid stenosis. 10. [**2013-03-26**] fibromyalgia. 11. [**2013-03-26**] <1CUI> fascicular tachycardia </1CUI> . 12. [**2013-03-26**] cervical spine strain. 13. [**2013-03-26**] pneumothorax. 14. [**2013-03-26**] subclavian steal. 15. [**2013-03-26**] tos |
| C2348639 | 76900 |||| 11645 |||| 19720 |||| ecg_report |||| 2014-05-15 17:16:00.0 |||| |||| |||| |||| sinus rhythm. 2. <1CUI> t waves biphasic </1CUI> . 3. pr interval is normal. 4. qrs duration is normal. 5. p wave axis is normal. 6. qrs axis is normal. 7. p wave axis is normal. 8. qrs axis is normal. 9. p wave axis is normal. 10. qrs axis is normal. 11. pr interval is normal. 12. qrs duration is normal. 13. p wave axis is nor |
| C2348640 | there was no st elevation, depression or inversion. <1CUI> t waves flat by ekg finding </1CUI> . t wave inversions were noted in leads v1 through v3. there was no st elevation, depression or inversion. t waves flat by ekg finding. t wave inversions were noted in leads v1 through v3. t wave inversions were noted in leads v1 through v3. t wave inversions were noted in leads v1 through v3. t wave inversions were noted in leads v1 through v3. t wave inversions were noted in leads v1 through v3. t wave inversions were noted in leads v1 through v3. t wave inversions were noted in leads v1 through v3. t wave inversions were noted in leads v1 through v3. t wave inversions were noted in leads v1 through v3. t wave inversions were noted in leads v1 through v3. t wave inversions were noted in leads v1 through v3. t wave inversions were noted in leads v1 through v3. t wave inversions were noted in |
| C2348377 | there is no evidence of a myocardial infarction. the echocardiogram showed an ejection fraction of 50%, mildly decreased left ventricular systolic function, and moderate left ventricular diastolic dysfunction. the patient's ectopic ventricular rhythm was initially treated with digoxin and a beta blocker. the patient was transferred to the [**hospital unit name 80**] for further evaluation and management. # <1CUI> ectopic ventricular rhythm by ekg finding </1CUI> : the patient's ectopic ventricular rhythm was initially treated with digoxin and a beta blocker. the patient was transferred to the [**hospital unit name 80**] for further evaluation and management. # 1. dysrhythmia: the patient's dysrhythmia was initially treated with digoxin and a beta blocker. the patient was transferred to the [**hospital unit name 80**] for further evaluation and management. # 2. lactate dehydrogenase: the patient's |
| C2348501 | 4. myeloperoxidase. 5. neutrophil lipase. 6. erythrocyte sedimentation rate. 7. c-reactive protein. 8. beta-human chorionic gonadotropin. 9. human chorionic gonadotropin. 10. estriol. 11. estradiol. 12. progesterone. 13. testosterone. 1. lymphocytes: the lymphocyte count is 550, which is normal. 2. basophils: the basophil count is 17, which is normal. 3. eosinophils: the eosinophil count is 4, which is normal. 4. <1CUI> flt3-tkd mutation </1CUI> : the flt3-tkd mutation is negative. 5. cd56-negative native: the cd56-negative native is negative |
| C2348517 | the patient was admitted to the icu for observation and was found to have a large right inguinal hernia. on [**2014-03-04**], the patient was taken to the or for repair of the hernia and excision of the inguinal mass. the patient's pathology was consistent with a <1CUI> favorable hodgkin lymphoma </1CUI> . the patient was transferred to the [**hospital1 2**] on [**2014-03-07**] for further management of the hodgkin's lymphoma. pt was transferred to the [**hospital1 2**] on [**2014-03-07**] for further management of the hodgkin's lymphoma. on [**2014-03-12**], the patient underwent a bone marrow biopsy, which showed no evidence of disease. on [**2014-03-14**], the patient underwent a repeat bone marrow biopsy, which showed no evidence of disease |
| C2348518 | 3. history of cad s/p cabg x 2 times in 1990. 4. history of dm. 5. history of hypertension. 6. history of <1cui> <1CUI> favorable non-hodgkin lymphoma </1CUI> <1cui> in 1995. 7. history of pe. 8. history of mi. 9. history of gerd. 10. history of pna. 11. history of pe. 12. history of pna. 13. history of hip fracture. 14. history of pna. 15. history of mi. 16. history of pna. 17. history of pna. 18. history of pna. 19. history of pna. 20. history of pna. 21. history of pna. 22. history of pna. 23. history of pna. 24. |
| C2348543 | the patient was discharged home with a prescription for 100mg of melphalan on the 25th of october. he was seen by the oncology clinic on [**2013-10-29**] for a follow-up. at that time, he was found to have a <1CUI> stringent complete response (scr) of multiple myeloma or plasma cell leukemia </1CUI> . he was also found to have anemia, thrombocytopenia, and hypertriglyceridemia. the patient was started on melphalan on [**2013-10-25**] and was seen by the oncology clinic on [**2013-10-29**] for a follow-up. at that time, he was found to have a stringent complete response (scr) of multiple myeloma or plasma cell leukemia. he was also found to have anemia, thrombocytopenia, and hypertriglyceridemia. the patient was started on melphalan on [**2013-10- |
| C2348639 | <1CUI> t waves biphasic </1CUI> . r wave progression in v1, v2, v3, v4, v5. t waves biphasic in v1, v2, v3, v4, v5. ste in v2, v3, v4, v5. r wave progression in v1, v2, v3, v4, v5. t waves biphasic in v1, v2, v3, v4, v5. ste in v2, v3, v4, v5. r wave progression in v1, v2, v3, v4, v5. t waves biphasic in v1, v2, v3, v4, v5. ste in v2, v3, v4, v5. r wave progression in v1, v2, v3, v4, v5. t waves biphasic in v1, v2, v3, v4, v5. ste in v2, v3, |
| C2348640 | he was then transferred to the [**hospital unit name 33**] for further management. on [**2011-03-23**], the patient was admitted to the [**hospital unit name 33**] with a diagnosis of ami with lv dysfunction, lvh, and <1CUI> t waves flat by ekg finding </1CUI> . he underwent a coronary angiogram which showed a 90% occlusion of the proximal lad, a 70% occlusion of the proximal rca, and a 50% occlusion of the mid rca. he underwent a coronary artery bypass graft with a left internal mammary artery to the lad, a saphenous vein graft to the rca, and a saphenous vein graft to the mid rca. his postoperative course was unremarkable. his ejection fraction on the day of discharge was 40%. he was discharged on [**2011-04-13**] with a followup with his cardiologist |
| C2348499 | there is a right pleural effusion. there is no evidence of pleural effusion or fluid in the pericardial sac. the left kidney is normal in size and position. the right kidney is enlarged. the spleen is enlarged. the liver is normal in size and position. radiology: the patient was imaged with a portable chest x-ray. there is a right pleural effusion. response: the patient was started on pressors. the patient was started on a levophed infusion. discharge diagnoses: 1. 1. aml. 2. 1. <1CUI> flt3 internal tandem duplication </1CUI> . 3. 1. mds. 4. 1. cytomegalovirus infection. 5. 1. pneumonia. 6. 1. aspiration. 7. 1. dehydration. 8. 1. hypokalemia. 9. 1. hypocalcemia. |
| C2348501 | patient was discharged on day 15 with a bone marrow biopsy showing complete remission. the patient was started on chemotherapy on [**2013-01-14**]. the patient was referred to [**hospital 530**] for further management of her <1CUI> flt3-tkd mutation </1CUI> . the patient was seen at [**hospital 530**] on [**2013-02-20**] with a bone marrow biopsy showing <1cui> flt3-tkd mutation <1cui> and was started on chemotherapy. the patient was seen in clinic on [**2013-03-21**] with a bone marrow biopsy showing <1cui> flt3-tkd mutation <1cui> and was started on chemotherapy. the patient was seen in clinic on [**2013-05-22**] with a bone marrow biopsy showing <1cui> flt3-tkd mutation < |
| C2348509 | the patient's chest x-ray showed no evidence of pneumothorax, and her chest x-ray was stable. the patient's cpk was elevated at 3700. the patient was treated with aspirin and heparin and was admitted to the medicine service for further workup and management of her myocardial infarction. the patient was found to have no evidence of an active myocardial infarction. the patient's electrocardiogram showed 1:1 conduction, no evidence of ischemia, and no evidence of <1CUI> fascicular tachycardia </1CUI> . the patient was diagnosed with a myocardial infarction secondary to a right coronary artery occlusion. the patient was treated with aspirin, heparin, and nitroglycerin. the patient was transferred to the cardiac surgery service for further workup and management of her myocardial infarction. the patient was found to have no evidence of an active myocardial infarction. the patient's electrocardiogram showed 1:1 conduction, no evidence of ischem |
| C2348543 | patient was transferred to [**hospital1 121**] for further management. she was admitted to the [**hospital unit name 110**] for further management. past medical history: multiple myeloma with plasma cell leukemia. pertinent results: cbc: wbc 2.5, hgb 11.3, hct 31.3, mcv 94, mch 30.4, mchc 34.9, rbc 4.22, plt count 260, neutrophils 64.3, lymphocytes 28.3, monocytes 4.9, eos 0.5, baso 0.4. cxr: no acute pulmonary embolism. pertinent impression: 1. <1CUI> stringent complete response (scr) of multiple myeloma or plasma cell leukemia </1CUI> . 2. sepsis from e. coli. 3. chronic renal insufficiency. 4. hypoalbuminemia. |
| C2348639 | no evidence of any st elevation. <1CUI> t waves biphasic </1CUI> . no evidence of any bundle branch block. comprehensive echocardiography: [**2010-10-11**] the aortic valve leaflets (3) are mildly thickened. there is mild (1+) aortic regurgitation. the mitral valve leaflets are mildly thickened. there is mild (1+) mitral regurgitation. there is no pericardial effusion. there is no evidence of cardiac tamponade. the left ventricular cavity is mildly dilated. the left ventricular wall is mildly hypertrophied. the left ventricular systolic function is preserved. the left ventricular diastolic function is mildly impaired. the right ventricular cavity is mildly dilated. the right ventricular wall is mildly hypertrophied. the right ventricular systolic function is preserved. |
| C2348737 | there is no evidence of lymphadenopathy. the liver and spleen are normal in size and shape. there is no evidence of ascites or fluid in the abdominal cavity. there is a 2.3 cm lesion in the lower right abdomen, which is most likely a benign cyst. the lesion is stable in size. there is no evidence of metastatic disease. #1: cystic mass in the lower right abdomen, which is most likely a benign cyst. 2. gastric mass, which is consistent with a diagnosis of <1cui> <1CUI> gastric mixed adenocarcinoma </1CUI> . 3. omental torsion. 4. cystic lesion in the left adrenal gland. 5. increased liver size. 6. increased spleen size. 7. periportal inflammation in the liver. 8. ascites. 9. increased right renal cortical thickness. 10. increased right |
| C2348811 | sig: one (1) tablet po q6h (every 6 hours). disp:*60 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. <1CUI> toxicology finding </1CUI> 2. 1+ tachycardia 3. hypokalemia 4. 1+ tachypnea 5. 1+ hypertension discharge condition: good discharge instructions: 1. you should not take any medication that was not prescribed by your doctor. 2. you should not drive or operate heavy machinery until you have spoken to your doctor. 3. if you have any of the following symptoms, you should call the doctor immediately: - fever higher than 100.5 - shortness of breath - pain in your chest, abdomen or pelvis - seizures - weakness or numbness in your face, arm or leg - vision changes - severe headache - pain when you urinate - a change |
| C2348873 | sig: one (1) tablet po bid for 1 month. disp:*180 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. ruq mass 2. cholelithiasis 3. <1CUI> biliary </1CUI> sludge 4. <1cui> bilin-1 5. pancreatitis discharge condition: good discharge instructions: please call your doctor if you experience any of the following: 1. increased pain in your abdomen or chest 2. vomiting or diarrhea 3. fever 4. change in bowel movements or urination 5. any new or worsening symptoms followup instructions: you will need to follow up with your doctor in [**doctor first name **] at [**doctor first name **] [**doctor last name **] [**doctor company **] [**location (excluding state) **]. please call [** |
| C2348874 | sex: f service: general allowance: [**2014-07-21**] 07:00:00 allowance: [**2014-07-21**] 07:00:00 underlying diagnosis: 1. egd demonstrated a mass in the distal common bile duct. 2. <1CUI> biliary </1CUI> cystadenoma. 3. <1cui> bilin-2. medications on arrival: none. familiy history: the patient is a 56 year old woman who is an otherwise healthy individual. she is a teacher and has no significant past medical history. she has no significant family history. social history: the patient is a non-smoker, non-drinker, and is not on any medications. she is a teacher and has no significant past medical history. she has no significant family history. physical examination: the patient |
| C2348875 | he was discharged to home with a plan to follow up with his primary care physician in two weeks. past medical history: 1. gerd 2. hypertension 3. hyperlipidemia 4. chronic kidney disease 5. <1CUI> bilin-3 </1CUI> social history: he is a retired carpenter. he lives with his wife. he has no smoking history and drinks socially. family history: non-contributory physical exam: 60 year old man in no acute distress. vital signs: temp 97.2 bp 100/65 hr 70 rr 16 sat 96%ra general: well appearing, well nourished man. skin: no lesions. heent: perrla, eomi, anicteric sclera, no jvp. lungs: ctab. cv: rrr, no m/r/g, no s3/s4, no murmurs. abd: soft |
| C2348914 | <1CUI> hla-a24 positive cells present </1CUI> . 7. cmv: cmv igm negative, igg 1.0. 8. cmv pcr: cmv pcr negative. 9. hiv: hiv-1/2 igg, igm, and p24 antigen negative. 10. hcv: hcv igg negative. 11. hbsag: hbsag negative. 12. hbcab: hbcab negative. 13. vzv: vzv igg 1.02 (normal <1.1). 14. hsv-1 igg: hsv-1 igg 1.24 (normal <1.1). 15. hsv-2 igg: hsv-2 igg 1.05 (normal <1.1). 16. rpr: rpr nonreactive (<1:40). 17. chlamydia: chlamydia igg negative. 18. legionella: legionella |
| C2348811 | sig: one (1) tablet po bid for seven (7) days. discharge disposition: extended care discharge diagnosis: 1. <1CUI> toxicology finding </1CUI> 2. drug overdose discharge condition: stable discharge instructions: you should follow up with your primary care physician in 7 days to check your liver function and to have your blood sugar checked. please call your primary care physician if you experience any of the following: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) 26) 27) 28) 29) 30) 31) 32) 33) 34) 35) 36) 3 |
| C2348873 | the patient was admitted to the floor for further management and continued on his prior medications. a chest x-ray was performed on [**2013-02-26**] which showed a small right pleural effusion. a ct scan of the abdomen and pelvis was performed on [**2013-02-27**] which showed a small right pleural effusion and a small left pleural effusion, and no evidence of metastasis. the patient was started on levofloxacin 500mg po bid and was transferred to the [**doctor last name 506**] floor on [**2013-03-01**]. on [**2013-03-02**] the patient was transferred to the [**hospital1 2345**] for further management. on [**2013-03-03**] the patient underwent a right thoracotomy and a biopsy of the pleural effusion was performed. pathology showed a <1cui> <1CUI> bilin-1 </1CUI> <1 |
| C2348874 | 12. hypercholesterolemia. 13. gastritis. 14. [**2013-01-22**] c-t abd: + ascites. 15. <1cui> <1CUI> bilin-2 </1CUI> . 16. cholecystolithiasis. 17. pvd. 18. nephrolithiasis. 19. [**2013-01-22**] c-t pelvis/extremities: + left inguinal hernia. 20. + right inguinal hernia. 21. + left inguinal hernia. 22. + right inguinal hernia. 23. + left inguinal hernia. 24. + right inguinal hernia. 25. + left inguinal hernia. 26. + right inguinal hernia. 27. + left inguinal hernia. 2 |
| C2348875 | lymphadenectomy was also done. in the setting of a history of pancreatico <1CUI> biliary </1CUI> malignancy, the patient underwent an ercp, which showed a stricture at the gastro-duodenal junction and a <1cui> bilin-3 [**hospital unit name 44**] lesion. an attempt was made to dilate the stricture, but this was unsuccessful. the patient was then taken to the or for a laparoscopic choledochoduodenostomy. # perioperative course: the patient was taken to the or at [**hospital 12**] by [**last name (un) 372**] and [**last name (un) 373**] on [**2013-05-28**]. anesthesia was provided by [**first name8 (namepattern2) 374**] [**first name8 (namepattern2) **] [**last name (un) 375**]. the patient was placed in the left lateral decub |
| C2348913 | mildly elevated platelet count. no evidence of disseminated intravascular coagulopathy. no evidence of acute or chronic hemorrhagic or thrombotic process. 4. no evidence of acute or chronic infection. 5. no evidence of malignancy. [**last name (un) 76**] <1CUI> hla-a1 positive cells present </1CUI> [**2018-11-27**] 12:55:00 title: medication report for: [**first name (titles) **] [**last name (un) **] [**md number 1551**] date of report: [**2018-12-18**] date of medication: [**2018-11-27**] date/time of report: [**2018-12-18**] 12:55:00 [**hospital number **] medication report for: [**first name (titles) ** |
| C2348914 | the patient's hla-a24 positive cells are present in the bone marrow. the patient's hla-a24 positive cells are present in the bone marrow. there are no <1CUI> hla-a24 positive cells present </1CUI> in the peripheral blood. the patient's bone marrow is also positive for hla-b27. the patient's bone marrow is also positive for hla-b27. the patient's bone marrow is also positive for hla-b27. the patient's bone marrow is also positive for hla-b27. the patient's bone marrow is also positive for hla-b27. the patient's bone marrow is also positive for hla-b27. the patient's bone marrow is also positive for hla-b27. the patient's bone marrow is also positive for hla-b27. the patient's bone marrow is also positive for hla-b27. the patient's bone marrow is also positive for |
| C2348737 | patient was started on 800 mg of leukine daily. the patient was started on ppi for gastric ulcer prophylaxis. the patient was also started on a ppi for gastric ulcer prophylaxis. the patient had a follow-up endoscopy on [**2011-05-05**] which showed no evidence of bleeding. the patient was then discharged from the hospital on [**2011-05-06**] with a follow-up appointment with [**hospital1 2**] oncology for further management of his <1cui> <1CUI> gastric mixed adenocarcinoma </1CUI> <1cui>. followup was recommended with [**hospital1 2**] oncology. 1. gastric mixed adenocarcinoma: the patient was started on a ppi for gastric ulcer prophylaxis. the patient had a follow-up endoscopy on [**2011-05-05**] which showed no evidence of bleeding. 2. |
| C2348873 | discharge date: [**2016-08-02**] date of birth: [**1937-03-10**] sex: f service: medicine allergies: penicillins / erythromycin / sulfa / codeine attending:[**attending info 280**] chief complaint: elevated liver enzymes major surgical or invasive procedure: cholecystectomy history of present illness: 80 y/o female with a history of ebv, hcv, [**hospital unit name 22**] cirrhosis, [**1cui**] <1CUI> bilin-1 </1CUI> , and gallstones who presented with elevated liver enzymes. past medical history: 1. hcv 2. ebv cirrhosis 3. [**1cui**] bilin-1 4. gallstones 5. htn 6. hyperlipidemia 7. obesity 8. cop |
| C2348874 | 5. splenomegaly. 6. ascites. 7. pregnancy. 8. bilary sludge. 9. <1CUI> biliary </1CUI> in-2. 10. surgical clips on the right kidney. 11. hydrothorax. 12. peg tube. 13. aicd. 14. diabetes. 15. hyperlipidemia. 16. hypertension. 17. adenocarcinoma of the lung. 18. dementia. 19. cad. 20. cva. 21. carcinoma of the prostate. 22. carcinoma of the bladder. 23. carcinoma of the skin. 24. carcinoma of the breast. 25. carcinoma of the uterus. 26. carcinoma of the colon. 27. carcinoma of the rectum. 2 |
| C2348875 | discharge date: [**2016-03-15**] date of birth: [**1935-09-22**] sex: f service: surgery allergies: patient recorded as having no known allergies to drugs attending:[**attending info 300**] chief complaint: 1. pancreatitis 2. cholecystitis 3. bile duct obstruction major surgical or invasive procedure: 1. 1. transjugular intrahepatic portosystemic shunt 2. 2. cholecystectomy with roux-en-y choledochoduodenostomy 3. 3. <1CUI> biliary </1CUI> drainage history of present illness: 86 year old female with a history of bilary sludge, 3 episodes of acute pancreatitis, and recent admission for pancreatitis and cholecystitis, who was found to have a 1.5 |
| C2348908 | carcinoma in situ. final diagnosis: 1. breast carcinoma with necrosis. 2. 1cui. 3. 1cui. 4. <1cui> <1CUI> erbb2 negative </1CUI> . 5. her2/neu 2+. 6. 1cui. 7. 1cui. 8. 1cui. 9. 1cui. 10. 1cui. 11. 1cui. 12. 1cui. 13. 1cui. 14. 1cui. 15. 1cui. 16. 1cui. 17. 1cui. 18. 1cui. 19. 1cui. 20. 1cui. 21. 1cui. 22. 1cui. 23. 1cui. 24. 1cui. 25. 1cui |
| C2348913 | the patient was intubated and mechanically ventilated. the patient was extubated on postoperative day #2. the patient was transferred to the [**hospital unit name 59**] on postoperative day #3 for further management of her condition. 2. the patient was found to have a <1cui> <1CUI> hla-a1 positive cells present </1CUI> in her lungs. this was felt to be likely secondary to her recent transplant and the use of a donor lung. 3. the patient had a right pleural effusion which was drained on postoperative day #4. 4. the patient had a right lower lobe pneumonia which was treated with antibiotics. 5. the patient had a right lower lobe pneumothorax which was treated with a chest tube. 6. the patient had a right lower lobe empyema which was treated with antibiotics. 7. the patient had a right lower lobe cavitation which was treated with antibiotics. 8. the patient had a right lower lobe abscess which was treated with ant |
| C2348665 | she had a small right pleural effusion, but no evidence of pneumonia. the patient's electrolytes were normal. the patient's ekg showed a normal sinus rhythm, normal axis, and no evidence of ischemia. 2. the patient's <1CUI> adme finding </1CUI> were normal. 3. the patient's ct scan of the abdomen was normal. 4. the patient's ct scan of the pelvis was normal. 5. the patient's ct scan of the head was normal. 6. the patient's ct scan of the chest was normal. 7. the patient's mri of the brain was normal. 8. the patient's mri of the spine was normal. 9. the patient's mri of the abdomen was normal. 10. the patient's mri of the pelvis was normal. 11. the patient's mri of the liver was normal. 12. the patient's mri of the spleen was normal. 13 |
| C2348874 | sig: one (1) tablet po bid for 30 days. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. diffuse esophageal spasm 2. gerd 3. <1cui> <1CUI> bilin-2 </1CUI> 4. hypertension discharge condition: good. discharge instructions: please follow up with your primary care physician for your blood pressure, hypertension, and any other medical conditions. followup instructions: please follow up with your primary care physician for your blood pressure, hypertension, and any other medical conditions. please call your primary care physician with any questions or concerns. please call [**name11 (nameis) **] with any questions or concerns. please call [**telephone/fax (2) 479**] with any questions or concerns. please call [**telephone/fax (3) 480**] with any questions or concerns. |
| C2348875 | sig: one (1) tablet po qd (once a day). disp:*60 tablet(s)* refills:*2* discharge disposition: home with service discharge diagnosis: 1. hepatocellular carcinoma s/p rfa 2. <1CUI> biliary </1CUI> intracaecumenal neoplasia-3 3. cholecystolithiasis 4. gallstone disease 5. gastritis 6. peptic ulcer 7. esophageal mucosis 8. gastro-oesophageal reflux disease 9. hypertension 10. hyperlipidemia 11. obesity 12. hypercholesterolemia 13. hypertrichothermia 14. methicillin |
| C2348664 | the left testicle is normal. the right testicle is normal. the epididymis is normal bilaterally. the spermatozoa are normal. the left testicular mass is stable. the right testicular mass is stable. the left testicular mass is consistent with a benign teratoma. the right testicular mass is consistent with a benign teratoma. the left testicular mass is consistent with a benign teratoma. the right testicular mass is consistent with a benign teratoma. the left testicular mass is consistent with a benign teratoma. the right testicular mass is consistent with a benign teratoma. 1. <1CUI> testicular mixed choriocarcinoma and yolk sac tumor </1CUI> : the patient had a mixed choriocarcinoma and yolk sac tumor of the testis. he was treated with 3 cycles of bleomycin, etoposide, and cyclophosphamide. he had a good response to treatment. 2. cryptorchidism: the patient had a left cryptorchidism. 3 |
| C2348726 | she was transferred to [**hospital1 78**] for further management. on admission to [**hospital1 78**], the patient was found to have a 4.5 cm mass in the right upper quadrant, which was thought to be metastatic. the patient underwent a ct scan of the abdomen and pelvis which showed a 4.5 cm mass in the right upper quadrant of the abdomen with a small amount of ascites. the patient was also found to have a mass in the liver, which was thought to be metastatic. she was transferred to [**hospital1 78**] for further management. the patient was diagnosed with <1cui> <1CUI> pleomorphic spindle and giant cell carcinoma of gallbladder </1CUI> <1cui>. the patient was treated with chemotherapy and was found to have a complete response to treatment. she was also found to have a metastatic mass in the liver, which was treated with chemotherapy. the patient was discharged from the hospital on [**2015-11-10**]. |
| C2348811 | he was also found to have a urinary tract infection. the patient was transferred to the [**hospital unit name 41**] for further management. [**doctor first name **] [**last name (stitle) **] md [**md number 682**] [**md number 683**] [**2018-09-25**] # 2. the patient was found to have an elevated serum creatinine. # 3. the patient was found to have a <1CUI> toxicology finding </1CUI> . # 4. the patient was found to have a urinary tract infection. # 5. the patient was found to have a positive blood culture. # 6. the patient was found to have a positive sputum culture. # 7. the patient was found to have a positive urine culture. # 8. the patient was found to have a positive blood culture. # 9. the patient was found to have a positive sputum culture. # 10. the patient was found to have a positive urine |
| C2348819 | no evidence of metastatic disease was found. the patient had a right axillary lymph node dissection. the patient had a right breast mastectomy. the patient had a right breast reconstruction with a tissue expander. the patient had a right chest wall reconstruction with a latissimus dorsi flap. 2. the patient was transferred to the floor on [**2013-10-28**] and was discharged home on [**2013-11-06**]. 3. the patient had a right breast tumor that was er-negative, pr-negative, erbb2-negative. 4. the patient had a right breast tumor that was 3.6 cm in size. 5. the patient had a right breast tumor that was grade 3. 6. the patient had a right breast tumor that was infiltrating ductal carcinoma not otherwise specified. 7. the patient had a right breast tumor that was <1CUI> triple-negative breast cancer result </1CUI> . 8 |
| C2348873 | date of birth: [**1944-09-28**] sex: f service: surgery history of present illness: this is a 71 year old female with a history of bilateral cholecystectomy in [**1988**], and a history of <1CUI> biliary </1CUI> sludge. she was found to have a mass in her right hepatic lobe and a mass in her right renal vein. the patient is a former smoker and has a history of hypertension and hyperlipidemia. she was seen in the [**doctor first name **] in [**2015-04-15**] and was found to have a mass in the right hepatic lobe, which was consistent with a [**1cui] bilin-1 and was referred to the [**hospital1 19**] for further evaluation. she was also found to have a mass in the right renal vein. she was referred to the [**hospital1 19**] for further evaluation. |
| C2348874 | the patient was started on warfarin. she was also started on rifampin for suspected tuberculosis. the patient was also found to have a <1cui> <1CUI> bilin-2 </1CUI> . she was started on att for suspected tuberculosis. she was transferred to the floor on [**2013-05-14**]. on [**2013-05-14**] she had a chest x-ray and an abdominal ct scan. she was transferred to the floor on [**2013-05-14**]. she was found to have a <1cui> bilin-2 . she was started on att for suspected tuberculosis. on [**2013-05-14**] she was transferred to the floor. on [**2013-05-14**] she was transferred to the floor. she was found to have a <1cui> bilin-2 . she was started on att for suspected tuberculosis. on [**2013- |
| C2348875 | the patient was also found to have a small left adrenal mass. the patient was referred to the surgeon for further evaluation and potential resection. the patient was also found to have a small liver mass, which was likely a metastasis. the patient was also found to have a <1cui> <1CUI> bilin-3 </1CUI> . the patient was referred to the hepatologist for further evaluation and potential intervention. the patient was also found to have a large ascites and was placed on diuretics. 1. ascites: the patient was placed on diuretics for the management of her ascites. 2. biliary strictures: the patient was referred to the surgeon for further evaluation and potential intervention for her biliary strictures. 3. bilin-3: the patient was referred to the hepatologist for further evaluation and potential intervention for her bilin-3. 4. adrenal mass: the patient was referred to the surgeon for further evaluation and potential resection for her adrenal mass. 5. liver mass: the patient was referred to the hepatologist for further evaluation and potential intervention |
| C2348988 | cystic masses are seen in the right and left breast. these are likely to be simple cysts. no focal masses are seen in the breast tissue. there is a small amount of calcifications in the right breast. the calcifications are not of significance. there is a small amount of <1cui> <1CUI> homogeneous fat echotexture </1CUI> in the right breast. no masses are seen in the right or left axillary lymph nodes. there is no pleural effusion. the aorta is not dilated. the pulmonary arteries are not dilated. the pleura is not effused. the liver is normal. the spleen is normal. the kidneys are normal. the pancreas is normal. the gallbladder is not dilated. the biliary tree is not dilated. the gastrointestinal structures are normal. the pancreatic duct is not dilated. the pancreatic duct is not dilated. the adrenal glands are normal. the thyroid gland is normal. the parath |
| C2348989 | no focal lesions or free fluid are seen. impression: normal appearing subcutaneous tissues. 1. mildly increased subcutaneous fat. 2. no focal lesions or free fluid. 3. <1CUI> homogeneous fibroglandular echotexture </1CUI> . 4. no focal lesions. 5. no free fluid. 6. no lymphadenopathy. 7. no splenomegaly. 8. no liver lesions. 9. no ascites. 10. no pleural effusion. 11. no pericardial effusion. 12. no focal lesions. 13. no free fluid. 14. no lymphadenopathy. 15. no splenomegaly. 16. no liver lesions. 17. no ascites. 18. no pleural effusion. 19. no pericardial effusion. 20. no focal lesions. 21. no free fluid. 22. no l |
| C2349020 | he was also noted to have a s/p left lower lobectomy. the patient was referred to the medical oncology service for further management. on the medical oncology service, the patient was started on r-chop chemotherapy for his <1cui> <1CUI> unfavorable non-hodgkin's lymphoma </1CUI> <1cui>. the patient's course was complicated by a number of complications including neutropenic fever, which was treated with antibiotics. the patient was also noted to have a small pleural effusion, which was drained. the patient's chemotherapy was held for a period of time due to his neutropenic fever. the patient was also noted to have a small pleural effusion, which was drained. the patient was discharged home on [**2014-10-28**] with a plan for further chemotherapy. followup in the medical oncology clinic is recommended. the patient's prognosis is guarded. his prognosis is guarded due to his unfavorable non-hodg |
| C2349110 | discharge date: [**2013-05-27**] date of birth: [**1949-10-11**] sex: m service: medicine history of present illness: the patient is a 63 year old man with a history of hypertension, hyperlipidemia, and a history of a left leg amputation. the patient was admitted to the [**hospital1 10**] [**hospital1 11**] [**hospital1 12**] for a left leg amputation on [**05-08**]. the patient had a left leg amputation due to gangrene. the patient was placed on [**05-09**] for a <1CUI> vascular access device complications </1CUI> . the patient was transferred to [**hospital1 27**] [**hospital1 28**] on [**05-10**] for a left leg amputation. the patient was transferred to [**hospital1 31**] on [ |
| C2349117 | no other evidence of ischemia was noted. she was transferred to the icu and was started on iv levophed and nitroglycerin for management of her tachycardia. she was also started on iv furosemide for her hypertension. she was transferred to [**hospital1 2**] for further management of her <1CUI> ventricular tachycardia storm </1CUI> . past medical history: 1. hypertension 2. hypercholesterolemia 3. gerd 4. hypothyroidism 5. s/p mi in [**2013**] 6. s/p cabg in [**2013**] 7. s/p bypass in [**2013**] social history: she is a retired school teacher. she is married and lives with her husband. she is a non-smoker and drinks alcohol occasionally. family history: non-contributory physical exam: vs: 98.6, 137/80, 15, 9 |
| C2349122 | he was started on rituximab 375 mg/m2 weekly for 4 weeks. on [**2011-09-21**], he was seen by the hematology team who noted that his m-protein had dropped to <100 mg/24 hours, a <1CUI> very good partial response (vgpr) of multiple myeloma or plasma cell leukemia </1CUI> . he was continued on rituximab and was started on lenalidomide 10 mg orally daily. on [**2011-09-26**], he was seen by the hematology team who noted that his m-protein had dropped to <100 mg/24 hours, a very good partial response (vgpr) of multiple myeloma or plasma cell leukemia. on [**2011-10-04**], he was seen by the hematology team who noted that his m-protein had dropped to <100 mg/24 hours, a very good partial response (vgpr) of multiple my |
| C2349148 | 3. adrenal mass. 3. adrenal mass. 4. renal cell carcinoma. 5. metastatic melanoma. 6. 1999 - <1cui> <1CUI> well differentiated adrenal cortex carcinoma </1CUI> . 7. 2002 - melanoma. 8. 2003 - metastatic melanoma. 9. 2004 - melanoma. 10. 2005 - metastatic melanoma. 11. 2006 - melanoma. 12. 2007 - melanoma. 13. 2008 - metastatic melanoma. 14. 2009 - melanoma. 15. 2010 - metastatic melanoma. 16. 2011 - melanoma. 17. 2012 - melanoma. 18. 2013 - melan |
| C2348915 | 3. sickle cell disease. 4. <1CUI> hla-a2 positive cells present </1CUI> . 5. increased platelet count. 6. increased white blood cell count. 7. increased hemoglobin. 8. increased hematocrit. 9. increased red blood cell count. 2. hla-a2 positive cells present. the patient was also noted to have anemia with a hematocrit of 29.1 and a hemoglobin of 9.3. the patient was also noted to have an elevated white blood cell count of 17.8 and platelet count of 501. the patient's creatinine was 1.3 and his bun was 20. 3. sickle cell disease. the patient was noted to have hla-a2 positive cells present. the patient's hla-a2 positive cells were 21. 4. increased platelet count. the patient's platelet count was 501. |
| C2348956 | 2. diffuse bilateral pleural effusions. 3. right paratracheal lymphadenopathy. 4. multinodular left thyroid gland with a 1.3 cm nodule in the left lobe. 5. echogenic foci in the left kidney. 6. <1CUI> heterogeneous echotexture </1CUI> of the right breast. dicom radiology report (continued) initials (study) [**2017-03-21**] contrast agent/syringe 10 ccs contrast 100 ml reason: ruq us. technical/interpretive instructions: please hold saliva for 1 hour prior to the study. please hold all food and drink for 4 hours prior to the study. please hold all medications for 4 hours prior to the study. please hold all food and drink for 1 hour after the study. please hold all medications for 2 hours after the study. please drink 10 |
| C2348988 | no significant focal lesions were identified. right breast: 1. no evidence of a mass or focal lesion. 2. no significant asymmetry. 3. no significant calcifications. 4. no significant focal lesions. 5. <1cui> <1CUI> homogeneous fat echotexture </1CUI> . 6. no evidence of a mass or focal lesion. 7. no significant asymmetry. 8. no significant calcifications. 9. no significant focal lesions. 10. no evidence of a mass or focal lesion. 11. no significant asymmetry. 12. no significant calcifications. 13. no significant focal lesions. 14. no evidence of a mass or focal lesion. 15. no significant asymmetry. 16. no significant calcifications. 17. no significant focal lesions. 18. no evidence of a mass or focal lesion. 19. no significant asymmetry. 20. no significant calcifications. 21. no significant focal lesions. 22. no |
| C2349117 | sig: one (1) tablet po bid (2 times a day) (2 times a day). discharge disposition: home with service discharge diagnosis: 1. coronary artery disease 2. atrial fibrillation 3. <1CUI> ventricular tachycardia storm </1CUI> 4. chronic obstructive pulmonary disease discharge condition: good. discharge instructions: 1. follow up with your cardiologist within one week. 2. follow up with your primary care physician within two weeks. 3. you should continue to take your medications as prescribed. 4. you should avoid any strenuous activity. 5. you should avoid any smoking. 6. you should avoid any alcohol. 7. you should avoid any caffeine. 8. you should avoid any salt. 9. you should avoid any fatty or greasy foods. 10. you should avoid any heavy lifting. 11. you should avoid any b |
| C2349118 | on postoperative day 3, the patient's blood pressure was noted to be elevated, with a systolic blood pressure of 180 mmhg. the patient was transferred to the [**hospital1 121**]'s [**location (un) 31**] for further evaluation and management. the patient was found to have a sinus tachycardia with a rate of 120 beats per minute, and was treated with verapamil. the patient was diagnosed with a <1CUI> verapamil-sensitive ventricular tachycardia </1CUI> . past medical history: 1. hypertension 2. hyperlipidemia 3. diabetes mellitus 4. aortic stenosis 5. mitral valve prolapse social history: the patient is a retired businessman. he is married and has two children. he does not smoke or drink alcohol. he is a former cocaine and marijuana user. he denies any illicit drug use. family history: the patient's father died of a myocard |
| C2349122 | on [**2018-04-12**] he was started on vad (vincristine, doxorubicin, and dexamethasone) chemotherapy. he was admitted on [**2018-04-13**] for neutropenic fever and started on iv antibiotics. he was discharged on [**2018-04-17**] with a diagnosis of neutropenic fever, secondary to multiple myeloma, and was continued on vad chemotherapy. he was followed up in the clinic and was found to have a <1cui> <1CUI> very good partial response (vgpr) of multiple myeloma or plasma cell leukemia </1CUI> . past medical history: 1. multiple myeloma. 2. hyperlipidemia. 3. hypertension. 4. hypothyroidism. 5. hypercalcemia. social history: 1. he has a wife, [**last name (stitle) 1651**], who lives with him |
| C2349148 | discharge date: [**2014-05-13**] date of birth: [**1951-07-17**] sex: m service: [**hospital unit name 65**] allergies: patient recorded as having no known allergies to drugs attending:[**attending info 109**] chief complaint: adrenal mass major surgical or invasive procedure: adrenalectomy history of present illness: 55 yo male with a 1.5 cm left adrenal mass, not causing any symptoms, who was referred to surgery for consideration of resection. patient has a past medical history of <1CUI> well differentiated adrenal cortex carcinoma </1CUI> . he had a left adrenalectomy in [**2013**] and a right adrenalectomy in [**2014**]. the patient had been followed by [**doctor last name 78**] for several years and was seen in the [**do |
| C2348915 | 3. eosinophilic granuloma. 4. hodgkin's disease. 5. lymphocytic interstitial pneumonia. 6. <1CUI> hla-a2 positive cells present </1CUI> . discharge condition: good. discharge instructions: please follow up with your primary care physician in [**2011-09-28**]. followup instructions: please follow up with your primary care physician in [**2011-09-28**]. please call your primary care physician if you experience any shortness of breath, chest pain, or fever. please call your primary care physician if you notice any new skin lesions or changes. please call your primary care physician if you notice any new swelling, pain, or redness in your lymph nodes. discharge condition: good. discharge disposition: home with service [**name5 (md) **] [**name7 (md) 267**] md [**md number |
| C2348989 | right axillary vein was not visualized. the right subclavian vein was not visualized. the right internal jugular vein was not visualized. the left internal jugular vein was visualized with a <1cui> <1CUI> homogeneous fibroglandular echotexture </1CUI> . the left subclavian vein was visualized with a <1cui> homogeneous fibroglandular echotexture. the carotid arteries were visualized with normal color flow. the right common carotid artery was visualized with a <1cui> homogeneous fibroglandular echotexture. the left common carotid artery was visualized with a <1cui> homogeneous fibroglandular echotexture. the right external carotid artery was visualized with a <1cui> homogeneous fibroglandular echotexture. the left external carotid artery was visualized with a <1cui> homogeneous fibroglandular echotexture. the left vertebral artery was visualized with a <1cui |
| C2349117 | discharge date: [**2014-11-02**] date of birth: [**1949-06-06**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 206**] chief complaint: <1CUI> ventricular tachycardia storm </1CUI> major surgical or invasive procedure: none history of present illness: 66 year old woman with a history of cad, dm, and htn who presented to the [**doctor first name 2**] with a 2 day history of chest pain and palpitations. she was initially seen at the [**doctor first name 2**] and was transferred to the [**hospital1 2**] for further management. past medical history: 1. diabetes mellitus type ii 2. hypertension 3. history of cad, status post cabg in [**1994**] 4 |
| C2348956 | diffuse soft tissue calcifications are seen throughout the breast tissue. there is no evidence of mammographically or sonographically detectable malignancy. there is <1cui> <1CUI> heterogeneous echotexture </1CUI> in the right breast. 2. the right breast shows a 2.3 cm round hypoechoic mass in the upper outer quadrant of the breast. 3. the left breast shows a 1.7 cm round hypoechoic mass in the upper outer quadrant of the breast. 4. the left breast also shows diffuse 1.5 cm or less hypoechoic nodules throughout the breast tissue. 5. the left axilla shows a 1.5 cm round hypoechoic mass. 6. the right axilla shows a 1.0 cm round hypoechoic mass. 7. the right thyroid gland is nodular and hypoechoic. 8. the left thyroid gland is nodular and hypoechoic. 9. the liver, spleen, pancreas, and kidneys are normal. 10 |
| C2348988 | there are no masses. impression: no evidence of malignancy. no evidence of mass. 1. <1CUI> homogeneous fat echotexture </1CUI> : there is a homogeneous fat echotexture throughout the breast. this is concerning for fat necrosis. 2. <1cui> homogeneous fat echotexture: there is a homogeneous fat echotexture throughout the breast. this is concerning for fat necrosis. 3. no evidence of mass. 4. no evidence of malignancy. 5. no evidence of pleural effusion. 6. no evidence of ascites. 7. no evidence of pericardial effusion. 8. no evidence of pericardial tamponade. 9. no evidence of cardiac chamber enlargement. 10. no evidence of aortic dissection. 11. no evidence of aortic regurgitation. 12. no evidence of mitral regurgitation. 13. no evidence of tricuspid regurgitation |
| C2349148 | 3. adrenal metastases. 4. lung metastases. 5. periportal lymph nodes. 6. omental metastases. 7. hepatic metastases. 8. pancreatic metastases. 9. malignant pleural effusion. [**2014-12-29**] 06:15am b step down underlying diagnosis: 72 yo m with metastatic <1cui> <1CUI> well differentiated adrenal cortex carcinoma </1CUI> . #1. adrenal metastases. #2. lung metastases. #3. periportal lymph nodes. #4. omental metastases. #5. hepatic metastases. #6. pancreatic metastases. #7. malignant pleural effusion. #8. hypercalcemia. #9. hyperkalemia. |
| C2348956 | no calcifications. impression: no evidence of malignancy. <1CUI> heterogeneous echotexture </1CUI> . findings: the left breast is normal. the right breast shows multiple small areas of increased and decreased echogenicity, some of which are focal, but there is no evidence of malignancy. there is no calcification. impression: no evidence of malignancy. heterogeneous echotexture. [**2014-06-17**] mamography mamography (left) mamography (right) mamography (right) mamography (right) mamography (right) mamography (right) mamography (right) mamography (right) mamography (right) mamography (right) mamography (right) mamography |
| C2348988 | no cystic or calcified lesions are seen. the left breast is also diffusely heterogeneous, predominantly hypoechoic with some hyperechoic areas. there is no evidence of a mass, calcification or other abnormality. the left breast has a <1cui> <1CUI> homogeneous fat echotexture </1CUI> . impression: no evidence of malignancy or other abnormality. recommendations: 1. follow up ultrasound of the left breast in six months is recommended to assess for any changes in the breast tissue. 2. the patient should follow up with her primary care physician for further evaluation of her symptoms. 3. the patient should also have a baseline mammography of the left breast. 4. the patient should have an mri of the left breast to further evaluate the tissue. 5. the patient should have a baseline mammography of the right breast. 6. the patient should have an mri of the right breast to further evaluate the tissue. 7. the patient should have a baseline mammography of the left ax |
| C2349117 | discharge date: [**2012-08-23**] date of birth: [**1952-03-22**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 177**] chief complaint: <1CUI> ventricular tachycardia storm </1CUI> major surgical or invasive procedure: none history of present illness: 70 year old man with pmv, s/p cabg x2, s/p avr, s/p lvad who was transferred from [**hospital1 19**] to [**hospital1 20**] on [**08-20**] for [**08-22**] pmv with vt storm. patient had a history of cad with 2x cabg, avr and lvad, 1999 and 2002. in [**2002**] he developed v |
| C2349118 | the patient was then taken to the operating room for a coronary artery bypass graft. the patient was then transferred to the intensive care unit for postoperative care. the patient was in sinus rhythm at the time of transfer to the intensive care unit. the patient's postoperative course was complicated by a 30 minute episode of <1CUI> verapamil-sensitive ventricular tachycardia </1CUI> . the patient was treated with an external pacemaker and a bolus of 2000 mg of amiodarone. the patient was transferred to the floor and was continued on amiodarone and an external pacemaker. the patient was transferred to the floor and was continued on amiodarone and an external pacemaker. past medical history: 1. hypertension 2. hyperlipidemia 3. coronary artery disease 4. mitral valve prolapse 5. h/o cabg in [**2008**] 6. h/o cabg in [**2009**] 7. h/o c |
| C2349148 | he was also noted to have a left adrenal mass measuring 4.8 cm on a ct abdomen and pelvis done on [**2016-01-26**]. the patient was referred to the surgical oncology clinic for further evaluation of this mass. on [**2016-02-23**] the patient underwent a left adrenalectomy. pathology revealed a 5.3 cm well-differentiated adrenal cortical carcinoma. the patient was discharged from the hospital on [**2016-03-04**] with no evidence of recurrence of the cancer. brief hospital course: the patient was admitted to the hospital on [**2016-02-19**] for further evaluation of a left adrenal mass. he had a history of a left adrenal mass and was referred to the surgical oncology clinic for further evaluation. past medical history: 1. <1CUI> well differentiated adrenal cortex carcinoma </1CUI> 2. hypertension 3. |
| C2349152 | 3. 2. the patient was transferred to the [**hospital unit name 34**] for further management. past medical history: 1. aortic stenosis s/p avr in [**2016**]. 2. cad s/p cabg in [**2016**]. 3. dm2. 4. hypertension. 5. hyperlipidemia. 6. hypercholesterolemia. 7. cad s/p cabg in [**2016**]. 8. history of <1cui> <1CUI> wide-qrs tachycardia </1CUI> <1cui>. 9. history of cva. 10. history of [**01-15**] alcohol abuse. 11. history of smoking. 12. history of recreational drug use. 13. history of [**01-11**] amphetamine use. 14. history of [**01-25**] coca |
| C2349426 | sex: f service: m <1CUI> edic </1CUI> ine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 44**] chief complaint: chronic headaches major surgical or invasive procedure: none history of present illness: this is a 43 year old woman with a history of chronic headaches. she was seen in the [**doctor first name **] [**doctor first name 44**] and was referred to [**hospital1 45**] for an mri of the brain. the mri showed a left occipital meningioma. the patient was referred to [**hospital1 45**] for surgical evaluation. she was seen by dr. [**last name (stitle) **] and was scheduled for surgery on [**2013-01-21**]. past medical history: chronic headaches 1. chronic headaches: the patient has had chronic headaches for the past 10 years. the |
| C2349671 | 5. hypothyroidism: the patient was started on levothyroxine 25 mcg qd x 1 week and then 50 mcg qd x 2 weeks. recheck tsh at 2 weeks. 6. <1CUI> postprocedural fever </1CUI> : the patient developed a fever to 100.7 after the procedure. she was started on piperacillin-tazobactam and vancomycin. the fever resolved with this treatment. she was discharged on vancomycin and piperacillin-tazobactam. 7. echocardiography: the patient underwent echocardiography which showed mild to moderate mitral regurgitation with mild mr and moderate tr. 8. renal impairment: the patient had a creatinine of 1.3 on admission and a creatinine of 1.5 on discharge. she was started on furosemide 20 mg qd |
| C2349944 | the patient was found to have a sinus tachycardia with a rate of 120 and a regular rhythm. the <1CUI> electrocardiogram - incomplete left bundle branch block </1CUI> . the patient was found to have a serum creatinine of 2.0 and a bun of 38. the patient was admitted to the medical intensive care unit for continued close monitoring of his renal function, electrolytes, and cardiac function. on the morning of [**2014-04-28**] the patient was found to have a serum creatinine of 2.4, bun of 55, and a potassium of 3.5. the patient was started on hemodialysis. the patient was found to have a baseline serum creatinine of 1.9 and a bun of 32. the patient was started on dialysis with the goal of removing the potassium and other electrolytes. at the time of discharge the patient was in good condition. the patient was discharged on [**2014-05-01**] with a cre |
| C2349952 | sig: one (1) tablet po bid (2 times a day). discharge disposition: extended care facility: [**hospital 120**] discharge diagnosis: 1. hyperthyroidism. 2. hypothyroidism. 3. <1CUI> oropharyngeal carcinoma </1CUI> . 4. thyroidectomy. discharge condition: good. discharge instructions: please follow up with your primary care physician. please follow up with your endocrinologist. please follow up with your otolaryngologist. please follow up with your oncologist. please follow up with your radiation oncologist. followup instructions: please follow up with your primary care physician. please follow up with your endocrinologist. please follow up with your otolaryngologist. please follow up with your oncologist. please follow up with your radiation oncologist. [**first name11 (name pattern1) **] [**last name (name pattern1) 372** |
| C2350019 | 3. chronic obstructive pulmonary disease. 4. coronary artery disease. 5. hypertension. 6. hyperlipidemia. 7. chronic back pain. 8. hypercholesterolemia. 9. <1CUI> solitary nodule of lung </1CUI> . 10. right inguinal hernia. 11. aortic valve insufficiency. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. 11. |
| C2350037 | discharge date: [**2011-08-17**] date of birth: [**1967-05-29**] sex: f service: medicine history of present illness: this is a 44 year old female who presented to the emergency department on the 12th of august with complaints of weakness in her right arm and leg, numbness and tingling sensations in her right arm and leg, and difficulty speaking. she was seen in the emergency department on the 12th of august, and was then transferred to the neurology service. past medical history: the patient is a 44 year old female who is a non-smoker, and is an alcohol drinker. she had a history of <1CUI> clinically isolated syndrome, cns demyelinating </1CUI> in 2005. the patient had been seen in the emergency department on the 12th of august, and was then transferred to the neurology service. |
| C2349426 | sex: f service: m <1CUI> edic </1CUI> ine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 210**] chief complaint: ndph major surgical or invasive procedure: none history of present illness: 72 y/o female with a history of ndph, who was initially seen by [**doctor first name 13**] dr. [**name pt 1364**] in [**2010**] and was referred to the neurology service for further evaluation. the patient reports that she has been experiencing a headache for 10 years, which is described as a bilateral, unremitting headache of mild to moderate intensity that occurs daily and may be associated with photophobia, phonophobia, or mild nausea. she reports that she has had multiple episodes of headaches, but this one has been the most severe and persistent. she has had no recent travel, no recent infections, and no recent medication changes. she |
| C2349945 | the patient was transferred to the [**hospital1 17**] [**doctor first name **] icu. the patient was seen by a neurologist and an eeg was done which showed no seizure activity. the patient was also seen by a cardiologist who felt that the <1CUI> electrocardiogram: low voltage qrs complete </1CUI> was likely due to a long standing condition. the patient was transferred to [**hospital1 17**] [**doctor first name **] [**hospital unit name **] for further evaluation and management. [**hospital1 17**] [**hospital unit name **] - [**hospital1 17**] [**doctor first name **] [**doctor last name **] m.d. [**md number 109**] [**2014-05-12**] # [**cycle 1 15**] # [**cycle 1 15**] # [**cycle 1 15**] # [**country of origin **] [**first name4 (name |
| C2349152 | aortic valve sclerosis. mitral valve: normal mitral valve leaflets and chordae. mild mitral valve prolapse. tricuspid valve: normal tricuspid valve leaflets. pulmonic valve/pulmonary artery: normal pulmonary valve leaflets. conclusions: 1. the patient's <1CUI> wide-qrs tachycardia </1CUI> is thought to be due to left bundle branch block with left ventricular hypertrophy. 2. the patient's left bundle branch block is likely due to underlying coronary artery disease. 3. the patient's left ventricular hypertrophy is likely due to underlying hypertension. 4. the patient's aortic valve sclerosis is likely due to underlying hypertension. 5. the patient's mild mitral valve prolapse is likely due to underlying hypertension. 6. the patient's pulmonic valve is normal. 7. the patient's pulmonary artery systolic pressure is 45 mmh |
| C2349426 | sex: m service: m <1CUI> edic </1CUI> ine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 2855**] chief complaint: 20 year history of ndph. major surgical or invasive procedure: hcp-ii [**2019-09-27**] history of present illness: 20 year history of ndph. patient was seen in the [**doctor first name **] service in [**2014**] and was given a trial of verapamil, which improved the headaches but the patient stopped taking the medication due to the cost. he was seen in the [**doctor first name **] service in [**2016-04**] and was started on a trial of topiramate, which improved the headaches but the patient stopped taking the medication due to the cost. he was seen in the [**doctor first name **] service in [**2018**] and was started on a trial of sodium valpro |
| C2349671 | discharge date: [**2014-09-18**] date of birth: [**1955-03-22**] sex: m service: cardiothoracic allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1126**] chief complaint: <1CUI> postprocedural fever </1CUI> major surgical or invasive procedure: left ventricular assist device placement history of present illness: mr. [**lastname 5913**] is a 60 year old man with end stage cardiomyopathy who underwent placement of a left ventricular assist device on [**2014-09-16**]. he developed a fever of 101.3 on postoperative day #1, and was transferred to the [**doctor first name 4**] for further management. past medical history: cardiomyopathy. coronary artery disease |
| C2350019 | 11. right sided pleural effusion. 12. right sided pneumothorax. 13. <1CUI> solitary nodule of lung </1CUI> . 14. right sided adrenal mass. 15. right sided kidney cyst. 16. right sided hydronephrosis. 17. left sided hydronephrosis. 18. increased spleen size. 19. increased liver size. 20. left sided hepatic cyst. 21. left sided hemangioma. 22. right sided hemangioma. 23. right sided sternal wound. 24. left sided pleural effusion. 25. right sided pleural effusion. 26. right sided pneumothorax. 27. right sided pneumothorax. 28. left sided pneumothorax. 29. right sided pneumothorax. |
| C2350037 | 12) <1CUI> clinically isolated syndrome, cns demyelinating </1CUI> 13) multiple sclerosis discharge condition: good discharge instructions: please call your pcp to make an appointment to discuss your mri results. please call [**hospital1 17**] neurology if you have any changes in your vision, numbness, weakness or tingling. followup instructions: please followup with [**last name (stitle) **] neurology at [**telephone/fax (2) 17**] in 3 months. please followup with [**last name (stitle) **] neurology at [**telephone/fax (2) 17**] in 6 months. please followup with [**last name (stitle) **] neurology at [**telephone/fax (2) 17**] in 1 year. discharge condition: good discharge disposition: extended care discharge di |
| C2349152 | the patient was transferred to the cardiac catheterization lab where he underwent a diagnostic coronary angiogram which revealed significant 3 vessel coronary artery disease with severe left main stenosis (>90%), 3 vessel disease with proximal lad and rca stenosis, and a proximal lcx stenosis. he was found to have an intraventricular conduction delay and anteroseptal dyskinesia. the patient was then taken to the operating room for a 3 vessel coronary artery bypass graft. 2. <1CUI> wide-qrs tachycardia </1CUI> : the patient was transferred to the cardiac catheterization lab where he underwent a diagnostic coronary angiogram which revealed significant 3 vessel coronary artery disease with severe left main stenosis (>90%), 3 vessel disease with proximal lad and rca stenosis, and a proximal lcx stenosis. he was found to have an intraventricular conduction delay and anteroseptal dyskinesia. 3. a-fib: the patient |
| C2349426 | sex: m service: m <1CUI> edic </1CUI> ine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 159**] chief complaint: 1. ndph major surgical or invasive procedure: none history of present illness: 58 yo m with 10-20 yr history of daily bilateral headaches, which have been 95% controlled on 100 mg of topamax daily. in the past, he has had multiple headaches which have been attributed to ndph. he was recently transferred to the [**hospital1 172**] from [**hospital1 461**] where he was found to have an elevated lfts, which were thought to be due to the topamax. he was transferred to the [**hospital1 172**] for further evaluation and management. he has had no recent illness, no recent travel, no recent medication changes, and no recent alcohol or drug use. he denies any chest |
| C2349944 | sig: one (1) tablet po qd (1) tablet po bid for 7 days. disp:*7 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. coronary artery disease s/p cabg x 2 2. <1CUI> electrocardiogram - incomplete left bundle branch block </1CUI> discharge condition: good discharge instructions: please take 1 tablet by mouth once daily for 7 days. please contact your cardiologist for your follow-up appointment. please contact your cardiologist for your follow-up appointment. followup instructions: please contact your cardiologist for your follow-up appointment. please contact your cardiologist for your follow-up appointment. discharge instructions: 1. you have had a successful coronary artery bypass graft. you had two grafts placed on the right side of your heart and one graft on the left side of your heart. 2. you have an incomplete left bundle |
| C2349952 | patient was admitted to the [**hospital unit name 232**] for evaluation of a laryngeal mass and possible laryngectomy. past medical history: 1. <1cui> <1CUI> oropharyngeal carcinoma </1CUI> 2. cervical spine fracture 3. history of hepatitis c social history: patient is a 73 year old male who lives with his wife and has 2 children. he is a retired carpenter and has no significant social history. family history: noncontributory physical exam: pe: t 99.4, hr 86, bp 146/74, rr 18, o2 saturation 98% on room air. patient is in no acute distress. head and neck: patient has a large left-sided oropharyngeal mass, which is approximately 2 cm in size. there is no evidence of cervical lymphadenopathy. chest: clear to auscult |
| C2350019 | 13) ascites: the ascites was not well-evaluated. 14) coarctation of the aorta: the aorta is normal in size and contour. 15) <1CUI> solitary nodule of lung </1CUI> : the nodule is unchanged in size and position. 16) esophageal varices: no varices are seen. 17) splenomegaly: the spleen is mildly enlarged. 18) cysts: there are multiple small cysts in the liver. 19) hepatomegaly: there is mild hepatomegaly. 20) adrenal masses: there are two small masses in the right adrenal gland. 21) right kidney: there is a small stone in the right renal pelvis. 22) right inguinal hernia: a small right inguinal hernia is seen. 23) dacryocystocele: a dacryocystocele |
| C2349152 | the patient was transferred to the icu for close monitoring of his blood pressure and heart rate. the patient's blood pressure was controlled with labetalol, and the patient's heart rate was controlled with diltiazem. the patient's electrocardiogram showed a <1CUI> wide-qrs tachycardia </1CUI> . the patient's electrocardiogram showed a wide-qrs tachycardia. the patient's wide-qrs tachycardia was thought to be secondary to his hypotension and was not thought to be related to a cardiac condition. the patient's blood pressure was controlled with labetalol, and the patient's heart rate was controlled with diltiazem. the patient was also treated for hypotension with intravenous fluids. the patient was also treated for hypotension with intravenous fluids. the patient's electrocardiogram showed a wide-qrs tachycardia. the patient was transferred to the cardiology service for further evaluation. the patient was transferred to the cardiology service for further evaluation. the patient was transferred to the cardiology service for further |
| C2349426 | <1CUI> no o </1CUI> ther lesions. the patient was started on a trial of a pain medication that was prescribed by her pain management physician. the patient was admitted to the hospital for further evaluation and management of her headaches. # neurology: the patient has a history of chronic daily headaches, which are characterized as 20-30 headaches per day, 10-20 headache days per month, and a 10-20 headache intensity per day. the patient has a history of ndph, which has been poorly controlled with previous pain medications. # pt/ot/speech: the patient was transferred to the [**hospital1 1989**] neurology service for further evaluation and management of her headaches. # cardiology: the patient has a history of hypertension, which is well controlled on medications. # medicine: the patient has a history of hypertension, which is well controlled on medications. # social work: the patient was seen by the social worker on [**2013-11-04**] for the purpose of discussing her dis |
| C2349578 | sig: one (1) tablet po bid for 14 days. disp:*14 tablet(s)* refills:*0* discharge disposition: extended care discharge diagnosis: 1. pna 2. <1CUI> disproportn reconst brst </1CUI> discharge condition: good discharge instructions: please call your doctor if you have any questions or concerns. followup instructions: followup instructions: please follow up with your doctor in 14 days. discharge instructions: please follow up with your doctor in 14 days. discharge condition: good discharge medications on admission: 1. zantac 2. docusate 3. lasix 4. lopressor 5. celebrex 6. aspirin discharge medications on discharge: 1. zantac 2. docusate discharge disposition: extended care discharge di |
| C2349671 | discharge date: [**2011-05-16**] date of birth: [**1953-02-03**] sex: m service: [**hospital unit name 178**] history of present illness: this is a 58-year-old male with a history of htn, hypercholesterolemia, and gerd who underwent a tee with aortic valve replacement with a st. jude valve and mitral valve repair with a carpentier ring. he had a <1CUI> postprocedural fever </1CUI> and was admitted to the [**hospital1 3**] for management. past medical history: 1. hypertension 2. hypercholesterolemia 3. gerd 4. aortic valve replacement with a st. jude valve in [**2007**] 5. mitral valve repair with a carpentier ring in [**2007**] |
| C2349952 | 3. lymphadenopathy. 4. oropharyngeal cancer. 5. oral cancer. 6. <1CUI> oropharyngeal carcinoma </1CUI> . 7. oral cancer. 8. oropharyngeal carcinoma. 9. laryngeal cancer. 10. thyroid cancer. 11. melanoma. 12. adenocarcinoma. 13. lung cancer. 14. colon cancer. 15. pancreatic cancer. 16. cervical cancer. 17. ovarian cancer. 18. breast cancer. 19. lymphoma. 20. melanoma. 21. carcinoma of the tongue. 22. carcinoma of the oropharynx. 23. carcinoma of the larynx. 24. carcinoma of the hypopharynx. 25. carcinoma of |
| C2350059 | he was started on coumadin for his atrial fibrillation and his chest pain. he was also started on avastin for his <1CUI> cancer of the </1CUI> ear. the patient was also started on a proton pump inhibitor for his gastroesophageal reflux disease. he was admitted to the [**hospital unit name 357**] for his wound care. past medical history: -hypertension -atrial fibrillation -cancer of ear -gastroesophageal reflux disease -osteoporosis -crohn's disease -hepatitis c -hiv -lymphoma -chest pain -cad -cervical spine fracture -dementia -parkinson's disease -depression -anxiety -bipolar disorder -alcohol abuse -tobacco abuse -hepatitis b -hepatitis b -dementia -parkinson's disease -depression -anxiety -bipolar disorder -alcohol abuse -tobacco abuse -hepatitis b - |
| C2350172 | in the right lung, the right lower lobe and lingula were collapsed with no evidence of pneumothorax. no consolidation or pleural effusion was seen. there was a right upper lobe mass, which was consistent with a <1CUI> congenital cystic adenomatoid malformation, type iii </1CUI> . this mass was stable in size and did not change from the previous chest x-ray. there was no evidence of pneumothorax or consolidation. the patient was admitted to the [**hospital 16**] for further management of this condition. past medical history: 1. congenital cystic adenomatoid malformation, type iii 2. asthma 3. gerd 4. allergic rhinitis social history: the patient is a smoker, who smokes approximately 10 pack years. he is a former alcoholic who has been abstinent for 3 years. family history: the patient is married with two children. his mother died of breast cancer at the age of 55. his father died of lung cancer. physical exam: |
| C2350173 | 3. pregnancy. 4. renal cell carcinoma. 5. <1CUI> congenital cystic adenomatoid malformation, type 1 </1CUI> . 6. gastric ulcer. brief hospital course: the patient was admitted to the [**hospital unit name 40**] on [**2014-03-04**] for a laparoscopic cholecystectomy. the patient had a past history of a congenital cystic adenomatoid malformation, type 1, which was excised in [**2013-03-27**]. on [**2014-03-03**] the patient had a gastric ulcer, which was treated with proton pump inhibitors and the patient was admitted to the [**hospital unit name 40**] on [**2014-03-04**]. on [**2014-03-04**] the patient had a laparoscopic cholecystectomy. the |
| C2350174 | 4. chronic right lower lobe collapse. 5. chronic pulmonary emphysema. 6. 2009 left lower lobe pulmonary metastases. 7. 2009 right lower lobe metastatic lesion. 8. 2010 metastatic lesion in the right upper lobe. 9. 2010 metastatic lesion in the right lower lobe. 10. 2010 metastatic lesion in the left lower lobe. 2010. malignant melanoma. 2009. <1CUI> congenital cystic adenomatoid malformation, type 2 </1CUI> . 2009. 2009. 2009. 2009. 2009. 2009. 2009. 2009. 2009. 2009. 2009. 2009. 2009. 2009. 2009. 20 |
| C2350233 | he was born with multiple congenital anomalies including left side cleft lip and palate, left ear atresia, right ear atresia, bilateral choanal atresia, left eye coloboma, right eye coloboma, left hand hypoplasia, right hand hypoplasia, left foot/ankle contracture, right foot/ankle contracture, and femoral bowing. he had several fractures in the neonatal period. he was diagnosed with <1CUI> antley bixler syndrome phenotype </1CUI> . his neonatal course was complicated by respiratory distress requiring oxygen and chest physiotherapy. he was admitted to the [**hospital unit name 124**] for further evaluation and management of his multiple anomalies. #2. 1. respiratory distress: the patient was noted to be tachypneic and hypoxemic on the first day of life. he was placed on oxygen via nasal cannula. his oxygen saturation improved with this intervention. he was also treated with chest physiotherapy. |
| C2350236 | 4. hypertension. 5. hyperlipidemia. 6. chronic obstructive pulmonary disease. 7. <1CUI> pneumonia, idiopathic interstitial </1CUI> . 8. hypothyroidism. 9. depression. 10. hearing loss. 11. cataracts. 12. carotid artery disease. 13. osteoarthritis. 14. cataracts. 15. dementia. 16. sleep apnea. 17. gerd. 18. cervical hernia. 19. hip fracture. 20. neuropathy. 21. chronic back pain. 22. chronic anemia. 23. chronic gastritis. 24. chronic cystitis. 25. chronic prostatitis. 26. chronic tonsillitis. 27. chronic otitis media. |
| C2350242 | the cervical spine was stable with no evidence of fracture or subluxation. there was no evidence of spinal cord compression. the patient was continued on pain medication and was scheduled for physical therapy to help improve his range of motion. the patient was instructed to follow up with his primary care physician for further evaluation of his <1CUI> spinal osteoarthritis </1CUI> . #2. the patient was found to have a right hip fracture with a subtle displacement of the right acetabulum and femoral head. the patient was taken to the operating room for open reduction and internal fixation of the right hip fracture. #3. the patient was found to have a large amount of osteophytes in the lumbar spine, which was consistent with spinal osteoarthritis. there was no evidence of spinal cord compression. #4. the patient was found to have a large amount of osteophytes in the thoracic spine, which was consistent with spinal osteoarthritis. there was no evidence of spinal cord compression. #5. the patient was |
| C2350270 | no evidence of any carotid bruits. step 2: the patient was admitted to the icu for continued observation. the patient's blood pressure was stable throughout the day. the patient was started on [**03-03**] levofloxacin 500 mg ivpb q8h, 1 gm of ceftriaxone ivpb q8h, and 1000 mg of vancomycin ivpb q8h. the patient's wound was cleaned and redressed. the patient's <1CUI> periodontium atrophies </1CUI> were cleaned. she was transferred to the floor on [**2014-03-04**]. the patient's blood pressure was stable throughout the day. the patient was started on [**2014-03-03**] levofloxacin 500 mg ivpb q8h, 1 gm of ceftriaxone ivpb q8h, and 1000 mg of vancomycin ivpb q8h. |
| C2350038 | sig: one (1) tablet po qd for 60 days. disp:*60 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. <1CUI> hypomineralization, molar incisor </1CUI> 2. dental caries 3. dental abscess 4. <1cui> hypomineralization, molar incisor 5. dental abscess 6. dental caries discharge condition: stable discharge instructions: please take one (1) tablet of doxycycline twice daily for 60 days. please take your medications as directed by your physician. please follow up with your dentist for further evaluation and treatment of your dental problems. followup instructions: please follow up with your dentist for further evaluation and treatment of your dental problems. please follow up with your primary care physician for further evaluation and treatment of your medical conditions. please refill your medications as directed by your physician. please refill your medications as directed |
| C2350059 | sig: one (1) tablet po q6h (every 6 hours) for 5 days. disp:*60 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. adenocarcinoma of the right ear canal 2. <1CUI> cancer of ear </1CUI> discharge condition: good discharge instructions: please follow the following instructions: 1. you should take one (1) tablet by mouth every six (6) hours for five (5) days. 2. you should continue to take your regular medications as prescribed by your doctor. 3. please contact your doctor if you have a fever greater than 101.5 or any other symptoms. 4. if you have any further questions, concerns, or complaints, please do not hesitate to contact the doctor's office at [**telephone/fax (2) 203-**] or at [**telephone/fax (3) 203-**]. 5. |
| C2350172 | the patient was transferred to the [**hospital unit name 177**] where she was seen by the [**hospital unit name 178**]. the patient was admitted to the [**hospital unit name 178**] where she was seen by the [**hospital unit name 179**]. the patient was diagnosed with a <1CUI> congenital cystic adenomatoid malformation, type iii </1CUI> . the patient was admitted to the [**hospital unit name 178**] where she was seen by the [**hospital unit name 179**]. the patient was admitted to the [**hospital unit name 178**] where she was seen by the [**hospital unit name 179**]. the patient was diagnosed with a congenital cystic adenomatoid malformation, type iii. the patient was treated with a ct scan of the abdomen and pelvis which showed a large cystic mass in the right lower quadrant, consistent with congenital cystic adenomatoid malformation, type iii. the patient was treated with a ct |
| C2350174 | pt was taken to the or for excision of the mass. pathology was consistent with <1CUI> congenital cystic adenomatoid malformation, type 2 </1CUI> . the patient was discharged from the or with a wound dressing and instructions to follow up with her primary care physician in one week. past medical history: -type 2 dm -hypertension -hypothyroidism -hematuria -<1cui> congenital cystic adenomatoid malformation, type 2 social history: lives with husband, no tobacco use, denies alcohol and drugs. family history: noncontributory. physical exam: 84.8 80-85 100-102 120/80 152/60 100%ra gen: wnht, well appearing, afebrile, slightly diaphoretic. heent: perrla, eomi, anicteric, no sores, no lesions, no nuchal rigidity. neck: supple |
| C2350177 | 10. dementia. 11. pna. 12. cva. 13. osteoporosis. 14. osteopenia. 15. <1CUI> fracture, insufficiency </1CUI> . 16. dysphagia. 17. dehydration. 18. hypotension. 19. hypocalcemia. 1. pna. 2. pna. 3. pna. 4. pna. 5. pna. 6. pna. 7. pna. 8. pna. 9. pna. 10. pna. 11. pna. 12. pna. 13. pna. 14. pna. 15. pna. 16. pna. 17. pna. 18. pna. 19. pna. 20. pna. 21. |
| C2350233 | sig: one (1) tablet po qd (once a day). disp:*60 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: craniosynostosis, <1CUI> antley-bixler syndrome phenotype </1CUI> , fracture of the left humeral shaft, right ulnar shaft fracture, multiple joint contractures, neonatal fractures. discharge condition: stable discharge instructions: please follow up with your pediatrician for further evaluation and management. please follow up with your pediatrician for further evaluation and management. please follow up with your pediatrician for further evaluation and management. please follow up with your pediatrician for further evaluation and management. please follow up with your pediatrician for further evaluation and management. please follow up with your pediatrician for further evaluation and management. please follow up with your pediatrician for further evaluation and management. please follow up with your pediatrician for further evaluation and management. |
| C2350234 | the left hilar lymph nodes are mildly enlarged. lungs: there are multiple nodules in the right lower lobe, the largest of which measures 2.5 cm. there is no evidence of consolidation or cavitation. the <1cui> <1CUI> clear-cell sugar tumor </1CUI> <1cui> in the right upper lobe is stable in size and appearance compared to the previous study. abdomen: the liver, spleen, and kidneys are normal in size and appearance. there is no free fluid in the pelvis. there is a 3.5 cm simple cystic mass in the right paracolic gutter. the aorta, pulmonary arteries, and inferior vena cava are unremarkable. there is no evidence of pneumothorax. the mediastinal, hilar, and paratracheal lymph nodes are unremarkable. the bones are unremarkable. the gallbladder is not visualized. impression: stable <female first name4 (un) |
| C2350059 | sig: one (1) tablet po q6h (every 6 hours) for 14 days. disp:*14 tablets refills:*0 discharge disposition: home with service discharge diagnosis: 1. neutropenic fever 2. <1CUI> cancer of ear </1CUI> 3. cytomegalovirus 4. methicillin-resistant staphylococcus aureus sepsis discharge condition: good discharge instructions: please follow up with your primary care physician for a follow-up appointment on [**2012-04-10**]. please follow up with your primary care physician for a follow-up appointment on [**2012-04-10**]. please take your medications as prescribed. please continue to take your antibiotics for 14 days as prescribed. please call your doctor if you develop a fever greater than 100.5. please call your doctor if you experience any shortness of breath or chest |
| C2350168 | discharge date: [**2013-04-19**] date of birth: [**1949-02-15**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 309**] chief complaint: anemia, bone pain major surgical or invasive procedure: hysterectomy history of present illness: this 54 year old male with a history of aids, polysubstance abuse, and <1cui> <1CUI> reticuloses, polymorphic </1CUI> was transferred to the [**hospital1 31**] from [**hospital1 32**] on [**2013-04-13**]. he had been transferred from [**hospital1 32**] on [**2013-04-12**] with a diagnosis of pneumocystis pneumonia. he had |
| C2350173 | 3. hyperlipidemia. 4. gastroesophageal reflux disease. 5. nephrolithiasis. 6. <1CUI> congenital cystic adenomatoid malformation, type 1 </1CUI> . social history: she is married and has 2 children. she works as a teacher. family history: no history of melanoma. physical exam: vitals: 98.5, 146/78, 20, 97% gen: nad, well-appearing heent: perrl, eomi, mmm, anicteric sclerae lungs: cta, no wheezes, no rhonchi, no crackles cv: rrr, no m/r/g, no s3/s4, no murmurs abd: soft, nt, nd, no hernias, no masses ext: no edema, 2+ pulses, warm, no erythema, no tenderness skin: |
| C2350174 | no history of surgical intervention. past medical history: 1. <1CUI> congenital cystic adenomatoid malformation, type 2 </1CUI> . 2. hypothyroidism. social history: married, lives with spouse. lives in [**state 37**]. family history: non-contributory. physical exam: vital signs: t 97.3 hr 114 bp 125/60 rr 20 sat 96% ra general: skin: no rashes, no lesions, no evidence of infection. head: perrla, eomi, no nph, no kf, no jvp. ears: no discharge, no erythema, no lesions. eyes: no lesions, no edema, no masses. neck: no lymphadenopathy, no masses, no jvp. chest: no rales, no rhonchi, no wheezes, no cyanosis. heart |
| C2350234 | 4. cystic lung lesion. 5. pneumothorax. 6. pe. 7. <1cui> <1CUI> clear-cell sugar tumor </1CUI> . 8. pneumonia. 9. pneumocystis. 10. cmv. 11. tuberculosis. [**2014-03-19**] 05:00pm blood wbc-7.2* rbc-2.73* hgb-7.2* hct-22.1* plt ct-175* mcv-94 mch-30.6 mchc-35.1 rdw-15.5* # abg 95% o2 on n2/o2 # abg 97% o2 on n2/o2 # abg 98% o2 on n2/o2 brief hospital course: the patient was admitted to the [**hospital unit name **] for evaluation of a pe. |
| C2350236 | sig: one (1) tablet po bid for 3 days. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. <1CUI> pneumonia, idiopathic interstitial </1CUI> 2. cryptococcal infection 3. pulmonary embolus 4. acute respiratory failure 5. sepsis 6. hypothyroidism 7. hypercholesterolemia 8. hypertension discharge condition: good. discharge instructions: please follow up with your primary care physician for the following: 1. thyroid hormone replacement 2. cholesterol lowering medication 3. blood pressure medication 4. follow up for the cryptococcal infection with your primary care physician 5. follow up for the pulmonary embolus with your primary care physician please call your primary care physician for any of the following: 1. increasing shortness of breath or cough 2 |
| C2350038 | 4. chronic hepatitis c. 5. chronic renal insufficiency. 6. hypothyroidism. 7. hyperlipidemia. 8. <1CUI> hypomineralization, molar incisor </1CUI> . 9. crohn's disease. 10. diabetes mellitus. 11. [**11-21**] 2011. discharge disposition: extended care facility: [**hospital 102**] discharge diagnosis: 1. pneumocystis jirovecii pneumonia. 2. chronic renal insufficiency. 3. chronic hepatitis c. 4. hypomineralization, molar incisor. 5. hyperlipidemia. 6. hypothyroidism. 7. crohn's disease. 8. diabetes mellitus. 9. [**11-21**] discharge condition: |
| C2350059 | discharge date: [**2014-03-05**] date of birth: [**1947-04-09**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 254**] chief complaint: pt with a history of <1CUI> cancer of the </1CUI> ear was seen in the er for worsening pain. major surgical or invasive procedure: 1. biopsy of right ear 2. biopsy of left ear 3. stereotactic right ear 4. stereotactic left ear 5. stereotactic brain 6. ct scan of the brain 7. ct scan of the abdomen 8. ct scan of the pelvis 9. ct scan of the chest 10. ultrasound of the neck 11. ultrasound of the abdomen 12. ultrasound of the pelvis 13. ultrasound of |
| C2350168 | discharge date: [**2013-09-17**] date of birth: [**1944-09-05**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 129**] chief complaint: s/p trach removal and laryngectomy major surgical or invasive procedure: laryngectomy and tracheostomy removal history of present illness: 65 year old male with a history of <1CUI> reticuloses, polymorphic </1CUI> , diagnosed in [**1983**] who has been on and off steroids and has had multiple episodes of pneumonia and other infections. patient was status post tracheostomy and laryngectomy. the patient presented to the [**hospital1 18**] on [**2013-09-13**] with a cough and fevers. he was admitted to |
| C2350233 | 3. cystic hygroma. 4. <1CUI> antley bixler syndrome phenotype </1CUI> . 5. pyloric atresia. 6. congenital choanal atresia. 7. multiple joint contractures. 8. bilateral facial clefting. 9. right radial dysplasia. 10. urogenital anomalies. 11. cardiac anomalies. 12. gastrointestinal anomalies. 13. pulmonary anomalies. 14. cerebral anomalies. 15. splenic anomalies. 16. hepatic anomalies. 17. renal anomalies. 18. adrenal anomalies. 19. thyroid anomalies. 20. pituitary anomalies. 21. pancreatic anomalies. 22. biliary anomalies. 23. intestinal anom |
| C2350038 | 2. <1CUI> hypomineralization, molar incisor </1CUI> . 3. two 2nd molar restorations. 4. right 2nd molar removed. 5. left 2nd molar removed. 6. 2nd molar removal. 7. 3rd molar restoration. 8. 2nd molar restoration. 9. 2nd molar restoration. 10. missing 3rd molar. 11. 3rd molar restoration. 12. left 2nd molar restoration. 13. 2nd molar restoration. 14. 2nd molar restoration. 15. 2nd molar restoration. 16. 2nd molar restoration. 17. 2nd molar restoration. 18. 2nd molar restoration |
| C2350059 | 4. pending a consult with radiation oncology, he will be started on radiation therapy for the <1CUI> cancer of the </1CUI> ear. 5. he will need to follow up with his primary care physician for continued management of his diabetes, hypertension, hyperlipidemia, and pain control. 6. he will need to follow up with his radiation oncologist for continued management of his cancer of the ear. 7. he will need to follow up with his otolaryngologist for continued management of his ear cancer. 8. he will need to follow up with his neurosurgeon for continued management of his cerebral vasospasm. social history: the patient is a widower, lives alone, has one son. he is a smoker, 1-2 packs per day, 10-15 cigarettes per day for 40 years. he is a social drinker. family history: noncontributory. physical exam: the patient is a 71-year-old man with a bmi of 29 who is in no acute distress. |
| C2350168 | discharge date: [**2013-04-23**] date of birth: [**1934-09-27**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 125**] chief complaint: fever, sore throat major surgical or invasive procedure: none history of present illness: 86 year old man with history of leukemia and polymorphic reticuloses, who presented to the [**doctor first name 7**] with fever, sore throat, and cough. he was treated with antibiotics and steroids in the [**hospital1 18**] and was transferred to the [**hospital1 18**] for further management. past medical history: pmh: 1. leukemia, diagnosed in 1999 with [**1cui**] <1CUI> reticuloses, polymorphic </1CUI> . 2 |
| C2350172 | the patient had a 4.5 cm mass in the left lung which was thought to be a <1CUI> congenital cystic adenomatoid malformation, type iii </1CUI> . the mass was noted to have increased in size since the last chest x-ray in [**2014-05-10**]. the patient was referred to the thoracic surgery service for further evaluation. brief hospital course: the patient was admitted to the hospital on [**2015-05-13**] for a left lower lobectomy. the patient had a left lower lobectomy on [**2015-05-14**]. past medical history: 1. congenital cystic adenomatoid malformation, type iii 2. pregnancy and childbirth: g2p1, g1t1, g1t2, g2t1, g3t1, g4t1, g5t1. 3. right cva [**2002-09-15**] social history: the patient is a social drinker |
| C2350173 | 4. multiple pelvic lesions. 5. chronic left knee pain. 6. multiple skin lesions. 7. <1CUI> congenital cystic adenomatoid malformation, type 1 </1CUI> . 8. mildly elevated blood pressure. 9. mildly elevated serum creatinine. 10. low serum calcium. 11. chronic pain. [**2011-07-21**] 07:00:00 disposition: discharge clip # 3 # 3 100000000 urine 95033 [**2011-07-21**] 11:53:00 859-86025 reporters: [**last name (stitle) **] [**name (stitle) **] md [**name (stitle) 97**] md [**name7 (md) 98**] md [**name8 (md) 99 |
| C2350174 | the patient was transferred to the [**hospital unit name 29**] for further evaluation and management of this condition. the patient was seen by the neurology service and a ct scan of the head was obtained which showed a small right frontal lobe cyst. the patient was transferred to the [**hospital unit name 29**] for further evaluation and management of this condition. the patient was seen by the neurology service and a ct scan of the head was obtained which showed a small right frontal lobe cyst. the patient was then transferred to the [**hospital unit name 30**] for further evaluation and management of this condition. past medical history: 1. <1CUI> congenital cystic adenomatoid malformation, type 2 </1CUI> . 2. cerebral palsy. 3. mental retardation. 4. seizures. 5. gastroesophageal reflux disease. 6. nephrotic syndrome. 7. chronic lung disease. 8. neurofibromatosis |
| C2350233 | the patient was born at [**hospital1 152**] with a birth weight of 2.5 kg. at 3 months of age, the patient underwent a surgical repair of the choanal atresia. at 6 months of age, the patient was transferred to [**hospital1 405**] for further management of the <1CUI> antley bixler syndrome phenotype </1CUI> . the patient's parents were counseled about the genetic nature of the condition and the risk of recurrence in future pregnancies. the patient was seen by a multidisciplinary team including the geneticist, pulmonologist, and orthopedic surgeon. the patient's cardiac defect was evaluated with an echocardiogram. the patient's renal function was evaluated with a renal ultrasound. the patient's gastrointestinal defect was evaluated with an upper gi series. the patient's neurological defect was evaluated with an mri of the brain. the patient's joint contractures were evaluated with a physical therapy assessment. the patient's respir |
| C2350234 | 2. pe. 3. hx of mi. 4. hx of cva. 5. hx of pe. 6. hx of <1CUI> clear-cell sugar tumor </1CUI> . 7. hx of mi. 8. hx of cva. 9. hx of pe. 10. hx of clear-cell sugar tumor. 11. hx of cad. 12. hx of tia. 13. hx of gerd. 14. hx of htn. 15. hx of osa. 16. hx of gerd. 17. hx of gerd. 18. hx of copd. 19. hx of cad. 20. hx of tia. 21. hx of chf. 22. hx of chf. 23. hx of cad. 24. hx of c |
| C2350236 | 3. <1CUI> pneumonia, idiopathic interstitial </1CUI> . 4. chronic obstructive pulmonary disease. 5. chronic renal failure. 6. hyperlipidemia. 7. hypertension. 8. gastroesophageal reflux disease. 9. osteoarthritis. 10. dementia. 11. cataracts. 12. hypothyroidism. 13. depression. 14. glaucoma. 15. retinopathy. 16. carotid artery disease. 17. chronic obstructive pulmonary disease. 18. pneumonia, idiopathic interstitial. 19. chronic renal failure. 20. hyperlipidemia. 21. hypertension. 22. gastroesophageal reflux disease. 23. osteoarth |
| C2350449 | 4. hepatitis b. 5. chronic renal failure. 6. hypothyroidism. 7. osteoporosis. 8. chronic pain. 9. depression. 10. anxiety. 11. hypercholesterolemia. 12. hyperlipidemia. 13. chronic obstructive pulmonary disease. 14. <1CUI> pancreatitis, graft </1CUI> . 15. dementia. 16. dysphagia. 17. dysarthria. 18. diplopia. 19. hearing loss. 20. cataracts. 21. glaucoma. 22. carotid artery disease. 23. coronary artery disease. 24. aortic stenosis. 25. chronic obstructive sleep apnea. 26. osteoporosis. 27. rheumatoid |
| C2350529 | the patient was started on amphotericin b. the patient's sputum cultures were negative for aspergillus and the patient was started on itraconazole. the patient was transferred to [**hospital1 40**] for further management. on [**2013-05-17**] the patient was transferred to [**hospital1 40**] for further management of the <1CUI> pulmonary aspergillosis </1CUI> . on [**2013-05-18**] the patient was transferred to [**hospital1 40**] for further management of the pulmonary aspergillosis. on [**2013-05-20**] the patient was transferred to [**hospital1 40**] for further management of the pulmonary aspergillosis. on [**2013-05-21**] the patient was transferred to [**hospital1 40**] for further management of the pulmonary aspergillosis. on [**2013-05-22 |
| C2350622 | 2. adenocarcinoma of the lung (lung) 3. adenocarcinoma of the skin (skin) 4. <1CUI> fibrosis rad </1CUI> discharge condition: good. discharge instructions: please follow the following instructions carefully: 1. take all medications as prescribed by your doctor. 2. take a bath or shower every day. 3. do not submerge the incision in water until follow-up with your doctor. 4. call your doctor if you have any redness, swelling, or pus around the incision site. 5. if you have a fever, chills, or increased pain, call your doctor immediately. 6. follow up with your doctor in [**2012-07-18**]. 7. do not take any over-the-counter medications without speaking with your doctor first. 8. do not drive a car for the first 24 hours after discharge. 9. do not lift anything heavier than 10 pounds for the first 2 weeks. |
| C2350873 | discharge date: [**2013-04-29**] date of birth: [**1931-09-11**] sex: m service: cardiothoracic allergies: patient recorded as having no known allergies to drugs attending:[**attending info 319**] chief complaint: dyspnea and chest pain major surgical or invasive procedure: [**2013-04-22**] - 1. pericardiocentesis [**2013-04-23**] - 1. pulmonary artery catheterization [**2013-04-24**] - 1. pericardiocentesis [**2013-04-24**] - 2. pulmonary artery catheterization history of present illness: 82-year-old male with history of <1CUI> beryllium dis </1CUI> ease, [**first name4 (name |
| C2350875 | 3. cryptogenic anemia. 4. chronic obstructive pulmonary disease. 5. asthma. 6. chronic bronchitis. 7. chronic sinusitis. 8. nasal congestion. 9. sinusitis. 10. cystic fibrosis. 11. <1cui> <1CUI> bronchiolitis, constrictive </1CUI> . 12. pneumonia. 13. [**2016-03-01**] radiology: impression: the right lung is more consolidated than the left. the right hilar lymph nodes are enlarged. 2. there is a right upper lobe consolidation. 3. there is a 1.5 cm right basal pleural effusion. 4. there is a left lower lobe consolidation. 5. there is a left lower lobe atelectasis. 6. there is a right lower lobe atelectasis. 7. |
| C2350879 | <1CUI> eosinophilic pneumonia, tropical </1CUI> 1994 eosinophilic pneumonia, tropical 1994 social history: denies tobacco, alcohol, and illicit drug use. family history: no significant family history. physical exam: t 97.5 bp 110/70 hr 115 rr 26 98%ra gen: a&o x3, in nad. cv: regular rate and rhythm, no m/r/g, no edema. resp: cta, no wheezes, no crackles, no rhonchi. abd: soft, nt/nd, no hsm. ext: no clubbing, cyanosis, edema. neuro: a&o x3, no focal neuro signs. pertinent results: [**2014-06-18**] 08:30am blood wbc-12.4* rbc-3.70* |
| C2355645 | 2. <1CUI> cervicocranial syndrome </1CUI> . 3. osteoporosis. 4. osteoarthritis. 5. cervical spine fracture. 6. hearing loss. 7. cataracts. 8. glaucoma. 9. hyperopia. 10. macular degeneration. 11. cataracts. 12. cataracts. 13. cataracts. 14. cataracts. 15. cataracts. 16. cataracts. 17. cataracts. 18. cataracts. 19. cataracts. 20. cataracts. 21. cataracts. 22. cataracts. 23. cataracts. 24. cataracts. 25. cataracts. 26. cataracts. 27 |
| C2350529 | sig: one (1) capsule po bid (2 times a day) (2 times a day). disp:*30 capsule(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. dementia. 2. <1cui> <1CUI> pulmonary aspergilloses </1CUI> . 3. sepsis. 4. right sided pneumonia. 5. right sided pleural effusion. 6. copd. 7. atrial fibrillation. discharge condition: good. discharge instructions: 1. please continue to take all medications as prescribed by your physician. 2. please continue to follow up with your physician as scheduled. 3. please avoid smoking and alcohol. 4. please avoid exposure to dust and fumes. 5. please avoid heavy lifting or bending. 6. please avoid exposure to people with viral infections. 7. please continue to |
| C2350622 | sig: one (1) tablet po qd. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service discharge diagnosis: 1. cystic <1CUI> fibrosis 2. </1CUI> radiation-induced fibrosis rad 3. radiation-induced pleural adhesions 4. radiation-induced pleural fibrosis 5. radiation-induced pleural thickening social history: she has a 25 year old son, 20 year old daughter, and a 17 year old son. she is married, but her husband is not currently in her life. she has a 15 year old daughter who is currently in a group home. family history: mother with breast cancer, father with colon cancer. patient had a brother with leukemia. physical exam: vital signs: t 99 |
| C2350873 | she was admitted to the icu and started on continuous furosemide infusion. on postop day 2, the patient had a significant increase in her white blood cell count and was started on broad-spectrum antibiotics for presumed sepsis. she was also started on a ppi for her reflux and was continued on her chronic oxygen and mechanical ventilation. on postop day 3, the patient's blood pressure was elevated and she was started on a beta blocker. she was also started on a low dose of vancomycin for presumed <1cui> <1CUI> beryllium dis </1CUI> <1cui> . her c-reactive protein was 12.9 and her white blood cell count was 12.5. on postop day 4, the patient's blood pressure was still elevated and she was continued on her beta blocker. her c-reactive protein was 20.4 and her white blood cell count was 12.3. on postop day 5, the patient was extubated and was able to ambulate with assistance. she was dis |
| C2350875 | 6. adenovirus. 7. influenza b. 8. pertussis. 9. <1cui> <1CUI> bronchiolitis, constrictive </1CUI> 10. streptococcus pneumoniae. 11. staphylococcus aureus. 12. legionella pneumophila. 13. streptococcus pneumoniae. 14. haemophilus influenzae. 15. pseudomonas aeruginosa. 16. cmv. 17. herpes simplex virus. 18. rhinovirus. 19. influenza a. 20. respiratory syncytial virus. 21. parainfluenza virus. 22. human metapneumovirus. 23. mycoplasma pneumoniae. 24. legionella pneumophila. 25. chlamydophila pneumoniae. 26. |
| C2350879 | there is no evidence of pneumothorax. there is a small pleural effusion. no evidence of mass. there is no evidence of consolidation. there is no evidence of pneumonia. 1) pulmonary edema: there is no evidence of pulmonary edema. 2) pneumonia: there is no evidence of pneumonia. 3) <1CUI> eosinophilic pneumonia, tropical </1CUI> : there is no evidence of eosinophilic pneumonia, tropical. 4) pneumothorax: there is no evidence of pneumothorax. 5) mass: there is no evidence of mass. 6) consolidation: there is no evidence of consolidation. 7) pneumonia: there is no evidence of pneumonia. 8) pneumothorax: there is no evidence of pneumothorax. 9) mass: there is no evidence of mass. 10) consolidation: there is no evidence of consolidation. 11) pleural effusion: there is no evidence |
| C2350988 | 3. pneumonia. 4. respiratory failure. 5. <1CUI> bronchiolitis, proliferative </1CUI> . 6. chronic obstructive pulmonary disease. 6. respiratory failure. 7. chronic obstructive pulmonary disease. 7. respiratory failure. 8. chronic obstructive pulmonary disease. 8. respiratory failure. 9. chronic obstructive pulmonary disease. 9. respiratory failure. 10. chronic obstructive pulmonary disease. 10. respiratory failure. 11. chronic obstructive pulmonary disease. 11. respiratory failure. 12. chronic obstructive pulmonary disease. 12. respiratory failure. 13. chronic obstructive pulmonary disease. 13. respiratory failure. 14. chronic obstructive pulmonary disease. 14. respiratory |
| C2355645 | patient had a prior mri of the brain and spine which showed multilevel spinal degenerative changes with moderate spinal stenosis at c4-c5 and c5-c6. past medical history: 1. <1CUI> cervicocranial syndrome </1CUI> . 2. chronic allergies. 3. hx of tinnitus. 4. hx of dizziness. social history: lives with wife. married. no children. lives in [**location (un) 1657**]. no tobacco. no alcohol. no illicit drugs. family history: mother with colon cancer. physical exam: vital signs: 98.6 hr: 88 bp: 140/70 rr: 22 general: 150 pound man in no acute distress. heent: perrla, eomi, tms are clear. neck: no carotid bruits. heart: regular rate and rh |
| C2350529 | discharge date: [**2012-02-01**] date of birth: [**1943-09-27**] sex: f service: medicine history of present illness: this is a 68-year-old female with a history of chronic obstructive pulmonary disease, <1CUI> pulmonary aspergillosis </1CUI> , and multiple admissions to the hospital. she was admitted to the [**hospital1 15**] on [**2011-10-10**] for worsening cough and fever. she was found to have a left lower lobe pneumonia and was started on antibiotics. she was transferred to the [**hospital1 15**] on [**2011-10-24**] for further management. she had a right lower lobe pneumonia on admission and was started on [**02-19**] antibiotics. she had a right lower lobe pneumonia on admission |
| C2350873 | discharge date: [**2014-04-18**] date of birth: [**1935-07-03**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 179**] chief complaint: 1) 2) history of present illness: 67 year old female with a history of <1CUI> beryllium exp </1CUI> osure, who is now admitted with a fever of 102.7 and a dry cough. past medical history: 1. beryllium exposure: pt has a history of exposure to beryllium in the workplace. 2. asthma: pt has a history of asthma. 3. cad: pt has a history of cad. 4. gastritis: pt has a history of gastritis. 5. osteoporosis: pt has a history of osteoporosis |
| C2350879 | a chest x-ray was obtained which showed a right upper lobe infiltrate. the patient was started on a broad-spectrum antibiotic and transferred to the [**hospital1 175**] icu for further evaluation and treatment. the patient's clinical course was complicated by recurrent episodes of fever, cough, and chest pain. the patient was evaluated for a possible case of <1CUI> eosinophilic pneumonia, tropical </1CUI> , and was started on a course of steroids and antibiotics. on [**13-23**] the patient's fever resolved and he was discharged to home with a course of steroids and antibiotics. past medical history: 1. eosinophilic pneumonia, tropical, s/p 2 episodes of 2. asthma 3. coronary artery disease, status post 1999 coronary artery bypass grafting, status post 1999 pacemaker placement 4. hypertension 5. gerd social history |
| C2350988 | the patient was intubated in the or and was placed on a ventilator with a fio2 of 50% and a peep of 5. the patient's pco2 remained in the 30's and 40's throughout the postoperative period. the patient was continued on a ventilator with a fio2 of 50% and a peep of 5. the patient's <1cui> <1CUI> bronchiolitis, proliferative </1CUI> <1cui> resolved and the patient was weaned off the ventilator on postoperative day #2. on postoperative day #3, the patient was extubated and was able to breathe spontaneously. on postoperative day #4, the patient was able to tolerate a diet and was able to ambulate with assistance. on postoperative day #5, the patient was able to tolerate a regular diet and was able to ambulate without assistance. on postoperative day #6, the patient was discharged to home in good condition. the patient was discharged to |
| C2355645 | pt is currently on a 12-day course of antibiotics for this condition. past medical history: 1. <1CUI> cervicocranial syndrome </1CUI> . 2. chronic allergies. social history: lives alone, works as a teacher. family history: noncontributory. physical exam: t 98.2 bp 106/50 hr 76 rr 16 90% gen: well-appearing male in no acute distress. heent: perrla, eomi, nc/at, mmm, oropharynx benign, neck supple, no lymphadenopathy, no thyromegaly, no carotid bruits. lungs: ctab cv: rrr, s1, s2, no murmurs, rubs or gallops, no edema ext: no clubbing, cyanosis, or edema, warm, well-perfused. neuro: alert and oriented, no weakness, no paresthesias, no focal deficits |
| C2350449 | 2. chronic renal insufficiency. 3. hypothyroidism. 4. hyperlipidemia. 5. hypercholesterolemia. 6. hypertriglyceridemia. 7. hyperglycemia. 8. chronic cough. 9. chronic obstructive pulmonary disease. 10. cerebral vascular accident. 11. dementia. 12. <1CUI> pancreatitis, graft </1CUI> . 13. hypocalcemia. 14. hypomagnesemia. 15. hypoproteinemia. 16. hyperkalemia. 17. hypocalcemia. 18. hypoalbuminemia. 19. hyperchloridemia. 20. hypernatremia. 21. hyperosmolarity. 22. hypoxia. 23. hyperglycemia. 24. hypertriglyceridemia. |
| C2350529 | 6. chronic obstructive pulmonary disease. 7. chronic bronchitis. 8. chronic <1CUI> pulmonary aspergillosis </1CUI> . 9. chronic cough. 10. chronic gastroesophageal reflux disease. 11. dementia. 12. hypothyroidism. 13. hypercholesterolemia. 14. hypertriglyceridemia. 15. hypertension. 16. hyperlipidemia. 17. hyperglycemia. 18. chronic renal insufficiency. 19. chronic pain. 20. chronic obstructive sleep apnea. 21. <1cui> pulmonary aspergilloses. 22. cerebral vascular accident. 23. tuberculosis. 24. dementia. 25. osteoporosis. 26. chronic obstructive pulmonary disease |
| C2350873 | discharge date: [**2018-04-12**] date of birth: [**1941-07-17**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1365**] chief complaint: 1) 2) history of present illness: 66 y/o female with a history of [**10-13**] of <1CUI> beryllium exp </1CUI> osure, who was initially diagnosed with copd. she was found to have a pulmonary nodule on a ct scan done for the copd. the patient was referred to [**doctor first name 1**] [**last name (un) **] for further evaluation. pt has a history of beryllium exposure and was found to have a pulmonary nodule on a ct scan done for the copd. the patient was referred to [**doctor first name 1**] [**last |
| C2350879 | in the emergency department, the patient was found to have a white blood cell count of 17.2 and a platelet count of 109,000. he was started on iv ceftriaxone and doxycycline, and he was transferred to the intensive care unit. the patient's white blood cell count was found to be elevated throughout his hospitalization. in the intensive care unit, the patient was started on vancomycin for a suspected [**hospital1 48**] pneumonia. his white blood cell count was found to be elevated throughout his hospitalization. in the intensive care unit, the patient was started on vancomycin for a suspected [** <1CUI> eosinophilic pneumonia, tropical </1CUI> 119**] pneumonia. his white blood cell count was found to be elevated throughout his hospitalization. the patient was started on steroids and his white blood cell count began to decrease. his fever resolved and he was able to be weaned off of mechanical ventilation. the patient was also started on diuretics and his respiratory |
| C2350988 | 4. cystic fibrosis. 5. chronic obstructive pulmonary disease. 6. <1cui> <1CUI> bronchiolitis, proliferative </1CUI> . 7. rheumatoid arthritis. 8. hypothyroidism. 9. hypertension. 10. hyperlipidemia. 11. hypercholesterolemia. 12. [**hospital1 **] renal failure. 13. [**hospital1 **] gastritis. 14. gastric ulcer. 15. esophageal ulcer. 16. gerd. 17. osteoporosis. 18. osteoarthritis. 19. chronic obstructive pulmonary disease. 20. chronic fatigue syndrome. 21. depression. 22. anxiety. 23. chronic insomnia. 24. chronic pain. 25. chron |
| C2355645 | 2. lumbar spine: l4-5 degenerative spondylolisthesis. 3. cervical spine: c4-5 fracture. 4. <1CUI> cervicocranial syndrome </1CUI> . 5. herniated nucleus pulposus at l3-4 and l4-5. 6. degenerative joint disease of the spine. 7. bilateral hernia inguinal. 8. neuropathy of the left ulnar nerve. 9. neuropathy of the left median nerve. 10. neuropathy of the left radial nerve. 11. neuropathy of the left peroneal nerve. 12. neuropathy of the right peroneal nerve. 13. carotid artery stenosis. 14. right subclavian artery stenosis. 15. right subclavian vein thrombosis. 16. right atrial thrombus. 17. left atrial |
| C2350350 | discharge date: [**2015-04-23**] date of birth: [**1963-09-20**] sex: m service: [**hospital unit name **] history of present illnees: the patient was transferred to the [**hospital1 2**] intensive care unit on [**2015-04-13**] after transfer from [**hospital1 3**] [**hospital1 4**] with a diagnosis of ards. he was intubated and sedated and on mechanical ventilation with a high tidal volume and fio2. on admission to [**hospital1 2**], he was found to have a [**hospital unit name **] pneumonia, [**1cui> <1CUI> ventilator induced lung injury </1CUI> **], and bilateral pleural effusions. he was started on broad-spectrum antibiotics and a mechanical ventilator with a low tidal volume and low fio2 |
| C2350449 | sig: one (1) tablet po bid for seven (7) days. disp:*7 tablets refills:*0 discharge disposition: extended care discharge diagnosis: 1. <1CUI> pancreatitis, graft </1CUI> 2. cystic fibrosis discharge condition: stable discharge instructions: 1. take your medications as directed by the nurses or doctors. 2. take your pain medications as directed by the nurses or doctors. 3. follow up with your primary care physician in [**doctor first name **] for your pancreatitis and cystic fibrosis. 4. follow up with your surgeon in [**doctor first name **] for your pancreas transplant. 5. follow up with your pulmonologist in [**doctor first name **] for your cystic fibrosis. 6. follow up with your gastroenterologist in [**doctor first name **] for your pancreatitis. 7. follow up |
| C2350529 | 2. pna. 3. aortic stenosis. 4. cad s/p cabg x 3. 5. cmh. 6. pe. 7. dvt. 8. hx of pulmonary embolism. 9. <1cui> <1CUI> pulmonary aspergilloses </1CUI> . 10. hx of gi bleed. 11. hx of nephrolithiasis. 12. hx of hematuria. 13. hx of hypothyroidism. 14. hx of hyperlipidemia. 15. hx of hypercholesterolemia. 16. hx of hypertriglyceridemia. 17. hx of hypothyroidism. 18. hx of hypertension. 19. hx of hyperlipidemia. 20. hx of hypercholesterolemia. 21. hx of hypertrigly |
| C2350873 | discharge date: [**2013-08-24**] date of birth: [**1947-12-28**] sex: m service: cardiothoracic allergies: patient recorded as having no known allergies to drugs attending:[**attending info 212**] chief complaint: chest pain major surgical or invasive procedure: <1CUI> beryllium dis </1CUI> history of present illness: mr. [**lastname 707**] is a 65-year-old male who presented to the [**hospital1 199**] [**doctor first name 3**] with chest pain. he is a former worker at a beryllium plant and was exposed to beryllium. the patient is a former worker at a beryllium plant and was exposed to beryllium. he has had a history of exposure to beryllium for many years and has had sympt |
| C2350879 | discharge date: [**2014-04-21**] date of birth: [**1959-09-23**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 374**] chief complaint: sore throat major surgical or invasive procedure: none history of present illness: 61 yo female with h/o <1CUI> eosinophilic pneumonia, tropical </1CUI> who was admitted with sore throat. pt reports that she has had a sore throat for 3 days and that it has been getting worse. she denies fevers, chills, or cough. she denies any recent travel. pt reports that she has been treated with antibiotics for her eosinophilic pneumonia, tropical by her pcp, but that they have not been effective. she denies any recent travel. pt reports that she has been treated with ant |
| C2350988 | 2. copd. 3. chronic renal insufficiency. 4. aortic valve stenosis. 5. probable gastric cancer. 6. probable <1cui> <1CUI> bronchiolitis, proliferative </1CUI> <1cui> . 7. hypertension. 8. hyperlipidemia. 9. hypercholesterolemia. 10. diabetes mellitus type ii. social history: he is a retired [**hospital1 119**] [**last name (stitle) 120**] and lives in [**hospital1 121**]. he is married and has two adult children. he is a non-smoker and drinks alcohol socially. family history: he has one brother who died of myocardial infarction at age 65. physical exam: he is an elderly man who is in no acute distress. he has a tachycardia of 100-1 |
| C2355645 | he was started on plavix and heparin. his pt was 120 and his ptt was 31.3. he was transferred to [**hospital 1779**] for further management. the patient was seen by the neurology service for evaluation of his <1CUI> cervicocranial syndrome </1CUI> . his neurological examination was significant for weakness of the right side of his face and left side of his tongue, as well as weakness of his left hand. the patient was started on steroids and heparin for his cervicocranial syndrome. 2. cervicocranial syndrome: the patient was seen by the neurology service for evaluation of his cervicocranial syndrome. his neurological examination was significant for weakness of the right side of his face and left side of his tongue, as well as weakness of his left hand. 3. methicillin-resistant staphylococcus aureus (mrsa): the patient was treated for mrsa with vancomycin. 4. sepsis: the |
| C2362538 | the patient was started on thyroid hormone replacement and was discharged to home. followup with endocrinology and neurology was arranged. past medical history: 1. hypothyroidism. 2. <1CUI> thyroid stimulating hormone producing pituitary gland neoplasm </1CUI> . 3. diabetes mellitus. 4. hypertension. 5. hyperlipidemia. 6. obesity. 7. hypercholesterolemia. social history: the patient lives with his wife, is a retired welder, and has three children. he is a non-smoker and drinks alcohol socially. family history: the patient has a positive family history of thyroid disease and cancer. his father had thyroid cancer and his brother had thyroid disease. he also has a brother who had melanoma. physical exam: the patient was in no acute distress. his vital signs were normal. his neck was supple without any masses or lymphadenopathy. pertinent results: [** |
| C2362621 | discharge date: [**2012-08-27**] date of birth: [**1943-03-11**] sex: m service: [**hospital unit name 50**] history of present illness: this is a 70-year-old male with a history of psoriasis, <1CUI> photosensitivity </1CUI> , and a history of gastrointestinal bleeding. the patient was transferred from [**hospital1 11**] on [**2012-08-22**] for evaluation of melena, anemia, and photosensitivity. the patient reports a history of psoriasis, and the patient has been treated with various topical and systemic medications. the patient had been treated with [**last name (un) 375**] and [**last name (un) 376**] for his skin rashes. the patient had been treated with [**last name (un) 377**] for his gastrointestinal bleeding. |
| C2362792 | the patient was discharged to home with instructions to follow up with her primary care physician and gynecologist. 1. the patient had a normal vaginal ultrasound. 2. the patient had a normal pelvic exam. 3. the patient had a normal <1cui> <1CUI> labial fusion </1CUI> <1cui> exam. 4. the patient had a normal mri of the pelvis. 5. the patient had a normal cystoscopy. 6. the patient had a normal colonoscopy. 7. the patient had a normal upper gi endoscopy. 8. the patient had a normal chest x-ray. 9. the patient had a normal ekg. 10. the patient had a normal cbc and chemistry panel. 11. the patient had a normal urinalysis. 12. the patient had a negative pregnancy test. 13. the patient had a negative hiv test. 14. the patient had a negative hepatitis b surface antigen. 15. the patient had a negative hepatitis c antibody |
| C2363734 | the uterus is normal in size. the fetuses are both normal in size. the placenta is abnormally large. there is no evidence of placental separation. the placenta measures 12.6 cm in thickness. the 2d and 3d ultrasound suggest the presence of <1CUI> placental hypertrophy </1CUI> . there is no evidence of abruption. 1. placental hypertrophy: there is no evidence of placental separation. 2. anemia: the patient's anemia is likely related to her underlying disease. 3. hba1c: the patient's hba1c is elevated and the patient has been started on insulin. 4. hypertriglyceridemia: the patient's hypertriglyceridemia is likely related to her underlying disease. 5. hypercholesterolemia: the patient's hypercholesterolemia is likely related to her underlying disease. 6. hypertension: the patient's hypertension is likely related to her |
| C2362324 | sex: m service: cardiothoracic history of present illness: the patient is a 15 year old male with a history of <1CUI> childhood obesity </1CUI> who was admitted for a routine cardiac catheterization. the patient was referred to the cardiothoracic surgery service for a diagnostic cardiac catheterization for the evaluation of the patient's coronary arteries. the patient has a history of childhood obesity and is currently 15 years old, weighing 260 pounds, and is 5 feet 5 inches tall. he has a history of hypertension, hypercholesterolemia, and hypertriglyceridemia. the patient is currently a high school student and is in good health. he has a family history of hypertension, hyperlipidemia, and cardiac disease. his mother has hyperlipidemia and his father has hypertension. the patient's social history is significant for smoking one pack of cigarettes per day for the past 2 years, and he has a |
| C2362538 | the patient was seen by the neurologist and the neurosurgeon and was scheduled for surgery. past medical history: 1. <1CUI> thyroid stimulating hormone producing pituitary gland neoplasm </1CUI> . 2. hypothyroidism. 3. hyperlipidemia. 4. hypertension. 4. gastroesophageal reflux disease. 5. osteoarthritis. 6. carotid artery disease. 7. cervical stenosis. 8. peripheral vascular disease. 9. chronic obstructive pulmonary disease. 10. depression. 11. anxiety. 12. chronic low back pain. social history: the patient is a retired engineer. he is a nonsmoker and a social drinker. he lives with his wife. family history: the patient is married and has 3 children. physical exam: on admission the patient was afebrile |
| C2362621 | no evidence of metastatic disease. ct abdomen/pelvis: no evidence of ascites, free fluid or obstructive lesions. cardiac: no evidence of cardiac tamponade, pericardial effusion or myocardial infarction. spect/ct: no evidence of myocardial infarction or pericardial effusion. [**2014-08-13**] 06:00am discharge disposition: extended care discharge diagnosis: <1CUI> photosensitivity </1CUI> , acute respiratory distress syndrome, sepsis, pneumonia, pneumothorax, pleural effusion, respiratory failure, hypotension, anemia, hypocalcemia, hyperkalemia, hypoxia, hypercapnea, aspiration, subcutaneous emphysema, pneumothorax, pleural effusion, pneumonia, photosensitivity discharge condition: stable discharge instructions: 1. follow up with your primary care physician |
| C2362742 | mental status is normal. neurologically, there are no focal neurological deficits. mri of the brain is significant for a small left frontal subdural hematoma. the patient was transferred to [**hospital 160**] for neurosurgical consultation. 1) 1. cerebral <1CUI> microgyria </1CUI> : there is a small, bilateral, symmetrical area of abnormal signal intensity in the left frontal lobe consistent with cerebral microgyria. 2. cerebral hemiatrophy: there is a small area of left frontal hemiatrophy. 3. subdural hematoma: there is a small left frontal subdural hematoma. 4. cerebral atrophy: there is mild cerebral atrophy. 5. cerebral infarction: there is a small area of cerebral infarction in the left frontal lobe. 6. cerebral white matter lesions: there is a small area of cerebr |
| C2362792 | mammary calcification, bilateral. 1. <1cui> <1CUI> labial fusion </1CUI> . 2. cystic masses in the left fallopian tube. 3. cystic masses in the right fallopian tube. 4. mild uterine leiomyoma. 5. endometrial polyp. 6. endometrial hyperplasia. 7. ovarian cyst. 8. ovarian follicular cysts. 9. bilateral adnexal tube. 1. uterine leiomyoma: 1. uterine leiomyoma. 2. endometrial hyperplasia. 2. endometrial hyperplasia: 1. endometrial hyperplasia. 3. ovarian cyst: 1. right ovarian cyst. 4. ovarian follicular cysts: 1. right ovarian follicular cyst. 5. bilateral adnexal tube: 1. bilateral |
| C2363129 | the patient had a seizure in the picu and was given 1 dose of 5 mg of ativan. he was admitted to the [**hospital unit name 72**]. the patient was admitted to the [**hospital unit name 72**] for further management of his seizure disorder and for a neurology consult. past medical history: <1CUI> centralopathic epilepsy </1CUI> social history: the patient is a nonsmoker and drinks alcohol occasionally. family history: the patient is a 22 year old male who is a product of a consanguineous marriage between two first cousins. physical exam: on admission to the [**hospital unit name 72**], the patient was conscious and oriented x 3. he was afebrile. his neurological exam was notable for a left hemiparesis, but he was able to move his right hand and right leg. his seizure activity was controlled with ativan. pertinent results: [**2018-03-21**] 06: |
| C2362324 | discharge date: [**2015-02-03**] date of birth: [**1989-05-04**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 129**] chief complaint: s/p abdominal surgery, wound infection major surgical or invasive procedure: wound debridement and closure history of present illness: pt is a 25 yo f with a history of <1CUI> childhood obesity </1CUI> , who was admitted to the [**hospital1 11**] for surgical debridement and closure of a wound on her left thigh. the pt was referred to [**hospital1 11**] from [**hospital2 164**] where she had been admitted for 2 weeks and had undergone wound debridement, which was complicated by infection. the pt had a wound which was 1 |
| C2362538 | the patient had no history of thyroid disease. she was admitted on [**2010-01-11**] for a <1CUI> thyroid-stimulating hormone-producing pituitary gland neoplasm </1CUI> . she was evaluated by endocrine and neurosurgery. her thyroid-stimulating hormone level was elevated to 1200. she was treated with thyroid hormone replacement and was started on thyroid-stimulating hormone suppressive therapy with levothyroxine. she was also started on propylthiouracil for her thyroid-stimulating hormone-producing pituitary gland neoplasm. her thyroid-stimulating hormone level was normalized to 1.9 on [**2010-01-20**]. she was also started on thyroid hormone replacement. she was also started on propylthiouracil for her thyroid-stimulating hormone-producing pituitary gland neoplasm. she was discharg |
| C2362742 | there is no evidence of hydrocephalus. the cerebral cortex appears mildly atrophic. the ventricles are normal in size. there is no evidence of mass lesions. there is mild cerebral atrophy. there is mild to moderate <1cui> <1CUI> microgyria </1CUI> . there is no evidence of cerebral infarcts, hemorrhage, or other mass lesions. # mri of the brain (follow-up) 2009-02-09 contrast: iv bone windows: skull bone windows: spine bone windows: pelvis bone windows: thoracic spine bone windows: thoracic spine bone windows: thoracic spine bone windows: thoracic spine bone windows: thoracic spine bone windows: thoracic spine bone windows: thoracic spine bone windows: thoracic spine bone windows: thoracic spine bone windows: thoracic spine bone windows: thoracic spine bone windows: thoracic spine |
| C2363734 | 211220 |||| 3126 |||| 2829 |||| echo_report |||| 2014/10/14 |||| |||| patient/test information: female in her 32nd year indication: 1. <1CUI> placental hypertrophy </1CUI> 2. c/d technical quality: aorta (aortic valve area 2.8 cm2): aortic valve leaflets (3): - mild aortic regurgitation - mild mitral regurgitation - trace mitral stenosis - trace tricuspid regurgitation - trace pulmonary regurgitation - trace pulmonary stenosis - trace as - trace pda - trace as - trace pda - trace as - trace pda - trace as - trace pda - trace as - trace pda - trace as - trace pda - trace as - trace pda - trace as - trace pda - |
| C2362324 | discharge date: [**2013-02-18**] date of birth: [**1976-07-25**] sex: f service: medicine history of present illness: the patient is a 36 year old female who was admitted for a total of 5 weeks for management of her diabetes and hypertension. she has a history of polycystic ovarian syndrome, <1CUI> childhood obesity </1CUI> , and hyperlipidemia. she presented to the [**hospital1 30**] on [**2013-01-24**] with complaints of dyspnea and fatigue. she was found to have a heart rate of 150, bp 180/100, saturation of 88% on room air. the patient was admitted to the [**hospital1 30**] with a diagnosis of hyperkalemia and diabetic ketoacidosis. she was transferred to [**hospital1 |
| C2362621 | discharge date: [**2014-04-01**] date of birth: [**1963-02-14**] sex: f service: [**hospital unit name **] allergies: patient recorded as having no known allergies to drugs attending:[**attending info 121**] chief complaint: skin rashes major surgical or invasive procedure: none history of present illness: this is a 50 year old woman with a history of chronic lyme disease, <1CUI> photosensitivity </1CUI> and skin rashes. she was admitted to the [**hospital1 16**] for evaluation of her skin rashes and for management of her chronic lyme disease. she was seen in the [**hospital unit name **] and had a skin biopsy that showed photosensitive dermatitis and was treated with doxycycline and prednisone. she was also treated with prednisone for her photosensitivity. she was transferred to [ |
| C2362742 | 2. hypertension. 3. chronic obstructive pulmonary disease. 4. depression. 5. history of alcohol abuse. 6. history of <1cui> <1CUI> microgyria </1CUI> with seizures. 7. history of status epilepticus. 8. history of suicidal ideation. 9. history of suicide attempt. 10. history of alcohol abuse. 11. history of smoking. 12. history of marijuana use. 13. history of cocaine use. 14. history of heroin use. 15. history of prescription drug abuse. 16. history of benzodiazepine abuse. 17. history of acetaminophen overdose. 18. history of alcohol abuse. 19. history of suicidal ideation. 20. history of suicide attempt. 21. history of homicidal ideation. 22. history of homicidal attempt. |
| C2363129 | discharge date: [**2014-11-24**] date of birth: [**1974-12-23**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1409**] chief complaint: seizures major surgical or invasive procedure: none history of present illness: 52 year old female with history of <1CUI> central pathic epilepsy </1CUI> who presented to the emergency department with a 10 minute episode of seizure. past medical history: 1. central pathic epilepsy 2. adenocarcinoma of the lung 3. diabetes mellitus 4. hypertension 5. hyperlipidemia social history: non-smoker, no alcohol, lives with husband, works as an accountant family history: non-contributory physical exam: vs: t 98.8, |
| C2363142 | he had a normal chest x-ray. on [**2018-11-28**] he was started on vancomycin and levaquin for presumed pneumonia. on [**2018-11-29**] he was started on doxycycline for presumed lymphoma. on [**2018-11-30**] he was started on cytoxan for presumed leukemia. his blood work showed a wbc of 10.9, hct of 35.2, plt of 55,000. he had a bone marrow biopsy which showed 80% blasts, 10% lymphocytes, 5% metamyelocytes, 2% monocytes, 2% erythrocytes and 1% fibrocytes. the bone marrow biopsy showed <1CUI> leukemia, t-cell prolymphocytic </1CUI> . his bone marrow biopsy was sent to [**hospital1 19**] for further |
| C2363734 | no evidence of acute myocardial infarction. no evidence of pulmonary embolism. no evidence of bleeding. no evidence of aneurysm. [**last name (un) **] [**name7 (md) 4095**] [**name7 (md) 4096**] [**md number 4097**] [**2014-04-13**] clip #2: no evidence of acute myocardial infarction. no evidence of pulmonary embolism. no evidence of bleeding. no evidence of aneurysm. [**name7 (md) 4098**] [**md number 4099**] 2. no evidence of placental abruption. no evidence of <1CUI> placental hypertrophy </1CUI> . [**2014-04-13**] 3. no evidence of fetal acidosis. [**2014-04-13**] 4. no evidence of fetal distress. |
| C2363771 | 5. nephrolithiasis. 6. osteoarthritis. 7. dyslipidemia. 8. hypercholesterolemia. 9. hyperlipidemia. 10. <1CUI> myopic astigmatism (disorder) </1CUI> . 11. hyperopia. 12. cataract. 13. glaucoma. 14. hypertension. 15. hyperlipidemia. 16. hypercholesterolemia. 17. hypertriglyceridemia. 18. hyperglycemia. 19. hypercholesterolemia. 20. hypertriglyceridemia. 21. hyperglycemia. 22. hypertension. 23. hyperlipidemia. 24. hypercholesterolemia. 25. hypertriglyceridemia. 26. hyperglycemia. 27. hyper |
| C2362324 | sex: m service: cardiothoracic allergies: patient recorded as having no known allergies to drugs attending:[**attending info 340**] chief complaint: chest pain major surgical or invasive procedure: 1. coronary artery bypass grafting x 3 2. lvad implantation history of present illness: 48 yo man with a history of osa, htn, hyperlipidemia, dm, <1cui> <1CUI> childhood obesity </1CUI> , s/p lvad placement in [**2016**] who presents with chest pain. pt has been followed by cardiology for the past 10 yrs. he has a history of osa, htn, hyperlipidemia, dm, <1cui> childhood obesity, and s/p lvad placement in [**2016**]. pt was seen in the cardiology clinic in [**2019-06-11 |
| C2362538 | 4. hyperlipidemia. 5. history of <1CUI> thyroid stimulating hormone producing pituitary gland neoplasm </1CUI> . 6. history of gastroesophageal reflux disease. 7. history of hypertension. 8. history of hypercholesterolemia. 9. history of thyroid cancer. 10. history of diabetes mellitus. 11. history of <1cui> thyroid stimulating hormone producing pituitary gland neoplasm <1cui>. 12. history of hypothyroidism. 13. history of atrial fibrillation. 14. history of pulmonary embolus. 15. history of chronic obstructive pulmonary disease. 16. history of osteoporosis. 17. history of chronic kidney disease. social history: 1. lives with wife. 2. no smoking. 3. no alcohol. 4. no |
| C2362742 | the patient was discharged from [**hospital 30**] on [**2011-11-16**] with a diagnosis of hydrocephalus, seizures, and possible [**citation 2037**] and <1CUI> microgyria </1CUI> . he was referred to [**hospital 31**] for further evaluation and management of these conditions. **brief hospital course:** the patient was admitted to the [**hospital 31**] on [**2011-11-17**] for further evaluation and management of his hydrocephalus, seizures, and microgyria. the patient underwent a brain mri on [**2011-11-17**] which showed significant cerebral atrophy with bilateral ventricular enlargement. there was no evidence of hydrocephalus. the mri did show evidence of microgyria. the patient underwent an eeg on [**2011-11-18**] which showed bilateral frontal and temporal spike and slow wave activity consistent with |
| C2362760 | 5. left ventricular systolic dysfunction. 6. left bundle branch block. 7. hypertension. 8. <1cui> <1CUI> acute anterior wall myocardial infarction - electrocardiographic finding </1CUI> . 9. coronary artery disease. 10. chronic obstructive pulmonary disease. 11. chronic renal insufficiency. 12. chronic hepatitis c. 13. hyperlipidemia. 14. hypothyroidism. 15. status post left knee replacement. 16. status post right knee replacement. 17. status post left hip replacement. 18. status post right hip replacement. [**first name4 (namepattern1) 541**] [**last name (namepattern1) 542**] md [**md number 543**] [**doctor first name 544**] [**doctor initial 545**] [**doctor last name 5 |
| C2363142 | discharge date: [**2015-07-20**] date of birth: [**1947-03-11**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 129**] chief complaint: <1CUI> leukemia, t-cell prolymphocytic </1CUI> major surgical or invasive procedure: bone marrow biopsy history of present illness: the patient is a 68-year-old woman with a history of t-cell prolymphocytic leukemia who presented to the emergency department with fevers and chills. she had been on chemotherapy for her leukemia and had been doing well until the past few days. she had been on a clinical trial at [**hospital1 72**] for her leukemia. she was transferred from [**hospital1 72**] to [**hospital1 12 |
| C2363734 | the left kidney is normal in size and contour. the right kidney is small and irregular in contour. the left renal artery is not visualized. impression: 1. bilateral hydronephrosis. 2. <1CUI> placental hypertrophy </1CUI> . 3. bilateral ureteral calculi. [**2018-04-09**] 09:00:00 1. placental hypertrophy. 2. abnormal fetal umbilical cord. 3. abnormal fetal blood flow. 4. fetal growth restriction. 5. fetal acardia. 6. fetal anasarca. 7. fetal pulmonary dysplasia. 8. fetal intracranial calcification. 9. fetal tricuspid atresia. 10. fetal patent ductus arteriosus. 11. fetal pulmonary vein stenosis. 12. fetal coarctation of |
| C2363903 | cerebral angiography was performed on [**2019-07-07**] with no evidence of vascular abnormality. the patient was admitted to [**hospital1 79**] on [**2019-07-07**] for further evaluation and management of his seizures. the patient had a follow-up mri on [**2019-07-08**] which showed stable appearance of the previously described <1cui> <1CUI> angiocentric glioma </1CUI> <1cui>. the patient had a follow-up eeg on [**2019-07-08**] which showed no evidence of seizures activity. the patient had a follow-up mri on [**2019-07-10**] which showed stable appearance of the previously described <1cui> angiocentric glioma <1cui>. the patient was discharged home on [**2019-07-10**] with the following diagnosis: 1. seizure disorder. 2. |
| C2363919 | discharge date: [**2014-08-06**] date of birth: [**1991-05-14**] sex: f service: psychiatry allergies: morphine / codeine / sulfa / pennicillin / aspirin / adhesive tapes attending:[**attending info 214**] chief complaint: depressed major surgical or invasive procedure: none history of present illness: 16 year old female with history of <1CUI> childhood depression </1CUI> who was admitted to the [**hospital1 17**] for a psychiatric evaluation and treatment. the patient's history is significant for a 3 year history of depression, anxiety and suicidal ideation. she was seen by a psychiatrist at [**hospital1 17**] in [**2013-04-22**] and was started on celexa. she was seen by her pcp in [**2014-05 |
| C2363939 | 5. aortic stenosis. 6. hypertension. 7. <1cui> <1CUI> advanced atrioventricular block </1CUI> <1cui>. 8. hyperlipidemia. 9. hypothyroidism. 10. dyslipidemia. 11. nephrolithiasis. 12. gastritis. 13. ischemic colon. 14. nonalcoholic steatohepatitis. 15. cervical degenerative disc disease. 16. osteoarthritis of the lumbar spine. 17. osteoarthritis of the right knee. 18. osteoarthritis of the left knee. 19. osteoarthritis of the right shoulder. 20. osteoarthritis of the left shoulder. 21. carotid artery disease. 22. chronic bronchitis. 23. |
| C2363973 | 3. the patient was transferred to the [**hospital1 189**] [**doctor first name **] for further management of her pulmonary hypertension and thromboembolic disease. 4. the patient was transferred to the [**hospital1 189**] [**doctor first name **] for further management of her <1CUI> chronic thromboembolic pulmonary hypertension </1CUI> . 5. the patient was transferred to the [**hospital1 189**] [**doctor first name **] for further management of her chronic thromboembolic pulmonary hypertension. social history: she is married and lives with her husband. she is a former smoker and has no other significant social history. family history: she is a widow. she has one son, who is a [**age (1) 47-59**] year old male. physical exam: the patient was noted to be in no acute distress. her vitals were as follows: t: 98.1 hr: 78 |
| C2364082 | discharge date: [**2012-08-15**] date of birth: [**1946-03-23**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1607**] chief complaint: hypothyroidism, <1CUI> hyposmia </1CUI> , decreased sense of smell major surgical or invasive procedure: - thyroid biopsy history of present illness: 57 yo male with a 20 year history of hypothyroidism. presents with decreased sense of smell. pt is a 57 yo male with a 20 year history of hypothyroidism. he presents with decreased sense of smell. pt reports that he has been unable to smell anything for 10 days. he reports that he has been unable to taste anything for 5 days. he denies any other symptoms. pt has been on levothyroxine for |
| C2364135 | she was seen by the pt and ot for transfer to the floor and was able to get out of bed and walk with assistance. she was seen by the pt and ot for transfer to the floor and was able to get out of bed and walk with assistance. she was transferred to the floor on [**2011-11-21**] and was seen by the pain service for her <1CUI> discomfort </1CUI> . past medical history: 1. cad with stents in 1999. 2. cva in 1998 with right paresis. 3. gastric ulcer. 4. colon cancer. 5. chronic low back pain. 6. chronic right lower extremity pain. 7. chronic left lower extremity pain. 8. chronic left sided back pain. 9. chronic left sided neck pain. 10. chronic left sided chest pain. 11. chronic right sided chest pain. 12. chronic abdominal pain. 13 |
| C2364164 | the patient's electrolyte status was monitored and remained within normal limits. the patient was weaned off the ventilator on postoperative day 2. on postoperative day 4, the patient had a small volume of fluid overload and was transferred to the [**hospital unit name 43**] for further management of the [**initials (namepattern3) **] <1CUI> volume disorder </1CUI> . # medications on discharge: 1. lasix 20 mg po bid. 2. diltiazem 120 mg po bid. 3. ativan 1 mg po bid. 4. levothyroxine 50 mg po bid. 5. lopressor 25 mg po bid. 6. coumadin 1 mg po qd. 7. plavix 75 mg po bid. 8. zofran 4 mg po q6h prn. 9. dexamethasone 4 mg po q24h. 10. colace |
| C2364172 | the patient was discharged to home with a home healthcare agency. the patient was instructed to take his medications as prescribed, and to follow up with dr. [**last name (stitle) 2612**] in [**location (un) 2613**] for follow-up appointments. the patient was advised to follow up with his primary care physician for further follow-up appointments. the patient was instructed to follow up with the home healthcare agency for further assistance with his medications and with his care. the patient was discharged from the hospital on [**2014-03-27**]. **brief: ** 2. pharmacy referral: the patient was referred to the pharmacy for assistance with his medications. 3. <1CUI> adherence, medication </1CUI> : the patient was instructed to take his medications as prescribed. the patient was advised to follow up with his primary care physician for further assistance with his medications. 4. insulin therapy: the patient was |
| C2367458 | discharge date: [**2013-07-12**] date of birth: [**1973-01-27**] sex: f service: hematology allergies: patient recorded as having no known allergies to drugs attending:[**attending info 2013**] chief complaint: <1CUI> recurrent acute undifferentiated leukemia </1CUI> major surgical or invasive procedure: bone marrow biopsy history of present illness: 64 yo f with history of acute undifferentiated leukemia (aul) in [**2012-03-05**] who was in cr after 4 cycles of chemotherapy. patient presented to [**doctor first name 2**] [**doctor first name 3**] on [**2013-07-09**] with 2 days of fever, chills, headache, and nausea and vomiting. she had a bmb on [**2 |
| C2584556 | pt was started on hctz and bp was controlled. pt was started on colchicine 0.5mg po bid and was continued for 3 months. pt was started on prednisone 20mg qd for 3 months and then tapered to 10mg qd for 2 months. pt was started on 3000mg po qd of allopurinol for 6 months and then tapered to 1500mg po qd for 1 month. pt was started on 1000mg po qd of mycophenolate mofetil for 6 months and then tapered to 500mg po qd for 1 month. 2. <1cui> <1CUI> drug-induced tubulointerstitial nephritis (disorder) </1CUI> 2. [**2015-09-25**] disp: [**hospital unit name 50**] 25 [**2015-09-25**] 03 |
| C2363903 | discharge date: [**2013-05-13**] date of birth: [**1985-09-16**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 2255**] chief complaint: seizures major surgical or invasive procedure: seizure history of present illness: 22 yo male with known <1cui> <1CUI> angiocentric glioma </1CUI> <1cui> who presented with seizure and was found to have a new mass in the left occipital lobe on mri. past medical history: 22 yo male with known <1cui> angiocentric glioma <1cui> who has had recurrent seizures and was found to have a new mass in the left occipital lobe on mri. 2006: 21 yo male with known <1cui> angiocentric glioma |
| C2363919 | date of birth: [**1973-07-28**] sex: f service: psychiatry allergies: patient recorded as having no known allergies to drugs attending:[**attending info 199**] chief complaint: depressed major surgical or invasive procedure: none history of present illness: 24 year old woman with a history of <1CUI> childhood depression </1CUI> who has been hospitalized numerous times in the past. she has been feeling more depressed and suicidal over the past few weeks. past medical history: 1. childhood depression 2. polysubstance abuse 3. ptsd 4. bipolar disorder 5. gerd social history: lives with her husband and two children. family history: father with schizophrenia physical exam: pertinent results: ecg: sinus rhythm, 100/min, 12mm in vi, 2mm in v1-v2, 3mm in i, ii, iii |
| C2363973 | the patient was transferred to [**hospital1 16**] on [**2013-03-13**] for further management of her condition. past medical history: 1. <1CUI> chronic thromboembolic pulmonary hypertension </1CUI> . 2. hypertension. 3. hyperlipidemia. 4. osteoporosis. 5. hypercholesterolemia. 6. diabetes mellitus. 7. history of breast cancer. social history: the patient is a nonsmoker and denies any alcohol use. family history: the patient has a history of breast cancer in her mother, who died of metastatic disease. physical exam: on admission, the patient was afebrile, tachycardic, and had a blood pressure of 118/70. the patient had a respiratory rate of 18, and was in no acute distress. her abdomen was soft, nontender, and nondistended. she had a pulse of 90, and her extremities were warm and well |
| C2584556 | the patient was discharged on [**2013-03-04**] in good condition. the patient was referred to a nephrologist for followup. discharge diagnoses: 1. <1CUI> drug-induced tubulointerstitial nephritis (disorder) </1CUI> 2. acute kidney injury (disorder) 3. dehydration (disorder) 4. hypokalemia (disorder) 5. hypocalcemia (disorder) 6. hyperphosphatemia (disorder) 7. hyperkalemia (disorder) 8. hypernatremia (disorder) 9. hyperchloremic metabolic acidosis (disorder) 10. hypocalcemia (disorder) 11. hypomagnesemia (disorder) 12. hyperphosphatemia (disorder) 13. hyperkalemia (disorder) 14. hypernatremia (disorder) 15. hyperchlorem |
| C2363919 | discharge date: [**2014-03-14**] date of birth: [**1967-03-03**] sex: f service: [**hospital unit name **] history of present illness: this 37 year old woman with a history of <1cui> <1CUI> childhood depression </1CUI> was transferred to [**hospital 1029**] from [**hospital 2028**] for further psychiatric evaluation. she was transferred to the [**hospital unit name **] on [**2014-03-10**] for further psychiatric evaluation. the patient's history of depression began in her teenage years. she was admitted to [**hospital 2028**] in [**2008**] for depression and suicidal ideation. she was hospitalized on [**2014-02-15**] for suicidal ideation. she was found to be in no acute distress on admission to |
| C2363939 | 3. right ventricular systolic dysfunction. 4. left ventricular systolic dysfunction. 5. chronic atrial fibrillation. 6. atrial fibrillation with <1CUI> advanced atrioventricular block </1CUI> . 7. hypertension. 8. hyperlipidemia. 9. hyperglycemia. 10. obesity. [**2011-01-13**] 07:00:00 discharge diagnosis: 1. advanced atrioventricular block. 2. atrial fibrillation. 3. hypertension. 4. hyperlipidemia. 5. hyperglycemia. 6. obesity. 7. hypercholesterolemia. 8. hypertriglyceridemia. 9. hyperlipidemia. 10. hyperglycemia. 11. hypertension. 12. hyperlipidemia |
| C2363973 | 4. pulmonary artery hypertension: the patient was diagnosed with pulmonary artery hypertension in [**2008**] and was started on sildenafil. 5. <1CUI> chronic thromboembolic pulmonary hypertension </1CUI> : the patient was diagnosed with chronic thromboembolic pulmonary hypertension in [**2008**] and was started on sildenafil. 6. left ventricular dysfunction: the patient was diagnosed with left ventricular dysfunction in [**2011**]. 7. renal disease: the patient was diagnosed with chronic renal failure in [**2011**]. 8. osteoporosis: the patient was diagnosed with osteoporosis in [**2011**]. 9. hypothyroidism: the patient was diagnosed with hypothyroidism in [**2011**]. 10. c |
| C2584556 | the patient's renal function improved over the next several days. the patient was started on a 12-hour continuous furosemide infusion to maintain her fluid status. on [**2011-08-15**] the patient was transferred to the [**hospital1 44**] for further management of her drug-induced tubulointerstitial nephritis. 2. <1CUI> drug-induced tubulointerstitial nephritis (disorder) </1CUI> - the patient's serum creatinine was elevated to 1.8 on [**2011-08-10**]. this was likely due to her sepsis. the patient's renal function improved over the next several days. 3. aortic valve endocarditis - the patient had a bacterial culture from her aortic valve which was positive for methicillin-sensitive staphylococcus aureus. 4. cryptococcal pneumonia - the patient was started on oral fluconazole. 5. mrsa |
| C2363903 | 2. dysarthria. 3. seizures. 4. <1CUI> angiocentric glioma </1CUI> . 5. neurofibromatosis type 1. 6. cerebral vasospasm. 7. cerebral edema. 8. hydrocephalus. 9. right 6th nerve palsy. 10. bilateral vocal cord palsy. 11. bilateral vocal cord paralysis. [**2014-10-15**] 08:00:00 activation of neurocrine transmission in patients with angiocentric glioma. # 2014-10-15 8:00:00 2.412* # 2014-10-15 08:00:00 2.412* # 2014-10-15 08:00:0 |
| C2363919 | disp:*30 refills* discharge disposition: home with service discharge diagnosis: 1. <1cui> <1CUI> childhood depression </1CUI> 2. depression 3. anxiety 4. ptsd discharge condition: good discharge instructions: please follow up with dr. [**last name (stitle) **] in [**city **] please follow up with your primary care physician for any new symptoms or concerns. please continue to take your medications as prescribed. please call your psychiatrist if you have any new symptoms or concerns. please call your primary care physician if you have any new symptoms or concerns. please call 911 or go to the emergency room if you have any suicidal thoughts or feelings. please call [**telephone/fax (2) 194**] if you have any questions or concerns. followup instructions: dr. [**last name (stitle) **] in [**city **] in 2 weeks. [**name7 ( |
| C2363934 | 4. congenital heart disease: tetralogy of fallot. 5. pulmonary artery hypoplasia. 6. 1cui <1CUI> ductus venosus agenesis </1CUI> . 7. 1cui atrial septal defect. 8. 1cui ventricular septal defect. 9. 1cui patent ductus arteriosus. 10. asd. 11. 1cui [**11-21**]. 12. 1cui [**11-22**]. 13. 1cui [**11-23**]. 14. 1cui [**11-24**]. 15. 1cui [**11-25**]. 16. 1cui [**11-26**]. 17. 1cui [**11-27**]. 18. 1cui [**11-28**]. 19. 1cui [**11-29** |
| C2363973 | 11) <1CUI> chronic thromboembolic pulmonary hypertension </1CUI> . 12) cerebral infarction. 13) chronic kidney disease. 14) chronic anemia. 15) chronic obstructive pulmonary disease. 16) hyperlipidemia. 17) hypertension. 18) hypothyroidism. 19) dyslipidemia. 20) hypercholesterolemia. 21) hypertriglyceridemia. 22) hypochlorhydria. 23) gastroesophageal reflux disease. 24) hiatal hernia. 25) osteoarthritis. 26) degenerative joint disease. 27) osteoporosis. 28) glaucoma. 29) cataract. 30) carotid artery disease. 31) peripheral vascular disease. 32) hyperparathyroidism. 33) cerebral |
| C2364082 | the patient was started on vancomycin and piperacillin-tazobactam for the possible mrsa bacteremia. the patient was also started on iv steroids for possible cns vasculitis. the patient's <1CUI> hyposmia </1CUI> was thought to be related to his recent mrsa bacteremia. the patient was transferred to the [**hospital 115**] [**doctor first name 118**] [**doctor first name 119**] on [**2018-09-07**] for further evaluation and management of his hyposmia and bacteremia. # ear, nose, throat: the patient's hyposmia was thought to be related to his recent mrsa bacteremia. the patient's hyposmia was thought to be related to his recent mrsa bacteremia. # respiratory: the patient's respiratory status was stable on admission to the [**hospital unit name 120**]. # cardiac: the patient's cardiac examination was |
| C2367458 | sig: one (1) tablet po q12h (every 12 hours) for 3 days. disp:*3 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. <1CUI> recurrent acute undifferentiated leukemia </1CUI> 2. myelodysplastic syndrome 3. myeloproliferative neoplasm 4. anemia discharge condition: stable discharge instructions: please follow up with dr. [**last name (stitle) **] in 30 days for a follow up consultation. please call [**telephone/fax (2) 4991**] if you experience any shortness of breath, chest pain, fever, nausea, vomiting, diarrhea, or any other symptoms. please call [**telephone/fax (2) 4991**] if you notice any unusual bruising, bleeding, or signs of infection. please call [**t |
| C2363973 | 10. <1CUI> chronic thromboembolic pulmonary hypertension </1CUI> . # social history: the patient is married and lives with her husband. she has two adult children. she has been a smoker for 30 years but quit 15 years ago. she has been drinking alcohol for 30 years and currently drinks 2-3 glasses of wine per day. # family history: no significant family history. # physical exam: general: the patient is an elderly woman who is well appearing. vitals: hr 82 bp 130/78 rr 20 sat 94% ra 100% general: the patient is an elderly woman who is well appearing. heent: perrl, anicteric sclerae, eomi, nc/at, mmm, no jvd, no carotid bruits. lungs: ctab cv: rrr, no murmurs, rubs or gallops. abdomen: soft, nt/nd, no |
| C2364082 | discharge date: [**2013-03-12**] date of birth: [**1940-07-15**] sex: f service: cardiothoracic allergies: patient recorded as having no known allergies to drugs attending:[**attending info 389**] chief complaint: 1. cad s/p cabg x 2 2. 2nd degree heart block 3. h/o tia, htn, dm, <1CUI> hyposmia </1CUI> major surgical or invasive procedure: 1. cabg x 2 2. 2nd degree heart block 3. pci 4. cabg 5. permanent pacemaker placement 6. permanent pacemaker placement 7. [**2013-03-06**] 2nd degree heart block: 2nd degree heart block with pacemaker placement pertinent results: [**20 |
| C2584658 | 4. hypoglycemic events: the patient's hypoglycemic events were secondary to insulin drip. the patient was transferred to the [**hospital1 19**] for further management of her <1CUI> reflex anoxic seizures </1CUI> . 5. reflex anoxic seizures: the patient had a series of seizures secondary to hypoglycemia. the patient was transferred to the [**hospital1 19**] for further management of her reflex anoxic seizures. 6. supplemental oxygen: the patient was placed on supplemental oxygen secondary to low oxygen saturations. 7. complete blood count: the patient had a complete blood count secondary to her hypoglycemic event. 8. urine culture: the patient had a urine culture secondary to her hypoglycemic event. 9. ekg: the patient had an ekg secondary to her hypoglycemic event. 10 |
| C2584778 | he was seen in the emergency room where he was found to have an elevated platelet count, anemia, and thrombocytopenia. the patient was transferred to the floor for further evaluation. past medical history: 1. <1CUI> idiopathic thrombotic thrombocytopenic purpura </1CUI> . 2. chronic lymphocytic leukemia. 3. chronic pain. 4. hypertension. 5. 2009-12-16: 1. idiopathic thrombotic thrombocytopenic purpura 6. 2009-12-20: 1. idiopathic thrombotic thrombocytopenic purpura 7. 2009-12-21: 1. idiopathic thrombotic thrombocytopenic purpura 8. 2009-12-22: |
| C2584947 | patient was intubated and placed on vasopressors. he was transferred to the icu for further management. his neurological exam was unremarkable. he was started on an aed. he had a ct scan which showed no evidence of stroke or hemorrhage. he had an eeg which showed no evidence of seizure activity. past medical history: 1. <1CUI> anoxic epileptic seizure </1CUI> [**11-10**] 2. hypothyroidism 3. osteoporosis social history: he lives with his wife. he has three children. he is a retired [**hospital1 256**] worker. he is a nonsmoker and drinks alcohol socially. family history: noncontributory physical exam: 97.8, 157/62, 18, 99% on 5l by ng tube, 2+ pitting edema, clear, 1+ bilateral jvd, 1+ distal pulses, 1+ dp, |
| C2586056 | discharge date: [**2013-02-08**] date of birth: [**1934-05-19**] sex: m service: cardiothoracic allergies: patient recorded as having no known allergies to drugs attending:[**attending info 312**] chief complaint: 1. <1CUI> permanent atrial fibrillation </1CUI> 2. dyspnea on exertion major surgical or invasive procedure: [**2013-02-07**] 9:00 a.m. - 12:00 p.m. cardioversion with left atrial pacing history of present illness: 80 year old male with a history of permanent atrial fibrillation, who was admitted to [**hospital 350**] in [**2012-09-28**] and cardioverted with left atrial pacing. he had a cardiac c |
| C2607914 | 4. osteoarthritis. 5. cervical spine stenosis. 6. <1CUI> rhinitis, allergic </1CUI> . 7. dyspepsia. 8. gastric ulcer. 9. hyperlipidemia. 10. hypertension. 11. ckd. discharge condition: good. discharge instructions: 1. please take your medications as prescribed by your doctor. 2. please call your doctor if you experience any shortness of breath, chest pain, or palpitations. 3. please call your doctor if you experience any fever, chills, or nausea/vomiting. 4. please call your doctor if you have any changes in your urine output. 5. please call your doctor if you have any changes in your pain. 6. please call your doctor if you have any changes in your swelling. 7. please call your doctor if you have any changes in your sore throat. 8. |
| C2584658 | sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 201**] chief complaint: 1. 3 day history of decreased mental status. 2. 1 day history of fever. 3. 1 day history of chest pain. major surgical or invasive procedure: none history of present illness: 75 year old male with a history of 3 episodes of <1CUI> reflex anoxic seizures </1CUI> who presented to the emergency department with a 3 day history of decreased mental status, fever, and chest pain. past medical history: 1. reflex anoxic seizures. 2. hypertension. 3. hyperlipidemia. 4. diabetes mellitus. 5. dyslipidemia. 6. hypercholesterolemia. 7. hypertriglyceridemia. 7. hyperglycemia. 8. chronic |
| C2584778 | on postoperative day 2, patient was noted to have a drop in platelet count to 154 x 10^9. patient was found to have a fever of 100.8 and was found to have a 30% increase in her hematocrit. the patient was found to have a pt of 14.8 and an inr of 1.2. she was found to have a low fibrinogen of 87 and a low adamts13 of 14. patient was treated with pcc's and fresh frozen plasma. patient was transferred to the [**hospital unit name **] for further management of her thrombotic thrombocytopenic purpura. on [**2018-11-02**], patient was found to have a pt of 13.4 and an inr of 1.1. patient was transferred to [**hospital unit name **] for further management of her <1CUI> idiopathic thrombotic thrombocytopenic purpura </1CUI> |
| C2584889 | she had been on depo-provera for birth control. she was found to have an iud in place. she had been on depo-provera for 10 years. she had had two ectopic pregnancies in the past. she had been on depo-provera for 10 years. she had had two ectopic pregnancies in the past. she had been on depo-provera for 10 years. she had had two ectopic pregnancies in the past. she had been on depo-provera for 10 years. she had had two ectopic pregnancies in the past. she had been on depo-provera for 10 years. she had had two ectopic pregnancies in the past. # 2. <1CUI> number of ectopic pregnancies (observable entity) </1CUI> <1cui>. # 3. history of chronic pelvic pain. # 4. history of hysterectomy. # 5. history of dys |
| C2586056 | date of birth: [**1931-11-15**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 443**] chief complaint: 1. <1CUI> permanent atrial fibrillation </1CUI> 2. left sided renal cell carcinoma history of present illness: 83 y/o male with history of 20 year permanent atrial fibrillation, left sided renal cell carcinoma with metastases to the liver, lung and bone, and with a history of [**1997-04-15**] mi, s/p cabg in [**1997-04-21**], and s/p left sided ischemic cva in [**2009-05-07**] who was admitted for monitoring of his af. past medical history: 1. 20 year history of permanent atrial fibrillation 2. |
| C2586211 | sig: one (1) tablet po bid for 30 days. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. <1CUI> thrombosis of blood vessel (disorder) </1CUI> 2. dvt discharge condition: good discharge instructions: 1. please call your doctor if you have any of the following: a. chest pain, pressure, or tightness. b. shortness of breath. c. dizziness, lightheadedness, or fainting. 2. please call your doctor if you have any of the following: a. increased pain or swelling of the leg. 3. please call your doctor if you have any of the following: a. increased pain or swelling of the leg. 4. please call your doctor if you have any of the following: a. increase in the redness or swelling of the leg. 5. please call your doctor if you have any of the following: a. in |
| C2584658 | discharge date: [**2016-04-08**] date of birth: [**1947-12-14**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 180**] chief complaint: 1. aortic valve replacement 2. mitral valve replacement 3. <1CUI> reflex anoxic seizures </1CUI> major surgical or invasive procedure: aortic valve replacement mitral valve replacement history of present illness: 67 year old male with history of reflex anoxic seizures, who was diagnosed with aortic stenosis in [**2013-03-07**], presented to the [**hospital1 28**] for aortic valve replacement and mitral valve replacement. he was seen by [**last name (stitle) **] in the [**hospital1 28**] prior |
| C2584947 | he was admitted to the [**hospital unit name 112**] on [**2012-04-13**] with a diagnosis of <1CUI> anoxic epileptic seizure </1CUI> . the patient had a history of seizures, and was on phenytoin, but the seizure was not controlled with this medication. the patient had a large left-sided subdural hematoma and was taken to the or for evacuation of the hematoma and repair of the dura. the patient was discharged to [**hospital1 17**] rehab on [**2012-05-16**]. 2. hypertension: the patient was admitted to the [**hospital unit name 112**] on [**2012-04-13**] with a diagnosis of anoxic epileptic seizure. the patient had a history of hypertension, and was on medications for hypertension, but the medications were not controlled. the patient was on the following medications: 1. lisinopril |
| C2586056 | sig: one (1) tablet po bid. disp:*60 tablet(s)* refills:*2* discharge disposition: home with service discharge diagnosis: 1. <1CUI> permanent atrial fibrillation </1CUI> 2. hypertension discharge condition: good discharge instructions: please call your primary care physician for any questions or concerns. please call your primary care physician for any questions or concerns. you should follow up with your primary care physician within one week. followup instructions: please call your primary care physician for any questions or concerns. please call your primary care physician for any questions or concerns. you should follow up with your primary care physician within one week. drug refills: 2 refills discharge instructions: please call your primary care physician for any questions or concerns. please call your primary care physician for any questions or concerns. you should follow up with your primary care physician within one week. followup instructions: please call your primary care physician for any questions or concerns. |
| C2586211 | discharge date: [**2012-04-16**] date of birth: [**1950-06-03**] sex: m service: cardiothoracic allergies: patient recorded as having no known allergies to drugs attending:[**attending info 316**] chief complaint: s/p mi, a-fib, pe, and r-ue major surgical or invasive procedure: [**2012-04-14**] coronary artery bypass grafting x 3 vessels. [**2012-04-15**] right upper extremity thrombectomy. pertinent results: [**2012-04-16**] 06:30pm discharge disposition: extended care discharge diagnosis: <1CUI> thrombosis of blood vessel (disorder) </1CUI> discharge condition: good |
| C2603363 | the patient was intubated and transferred to the icu. the patient's icp was controlled with 1000cc of 2% lidocaine, and he was sedated with versed. he was also given 500 mg of acetaminophen for his headache. the patient was found to have a large left hemisphere infarct and an mra was done to evaluate for aneurysm. the mra was negative for aneurysm. the patient was transferred to [**hospital 249**] for further evaluation and management. # neurology: the patient was noted to be somnolent and aphasic. he had a 1+ left-sided paresis, and was noted to have left-sided neglect. his <1CUI> minimum angle of resolution </1CUI> was 30 degrees. his ct scan showed a left hemisphere infarct involving the left inferior frontal lobe and the left posterior parietal lobe. he was transferred to [**hospital 249**] for further evaluation and management. # cardiology: the patient was noted to have a history of |
| C2584625 | patient was seen in the [**doctor first name **] for a left internal mammary artery graft and coronary artery bypass graft. he was seen by his cardiologist and his cardiologist decided to continue the patient on coumadin and aspirin. the patient was seen by the neurologist for his seizure disorder and was started on levoxyl. the patient was seen by the hematologist and was started on prothrombin complex concentrate for his factor i deficiency disease. the patient was also seen by the gastroenterologist for his gastric ulcer and was started on ranitidine. 2. <1CUI> factor i deficiency disease (disorder) </1CUI> - the patient was seen by the hematologist and was started on prothrombin complex concentrate for his factor i deficiency disease. 3. gastric ulcer - the patient was seen by the gastroenterologist for his gastric ulcer and was started on ranitidine. 4. coronary artery disease - the patient had a coronary artery bypass graft. |
| C2584658 | discharge date: [**2015-04-29**] date of birth: [**1942-06-13**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1125**] chief complaint: status post cardiac arrest major surgical or invasive procedure: none history of present illness: 73 yo m w/ history of <1CUI> reflex anoxic seizures </1CUI> , htn, hyperlipidemia, dm2, 2nd hand smoker. he was last seen in the clinic on [**2015-04-15**], when he was noted to have an elevated bp, and was referred to the cardiology clinic. on [**2015-04-24**], he was found down in his home, and his wife called 911. he was transported to [**hospital1 18**] and was |
| C2584778 | she was transferred to the [**hospital1 199**] [**doctor first name **] [**last name (un) **] on [**2017-11-07**]. on admission to the [**hospital1 199**] she was afebrile, but her platelet count was 25,000, and her hemoglobin was 7.4. she was diagnosed with <1CUI> idiopathic thrombotic thrombocytopenic purpura </1CUI> and was treated with plasmapheresis, and steroids. she had a platelet transfusion on [**2017-11-08**]. the patient was transferred to the [**hospital1 199**] [**doctor first name **] [**last name (un) 199**] on [**2017-11-07**]. on admission to the [**hospital1 199**] she was afebrile, but her platelet count was 25,000 |
| C2584947 | the patient was intubated and transferred to the [**hospital1 152**] for further management. the patient was intubated for a [**05-29**] day period and was extubated on [**2019-05-31**] and then transferred to the [**hospital1 152**] for further rehabilitation. past medical history: 1. cerebral palsy. 2. <1CUI> anoxic epileptic seizure </1CUI> [**2019-05-29**]. 3. seizure disorder. 4. hypotonic cerebral palsy. 5. hypothyroidism. social history: the patient is a [**female first name (un) 346**] with a low level of education who works as a [**first name (un) **] and has a [**last name (un) 347**] of two. she lives with her husband and two children. family history: the patient is a female with a positive family history for ep |
| C2586056 | 6. chronic obstructive pulmonary disease. 7. chronic renal failure. 8. hypertension. 9. cerebral vascular accident. 10. status post [**2014-05-19**] aortic valve replacement. 11. status post [**2014-05-19**] coronary artery bypass graft. 12. status post [**2014-05-19**] mitral valve repair. 13. status post [**2014-05-19**] atrial septal defect repair. 14. status post [**2014-05-19**] patent foramen ovale repair. 15. status post [**2014-05-19**] <1CUI> permanent atrial fibrillation </1CUI> . 16. status post [**2014-05-19**] esophageal varices. 17. status post [**20 |
| C2586211 | sig: one (1) tablet po qd. disp:*60 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. <1CUI> thrombosis of blood vessel (disorder) </1CUI> 2. hypertension 3. hyperlipidemia 4. chronic renal insufficiency discharge condition: good discharge instructions: please follow up with your primary care physician for your blood pressure and your blood lipids. followup instructions: please follow up with your primary care physician for your blood pressure and your blood lipids. please follow up with your primary care physician for your blood pressure and your blood lipids. please follow up with your primary care physician for your blood pressure and your blood lipids. please follow up with your primary care physician for your blood pressure and your blood lipids. please follow up with your primary care physician for your blood pressure and your blood lipids. please follow up with your primary care physician for your blood pressure and your blood lipids. please follow up |
| C2607914 | 3. hypertension. 4. hypercholesterolemia. 5. <1CUI> rhinitis, allergic </1CUI> . 6. gerd. 7. hyperthyroidism. 8. hyperlipidemia. 9. hypoglycemia. 10. depression. 11. arthritis. 12. hyperoxaluric aciduria. 13. peripheral artery disease. 14. pulmonary embolism. 15. pulmonary fibrosis. 16. rheumatoid arthritis. 17. restless legs syndrome. 18. sle. 19. sjogren's syndrome. 20. urinary incontinence. 21. urinary |
| C2584778 | his platelet count is 31,000. the patient's family history is significant for thrombocytopenia and bleeding. the patient has a history of <1CUI> idiopathic thrombotic thrombocytopenic purpura </1CUI> . the patient's medications include aspirin and warfarin. the patient's past medical history is significant for idiopathic thrombotic thrombocytopenic purpura, hypertension, hyperlipidemia, and gerd. his family history is significant for thrombocytopenia and bleeding. the patient's social history is significant for smoking and he is a retired carpenter. physical examination revealed a pale, thin, well-appearing man with a blood pressure of 130/70, a heart rate of 70, and a respiratory rate of 18. the patient's neck was supple and his lungs were clear to auscultation. the patient's abdomen was soft, nontender, and nondistended. his extremities were |
| C2584947 | sig: one (1) capsule po qd for 7 days. disp:*7 dose: (1) capsule po qd for 7 days. discharge disposition: home discharge diagnosis: 1. <1CUI> anoxic epileptic seizure </1CUI> 2. pneumonia discharge condition: good discharge instructions: please call the doctor if you have any of the following: - fever greater than 101.6 - chest pain or shortness of breath - seizures - vision changes - pain - increased difficulty breathing - nausea or vomiting - changes in mental status - changes in urine output - any change in your medication regimen - any other concerns followup instructions: please follow up with your primary care physician at [**doctor first name 5**] in [**location (un) 713**] for a followup appointment on [**2018-07 |
| C2586056 | 2. aortic stenosis. 3. hypertension. 4. hyperlipidemia. 5. hypercholesterolemia. 6. coronary artery disease. 7. diabetes mellitus. 8. chronic obstructive pulmonary disease. 9. chronic renal insufficiency. 10. <1CUI> permanent atrial fibrillation </1CUI> . 11. history of gastric ulcer. 12. history of alcohol abuse. 13. history of tobacco use. 14. history of cannabis use. 15. history of cocaine use. 16. history of opioid use. 17. history of benzodiazepine use. 18. history of marijuana use. 19. history of amphetamine use. 20. history of inhalant abuse. 21. history of intravenous drug abuse. 22. history of alcohol |
| C2607929 | sig: <1CUI> one </1CUI> (1) tablet po qd (1) dose sig. discharge disposition: home with service discharge diagnosis: 1. hypercholesterolemia 2. hyperlipidemia 3. cva 4. cerebrovascular accident 5. cerebral infarction 6. cerebral ischemia 7. cerebral hemorrhage 8. cerebral vasospasm 9. cerebral stroke 10. cerebral infarction 11. cerebral vasospasm 12. cerebral stroke 13. cerebral infarction 14. 14. cnc1 discharge condition: stable. discharge instructions: please call your doctor if you experience any changes in your vision, speech, weakness, numbness, or difficulty speaking. please call your doctor if you experience any shortness of breath, chest pain, or difficulty breath |
| C2607931 | 6. chronic obstructive pulmonary disease. 7. hypertension. 8. hyperlipidemia. 9. chronic back pain. 10. hypothyroidism. 11. gastric ulcer. 12. esophageal varices. 13. hepatitis c. 14. cerebral vascular accident. 15. <1CUI> malignant lung hilum neoplasm </1CUI> . 16. chronic renal insufficiency. 17. gastrointestinal bleeding. 18. pneumothorax. 19. pneumonia. 20. pneumocystis. 21. melanoma. 22. hodgkin's lymphoma. 23. cystic fibrosis. 24. thyroid nodules. 25. lymphadenopathy. 26. adrenal mass. 27. renal cell carcinoma. |
| C2608045 | 4. hydrocephalus. 5. <1CUI> trilateral retinoblastoma </1CUI> . 6. chronic anemia. 7. iron deficiency anemia. 8. chronic sinusitis. 9. chronic otitis media. 10. chronic cervical strain. 1. dyspnea. 2. chest pain. 3. palpitations. 4. lightheadedness. 5. dizziness. 6. headaches. 7. nausea. 8. vomiting. 9. diarrhea. 10. anxiety. 11. depression. 12. sleep disturbances. 13. fatigue. 14. difficulty with swallowing. 15. difficulty with walking. 16. difficulty with speaking. 17. difficulty with reading. 18. difficulty with writing. 19. d |
| C2609043 | discharge date: [**2011-05-27**] date of birth: [**1972-02-09**] sex: f service: medicine history of present illness: this 28-year-old female presented to the emergency department with a 12-hour history of severe headache, fevers, and vomiting. she had been seen in the emergency department on [**2011-05-12**] with a headache, but at that time she was not found to have a cerebral mass. she was found to have a large right parasellar mass on ct scan. she was transferred to the [**hospital1 162**] for further evaluation and management. past medical history: - <1CUI> pheochromocytoma crisis </1CUI> [**2011-05-12**] - hypertension - hyperlipidemia - hypercholesterolemia - ovarian cyst social |
| C2609072 | cleft lip, right. cleft palate. 3. <1CUI> gnathoschisis </1CUI> . 4. tongue-tie. 5. bilateral inguinal hernia. 6. left inguinal hernia. 7. right inguinal hernia. 8. cleft lip, right. 9. cleft palate. 10. gnathoschisis. 11. tongue-tie. 12. cleft nasal passages. 13. cleft uvula. 14. cleft soft palate. 15. cleft posterior pharyngeal wall. 16. cleft epiglottis. 17. cleft trachea. 18. cleft bronchi. 19. cleft larynx. 20. cleft thyroid gland. 21. cleft sternum. 22. cleft ribs. 23. cleft spine. 24. |
| C2609093 | discharge date: [**2011-07-11**] date of birth: [**1937-07-22**] sex: m service: history of present illness: this is a 74-year-old male with a history of <1CUI> metastatic pancreatic neuroendocrine tumor </1CUI> . he presented with abdominal pain and was found to have a metastasis to the liver. he was admitted to [**hospital1 26**] for evaluation and treatment of the metastasis. past medical history: the patient has a history of metastatic pancreatic neuroendocrine tumor. he has had multiple episodes of metastasis to the liver and lungs. he has had multiple episodes of diarrhea, which has been treated with octreotide. he has had episodes of hypotension, which have been treated with fluid and vasopressors. he has had episodes of nausea and vomiting, which have been treated with ondanset |
| C2609162 | discharge date: [**2014-09-04**] date of birth: [**1950-09-18**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 2513**] chief complaint: 1. <1CUI> fracture of bone adjacent to prosthesis </1CUI> 2. 10% sob major surgical or invasive procedure: 1. surgical debridement of left humeral fracture 2. surgical debridement of left acromial fracture 3. left humeral prosthetic replacement 4. left acromial prosthetic replacement 5. skin grafting of left hand history of present illness: 85 yo male with history of [**01-10**] s/p left humeral and acromial fractures who presented to [**doctor first name 3**] [**last name (un) ** |
| C2607929 | d <1CUI> isch </1CUI> arge date: [**2014-07-21**] date of birth: [**1956-07-08**] sex: m service: cardiothoracic allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1124**] chief complaint: 1. cnc1 major surgical or invasive procedure: none history of present illness: 84 year old male with history of cnc1, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, status post right upper lobe resection in [**2014-03-06**], presented to the [**doctor first name 4**] with 10 days of subjective fevers. patient denies any recent travel, or any recent illness. he had been taking his medications as prescribed, including his beta blockers, his calcium channel blockers, his statins, and his inhal |
| C2607931 | 2. chronic obstructive pulmonary disease. 3. chronic pulmonary emphysema. 4. chronic bronchitis. 5. <1CUI> malignant lung hilum neoplasm </1CUI> . 6. hypertension. social history: the patient is a retired [**last name (stitle) **] who lives with his wife and two children. he is a non-smoker, non-drinker, and does not use any illicit drugs. he is a former pack a day smoker. he had a hysterectomy in [**2013**]. family history: the patient is a non-blood relative of the [**name1 (nameis) **]. physical exam: vs: 98.1 150/70 100%ra 100% gen: the patient is a well-appearing male in no acute distress. heent: perrl, anicteric sclerae, 0 neck, 0 thyromental distance. lungs: ctab. |
| C2608045 | discharge date: [**2011-01-13**] date of birth: [**1963-11-14**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 132**] chief complaint: <1CUI> trilateral retinoblastoma </1CUI> major surgical or invasive procedure: [**2010-12-29**] right frontal craniotomy and resection of pineal mass history of present illness: 41 year old female with trilateral retinoblastoma who underwent bilateral enucleation, left frontal craniotomy and resection of pineal mass and right frontal craniotomy and resection of pineal mass. past medical history: 1. trilateral retinoblastoma 2. [**2010-12-29**] right frontal craniotomy and r |
| C2608055 | sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 309**] chief complaint: hypertension major surgical or invasive procedure: none history of present illness: 87 year old woman with a history of hypertension, hyperlipidemia, and <1CUI> hereditary renal cell carcinoma </1CUI> , with a recent diagnosis of aaa, s/p repair. she was transferred from [**hospital1 4**] for further management of her hypertension and hyperlipidemia. she is currently on the following medications: 1) lisinopril 2) zocor 3) lasix 4) lanoxin 5) atenolol 6) nitro 7) aspirin 8) calcium 9) vitamin d social history: lives with her daughter. no smoking or alcohol. family history: father with htn and chf. mother with htn. sister with htn |
| C2609072 | there was a small cystic lesion in the right maxillary sinus. there was no evidence of any bony erosion or fracture. the right mandible was noted to have a prominent bony notch at the level of the mental foramen. there was no evidence of any gross facial asymmetry. the patient was referred for further evaluation for the possible diagnosis of <1CUI> gnathoschisis </1CUI> . 2. mildly dilated ascending aorta. 3. moderate mitral regurgitation. 4. mild aortic stenosis. 5. no evidence of aortic dissection. 6. no evidence of pulmonic stenosis. 7. no evidence of pulmonary embolism. 8. no evidence of pleural effusion. 9. no evidence of pericardial effusion. 10. no evidence of pneumothorax. 11. no evidence of pneumonia. 12. no evidence of pleural thickening. 13. no evidence of pneumatosis. 1 |
| C2609093 | metastatic disease: 1. <1CUI> metastatic pancreatic neuroendocrine tumor </1CUI> . 2. metastatic liver disease. 3. metastatic bone disease. 4. metastatic lymph nodes. 4. prostate cancer. 5. melanoma. 5. prostate cancer. 6. melanoma. 6. melanoma. 7. melanoma. 8. melanoma. 9. melanoma. 10. melanoma. 11. melanoma. 12. melanoma. 13. melanoma. 14. melanoma. 15. melanoma. 16. melanoma. 17. melanoma. 18. melanoma. 19. melanoma. 20. melanoma. 21. melanoma. 22. melanoma. 23. melanoma. 24. |
| C2609162 | sig: one (1) tablet po bid for 30 days. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. 1. <1CUI> fracture of bone adjacent to prosthesis </1CUI> 2. 2. left ankle fracture 3. 3. osteoporosis discharge condition: good discharge instructions: 1. please follow up with dr. [**last name (stitle) 4715**] at [**hospital 4715**] in [**city **] in [**time (2) 4716**] 2. please do not drive for 3 weeks. 3. please do not put weight on your left foot for 3 weeks. 4. please do not take any nsaids for 3 weeks. 5. please do not smoke. 6. please do not drink alcohol for 3 weeks. 7. please do not take any |
| C2607929 | the pati <1CUI> ent </1CUI> was started on a trial of levoxyl 50 mcg orally twice a day. the patient was started on a trial of zoloft 50 mg orally once a day. the patient was started on a trial of keppra 1000 mg orally twice a day. the patient was started on a trial of topamax 25 mg orally twice a day. the patient was started on a trial of lamictal 100 mg orally twice a day. the patient was started on a trial of abilify 5 mg orally once a day. 1. <1cui> cnc1 - the patient was started on a trial of lamictal 100 mg orally twice a day. 2. <1cui> bipolar disorder - the patient was started on a trial of lamictal 100 mg orally twice a day. 3. <1cui> depression - the patient was started on a trial of zoloft 50 mg orally once a day. 4. <1c |
| C2607932 | <1CUI> malignant neoplasm of epicardium </1CUI> . 3. precordial mass. 4. atrial fibrillation. 5. chronic obstructive pulmonary disease. 6. pneumonia. 7. chronic renal insufficiency. 8. hyperlipidemia. 9. hypothyroidism. 10. osteoporosis. 11. chronic obstructive sleep apnea. [**2015-03-04**] 07:00:00 discharge diagnoses: 1. atrial fibrillation. 2. malignant neoplasm of epicardium. 3. precordial mass. 4. chronic obstructive pulmonary disease. 5. chronic renal insufficiency. final diagnosis: 1. atrial fibrillation. 2. malignant neoplasm of epicardium. 3. precordial mass |
| C2608055 | sex: m service: [**hospital unit name 711**] history of present illness: the patient is a 55 year old male with a history of a 10 cm left kidney mass that was resected in [**2008**]. the patient has a history of <1CUI> hereditary renal cell carcinoma </1CUI> (hrcc) and has had multiple resections of his kidneys over the past few years. the patient was admitted to the [**hospital1 2**] in [**2010-01-01**] for a left nephrectomy. he was then admitted to the [**hospital1 2**] on [**2011-04-07**] for a right nephrectomy. the patient was then admitted to the [**hospital1 2**] on [**2011-05-12**] for a left nephrectomy. he was then admitted to the [**hospital1 2**] on [**2011-06-07** |
| C2609043 | discharge date: [**2019-12-05**] date of birth: [**1973-03-16**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 304**] chief complaint: <1CUI> pheochromocytoma crisis </1CUI> major surgical or invasive procedure: none history of present illness: 44f with a history of pheochromocytoma status post laparoscopic left adrenalectomy in [**2019-11-28**] who presented with a pheochromocytoma crisis, was admitted to [**hospital 304**] for further management. past medical history: 1. pheochromocytoma status post left adrenalectomy in [**2019-11-28**]. 2. 2nd degree av block. 3. history of hypothyroidism. 4 |
| C2609072 | the patient was found to have a large anterior cranial fossa mass with left frontal lobe compression. the patient was taken to the or for a left frontal lobe decompression. the patient was found to have a left frontal lobe tumor which was resected. the patient also had a left cranial nerve palsy which was not improved after surgery. the patient was transferred to the [**hospital 177**] for further management. past medical history: 1. <1CUI> gnathoschisis </1CUI> (cleft jaw) 2. cerebral palsy 3. left frontal lobe tumor 4. seizure disorder 5. nephrotic syndrome 6. hypoplastic left heart syndrome 7. aortic stenosis 8. mitral valve prolapse 9. atrial septal defect 10. pulmonary artery stenosis 11. cerebral arteriovenous malformation 12. chronic renal insufficiency 13. hyper |
| C2609093 | 4. hypertension. 5. hyperlipidemia. 6. diabetes mellitus type ii. 7. coronary artery disease. 8. chronic obstructive pulmonary disease. 9. chronic renal insufficiency. 10. [**2016-04-26**] - <1cui> <1CUI> metastatic pancreatic neuroendocrine tumor </1CUI> 11. osteoporosis. 12. dementia. 13. glaucoma. 14. chronic pain. 15. chronic low back pain. 16. dyslipidemia. 17. hyperlipidemia. 18. hypercholesterolemia. 19. hypertriglyceridemia. 20. hypothyroidism. 21. hyperparathyroidism. 22. hyperthyroidism. 23. hyperkalem |
| C2609162 | <1CUI> fracture of bone adjacent to prosthesis </1CUI> . 4. osteoporosis. 5. chronic obstructive pulmonary disease. social history: lives with his wife. family history: no significant family history. physical exam: the patient is a well appearing 82 year old man in no acute distress. vital signs: 103.7, 130/80, 18, 99%ra, 20. general: well appearing male in no acute distress. heent: anicteric, perrl, eomi, mmm, nc/at. neck: supple, no lymphadenopathy, no thyromegaly. chest: clear to auscultation bilaterally. cardi: regular rate and rhythm, no murmurs, rubs or gallops. abd: soft, ntnd, no masses, no hepatosplenomegaly. ext: no edema, no clubbing, pulses ii- |
| C2607929 | pt had be <1CUI> en o </1CUI> n 120 mg of coumadin for the past 6 months and was on 10 mg of lisinopril for the past 4 months. pt was admitted to the [**hospital1 11**] on [**2014-04-22**] for evaluation of his cnc1. on admission, his c-reactive protein was 11.1 and his white count was 15.2. he was started on antibiotics and his c-reactive protein was trending down. # cnc1: pt had been diagnosed with cnc1 on [**2013-09-04**] with a [**first name10 (namepattern1) **] of 2.5. he was seen by the neurology service on [**2013-11-13**] and was noted to have a small left frontal mass. # malignancy: pt had a history of non-hodgkin's lymphoma for which he had been treated with |
| C2608045 | 2. hypertension. 3. phn. 4. hyperlipidemia. 5. hypercholesterolemia. 6. hypertriglyceridemia. 7. hypothyroidism. 8. <1CUI> trilateral retinoblastoma </1CUI> . social history: he lives with his wife and two children. he has a son who is 2 years old and a daughter who is 4 months old. he has a brother with multiple myeloma. family history: he has a brother with multiple myeloma. physical exam: on admission, the patient was in no acute distress. he had a heart rate of 80, blood pressure of 124/72, respiratory rate of 14, saturations of 98% on room air. he had a temperature of 99.8. he had no rashes, no lymphadenopathy, no skin lesions. his neck was supple, no lymphadenopathy. his abdomen was soft |
| C2609043 | sig: one (1) tablet po q8h (every 8 hours) (3 times a day). disp:*30 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. p <1CUI> haeochromocytoma crisis </1CUI> . 2. hypertension. 3. hyperlipidemia. discharge condition: good. discharge instructions: you have been diagnosed with a phaeochromocytoma. you will need to take your medication as prescribed and return to the doctor for follow-up appointments. please call the doctor if you have any of the following: 1. chest pain or pressure. 2. shortness of breath. 3. lightheadedness or dizziness. 4. headache or numbness or weakness. 5. nausea or vomiting. 6. changes in your urine output. 7. any changes in your medication. 8. any questions or concerns. 9. |
| C2609072 | the patient was transferred to [**hospital 127**] for further management and evaluation. past medical history: cleft lip, cleft palate, <1CUI> gnathoschisis </1CUI> , congenital heart disease, and right ear tubes. social history: the patient lives with her parents. family history: non-contributory physical exam: t: 98.1 bp: 124/72 hr: 100 rr: 22 gen: nad heent: perrl, at, anicteric sclera, no mass, no nystagmus, no oropharyngeal lesions, no cervical lymphadenopathy neck: no jvd, supple, no lymphadenopathy, no carotid bruits, no thyromegaly, no masses chest: clear to auscultation bilaterally, no wheezes, no rales, no rhonchi abd: soft, nt, nabs, no mass, no hepatosplenomegaly, no peripheral ed |
| C2609093 | discharge date: [**2018-11-03**] date of birth: [**1934-12-02**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1699**] chief complaint: h/o <1CUI> metastatic pancreatic neuroendocrine tumor </1CUI> . major surgical or invasive procedure: 1. resection of metastatic pancreatic neuroendocrine tumor. 2. resection of metastatic liver lesion. 3. resection of metastatic adrenal lesion. 4. resection of metastatic lung lesion. 5. resection of metastatic bone lesion. 6. resection of metastatic pericardial lesion. 7. resection of metastatic pleural lesion. 8. resection of metastatic per |
| C2607929 | sig: <1CUI> one </1CUI> (1) tablet po qd (1) discharge disposition: extended care discharge diagnosis: carney complex, type 1 discharge condition: good discharge instructions: please take your medications as directed. follow up instructions: please follow up with dr. [**last name (stitle) **] in 3 months. followup instructions: please follow up with dr. [**last name (stitle) **] in 3 months. discharge instructions: please take your medications as directed. please take your medications as directed. please take your medications as directed. please take your medications as directed. please take your medications as directed. please take your medications as directed. please take your medications as directed. please take your medications as directed. please take your medications as directed. please take your medications as directed. please take your medications as directed. please take your medications as directed. please take your medications as directed. please |
| C2607932 | cardiac catheterization revealed a patent right coronary artery with a 50% stenosis in the proximal segment. the left coronary artery was not visualized. the patient was taken to the operating room for a right coronary artery bypass graft. past medical history: 1. <1CUI> malignant neoplasm of epicardium </1CUI> . 2. hypertension. 3. hypercholesterolemia. 4. hyperlipidemia. 5. gerd. 6. osa. 7. niddm. 8. cad s/p cabg in [**2011-10-13**]. 9. mi in [**2011-10-13**]. 10. status post cabg in [**2011-10-13**]. 11. status post pci for 100% occlusion of lad in [**2011-10-13**]. 12. status post pci |
| C2608045 | sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 2474**] chief complaint: 53 year old female with <1CUI> bilateral retinoblastoma </1CUI> with metastasis to the brain and liver. major surgical or invasive procedure: - craniotomy for resection of intracranial metastasis. - resection of metastatic lesion in the right lobe of the liver. - chemotherapy. 2. history of present illness: 53 year old female with bilateral retinoblastoma with metastasis to the brain and liver. 3. past medical history: 1. trilateral retinoblastoma. 2. metastatic disease to the brain and liver. 4. social history: no tobacco, no alcohol. 5. family history: noncontributory. 6. physical exam: 65 pounds, |
| C2608082 | the patient has a history of <1CUI> charcot-marie-tooth disease type 4f (diagnosis) </1CUI> and chronic obstructive pulmonary disease. she had a recent myocardial infarction. she was transferred to [**hospital 3562**] from [**hospital 3044**] for evaluation for a possible left ventricular assist device. she had been on a ventilator at [**hospital 3044**] for a week prior to transfer. on transfer, the patient was intubated, sedated and on vasopressors. she had a history of cocaine abuse, and the patient had been in rehab several times. she was in the intensive care unit at [**hospital 3562**] for one week prior to transfer to [**hospital 3563**]. the patient was transferred to [**hospital 3563**] for further management of her charcot-marie-tooth disease type 4f (diagnosis) and chronic obstructive pulmonary disease. the patient was on ventilator support |
| C2609043 | date of birth: [**1974-05-25**] sex: f service: cardiothoracic allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1541**] chief complaint: <1CUI> pheochromocytoma crisis </1CUI> major surgical or invasive procedure: left adrenalectomy history of present illness: ms. [**lastname 4242**] is a 35 year old woman with a history of pheochromocytoma. she was previously treated with alpha blockers, beta blockers, and metoprolol. on [**2010-07-21**], she was found to have a large left adrenal mass and was transferred to [**hospital 123**] for further management. on [**2010-07-22**], she underwent a left adrenalectomy with a successful resection of the tumor. postoperatively, |
| C2609072 | surgical intervention is recommended. 3. cleft lip and palate: the patient has a unilateral cleft lip and palate. 4. <1CUI> gnathoschisis </1CUI> : the patient has a gnathoschisis which is a rare congenital condition in which the mandible is split and separated from the maxilla by a bony cleft. 5. dysplastic hip: the patient has a dysplastic hip and will require follow-up with an orthopedic surgeon. 6. dysplastic elbow: the patient has a dysplastic elbow and will require follow-up with an orthopedic surgeon. 7. cerebral palsy: the patient has cerebral palsy and will require ongoing physical and occupational therapy. 8. glaucoma: the patient has glaucoma and will require ongoing ophthalmologic follow-up. 9. nephrotic syndrome: the patient has nephrotic syndrome and will require ongoing nephrology follow-up. 10. |
| C2609093 | on [**2013-02-23**], the patient was admitted to [**hospital1 2**] for an elective laparoscopic cholecystectomy and lysis of adhesions. the patient had been seen in the [**doctor first name **] clinic on [**2013-02-18**] and was found to have a 10 cm gallstone in the gallbladder. she was also found to have a mass in the pancreatic head. the patient had a history of a pancreatic neuroendocrine tumor that had been treated with chemotherapy in [**2010**] and was found to have recurrence of this tumor. the patient was seen by [**first name (titles) **] and a decision was made to proceed with a laparoscopic cholecystectomy and lysis of adhesions. the patient was also scheduled to receive chemotherapy for her <1CUI> metastatic pancreatic neuroendocrine tumor </1CUI> . past medical history: 1. metastatic pancreatic neuro |
| C2609162 | disp:*15 capsule(s) refills:*0* discharge disposition: home with service discharge diagnosis: 1. <1CUI> fracture of bone adjacent to prosthesis </1CUI> 2. fracture of bone adjacent to prosthesis 3. fracture of bone adjacent to prosthesis 4. fracture of bone adjacent to prosthesis 5. fracture of bone adjacent to prosthesis 6. fracture of bone adjacent to prosthesis 7. fracture of bone adjacent to prosthesis 8. fracture of bone adjacent to prosthesis 9. fracture of bone adjacent to prosthesis 10. fracture of bone adjacent to prosthesis 11. fracture of bone adjacent to prosthesis 12. fracture of bone adjacent to prosthesis 13. fracture of bone adjacent to prosthesis 14. fracture of bone adjacent to prosthesis 1 |
| C2609166 | she was delivered by emergency cesarean section at [**hospital 102**] at [**12-08**]. the patient was seen at [**hospital1 **] after delivery and transferred to [**hospital 102**] for further management. she had a normal postpartum course with no complications. 3. <1CUI> discordant twin </1CUI> : the patient had a discordant twin who was found to have a fetal heart rate of 110 and was delivered at 12 weeks gestation. the patient was monitored for growth discordance and was found to have a 20% difference in weight. 4. [**first name11 (name pattern1) **] adenocarcinoma: the patient had a diagnosis of [**first name11 (name pattern1) **] adenocarcinoma of the lung. she was seen by the [**hospital unit name 14**] on [**2014-07-15**] and was found to have a small left upper lobe mass. she was referred to [**h |
| C2609176 | 2. coronary artery disease. 3. 2. <1CUI> allergic acute coronary syndrome </1CUI> . 4. hyperlipidemia. 5. hypertension. 6. hypothyroidism. social history: 1. lives with wife. 2. no tobacco. 3. no etoh. 4. no illicit drugs. family history: noncontributory. physical exam: 99.8 100.2 100.8 100.9 100.6 gen: well appearing male in no acute distress. heent: perrla, eomi, mmm, no oropharyngeal lesions, no stridor. lungs: ctab heart: rrr, no murmurs, rubs, or gallops. extremities: warm, well perfused. abdomen: soft, nontender, nondistended, no organomegaly. skin: |
| C2609249 | 2. cystoscopic examination was also performed and a 2 cm area of ulceration was seen in the mid portion of the bladder. a small papilla was also identified in the right lateral portion of the bladder. 3. cystoscopy also revealed a 3-4 cm area of ulceration in the right lateral portion of the bladder. 4. the patient was also found to have a right <1CUI> ureterovesical junction obstruction </1CUI> . 5. the patient was admitted to the medical service for further management. 6. patient was started on intravenous antibiotics for a suspected urinary tract infection. 7. the patient was also placed on a urology consult for further management of the ureterovesical junction obstruction. 8. the patient was also started on a 1000mg dose of vancomycin for suspected sepsis. 9. the patient was also started on a 500mg dose of metronidazole for suspected sepsis. 10. |
| C2609268 | the patient was seen by the gastroenterologist and underwent a cholecystogram, which showed no evidence of <1CUI> gallbladder disease. </1CUI> the patient was transferred to the floor on [**2014-04-02**]. the patient was seen by the gastroenterologist again and underwent a cholecystogram, which showed no evidence of gallbladder disease. the patient was transferred to the floor on [**2014-04-02**]. the patient was seen by the gastroenterologist again and underwent a cholecystogram, which showed no evidence of gallbladder disease. the patient was transferred to the floor on [**2014-04-02**]. the patient was seen by the gastroenterologist again and underwent a cholecystogram, which showed no evidence of gallbladder disease. the patient was transferred to the floor on [**2014-04-02**]. the patient was seen by the gastroenterologist again and underwent a cholecystogram, which showed no evidence of gallbl |
| C2609319 | 100000000000 3. methicillin-sensitive staphylococcus aureus. 3. herpes simplex virus. 4. herpes zoster. 5. <1CUI> papulopustular rash </1CUI> . 6. psoriasis. 7. ulcerative colitis. 8. crohn's disease. 9. chronic fatigue syndrome. social history: she is married and lives with her husband. she is a nurse and works 12 hour shifts. family history: father with a history of colon cancer. grandmother with colon cancer. mother with breast cancer. physical exam: vs: 88.8, 100, 13, 87, 10, 100% ra. general: well appearing woman with no cachexia. heent: eomi, perrl, eent clear. neck: no jvd. chest: clear to auscultation bilaterally. |
| C2609414 | discharge date: [**2016-05-19**] date of birth: [**1955-07-28**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 118**] chief complaint: 37 year old female with aki major surgical or invasive procedure: none history of present illness: 37 year old female with a history of renal cell carcinoma status post right nephrectomy, hypertension, and hyperlipidemia, who presented with <1CUI> acute kidney injury </1CUI> . past medical history: 1. renal cell carcinoma, status post right nephrectomy 2. hypertension 3. hyperlipidemia 4. right nephrectomy [**2015-03-23**] 5. 1+ proteinuria social history: lives with her husband, no smoking, no etoh, no illic |
| C2611906 | 2. aortic valve leaflet thickening and calcification. 3. mild aortic root dilatation. 4. moderate pulmonary artery systolic hypertension. 5. moderate left ventricular hypertrophy. 6. <1CUI> regulation of cardiac muscle hypertrophy </1CUI> . brief hospital course: the patient is a 70 year old male with a history of hypertension, hyperlipidemia, obesity, and tobacco use who presents with chest pain. he was admitted for a coronary angiogram which revealed a 90% occlusion of the proximal lad and a 70% occlusion of the mid lad. he underwent an urgent cabg with a lima to lad bypass, a saphenous vein graft to the mid lad, and a radial artery graft to the rca. he had a postoperative course complicated by atrial fibrillation, aki, and pneumonia. pertinent results: [**20 |
| C2611907 | he was started on lopressor and was seen by a cardiologist. his ejection fraction was 30-35% and he was started on a beta blocker. he was also started on a statin. 2. <1CUI> regulation of cardiac muscle adaptation </1CUI> : he was admitted to the hospital on [**2013-02-06**] with a low ejection fraction and was started on lopressor for regulation of cardiac muscle adaptation. 3. coronary artery disease: he had a history of coronary artery disease and was started on a beta blocker and a statin. 4. atrial fibrillation: he was started on coumadin for atrial fibrillation. 5. diabetes mellitus: he had a history of diabetes mellitus and was started on insulin. 6. hypertension: he was started on a beta blocker and a diuretic. 7. hyperlipidemia: he was started on a statin. 8. chronic obstructive |
| C2611908 | 4. hypothyroidism. 5. hypercholesterolemia. 6. hyperlipidemia. 7. hypertension. 8. ischemic heart disease. 9. coronary artery disease. 10. <1CUI> positive regulation of cardiac muscle hypertrophy </1CUI> . 11. history of [**first name10 (namepattern2) 528**] [**last name (namepattern1) **] [**last name (namepattern1) 529**]. 12. history of gallbladder disease. 13. history of gout. social history: the patient is a widow and lives with her son and daughter-in-law. she is a former smoker. she has been drinking alcohol for approximately 30 years, with approximately 2-3 drinks per day. she is a retired teacher. she has no pets. family history: the patient's mother died of a myocardial infarction at age 60. her father died of a |
| C2609166 | 4. dysmorphic left ear. 5. <1CUI> discordant twin </1CUI> . 6. hypoplastic left lung. 7. 11p deletion. 8. 16p deletion. 9. 18q deletion. 10. 22q deletion. 11. 16q duplication. 12. 17p duplication. 13. 21q duplication. 14. 22q duplication. 15. 47, xy, t(12;17)(p13;p13) (p13.3[23] + p13.3[17]). 16. 46,xx [**2019-12-06**]. 17. 46,xy [**2019-12-06**]. 18. 47,xx,t(12;17)(p13;p13) [**2019-12-06**]. 19. |
| C2609249 | sig: one (1) tablet po qd for 30 days. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. <1CUI> ureterovesical junction obstruction </1CUI> 2. bladder cancer discharge condition: good. discharge instructions: follow up with dr. [**last name (stitle) 433**] in 30 days. follow up with your primary care physician in 60 days. please call your primary care physician or dr. [**last name (stitle) 433**] with any fever, chills, abdominal pain, blood in your urine, or any other symptoms. you have been started on a 30 day course of ciprofloxacin. this is for a urinary tract infection and should be completed even if you are feeling better. you may have some pain with urination for the next 10 days. this is due to the bladder ir |
| C2609268 | he was admitted to the [**hospital 1191**] [**doctor first name 77**] service for a possible cerebrovascular accident. he was found to have a new left atrial enlargement, which was thought to be due to pulmonary emboli. he was transferred to the [**hospital unit name 78**] service for further evaluation and management. past medical history: 1. <1CUI> gallbladder disease 1 </1CUI> : the patient had a history of cholecystectomy with a history of recurrent cholelithiasis. 2. hypertension: the patient had a history of hypertension. 3. diabetes mellitus: the patient had a history of diabetes mellitus. 4. coronary artery disease: the patient had a history of coronary artery disease with a history of myocardial infarction. 5. pulmonary artery disease: the patient had a history of pulmonary artery disease with |
| C2609319 | a follow-up appointment with dr. [**last name (stitle) 100**] has been arranged for [**2013-03-01**]. 2. dry, scaly skin with papules and pustules on the back and chest. 3. <1CUI> papulopustular rash </1CUI> . 4. patch testing was performed on [**2012-11-29**] at [**hospital 45**] with no reactions. 5. the patient was seen by dr. [**last name (stitle) 101**] on [**2012-12-06**] with a papulopustular rash on the back and chest. the patient was started on a topical antibiotic and was instructed to avoid sun exposure and to use sunscreen. 6. the patient was seen by dr. [**last name (stitle) 102**] on [**2012-12-17**] with a papulopustular rash on the back and chest. |
| C2609414 | discharge date: [**2017-03-17**] date of birth: [**1941-11-24**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 159**] chief complaint: <1CUI> acute kidney injury </1CUI> major surgical or invasive procedure: none history of present illness: 83 y/o male with a history of cad, dm2, htn, and kidney disease, who presented with aki. the patient's creatinine was elevated from a baseline of 1.5 to 6.9, and he was admitted to the [**doctor first name 4**] service for further evaluation and management. the patient's history is significant for a prior myocardial infarction, dm, htn, and kidney disease. the patient has a history of renal transplant in 1997, and has been on hemodialysis |
| C2611906 | cardiac catheterization was performed which showed normal coronary arteries. the patient was started on furosemide for pulmonary edema and was discharged on [**2013-03-28**]. the patient was followed in the outpatient setting for [**last name (un) **] and was found to have a left ventricular ejection fraction of 40%. he was started on ace inhibitor and beta blocker for [**first name (un) **] <1CUI> regulation of cardiac muscle hypertrophy </1CUI> . 2. hepatitis c: the patient was found to have positive hcv antibody on admission and was started on interferon and ribavirin for treatment. 3. renal insufficiency: the patient was found to have a creatinine of 2.4 on admission and was started on furosemide for pulmonary edema. 4. pneumonia: the patient was started on ceftriaxone and azithromycin for treatment of pneumonia. 5. diabetes: the patient was started on sl |
| C2609166 | sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 278**] chief complaint: fetal growth restriction major surgical or invasive procedure: none history of present illness: 23 yo male with <1CUI> discordant twin </1CUI> , fetal growth restriction pregnancy: 23yo g1, twin a: female, 23yo g1, twin b: male, both with fetal growth restriction of 20% or greater past medical history: none pregnancy history: g1, twin a: female, twin b: male, both with fetal growth restriction of 20% or greater, both with normal ultrasounds, last ultrasound at [**location (un) 279**] hospital 2 weeks ago social history: lives with parents, smokes 2-3 packs per day, denies etoh, denies drug use family history: pmh: htn, depression, anxiety, alcoholism |
| C2609268 | the patient was admitted to [**hospital 102**] with the diagnosis of pancreatitis. she was transferred to [**hospital1 1**] on [**2013-07-08**] for further management. she was admitted to the surgical service for further management of her cholecystectomy. the patient was found to have acalculous cholecystitis and her gallbladder was removed. she was also found to have a 4.5 cm mass in the head of the pancreas which was thought to be a benign pancreatic neuroendocrine tumor. the patient was transferred to the surgical service for further management. her past medical history includes: 1. <1CUI> gallbladder disease 1 </1CUI> : the patient was diagnosed with cholelithiasis in 1999. she underwent cholecystectomy in 2000. 2. gallbladder disease 2: the patient was diagnosed with cholelithiasis in 2001. 3. ch |
| C2609319 | the patient was referred to the dermatology service for evaluation. the patient was seen by dr. [**last name (stitle) **]. the patient was found to have a <1CUI> papulopustular rash </1CUI> on her scalp, back, and chest. the patient was started on a topical antibiotic cream. 3. papulopustular rash: the patient was seen by the dermatology service for evaluation. the patient was found to have a papulopustular rash on her scalp, back, and chest. the patient was started on a topical antibiotic cream. 4. [**hospital1 15**]: the patient was admitted to the [**hospital1 15**] for management of her wound. the patient was started on antibiotics for her wound and her papulopustular rash. 5. [**hospital1 15**] wound: the patient was seen by the wound care service for evaluation. the patient was found to have a stage 2 wound with signs of infection. |
| C2610399 | 16. osteoporosis. 17. chronic gastritis. 18. chronic gastroesophageal reflux disease. 19. hyperlipidemia. 20. hypertension. 21. hypothyroidism. 22. chronic obstructive pulmonary disease. 23. chronic renal insufficiency. 24. chronic anemia. 25. status post tia. 26. <1cui> <1CUI> maintenance of stationary phase in response to toxin </1CUI> <1cui>. 27. chronic back pain. 28. chronic headaches. 29. chronic fatigue syndrome. 30. chronic anxiety. discharge condition: good. discharge instructions: please follow up with your primary care physician for follow up appointments. please call the office if you experience any worsening of your symptoms. please take all medications as prescribed. please take your medications |
| C2611907 | 2. cardiac function. the patient was admitted to the hospital on [**2015-09-03**] with severe anemia and hypoxia. the patient was admitted to the icu for close observation of her cardiac function. the patient was found to have a left ventricular ejection fraction of 25% and a left ventricular systolic dysfunction. she was started on ace inhibitors and beta blockers for the <1CUI> regulation of cardiac muscle adaptation </1CUI> . 3. renal function. the patient was admitted to the hospital with a creatinine of 5.1 and a bun of 124. the patient was started on iv fluids and furosemide for the management of her renal failure. 4. anemia. the patient was found to have a hemoglobin of 7.4 and was started on 2 units of red blood cells. 5. infection. the patient was found to have a urinary tract infection and was started on antibiotics. 6. pain. the patient was started on fent |
| C2609166 | sig: one (1) tablet po bid for 10 days. disp:*10 tablet(s)* refills:*0* discharge disposition: extended care facility: [**hospital 2217**] discharge diagnosis: <1CUI> discordant twin </1CUI> , hydrocephalus, cerebral palsy, spastic quadriplegia discharge condition: stable discharge instructions: please follow up with your neurologist in [**location (un) 2218**]. please follow up with your neurologist in [**location (un) 2218**]. followup instructions: please follow up with your neurologist in [**location (un) 2218**]. followup instructions: please follow up with your neurologist in [**location (un) 2218**]. discharge condition: stable discharge disposition: extended care discharge disposition: extended care |
| C2609173 | 2. neuroprotectants. 3. gi: patient is npo. 4. intravenous antibiotics. 5. pain management. 6. cxr. 7. abgs. 8. chest x-ray. 9. ct abdomen/pelvis. 9. discharge instructions: please follow up with your primary care physician. discharge condition: good. discharge disposition: extended care. discharge diagnosis: 1. respiratory failure. 2. <1CUI> gasping syndrome </1CUI> . 3. aspiration pneumonitis. 4. sepsis. discharge medications: 1. lovenox. 2. cefepime. 3. vancomycin. discharge instructions: please follow up with your primary care physician. discharge condition: good. discharge disposition: extended care. disch |
| C2609176 | 13. 1. cardiac disease: a. history of previous cardiac disease: the patient had a history of a myocardial infarction in [**2008**]. b. coronary artery disease: the patient had a history of stable effort angina with multiple episodes of chest pain. in [**2010-03-22**], the patient had a cardiac catheterization which revealed a 90% left main coronary stenosis. he underwent a cabg with a left internal mammary artery to the left anterior descending, a saphenous vein graft to the left posterior descending, and a saphenous vein graft to the right coronary artery. he was discharged on clopidogrel and aspirin. c. <1CUI> allergic acute coronary syndrome </1CUI> : the patient had an episode of chest pain in [**2011-01-12**] with a |
| C2609259 | discharge date: [**2014-11-10**] date of birth: [**1974-11-15**] sex: f service: medicine history of present illness: the patient is a 39 year old female who was admitted to the [**hospital1 2**] on [**2014-10-15**] with a one day history of severe pelvic pain and vaginal bleeding. the patient had been seen at an outside hospital where a pelvic ultrasound was performed which revealed a 4.5 cm mass in the right adnexa. the patient was transferred to the [**hospital1 2**] for further management. past medical history: 1. <1CUI> dysfunctions, symphysis pubis </1CUI> 2. endometriosis 3. ovarian cyst social history: the patient is a former smoker who quit 10 years ago. family history: noncontributory. physical exam: the patient is a |
| C2609319 | 2. chronic fatigue syndrome. 3. <1CUI> papulopustular rash </1CUI> . 4. psoriasis. 5. hyperlipidemia. 6. hypothyroidism. 7. osteoporosis. discharge condition: good. discharge instructions: 1. please take all medications as prescribed by your doctor. 2. please follow-up with your primary care physician for further evaluation and management of your condition. 2. please do not miss any doses of your medications. 3. please do not take any new medications without speaking with your doctor first. 4. please avoid any strenuous activity or exercise for the next 2 weeks. 5. please avoid any sun exposure for the next 2 weeks. 6. please avoid any scratching or rubbing of your rash. 7. please follow-up with your primary care physician for further evaluation and management of your condition. 8. please follow-up with your primary care physician for further evaluation and management of your chronic fat |
| C2611907 | 5. cardiac catheterization was done on [**2010-05-04**] with no significant findings. 6. the patient was started on ciprofloxacin and doxycycline for presumed endocarditis. 7. the patient was transferred to [**hospital1 2**] on [**2010-05-06**] for further management of his endocarditis and <1CUI> regulation of cardiac muscle adaptation </1CUI> . 8. on [**2010-05-07**] the patient had a repeat echocardiogram which showed moderate to severe mr with moderate to severe lv systolic dysfunction. 9. on [**2010-05-10**] the patient had a repeat echocardiogram which showed moderate to severe mr with moderate to severe lv systolic dysfunction. 10. the patient was continued on ciprofloxacin and doxycycline for endocarditis and his condition was stable. 11. |
| C2609166 | discharge date: [**2013-07-02**] date of birth: [**1985-12-06**] sex: f service: obgyn allergies: patient recorded as having no known drug allergies attending:[**attending info 110**] chief complaint: fetal growth discordance major surgical or invasive procedure: 1. fetal growth <1CUI> discordant twin </1CUI> 2. hysterectomy history of present illness: 34 year old g1p0, 34 year old twin a, t12-l5 spina bifida, with discordant twin. on [**2013-06-03**], patient was transferred to [**hospital1 11**] for further management of discordant twin. on [**2013-06-04**], patient was seen by dr. [**last name (stitle) 70**] and was |
| C2609176 | 14) allergic reaction to medication: patient was given an intravenous dose of epinephrine and atropine for this condition. 15) <1CUI> allergic acute coronary syndrome </1CUI> : patient was given an intravenous dose of epinephrine and atropine for this condition. 16) cardiac arrest: patient was given an intravenous dose of epinephrine and atropine for this condition. 17) cerebral vasospasm: patient was given an intravenous dose of calcium gluconate for this condition. 18) seizures: patient was given an intravenous dose of midazolam for this condition. 19) hypotension: patient was given an intravenous dose of vasopressin for this condition. 20) renal failure: patient was given an intravenous dose of furosemide for this condition. 21) pulmonary embolism: patient was given an intravenous dose of |
| C2609249 | 2. <1CUI> ureterovesical junction obstruction </1CUI> . 3. bladder outlet obstruction. 4. neurogenic bladder. 5. cystitis. 6. hematuria. 7. proteinuria. 8. nephrolithiasis. 9. hypertension. 10. hyperlipidemia. 11. hypercholesterolemia. 12. hypertriglyceridemia. 13. hyperglycemia. 14. diabetes mellitus. 15. ckd. discharge condition: good. discharge instructions: 1. take your medications as prescribed. 2. drink at least 8-10 glasses of water per day to help flush out the toxins from your kidneys. 3. follow up with your urologist in [**2015-07-14**]. 4. if you have any fever, chills, or burning sensation while urinating, please go to the emergency room. |
| C2609259 | discharge date: [**2013-07-13**] date of birth: sex: m service: chi st. alexius medical center history of present illness: mr. [**lastname 554**] is a 56 year old male who was transferred to the [**hospital1 15**] for further management of his injuries. he was admitted to the [**hospital1 15**] on [**2013-07-12**] after he was found to be unresponsive in his home. his wife called 911 and the patient was found to be unresponsive with a temperature of 101.6. the patient was transferred to the [**hospital1 15**] for further management of his injuries. past medical history: the patient is a 56 year old male with a history of <1CUI> dysfunctions, symphysis pubis </1CUI> , who was found unresponsive in his home. he was transferred to the [**hospital1 |
| C2609268 | sig: 1 tablet po bid (2 times a day) discharge disposition: home with service discharge diagnosis: 1. cholecystitis 2. <1CUI> gallbladder disease 3 </1CUI> . gallstone 4. gallbladder disease 5. gallstone 6. cholecystectomy 7. gallbladder disease 8. gallstone 9. cholecystectomy 10. gallbladder disease 11. gallstone 12. gallbladder disease 13. gallstone 14. cholecystectomy 15. gallbladder disease 16. gallstone 17. cholecystectomy 18. gallbladder disease 19. gallstone 20. gallbladder disease 21. gallstone 22. cho |
| C2609414 | discharge date: [**2011-04-23**] date of birth: [**1937-04-09**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 525**] chief complaint: <1CUI> acute kidney injury </1CUI> major surgical or invasive procedure: none history of present illness: 83 year old man with a history of ckd, hypertension, hyperlipidemia, and dm, who presented to the emergency department with anuria, and elevated bun and creatinine. he had a urinalysis which showed no red blood or white blood cells, and a 24-hour urine output of 120 ml. he was started on ddavp and was transferred to the floor for further management. 83 year old man with a history of ckd, hypertension, hyperlipidemia, and dm, who presented to the emergency department |
| C2673395 | there is no evidence of a right knee effusion. the right knee range of motion is full. there is no evidence of <1cui> <1CUI> proximal fibular overgrowth </1CUI> . the right ankle is stable. there is no evidence of a fracture. the left knee is stable with full range of motion. the left ankle is stable. the left foot is stable. there is no evidence of a fracture. there is no evidence of a subluxation or dislocation. there is no evidence of a deformity. there is no evidence of an effusion. there is no evidence of a hernia. the right and left hips are stable. the abdomen is soft, nontender, nondistended, and nonsignificant. the left knee is stable. the left ankle is stable. the left foot is stable. the left knee is stable. the left ankle is stable. the left foot is stable. the left knee is stable. the left ankle is stable. the left foot is |
| C2673441 | disp:*10 capsule(s)* refills:*0* discharge disposition: home with service discharge diagnosis: s/p [**last name (stitle) 177**] stent placement in [**2012-03-28**] s/p cabg in [**2012-03-29**] s/p mi in [**2012-03-29**] s/p stent thrombosis in [**2013-05-20**] <1CUI> renal calcium wasting </1CUI> discharge condition: stable discharge instructions: call your pcp if you develop any chest pain, shortness of breath, dizziness, or any other concerning symptoms. followup instructions: followup instructions: you need to follow up with your primary care physician. followup in [**doctor first name 13**] [**doctor first name 13**] clinic in [**doctor first name 1 |
| C2673462 | discharge date: [**2012-10-12**] date of birth: [**1955-04-02**] sex: m service: medicine allergies: penicillin / cephalosporins / sulfa attending:[**attending info 215**] chief complaint: 1) recurrent staphylococcus aureus infections 2) chronic cough history of present illness: 62 yo male with history of recurrent staphylococcus aureus infections who was admitted to the [**hospital1 17**] for treatment of a right upper lobe pneumonia. past medical history: 1) recurrent <1CUI> staphylococcus aureus infections, recurrent </1CUI> 2) chronic cough 3) chronic obstructive pulmonary disease 4) hypertension 5) hyperlipidemia 6) gerd 7) chronic back pain 8) sleep apnea 9) non |
| C2673535 | he had a good response to the levodopa. he was started on a trial of 500 mg of sinemet (carbidopa/levodopa) q.i.d. he was discharged to home with a follow-up appointment with his neurologist and was referred to the physical therapy department for evaluation and treatment. past medical history: 1. <1CUI> segawa syndrome, autosomal recessive </1CUI> 2. hypothyroidism 3. dyskinesias 4. cerebral palsy 5. gastroesophageal reflux disease social history: he is a high school graduate. he is married. he lives with his wife and two children. he has a history of smoking and drinking alcohol. he is a retired truck driver. family history: no significant family history. physical exam: on admission, the patient was a 45-year-old man who was alert and oriented. he was in no acute |
| C2673646 | sex: f service: cardiothoracic allergies: patient recorded as having no known allergies to drugs attending:[**attending info 422**] chief complaint: 39 y/o g2p1 w/h/o s/p/p/c/d major surgical or invasive procedure: none history of present illness: 39 y/o g2p1 w/h/o s/p/p/c/d, <1CUI> antenatal onset </1CUI> , hypertension, s/p 1999 c/s with [**lastname 1402**] [**name14**] [**name14**] [**name14**] at [**hospital 1211**] hospital. hypertension was controlled with 2 meds during this pregnancy. she had a [**lastname 1402**] [**name14**] [**name14**] [**name14**] [**lastname 1402** |
| C2673649 | he is also known to have spinal stenosis. he is a known case of <1CUI> spondyloepiphyseal dysplasia-brachydactyly and distinctive speech </1CUI> . he had a recent upper gi series which showed no evidence of esophageal stenosis or gastric outlet obstruction. he is also known to have chronic obstructive pulmonary disease, chronic back pain, and benign prostatic hypertrophy. social history: the patient is a social drinker. family history: the patient's father had a myocardial infarction at age 60. physical exam: the patient is a thin man with a prominent forehead, blepharophimosis, upward slanting eyes, abundant eyelashes and eyebrows, coarse voice, short stature, and short hands and feet. he has a high pitched voice. pertinent results: [**2013-07-22**] 08:13am blood wbc-9. |
| C2673395 | discharge date: [**2012-10-19**] date of birth: [**1950-09-29**] sex: f service: [**hospital unit name **] chief complaint: 1. 20-year history of left lower extremity pain. 2. 20-year history of right lower extremity pain. 3. 10-year history of <1cui> <1CUI> proximal fibular overgrowth </1CUI> . history of present illness: mrs. [**last name (stitle) **] is a 52-year-old woman who was referred to the [**hospital unit name **] for evaluation of her painful lower extremities. the patient was referred from [**hospital 199**] by [**name2 (md) **] [**name1 (md) **]. the patient has a 20-year history of left lower extremity pain, which is thought to be due to a congenital bone defect. she was also |
| C2673444 | discharge date: [**2014-08-07**] date of birth: [**1955-03-13**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1145**] chief complaint: <1CUI> hypocitraturia </1CUI> major surgical or invasive procedure: none history of present illness: 81 year old male with a history of renal insufficiency with a creatinine of 2.4, hypercalcemia, and a history of bladder cancer presents with hypocitraturia. past medical history: 1. hypertension 2. hypercalcemia 3. bladder cancer 4. renal insufficiency with creatinine of 2.4 5. chronic obstructive pulmonary disease social history: no tobacco, no alcohol, lives with his wife, lives in [**location (un |
| C2673535 | 2. hypothyroidism. 3. <1CUI> segawa syndrome, autosomal recessive </1CUI> . 4. epilepsy. 5. hypercholesterolemia. 6. hypertension. 7. hyperlipidemia. 8. coronary artery disease. 9. obesity. 1. seizure disorder. the patient has had a history of seizures since infancy. he had a seizure in the emergency room on [**2018-07-01**] and was admitted to the hospital. the patient was noted to have had a seizure in the emergency room on [**2018-07-01**] and was admitted to the hospital. the patient had been seen at the [**hospital1 4**] neurology clinic on [**2018-06-18**] and was seen at the [**h |
| C2673649 | 3. mucopolysaccharidosis type vii. 4. <1CUI> spondyloepiphyseal dysplasia-brachydactyly and distinctive speech </1CUI> . 5. hip dysplasia. 6. pectus excavatum. social history: mr. [**lastname 4040**] is a 54 year old male who was transferred from [**hospital 4041**] to the [**hospital 176**] with a diagnosis of mucopolysaccharidosis type vii, spondyloepiphyseal dysplasia-brachydactyly and distinctive speech. mr. [**lastname 4040**] is a non-smoker, who drinks alcohol socially. he is a retired [**hospital unit/clinic 163**] worker. he lives with his wife. family history: the patient's family history is unremarkable. physical exam: mr. [**lastname 4040**] is a 54 year old |
| C2673646 | sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1258**] chief complaint: <1CUI> antenatal onset </1CUI> of fever, abdominal pain and vaginal bleeding. major surgical or invasive procedure: none history of present illness: pt is 26 y/o g1p0 at [**location (un) 1717**] with antenatal onset of fever, abdominal pain and vaginal bleeding. pt was seen in the [**doctor first name 1259**] and was sent to [**hospital1 1260**] for further evaluation. pt denies chills, shortness of breath, palpitations, n/v, or abdominal pain. she reports that she was seen in the [**doctor first name 1259**] and was sent to [**hospital1 1260**] for further evaluation. pt |
| C2673649 | pt is currently on the floor and doing well. he is currently on a picc line for blood draws and iv antibiotics. he has had a few episodes of hypotension and tachycardia, but has been stable for the past 24 hours. he is on iv antibiotics for the pneumonia and is tolerating his diet. he is not taking any medications at this time. pt has a history of <1CUI> spondyloepiphyseal dysplasia-brachydactyly and distinctive speech </1CUI> and is currently being seen at the [**hospital 494**] for follow up. pt is currently stable and will be transferred to the [**hospital unit name 410**] for further management. pt will need to be followed by a hematologist for his anemia and a geneticist for his spondyloepiphyseal dysplasia-brachydactyly. pt is a 22 year old male with a history of spond |
| C2673395 | 3. multiple joints with severe degenerative joint disease. 4. bilateral hernia. 5. <1CUI> proximal fibular overgrowth </1CUI> . 6. chronic lumbago. [**2013-10-29**] 14:21:00 discharge disposition: extended care discharge diagnosis: 1. pneumonia 2. cellulitis of the left foot 3. <1cui> proximal fibular overgrowth discharge condition: stable discharge instructions: please follow up with your primary care physician for any questions or concerns. followup instructions: please follow up with your primary care physician for any questions or concerns. followup: [**2013-11-04**] 9:00am [**name10 (nameis) 587**] [**name10 (nameis) 588**] md 2914 n 30th rd p |
| C2673441 | 3. <1CUI> renal calcium wasting </1CUI> : this patient has a history of hypercalcemia secondary to a parathyroid adenoma and she has a history of hypercalcemia. she had a parathyroidectomy in [**2015-07-11**]. her calcium level has been elevated on admission. she has been treated with calcium-free fluids and has had no evidence of hypercalcemia. her renal calcium wasting has been evaluated and is likely secondary to her parathyroid adenoma. 4. hypoparathyroidism: this patient has a history of parathyroid adenoma and has had a parathyroidectomy in [**2015-07-11**]. 5. other: this patient has a history of prostate cancer and has been treated with radiation therapy. 6. physical examination: on admission, the patient's physical examination was significant for her hypocalcemia. her blood pressure |
| C2673444 | a 61 year old male with a history of chronic kidney disease s/p a renal transplant in [**2006**] who presented with a 3 day history of fever, chills, myalgias, arthralgias, nausea and vomiting. he was seen in the emergency room on [**11-12**] where he was found to have a temperature of 103.5 and was started on broad-spectrum antibiotics. he was admitted to the hospital on [**11-12**] and was found to have a left upper lobe pneumonia. he was started on vanco and cefotaxime and his fever resolved. he was also found to have <1CUI> hypocitraturia </1CUI> and was started on allopurinol. past medical history: 1. chronic kidney disease s/p renal transplant in [**2006**]. 2. diabetes mellitus. 3. hypertension. 4. hyperlipidemia. 5. gout. social history |
| C2673646 | sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 206**] chief complaint: <1CUI> antenatal onset </1CUI> of abdominal pain major surgical or invasive procedure: vaginal delivery history of present illness: pt is a 33-year-old g1p0 who presented with antenatal onset of abdominal pain at 36 weeks of gestation. pt had a normal pregnancy up until this point. she had been experiencing abdominal pain for several days prior to presentation. she denies any vaginal bleeding, leukorrhea, or fever. pt denies any previous uterine surgery. she denies any history of cervical cancer or cervical dysplasia. she denies any history of cervical cytology. pt reports no history of stds. pt reports no history of smoking, alcohol, or drug use. pt den |
| C2673649 | sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: patient w/ <1CUI> spondyloepiphyseal dysplasia-brachydactyly and distinctive speech </1CUI> . discharge condition: good discharge instructions: please follow up with your primary care physician for any concerns. please continue to take your medications as prescribed. please follow up with your orthopedic surgeon for your scheduled surgery in [**2013-06-18**]. please follow up with your speech therapist for your scheduled speech evaluation in [**2013-06-18**]. please follow up with your geneticist for your scheduled genetic counseling in [**2013-06-18**]. please follow up with your endocrinologist for your scheduled endocrinology appointment in [**20 |
| C2613439 | 2. history of chronic lymphocytic leukemia (malignancy) 3. history of myelodysplastic syndrome (malignancy) 4. history of polycythemia vera (malignancy) 5. history of <1CUI> extramedullary hematopoiesis (disorder) </1CUI> social history: lives with his wife. no smoking. no alcohol. no drugs. family history: noncontributory physical exam: pertinent physical exam: he is a 65 year old man in no acute distress. he is afebrile. his blood pressure is 118/60. his heart rate is 70. he is a baseline oxygenator. his respiratory exam is clear. his abdomen is soft, nontender, nondistended, with no organomegaly. his neurological exam is intact. his extremities are warm and well perfused. the remainder of his examination is unremarkable. [**2 |
| C2673395 | he was referred to the orthopedic department for evaluation. past medical history: 1. aortic valve replacement 1991 2. <1CUI> proximal fibular overgrowth </1CUI> 3. gastric bypass 4. cholecystectomy 5. uterine fibroids social history: he is a retired laboratory technician. he is married and has three children. he has a history of tobacco use. family history: no significant family history. physical exam: the patient is a well appearing 75 year old man with a bp of 140/80, hr 80, rr 18, 97.8f, 100% ra. he has no c/c/g/l. skin: the skin is clean and well groomed. heent: mmm, perrl, op clear. neck: no jvd. chest: cta, cta, no r/r/r/r. heart: rrr, |
| C2673441 | the patient was started on calcium supplements. she was also started on alendronate for her osteoporosis. she was discharged to [**hospital 511**] rehab for further physical therapy. the patient was seen by the urologist and the urologist did not feel that the patient had any urinary tract infection. the patient was seen by the nephrologist who felt that the patient's <1CUI> renal calcium wasting </1CUI> was likely secondary to her osteoporosis and was not related to her calcium supplements. the patient was also seen by the endocrinologist who felt that the patient's hypocalcemia was likely secondary to her osteoporosis and was not related to her calcium supplements. the patient was seen by the orthopedic surgeon who felt that the patient's fractures were likely secondary to her osteoporosis and was not related to her calcium supplements. the patient was seen by the psychiatrist who felt that the patient's depression was not related to her calcium supplements. the patient was seen |
| C2673444 | she had a ct of the abdomen and pelvis which was unremarkable. she was admitted to the floor and treated with vancomycin, piperacillin-tazobactam, and metronidazole. she was also started on a picc line. she was started on a sodium polystyrene sulfonate (kayexalate) for her hyperkalemia. she was treated with a single dose of dilaudid for her pain. her <1CUI> hypocitraturia </1CUI> was thought to be due to her renal insufficiency. her creatinine remained stable at 1.3. she was treated with a single dose of dilaudid for her pain. her hypocitraturia was thought to be due to her renal insufficiency. her creatinine remained stable at 1.3. she was transferred to [**hospital 50**] for further management. past medical history: 1. hypertension 2. hyperlipidemia 3. hypocitraturia 4. hyperkalemia |
| C2673462 | sig: one (1) tablet po q8h. disp:*60 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. <1cui> <1CUI> staphylococcus aureus infections, recurrent </1CUI> 2. clavicle fracture 3. right upper extremity cellulitis 4. right upper extremity abscess 5. cellulitis 6. clavicle fracture discharge condition: good. discharge instructions: 1. 1. continue to take your antibiotics as prescribed. 2. call your pcp if you develop fevers or chills. 3. you should follow up with your pcp in one week for a followup. 4. if you are taking any medications, please make sure to continue taking them as prescribed. 5. if you have any questions, please do not hesitate to contact your pcp or your surgeon. 6. you should avoid heavy lif |
| C2673535 | 12. dystonia. 13. <1CUI> segawa syndrome, autosomal recessive </1CUI> . 14. cerebral atrophy. 15. loss of visual acuity. 16. dysphagia. 17. esophageal varices. 18. gastric ulcer. 19. cholecystitis. 20. cholelithiasis. [**2016-07-28**] # 401612000/10153 discharge diagnoses: 1. segawa syndrome, autosomal recessive. 2. cerebral atrophy. 3. dysphagia. 4. esophageal varices. 5. gastric ulcer. 6. cholecystitis. 7. cholelithiasis. final diagnoses: 1 |
| C2673646 | discharge date: [**2014-05-07**] date of birth: [**1987-09-03**] sex: m service: cardiothoracic allergies: patient recorded as having no known allergies to drugs attending:[**attending info 606**] chief complaint: <1CUI> antenatal onset </1CUI> . major surgical or invasive procedure: none. history of present illness: 34 year old g1p0 with a prior tolac at 2006 with an apgar of 7, spontaneous abortion at 2007 at 6 weeks, and a term delivery in 2008 with a fetal demise at 37 weeks, currently at 15 weeks of gestation with a breech presentation with an unstable cervix, the patient was transferred to [**hospital 30**] for further management. past medical history: 1. 2. 3. 4. 5. |
| C2673652 | the patient was discharged home with follow-up appointments with her primary care physician and the neurology clinic. discharge diagnoses: 1. hypertension. 2. cervical spine fracture. 3. <1CUI> anterior scalloping vertebral bodies </1CUI> . 3. neck pain. 4. headache. 5. diffuse pain. 6. fatigue. 7. nausea. 8. vomiting. 9. dysphagia. 10. dysphasia. 11. sleep disturbances. 12. difficulty with concentration and memory. 13. depression. 14. anxiety. 15. seizure disorder. 16. hypothyroidism. 17. hyperlipidemia. 18. osteoporosis. 19. chronic fatigue syndrome. 20. fibromyalgia. 21. hyperpar |
| C2673776 | diffuse bilateral pulmonary infiltrates. no evidence of pneumothorax. no pleural effusion. no evidence of cardiomegaly. no evidence of ascites. no evidence of hepatosplenomegaly. no evidence of <1CUI> vascular tortuosity </1CUI> . brief hospital course: the patient was admitted to the hospital for further management of his pneumonia. he was started on piperacillin-tazobactam, clindamycin and ceftriaxone for his pneumonia. he was also started on vancomycin for his mrsa-colonized status. he was also started on levofloxacin for his mrsa-colonized status. he was also started on colchicine for his gout. he was also started on atorvastatin for his hyperlipidemia. he was also started on furosemide for his hypertension. he was also started on digoxin for his atrial fibrillation. he was also started on aspirin for his atrial fibrillation. |
| C2673793 | 2. hypertension. 3. hyperlipidemia. 4. hypothyroidism. 5. osteoarthritis. 6. <1CUI> gingivitis, severe </1CUI> . 7. depression. 8. anxiety. 9. ptsd. 10. chronic back pain. 11. history of hepatitis c. 12. history of cholecystectomy. 13. history of hysterectomy. 14. history of appendectomy. 15. history of varicose veins. 16. history of cholecystectomy. 17. history of hernia repair. 18. history of hemorrhoidectomy. 19. history of polypectomy. 20. history of cataracts. 21. history of cataract surgery. 22. history of cataract surgery. 23. history of renal calculi. 24. history of pul |
| C2673883 | 2. <1CUI> renal-hepatic-pancreatic dysplasia </1CUI> . 2. renal-hepatic-pancreatic dysplasia. final diagnoses: 1. polycystic kidney disease. 2. renal-hepatic-pancreatic dysplasia. 2. renal-hepatic-pancreatic dysplasia. 3. polycystic kidney disease. 4. renal artery thrombosis. 5. cystic fibrosis. 6. gastro-oesophageal reflux disease. 7. pulmonary embolism. 8. acute respiratory distress syndrome. 9. sepsis. 10. acute renal failure. |
| C2673888 | increased renal mass. cystic renal mass. <1CUI> decreased number of nephrons </1CUI> . echocardiogram on [**2018-03-08**] revealed a right ventricular mass. the mass was thought to be a benign cystic mass. impression: 1. decreased number of nephrons. 2. right ventricular mass. 3. mild right ventricular hypertrophy. 4. mild left ventricular hypertrophy. 5. normal left atrium. 6. normal left ventricular systolic function. 7. normal right ventricular systolic function. 8. normal mitral valve. 9. normal aortic valve. 10. normal pulmonary valve. 11. normal tricuspid valve. 12. normal pulmonary artery systolic pressure. 13. mild pulmonary artery diastolic pressure. 14. normal aortic root diameter. |
| C2673892 | 3. pregnancy. 4. cholangiocarcinoma. 5. hcv. 6. <1CUI> ductal plate malformation </1CUI> . 7. ptsd. 8. bipolar disorder. 9. cocaine use. 10. alcohol use. 11. depression. 12. anxiety. 13. hiv. 14. hepatitis b. 15. hepatitis c. 16. pcp. 17. pertussis. 18. tuberculosis. 19. hodgkin's disease. 20. thyroid cancer. 21. melanoma. 22. lymphoma. 23. breast cancer. 24. ovarian cancer. 25. uterine cancer. 26. prostate cancer. 27. testicular cancer. 28. hysterectomy. 29. |
| C2673931 | discharge date: [**2019-05-08**] date of birth: [**1950-04-10**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 109**] chief complaint: 20 year old woman with <1CUI> hyperthreoninuria </1CUI> major surgical or invasive procedure: none history of present illness: 20 year old woman with hyperthreoninuria. the patient is a 20 year old woman with a history of hyperthreoninuria who was found to have elevated levels of threonine in her urine. she was referred to the nephrologist for evaluation. the patient is currently taking a diet low in threonine and has been taking medications including amino acid supplements and ammonium chloride. the patient was admitted to the hospital for further evaluation and management of her hyperthreoninuria. pertinent results |
| C2673946 | a small left lateral ventricle with a prominent cerebral aqueduct. there is a small left occipital lobe with a cerebral cyst. the rest of the cerebral cortex appears normal. the ventricular system is unremarkable. there is a small right occipital cerebral cyst. there is a <1cui> <1CUI> foveal hypoplasia (finding) </1CUI> of the left optic disc. there is no evidence of a right-sided cerebral infarction. there is no evidence of hydrocephalus. impression: 1. there is a small left lateral ventricle with a prominent cerebral aqueduct. 2. there is a small left occipital lobe with a cerebral cyst. 3. the rest of the cerebral cortex appears normal. 4. there is a small right occipital cerebral cyst. 5. there is a <1cui> foveal hypoplasia (finding) of the |
| C2673776 | pertinent results: cxr: no acute lung injury or infiltrate. ekg: sinus tachycardia. ct head/neck/chest/abd/pelvis: no acute intracranial hemorrhage. no evidence of pulmonary embolism. no evidence of <1CUI> vascular tortuosity </1CUI> . [**2016-08-24**] 06:20pm discharge diagnoses: 1. aortic dissection 2. septic shock 3. hypotension 4. anemia 5. hypocalcemia 6. hyperkalemia 7. hypoproteinemia 8. hyperlipidemia 9. pulmonary embolus 10. vascular tortuosity discharge instructions: you have been diagnosed with aortic dissection and pulmonary embolism. you are to follow up with your cardiologist and pulmonologist in one week. you are |
| C2673793 | discharge date: [**2013-09-18**] date of birth: [**1945-06-20**] sex: f service: [**hospital unit name **] history of present illness: ms. [**lastname 5525**] is a 68 year old female with a history of severe periodontal disease, [**1cui**] <1CUI> gingivitis, severe </1CUI> , and multiple teeth extractions. she presents to the [**hospital unit name **] for a routine dental appointment. past medical history: 1. gingivitis, severe 2. multiple extractions 3. dementia 4. atrial fibrillation 5. cva 1995 with right sided weakness and aphasia 6. osteoporosis 7. chronic low back pain 8. hyperlipidemia 9. hypothyroidism 10. chronic obstruct |
| C2673931 | sex: m service: cardiology history of present illness: the patient is a 53-year-old male who was admitted on [**2012-06-24**] with a history of acute onset of chest pain and shortness of breath. the patient had been in good health until the day prior to admission when he developed a sudden onset of chest pain while walking. he was seen in the emergency room at [**hospital 123**] where an ekg showed st elevations and he was transferred to [**hospital 124**]. past medical history: the patient has a history of hyperlipidemia, hypercholesterolemia, hypertension, hypertriglyceridemia, <1CUI> hyperthreoninuria </1CUI> , and aortic valve replacement in [**1999**]. he has also had a history of smoking and alcohol abuse. social history: the patient is a former smoker and drinks alcohol socially. family history: the |
| C2673700 | neurological examination: cn ii-vi, iii-iv, v-vi intact. cn i-xii intact. cerebellar examination: intact. extremities: no clubbing, cyanosis, edema. <1CUI> brisk reflexes </1CUI> . pertinent results: [**2017-09-03**] 06:15am blood wbc-10.4* rbc-3.53* hgb-11.1* hct-34.5* mcv-90 mch-30.6 mchc-34.1 rdw-13.4* plt ct-254* [**2017-09-03**] 06:15am glucose-120* urea n-30* creat-0.6 sodium-134 potassium-4.2 chloride-97 total co2-23 anion gap |
| C2673793 | 2. chronic obstructive pulmonary disease. 3. hypothyroidism. 4. hyperlipidemia. 5. chronic back pain. 6. hypercholesterolemia. 7. <1CUI> gingivitis, severe </1CUI> . 8. hypertension. 9. hyperlipidemia. 10. obesity. 11. depression. 12. chronic pain. 13. dyspepsia. 14. osteoarthritis. 15. hyperlipidemia. 16. hypothyroidism. 17. hypercholesterolemia. 18. chronic back pain. 19. hypertension. 20. diabetes mellitus type 2. 21. osteoarthritis. 22. chronic fatigue. 23. chronic cough. 24. chronic sinusitis. 25. dyspepsia. |
| C2673885 | 2. chronic renal failure secondary to chronic interstitial nephritis. 3. chronic hepatic fibrosis. 4. <1CUI> meckel-like syndrome </1CUI> . 5. cerebral atrophy. social history: 1. lives with his wife and his wife's 87-year-old mother. 2. works as a mechanic. 3. drinks 2-3 beers per day. 4. no etoh since [**2013-04-01**]. 5. no cigarettes since [**2013-04-01**]. 6. no other drug use. 7. lives in [**location 4514**] and works in [**location 4515**]. 8. has a 32-year-old daughter who lives in [**location 4516**]. 9. no pets. 10. no travel. 11. no hobbies. 12. no known |
| C2673888 | the patient had been taking ibuprofen, which was discontinued. the patient was admitted to the icu for pain management and nephrotoxicity. the patient's renal function improved with hydration, but remained elevated. the patient had a 20% decrease in her baseline creatinine. the patient was continued on iv fluids and was started on a diuretic. on [**09-26**], the patient was continued on her iv fluids and diuretic and was continued to improve. the patient was then transferred to the floor and continued on her diuretic. on [**09-27**], the patient had a urine output of 400 ml and her creatinine was 2.8. the patient was then discharged home on [**09-28**]. # 2. <1CUI> decreased number of nephrons </1CUI> . # 3. decreased number of nephrons. # 4. decreased number of nephrons. # 5. decreased number of nephrons |
| C2673892 | 102233 |||| 12051 |||| 17250 |||| echo_report |||| 2016-01-20 00:00:00.0 |||| |||| patient/test information: indication: evaluate for biliary atresia and/or <1CUI> ductal plate malformation </1CUI> . date of birth: [**2013-12-28**] date of birth: 1979 date of birth: 1979 patient type: mf name: [**first name10 (namepattern1) **] [**last name (namepattern1) 105**] sex: m age: 36 civil status: m race: [**race 133**] height: 64 weight (kg): 789 bmi: 26 study date: 2016-01-20 patient position: rt/supine allergies: patient disp: [**last name (st |
| C2673931 | cardiac catheterization revealed 2vd and 2vd in the rca with 90% lad stenosis, 70% lcx stenosis, and 50% rca stenosis. the patient had a previous history of a myocardial infarction in [**2012**] and was found to have a left main coronary artery stenosis of 90%. he was admitted to the hospital for a coronary artery bypass graft and was found to have <1CUI> hyperthreoninuria </1CUI> . past medical history: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34 |
| C2673652 | 2. hypertension. 3. hyperlipidemia. 4. osteoporosis. 5. chronic pain. 6. <1cui> <1CUI> anterior scalloping vertebral bodies </1CUI> <1cui>. 7. osteoporosis. 8. osteopenia. 9. precordial pain. 1. precordial pain. 2. cervical spine fracture. 3. cervical spine osteoporosis. 4. cervical spine osteopenia. 5. cervical spine fracture. 6. anterior scalloping vertebral bodies. 7. osteoporosis. 8. osteopenia. 9. precordial pain. 10. precordial mass. 11. precordial mass. 12. precordial mass. 13. precordial mass. 14. precordial mass. 15. precordial mass. 16. precordial mass. |
| C2673759 | discharge date: [**2015-02-12**] date of birth: [**1951-09-25**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 450**] chief complaint: hearing loss major surgical or invasive procedure: 1. hearing implant history of present illness: 34 y/o male with a history of profound sensorineural hearing loss and vestibular dysfunction. he is a carrier of the <1CUI> deafness, autosomal recessive 1a </1CUI> . he underwent a hearing implant in the left ear on [**2015-02-04**] and the right ear on [**2015-02-06**] at an outside facility. he was transferred to [**hospital1 1**] on [**2015-02-11 |
| C2673883 | 2. pancreatic insufficiency. 3. pancreatic cysts. 4. renal dysplasia. 5. <1CUI> renal-hepatic-pancreatic dysplasia </1CUI> . 6. hypopituitarism. discharge condition: good. discharge instructions: 1. you should take 100% pancreatic enzymes with meals. 2. you should avoid alcohol and spicy foods. 3. you should continue your current medications unless otherwise instructed. 4. you should follow up with your primary care physician within two weeks. 5. you should follow up with your nephrologist within two weeks. 6. you should follow up with your gastroenterologist within two weeks. 7. you should follow up with your endocrinologist within two weeks. 8. you should follow up with your surgeon within two weeks. 9. you should follow up with |
| C2673888 | pt's creatinine has been stable. the pt's serum sodium has been stable. pt's urine output has been stable. pt's urine output has been stable. pt's urine output is stable. pt's urine output is stable. pt's urine output has been stable. pt's urine output is stable. pt's urine output has been stable. pt's urine output is stable. pt's urine output is stable. pt's urine output is stable. pt's urine output is stable. pt's urine output is stable. pt's urine output is stable. # 6. <1CUI> decreased number of nephrons </1CUI> : the pt's serum creatinine has been stable. # 7. decreased number of nephrons: the pt's serum creatinine has been stable. # 8. decreased number of nephrons: the pt's serum creatinine has been stable. |
| C2673892 | the patient was placed on an ng tube for nutrition. the patient was transferred to the floor for further management of her condition. the patient was seen by the gi service and it was felt that the patient had a <1cui> <1CUI> ductal plate malformation </1CUI> <1cui> which was causing the cholestasis. she was referred for an endoscopic retrograde cholangiopancreatography [initials (namepatternis) 1510]. she was also seen by the hepatology service and it was felt that the patient may require a liver transplant. the patient was also started on a course of proton pump inhibitors for the management of her esophageal varices. the patient was also started on a course of proton pump inhibitors for the management of her esophageal varices. the patient was discharged to a rehabilitation facility for further management of her condition. discharge disposition: [**first name12 (namepatternis) 1117**] [**last name (namepatternis) 1118** |
| C2673931 | sex: f service: cardiothoracic history of present illness: the patient is a 43 year old woman who presented to the emergency room with shortness of breath. the patient had a history of high blood pressure, hypercholesterolemia, hypertriglyceridemia, hyperthyroidism, hyperparathyroidism, and <1CUI> hyperthreoninuria </1CUI> . she had been on lisinopril, amlodipine, and levothyroxine. the patient had been in the emergency room on [**01-16**] for a cough, and had been found to have a large left atrial mass. she was referred to the cardiothoracic surgical service for further evaluation. past medical history: the patient had been diagnosed with hyperthyroidism when she was 20 years old. she had been treated with levothyroxine for this condition. past surgical history: cholecystectomy 1990. gast |
| C2673946 | 6. retinal detachment. 7. vitreous hemorrhage. 8. retinal vessel occlusion. 9. retinal vein occlusion. 10. <1CUI> foveal hypoplasia (finding) </1CUI> . 11. optic disc edema. 1. right 3+ homonymous hemianopsia. 2. right 2+ homonymous hemianopsia. 3. left 2+ homonymous hemianopsia. 4. left 1+ homonymous hemianopsia. 5. right 1+ homonymous hemianopsia. 6. left 1+ homonymous hemianopsia. 7. right 1+ homonymous hemianopsia. 8. left 1+ homonymous hemianopsia. 9. right 1+ homonymous hemianopsia. 10. left 1+ homonymous hemianopsia. 11. right 1+ homonymous hemianopsia. 12. left 1+ homonymous hemianopsia. 1 |
| C2673700 | lungs: clear to auscultation bilaterally. abd: soft, nontender, nondistended, no organomegaly, no masses, no hernias. ext: no clubbing, cyanosis, edema. neuro: intact, alert, oriented x3, follows commands. no weakness, ataxia, dysmetria, tremor, or rigidity. no focal deficits. 9/10 strength in upper and lower extremities. 9/10 reflexes. <1CUI> brisk reflexes </1CUI> . 3+ patellar. brief, spontaneous extensor posturing. no tremor, ataxia, or dysmetria. no ankle clonus. no wrist clonus. no extensor plantar response. no babinski. no romberg. no gaze evoked nystagmus. no ophthalmoplegia. no dysarthria. no dysphagia. no hoarseness. no tremor. no cerebellar at |
| C2673883 | sig: one (1) tablet po q12h (sun-sat). disp:*90 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. renal failure. 2. chronic jaundice. 3. insulin-dependent diabetes mellitus. 4. <1CUI> renal-hepatic-pancreatic dysplasia </1CUI> . 5. hepatic cysts. 6. portal hypertension. 7. ascites. 8. gi bleeding. discharge condition: good. discharge instructions: please continue to follow up with your primary care physician. please follow up with your primary care physician in one week. please follow up with your primary care physician for a blood test to check your liver function. please follow up with your primary care physician for a blood test to check your kidney function. you should continue to take your medications as prescribed by your primary care physician. please |
| C2673885 | 3. chronic renal failure. 4. neurofibromatosis type 1. 5. nephrocalcinosis. 6. nephrocalcinosis. 7. hyperparathyroidism. 8. hypothyroidism. 9. hyperlipidemia. 10. <1CUI> meckel like syndrome </1CUI> . 11. chronic renal failure. 12. hypotension. 13. hypertension. 14. hyperkalemia. 15. hypocalcemia. 16. hyperphosphatemia. 17. hyperuricemia. 18. hyperglycemia. 19. hypoglycemia. 20. hypertriglyceridemia. 21. hypotension. 22. hyperlipidemia. 23. hypocalcemia. 24. hyperphosphatemia. 25. hyperuricemia. 26. hyperglycemia. |
| C2673892 | pt was started on tpn and had improvement in liver enzymes. pt was then transferred to [**hospital 1199**] for further management. on [**2011-10-28**] pt was seen by dr. [**last name (stitle) 111**] and was diagnosed with <1CUI> ductal plate malformation </1CUI> . he had a liver biopsy on [**2011-10-28**] which showed chronic inflammation, mild fibrosis, and bile duct proliferation consistent with ductal plate malformation. pt was started on ursodiol 300mg po bid. on [**2011-11-07**] pt was seen by dr. [**last name (stitle) 111**] and was diagnosed with [**first name14 (name pattern1) 155**] cirrhosis. he was started on lovenox and his ursodiol was increased to 600mg po bid. on [**201 |
| C2673931 | disp:*20 capsule(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. cerebral infarction 2. hypertension 3. <1CUI> hyperthreoninuria </1CUI> 4. hypothyroidism discharge condition: good discharge instructions: follow up with dr. [**last name (stitle) 2404**] in 2 weeks. follow up with dr. [**last name (stitle) 2405**] in 2 weeks. follow up with dr. [**last name (stitle) 2406**] in 2 weeks. take 2 aspirin 325 mg twice a day. take 100 mg of levothyroxine twice a day. take 10 mg of lisinopril twice a day. take 5 mg of hydrochlorothiazide twice a day. take 5 mg of meloxicam twice a day. take |
| C2673954 | sig: one (1) tablet po bid for one (1) week. discharge disposition: extended care discharge diagnosis: 1. hiv [**hospital unit name 14**] 2. aids 3. pcp 4. hypotension 5. anemia 6. <1CUI> absent skin pigmentation </1CUI> discharge condition: stable. discharge instructions: please follow up with your pcp at [**location (un) 14**] within 1 week. please follow up with your hiv specialist at [**location (un) 15**] within 2 weeks. followup instructions: please follow up with your pcp at [**location (un) 14**] within 1 week. please follow up with your hiv specialist at [**location (un) 15**] within 2 weeks. discharge condition: stable. discharge medications on admission: 1. ativan 2. celebre |
| C2674432 | sig: one (1) tablet, delayed release (2000 mg) po bid (2 times a day). disp:*20 tablet, delayed release(s) refills:*0* discharge disposition: home with service discharge diagnosis: 1. aortic valve stenosis 2. <1CUI> decreased bone mineral density z score </1CUI> 3. osteoporosis 4. hyperparathyroidism 5. hyperlipidemia discharge condition: good discharge instructions: please call your doctor if you notice any weight gain, or any shortness of breath, or any new chest pain. followup instructions: you will need to follow up with your primary care physician and cardiologist. please call [**last name (stitle) **] [**telephone/fax (2) 316**] with any questions. please call [**telephone/fax (2) 316**] with any questions. please call [ |
| C2674451 | there are no acute injuries to the joint. there is a small amount of osteophyte formation in the distal humeral and proximal radial metaphyses. the elbow joint is stable with no evidence of instability or acute injury. impression: 1. no acute injury to the elbow joint. 2. <1CUI> anterior dislocation of radial head </1CUI> . 3. no evidence of instability of the elbow joint. [**first name4 (namepattern1) **] [**last name (namepattern1) **] md [**md number 262**] [**2015-06-24**] 5:00 pm allergies: patient recorded as having no known drug allergies motor: 2/5 muscle strength in the left upper extremity. sensation: 2/5 in the left upper extremity. pertinent results: [**2015-06-24**] 04:45pm urine: nitrite: 0-10 rbc: |
| C2674459 | date of birth: [**1941-05-25**] sex: m service: [**hospital unit name 31**] history of present illness: this is a 75-year-old man with a history of hypertension, hyperlipidemia, and <1CUI> limited walking abilities </1CUI> . the patient is status post aortic valve replacement and mitral valve repair 11 months ago. he was admitted to [**hospital1 12**] on [**2013-03-14**] with a fever of 102.4, tachycardia, and tachypnea. his blood cultures were negative. he was transferred to the [**hospital unit name 31**] on [**2013-03-15**] for further evaluation. physical examination: on admission the patient was afebrile, tachycardic, tachypneic, and diaphoretic. he had a normal airway, breath |
| C2674608 | discharge date: [**2011-08-05**] date of birth: [**1988-04-14**] sex: m service: cardiothoracic allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1117**] chief complaint: abdominal pain major surgical or invasive procedure: cardiac catheterization history of present illness: pt is a 23 yo male with a history of <1CUI> feeding difficulties in infancy </1CUI> who presented to the [**hospital1 3**] on 7/29 with abdominal pain, vomiting and diarrhea. pt was found to have a large ascending aortic aneurysm and was transferred to [**hospital1 3**] for cardiac catheterization. past medical history: pt is a 23 yo male with a history of feeding difficulties in infancy. pt had a g |
| C2674705 | di <1CUI> scha </1CUI> rge date: [**2012-10-05**] date of birth: [**1949-06-01**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 124**] chief complaint: chronic renal failure with hyperkalemia major surgical or invasive procedure: none history of present illness: 61 year old woman with chronic renal failure secondary to mcto. she was admitted to the [**hospital 100**] on [**2012-09-25**] for hyperkalemia and was transferred to the [**hospital1 100**] on [**2012-10-02**] for dialysis. she was dialyzed twice at the [**hospital1 100**] before being transferred to the [**hospital1 110**]. she had a |
| C2674403 | the right optic nerve head is flat. the left optic nerve head is flat with a trace of tortuosity. the right optic nerve sheath is 2.5 mm. the left optic nerve sheath is 2.2 mm. there is no evidence of optic nerve compression. there is no evidence of <1CUI> scleral thickening </1CUI> or tortuosity. the left macula is within normal limits. the right macula is within normal limits. [**04-10**] cta: no evidence of aortic arch aneurysm. no evidence of intracranial or intraocular aneurysm. [**04-11**] 1. no evidence of retinal detachment. 2. no evidence of scleral thickening. 3. no evidence of macular edema. 4. no evidence of macular exudate. [**05**] 1. no evidence of retinal detachment. 2. no evidence of scleral thickening. 3. no evidence of macular edema. 4. no evidence of macular exudate. |
| C2674407 | 4. dry amd. 5. macular hole. 6. <1cui> <1CUI> foveoschisis </1CUI> . 7. cataract. 8. cataract. 9. cataract. 10. cataract. 11. optic disc edema. 12. narrowing of the right and left retinal veins. 13. vitreous hemorrhage. 14. optic disc edema. 15. macular hole. 16. dry amd. 17. cataract. 18. cataract. 19. cataract. 20. cataract. 21. cataract. 22. cataract. 23. cataract. 24. cataract. 25. cataract. 26. cataract. 27. cataract. 28. cataract. 29. cataract. 3 |
| C2674705 | d <1CUI> ispo </1CUI> sition: discharge date of discharge: [**2013-07-23**] 06:00 am discharge disposition: home with service discharge diagnosis: mcto, renal failure, hyperparathyroidism sign out [**2013-07-22**] @ 1300 # mcto # renal failure # hyperparathyroidism discharge instructions: please follow up with your primary care physician or your nephrologist to assess the progression of your renal failure. please follow up with your endocrinologist to assess the progression of your hyperparathyroidism. please follow up with your primary care physician or your nephrologist to assess the progression of your mcto. please contact your primary care physician if you have any questions or concerns. please contact your primary care physician or your nephrologist if you have any new symptoms or complaints. please contact your endocrinologist if you have any new symptoms or complaints. please |
| C2674403 | the left optic nerve is slightly swollen, but the right optic nerve is normal. there is mild <1cui> <1CUI> scleral thickening </1CUI> . there is a small left inferior hyperplastic optic disc. the left inferior retinal vein is slightly dilated. pupils are equal, round and reactive to light and accommodation. extraocular muscles are intact. there is no evidence of proptosis or afferent pupillary defect. impression: there is no evidence of optic neuritis. there is mild <1cui> scleral thickening. there is no evidence of retinal detachment or retinal vein occlusion. there is no evidence of acute or chronic optic nerve damage. mild hyperplasia of the optic disc. there is no evidence of toxic or metabolic optic neuropathy. there is no evidence of retinal arteriovenous malformation. there is no evidence of retinal vasculitis. there is no evidence of retinal artery or vein occlusion |
| C2674407 | 3. hypertensive retinopathy. 4. macular degeneration. 5. <1CUI> foveoschisis </1CUI> . 6. retinal vein occlusion. 6. retinal vein occlusion. the patient was seen by [**last name (stitle) 824**] [**first name (stitle) **] [**last name (stitle) 824**] on [**2014-04-07**]. the patient was seen by [**first name (namepattern1) **] [**last name (namepattern1) **] on [**2014-04-07**]. the patient was seen by [**first name (namepattern1) **] [**last name (namepattern1) **] on [**2014-04-07**]. the patient was seen by [**first name (namepattern1) **] [**last name (namepattern1) **] on [**2014-04-07**]. 7. macular degeneration. |
| C2674432 | the patient was discharged with a home health care company to help with all of her needs. the patient is to be seen in the clinic in [**2013-07-03**] for a bone density study. the patient is to be seen in the clinic in [**2013-07-17**] for a bone density study. the patient is to be seen in the clinic in [**2013-07-24**] for a bone density study. past medical history: 1. <1CUI> decreased bone mineral density z score </1CUI> . 2. chronic low back pain. 3. osteoporosis. 4. hyperlipidemia. 5. hypertension. 6. gerd. 7. fibromyalgia. 8. cervical spine stenosis. 9. history of cervical spine surgery. 10. history of breast cancer. 11. history of melanoma. 12. history of thyroid cancer. 1 |
| C2674459 | the patient was discharged to [**hospital1 326**] rehabilitation. she was instructed to follow up with her pcp and orthopedic surgeon as well as her rehabilitation team. the patient was instructed to not drive for six weeks and to have someone assist her with her daily activities. the patient was instructed to continue to take her pain medication as prescribed and to follow up with her orthopedic surgeon at [**hospital1 326**] in two weeks for a follow up appointment. the patient was instructed to have her pt and ot continue to assess her for her <1CUI> limited walking abilities </1CUI> and to provide her with appropriate exercises and assistive devices. social history: the patient lives with her husband and has three children. she is a homemaker and has limited walking abilities. family history: the patient has two brothers who have died from heart disease. her mother died of colon cancer. physical exam: vital signs: t 97.9 hr 75 bp 127/70 rr 22 96 |
| C2674608 | discharge date: [**2014-07-15**] date of birth: [**1983-07-13**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 2329**] chief complaint: <1CUI> feeding difficulties in infancy </1CUI> major surgical or invasive procedure: n/a history of present illness: 21-year-old female with feeding difficulties in infancy who was seen in the [**hospital1 26**] at age 5 and was thought to have a neurological cause of her feeding difficulties. she was treated with a nasogastric tube and was able to be weaned off of it by age 10. she has had no further feeding difficulties until the past week, when she experienced vomiting after eating and was seen in the [**hospital1 26**] where she had an upper gi series which was negative for any an |
| C2674616 | sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. hypertension 2. <1CUI> adenomatous polyposis coli, attenuated </1CUI> 3. morbid obesity 4. peripheral arterial disease 5. dyslipidemia 6. chronic low back pain 7. depression discharge condition: good. discharge instructions: please follow up with your primary care physician in two weeks. follow up appointment with [**hospital 5195**] gastroenterology in 2 weeks. please call your primary care physician with any concerns or if you experience any chest pain, shortness of breath, or severe abdominal pain. please take all of your medications as directed. please take your blood pressure medications |
| C2674705 | a <1CUI> orti </1CUI> c valve calcification mild. mitral valve: mild mitral valve prolapse. tricuspid valve: mild tricuspid valve thickening. pulmonic valve/pulmonary artery: mild pulmonic valve insufficiency. pericardium: no pericardial effusion. heart: normal sized heart. lungs: no acute pulmonary edema. abdomen: soft, nontender, nondistended, with no fluid wave. extremities: no clubbing, cyanosis, or edema. skin: no lesions. neurologic: no focal neurological deficits. physical examination: no carotid bruits. medications on admission: [**2014-05-23**] 08:00:00.846 solu-cortef 1000 mg take one |
| C2674177 | sig: one (1) tablet po q6h (every 6 hours) for 7 days. disp:*7 tablet(s)* refills:*0* discharge disposition: extended care discharge diagnosis: 1. probable bacterial meningitis 2. <1CUI> areflexia of the upper limbs </1CUI> discharge condition: good discharge instructions: please follow all instructions and take all medications as prescribed. 1. please follow up with your primary care physician to complete your 7-day course of antibiotics. 2. please call your primary care physician if you experience any fevers, chills, headache, nausea, vomiting, or weakness. 3. please call your primary care physician if you experience any new or worsening symptoms. 4. please call your primary care physician if you have any questions or concerns. followup instructions: please follow up with your primary care physician to complete your 7-day course of antibiotics. please call your primary care physician if |
| C2674407 | no evidence of vitreous hemorrhage. there is no evidence of retinal detachment. no evidence of optic nerve sheath meningioma. no evidence of retinal vein occlusion. no evidence of retinal artery occlusion. no evidence of <1CUI> foveoschisis </1CUI> . [**2015-03-21**] 10:57pm blood work: hematocrit 43.8; hb 14.8; plt ct 465; neutrophils 84.8% b 11.5%; lymphocytes 6.6%; monocytes 3.1%; eos 1.4%; b/w 1.2; plt ct 465; pt 14.2; ptt 29.5; inr 1.1; [**2015-03-21**] 03:30pm blood work: wbc 13.6; neutrophils 73 |
| C2674432 | physician: ms. [**name4 (stitle) 5531**] is a 67-year-old female who presents with a history of a fall approximately two weeks ago. she was admitted to the [**hospital1 15**] for her injuries, which included a fracture of the left humeral head, a fracture of the left acetabulum, and a fracture of the right hip. she was treated with open reduction and internal fixation of the left humeral head fracture, open reduction and internal fixation of the left acetabular fracture, and was treated nonoperatively with a hip spica cast for the right hip fracture. she was transferred to the [**hospital1 15**] for further management of her fractures. her history is significant for a hysterectomy, a history of smoking, and a history of <1CUI> decreased bone mineral density z score </1CUI> . the patient is a 67-year-old female who presents with a history of a fall approximately two weeks ago. she was admitted to the [** |
| C2674451 | the patient was transferred to the [**hospital unit name 311**] where he was placed on blood pressure medications and given a low-sodium diet. he was also placed on coumadin for his dvt. he was seen by the hand surgeon and a decision was made to do a pinning of the radial head. 1. <1CUI> anterior dislocation of radial head </1CUI> : the patient had a pinning of the radial head on [**2019-01-22**] by the hand surgeon. the patient was taken to the or under general anesthesia. 2. dvt: the patient was started on coumadin for his dvt. 3. pna: the patient had a pna in the right hand which was drained and the patient was started on antibiotics. 4. esrd: the patient was started on dialysis. 5. gi bleed: the patient had a gi bleed which was controlled with endoscopy. 6. sepsis: the patient had a sepsis workup and was started on antibiotics |
| C2674608 | sex: m service: [**hospital unit name 45**] allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1954**] chief complaint: fever and vomiting major surgical or invasive procedure: none history of present illness: this is a 2 month old male with fever and vomiting. he was seen in the [**hospital unit name 45**] and had a normal exam. he was discharged from the [**hospital unit name 45**] with a diagnosis of possible gastroenteritis. he was seen again by his primary care physician and was started on antibiotics for possible sepsis. he was started on antibiotics and was admitted to the [**hospital unit name 45**] with a diagnosis of possible sepsis and <1cui> <1CUI> feeding difficulties in infancy </1CUI> <1cui>. he was transferred to the [**hospital unit name 45**] and was started on ant |
| C2674705 | di <1CUI> scha </1CUI> rge date: [**2012-11-11**] date of birth: [**1959-03-23**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 423**] chief complaint: hip pain major surgical or invasive procedure: hip replacement history of present illness: 65 y/o female with a history of mcto, presented to the [**hospital1 319**] with pain and difficulty ambulating. past medical history: mcto with multiple hip replacements, chronic renal failure, hypertension, hyperlipidemia, osteoporosis, osa, hypothyroidism, gerd, and mild copd pertinent results: ekg: sinus tachycardia labs: wbc 3.9, hgb 10.8, hct 32.2, p |
| C2674432 | 3. hyperlipidemia. 4. <1CUI> decreased bone mineral density z score </1CUI> . 5. chronic low back pain. 6. chronic right shoulder pain. 7. right foot ulcer. 8. chronic sinusitis. discharge disposition: extended care discharge diagnosis: 1. chronic obstructive pulmonary disease. 2. hypertension. 3. <1cui> decreased bone mineral density z score. 4. hyperlipidemia. 5. chronic low back pain. 6. chronic right shoulder pain. discharge condition: stable. discharge instructions: please follow up with your primary care physician at [**doctor first name 28**] [**last name (un) **] or [**telephone/fax (un) **] for any changes in your symptoms. followup instructions: please follow up with your primary care physician at [**doctor first name 28**] |
| C2674608 | discharge date: [**2011-03-03**] date of birth: [**1974-07-27**] sex: m service: [**hospital unit name 152**] history of present illness: mr. [**lastname 1234**] is a 35-year-old man with a history of <1CUI> feeding difficulties in infancy </1CUI> . he was admitted to [**hospital1 436**] in [**2010-03-21**] with a diagnosis of esophageal atresia, tracheo-oesophageal fistula, and pneumothorax. he was transferred to [**hospital1 436**] for evaluation and management of his feeding difficulties. at [**hospital1 436**], he underwent a barium swallow which demonstrated a narrowing of the esophagus at the level of the thoracic inlet, and a tracheo-oesophageal |
| C2674620 | he has a history of hyperlipidemia, hypertension, and diabetes mellitus. he has had multiple abdominal surgeries for diverticulitis. he has had multiple dental extractions and has been told he has <1CUI> fragile teeth </1CUI> . he was started on a 1:1:1 insulin regimen on [**2014-10-11**]. he has been started on a low-fat diet. he has had a history of [**hospital1 54**] and [**hospital1 55**] as well. he was started on a 1:1:1 insulin regimen on [**2014-10-11**]. social history: he is a retired engineer and has a history of smoking but quit 15 years ago. he is a widower. he is a resident of [**hospital1 79**] and has lived there for 10 years. he has a daughter in [**state **] who is a doctor. he has a son in [**state **] who is a |
| C2674705 | 3. <1CUI> chr </1CUI> onic renal failure. 4. mcto. 5. fractures. [**2014-03-04**] 06:13:00 act # 38732 urine cytology: appearance: clear, pale yellow microscopic: moderate number of red blood cells, no white blood cells, few epithelial cells. rbc: 2+ wbc: 1+ bacteria: 2+ crystals: 1+ casts: 1+ epithelial cells: 1+ other: no casts, no crystals, no rbcs, no wbcs. color: light yellow spin: 1. nephrocalcinosis. 2. hyperkalemia. 3. hyperphosphatemia. 4. hypocalcemia. 5. hyperchloridemia. 6. hypernatremia. 7. hypotremia. |
| C2674723 | hb 13.6 (11.8) hct 44.2 (43.1) rbc 4.44 (4.28) wbc 11.3 (10.9) neutrophils 73.7 (68.6) lymphocytes 19.4 (20.9) monocytes 6.6 (7.5) eosinophils 1.3 (1.3) basophils 0.3 (0.2) plt count 420 (421) pt 14.6 (14.6) ptt 27.3 (27.1) inr 1.1 (1.1) activated clotting time 128 (128) cxr no acute pulmonary edema. no pleur <1CUI> al ef </1CUI> fusion. ct abd no ascites. no free fluid in the peritoneum. no bowel wall thickening. pt/ptt the pt and ptt were within normal limits. mri brain: |
| C2674737 | family history: father died of mi at age 70. mother died of breast cancer at age 62. one brother with hx of mi at age 47. two sisters with hx of breast cancer. social history: smoked 1 pack a day for 40 years, quit 15 years ago. drinks 2-3 alcoholic drinks per day. [**hospital unit name **] [**hospital unit name 21**] 1. pertussis. 2. <1CUI> finger abnormalities </1CUI> . 3. seizures. discharge condition: stable. discharge instructions: please call your pcp if you have any new onset of fevers, chills, cough, or shortness of breath. please call your pcp if you have any new onset of seizures. please call your pcp if you have any new onset of pain or weakness in your hands. followup instructions: please follow up with your pcp in 2 weeks. [**first name10 (name pattern1 |
| C2674738 | sig: one (1) tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: pituitary tumor [**2018-04-12**] - [**initials (namepattern1) 720**] - mild left atrial enlargement - <1CUI> toe abnormalities </1CUI> - [**initials (namepattern1) 720**] - pituitary tumor - [**initials (namepattern1) 720**] - hypothyroidism - [**initials (namepattern1) 720**] - hypoparathyroidism - [**initials (namepattern1) 720**] - osteoporosis - [**initials (namepattern1) 720**] - hypertriglyceridemia - [**initials (namepattern1) 720**] - hypercholesterolemia - [**initials (namepattern1) |
| C2674853 | peripheral artery disease - right lower extremity peripheral artery disease. dysattachment of the right pelvic floor - dysattachment of the right pelvic floor. radiculopathy - radiculopathy of the right lower extremity. periposteal reaction - <1CUI> periosteal reaction </1CUI> . peripheral artery disease - right lower extremity peripheral artery disease. peripheral vascular disease - peripheral vascular disease. osteoporosis - osteoporosis. s/p radiculopathy - s/p radiculopathy. radiculopathy - radiculopathy of the right lower extremity. periposteal reaction - periosteal reaction. peripheral artery disease - right lower extremity peripheral artery disease. peripheral vascular disease - peripheral v |
| C2674949 | discharge date: [**2016-04-05**] date of birth: [**1997-06-28**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 116**] chief complaint: <1CUI> chromosome 3q29 deletion syndrome </1CUI> . major surgical or invasive procedure: none history of present illness: 14 year old female with a known chromosome 3q29 deletion syndrome. she is currently admitted for evaluation for potential bone marrow transplant. she has been followed at [**hospital 123**] by dr. [**last name (stitle) **] and dr. [**last name (stitle) **]. she has a known deletion of the 3q29 chromosome and has had multiple surgeries for her cleft lip and palate. she is currently in the process of being evaluated for a bone mar |
| C2675111 | no edema. pupils are equal, round, and reactive to light. no nph. sclera are anicteric. no <> abnormality. <> <1CUI> eyelash abnormality </1CUI> . <> no ptosis, opthalmoplegia, or horner's syndrome. <> no facial asymmetry, mass, or erythema. <> no neck masses. <> no lymphadenopathy. <> no thyromegaly. <> no carotid bruits. <> no jvd. <> no clubbing. <> no cyanosis. <> no erythema. <> no nail clubbing. <> no nail ridging. <> no nail pitting. <> no nail brittleness. <> no nail thickening. <> no nail opacities. <> no nail discoloration. <> no nail trauma. <> no nail infection. <> no nail paronychia. |
| C2675211 | discharge date: [**2015-02-25**] date of birth: [**1962-03-09**] sex: f service: neurology allergies: patient recorded as having no known allergies to drugs attending:[**attending info 420**] chief complaint: episodic ataxia major surgical or invasive procedure: none history of present illness: 39 year old woman with a history of <1CUI> episodic ataxia, type 6 </1CUI> , who has been followed by dr. [**last name (stitle) 3731**] and dr. [**last name (stitle) 3732**] for approximately 15 years. the patient has had multiple episodes of ataxia, slurred speech, confusion, headache, and hemiplegia, with the most recent episode occurring on [**2015-02-11**]. the patient has been seen by neurology at [**hospital |
| C2675336 | 3. <1CUI> chromosome 15q11-q13 duplication syndrome </1CUI> : the patient is a 37 year old female with a history of autism, mental retardation, ataxia, seizures, developmental delays, and behavioral problems. the patient was diagnosed with chromosome 15q11-q13 duplication syndrome. the patient has a history of seizures, but these have been well controlled with medications. she has been treated with phenobarbital, levetiracetam, and topiramate. the patient was seen by [**hospital 711**] neurology and was started on a new medication, valproic acid. the patient has had no recent seizures. she has had no recent falls. the patient is at risk for seizures and falls. the patient is also at risk for developmental delays, behavioral problems, and mental retardation. the patient has a history of depression and anxiety, and has been treated with sertraline. the patient is at |
| C2675369 | discharge date: [**2013-02-18**] date of birth: [**1985-10-24**] sex: m service: [**hospital unit name 27**] allergies: patient recorded as having no known allergies to drugs attending:[**attending info 49**] chief complaint: left lower extremity laceration major surgical or invasive procedure: left lower extremity debridement history of present illness: mr. [**lastname 4021**] is a 27-year-old man with <1CUI> chromosome 22q11.2 duplication syndrome </1CUI> who was transferred to [**hospital1 19**] from [**hospital2 531**] with a 10-cm laceration on his left lower extremity. he was initially treated at [**hospital2 531**] with a hematoma and was transferred to [**hospital1 19**] |
| C2674723 | the patient had a fever of 100.7, a heart rate of 104, a blood pressure of 102/55, and a respiratory rate of 18. she was in her norm <1CUI> al st </1CUI> ate of health. on examination, the patient was found to have a fever, a tachycardia, a tachypnea, and a mildly elevated blood pressure. she had a cardiac murmur. she was afebrile and her white blood cell count was 13. 2. the patient was transferred to the intensive care unit. she was started on ceftriaxone and vancomycin for presumed sepsis. 3. the patient's fever was treated with acetaminophen. 4. the patient was placed on a nasogastric tube for feeding. 5. the patient was placed on a diuretic and her fluid intake was restricted. 6. the patient was started on intravenous steroids for presumed autoimmune hemolytic anemia. 7. the patient was given pack |
| C2674738 | pt. was also noted to have a mass in his right parotid gland, which was not felt to be a cyst. pt. was referred to [**hospital 248**] for further evaluation of this mass. pt. was also noted to have some <1CUI> toe abnormalities </1CUI> . # 2. toe abnormalities: pt. has a large soft tissue mass in his right 4th toe. this mass is thought to be an infected cyst. # 3. pt. has a mass in his right parotid gland. # 4. pt. has a mass in his right inguinal region. # 5. pt. has a hernia in his right inguinal region. # 6. pt. has a mass in his left inguinal region. # 7. pt. has a mass in his left parotid gland. # 8. pt. has a mass in his left submandibular gland. # 9. pt. has a mass in his left neck. |
| C2674853 | the patient was started on a course of antibiotics for the presumed osteomyelitis. she was also given a course of steroids to help with the pain. she was also seen by the orthopedic service and they felt that the <1CUI> periosteal reaction </1CUI> was not necessarily osteomyelitis but rather a response to the recent trauma. she was discharged on [**2014-09-01**] and was scheduled to follow up with the orthopedic service in [**location (un) 13**]. 3. periosteal reaction: the patient was noted to have a periosteal reaction on the left distal femur. 4. cellulitis: the patient was noted to have cellulitis of the left distal thigh. 5. fracture: the patient had a fracture of the left distal femur. 6. pneumonia: the patient was noted to have pneumonia on the left side. 7. wound infection: the patient had a wound infection of the left thigh. 8. sepsis: the |
| C2675014 | 4. hypogonadism. 5. hypothyroidism. 6. hypocalcemic nephrocalcinosis. 7. <1CUI> mullerian aplasia and hyperandrogenism </1CUI> . 8. microvesicular gastrointesinal disease. 9. polycystic ovarian disease. 10. 40,xx,mca/46,xx,mca (mullerian aplasia and hyperandrogenism). 11. 40,xx,mca/46,xx,mca (mullerian aplasia and hyperandrogenism). 12. 40,xx,mca/46,xx,mca (mullerian aplasia and hyperandrogenism). 13. 40,xx,mca/46,xx,mca (mullerian aplasia and hyperandrogenism). 14. 4 |
| C2675074 | 5. chronic back pain. 6. painful left shoulder. 7. carotid artery stenosis. 8. <1cui> <1CUI> enlarged peripheral nerve </1CUI> . 9. hyperlipidemia. 10. hypercholesterolemia. 11. hypertriglyceridemia. 12. hypothyroidism. 13. osteoporosis. 14. vitamin d deficiency. 15. osteoarthritis. 16. gerd. 17. irritable bowel syndrome. 18. chronic cough. 19. chronic sinusitis. 20. chronic obstructive pulmonary disease. 21. chronic bronchitis. 22. hyperparathyroidism. 23. hypoparathyroidism. 24. hyperkalemia. 25. hypernatremia. 26. hypochlorh |
| C2675111 | discharge date: [**2013-08-13**] date of birth: [**1946-11-13**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 109**] chief complaint: 1. 1. <1CUI> eyelash abnormality </1CUI> 2. fever 3. headache 4. nausea and vomiting 5. difficulty speaking major surgical or invasive procedure: none history of present illness: 82 year old man with history of multiple sclerosis, who was transferred from [**hospital 57**] to [**hospital1 20**] for further workup of fever, nausea, vomiting, and difficulty speaking. patient's eyelashes were noted to be abnormal upon transfer from [**hospital 57**] to [**hospital1 20** |
| C2675211 | discharge date: [**2013-10-02**] date of birth: [**1952-07-24**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 2823**] chief complaint: 1) <1CUI> episodic ataxia, type 6 </1CUI> 2) hypertension major surgical or invasive procedure: 1. left upper extremity arteriovenous fistula creation on [**2013-09-27**] 2. left upper extremity arteriovenous fistula revision on [**2013-09-27**] history of present illness: 44 y/o f with a history of episodic ataxia, type 6, hypertension, and [**13-10-13**] s/p [**last name |
| C2675336 | the patient was discharged on [**2013-05-23**] in good condition with follow-up appointments with her primary care physician, neurologist, and geneticist. discharge disposition: extended care discharge diagnosis: <1CUI> chromosome 15q11-q13 duplication syndrome </1CUI> discharge condition: good discharge instructions: 1. follow-up appointment with her primary care physician on [**2013-05-29**] 2. follow-up appointment with her neurologist on [**2013-06-05**] 3. follow-up appointment with her geneticist on [**2013-06-26**] 4. continue to take her medications as prescribed. 5. she should avoid any physical activity that could cause injury. 6. she should avoid any activity that could cause a seizure. 7. follow-up with her primary care physician as scheduled. 8. follow-up |
| C2675369 | the patient has a history of cleft palate and velopharyngeal insufficiency, which has been managed with speech therapy and has not been a significant issue. the patient also has a history of mild learning disabilities. 2. <1CUI> chromosome 22q11.2 duplication syndrome </1CUI> : the patient has a history of chromosome 22q11.2 duplication syndrome. the patient has had numerous evaluations over the years, including a ct scan of the head and a cranial mri, which have not shown any evidence of the duplication. 3. 22q11.2 duplication syndrome: the patient has a history of 22q11.2 duplication syndrome. 4. 22q11.2 duplication syndrome: the patient has a history of 22q11.2 duplication syndrome. 5. 22q11.2 duplication syndrome: the patient has a history of 22q11.2 duplication syndrome. |
| C2674738 | sex: f service: medicine history of present illness: the patient is a 70 year old female with a history of hypertension, hyperlipidemia, and osteoporosis who presented to the [**hospital 119**] with worsening abdominal pain and nausea. she had an upper gi series which revealed a hiatal hernia, gastritis, and a small gastric ulcer. she was started on ranitidine and then transferred to [**hospital 120**] for further management. past medical history: the patient has a history of hypertension, hyperlipidemia, osteoporosis, and chronic pain syndrome. she has a history of depression and anxiety. she also has a history of chronic <1CUI> toe abnormalities </1CUI> which have been managed with shoe lifts. social history: the patient lives with her husband and is a homemaker. she has one adult son. she is a nonsmoker and does not |
| C2675014 | the patient was transferred to the [**hospital1 75**] for further management of her condition. the patient's postoperative course was complicated by a urinary tract infection. the patient was treated with antibiotics and was discharged home on [**2015-08-11**]. 2. <1CUI> mullerian aplasia and hyperandrogenism </1CUI> : the patient's mullerian aplasia and hyperandrogenism was evaluated by a multidisciplinary team. the patient underwent an mri of the pelvis which showed a normal uterus, fallopian tubes and ovaries. the patient was treated with hormone replacement therapy and was referred to a specialist for further management of her condition. 3. pulmonary embolism: the patient was transferred to the [**hospital1 75**] for further management of her pulmonary embolism. 4. pneumocele: the patient was transferred to the [**hospital1 75 |
| C2675369 | 3. hypothyroidism. 4. hypoadrenism. 5. cardiac abnormalities. 6. 22q11.2 duplication syndrome. 7. 22q11.2 deletion syndrome. 8. 22q11.2 microdeletion syndrome. 9. 22q11.2 duplication syndrome. 10. <1CUI> chromosome 22q11.2 duplication syndrome </1CUI> . 11. chromosome 22q11.2 deletion syndrome. 12. chromosome 22q11.2 microdeletion syndrome. 13. chromosome 22q11.2 microdeletion syndrome. 14. chromosome 22q1 |
| C2674723 | 11. hypersplenism. 12. neutropenic fever. 13. thrombocytopeni <1CUI> a. 14 </1CUI> . alps4. 15. hepatosplenomegaly. 16. hypergammaglobulinemia. 17. monocytosis. 18. neutropenic fever. 19. hypertriglyceridemia. 20. hypercholesterolemia. 21. hyperlipidemia. 22. hypercalcemia. 23. hyperkalemia. 24. hypocalcemia. 25. hypochloridemia. 26. hypernatremia. 27. hyperosmolarity. 28. hyperuricemia. 29. hypophosphatemia. 30. hyperphosphatemia. 31. hyperparathyroidism. 32. hyperthyroidism. 33 |
| C2674853 | on the right, there is a peripheral soft tissue mass that is most consistent with a hematoma. there is a question of a small s/p chest tube, but it is not well-visualized. there is a small left pleural effusion. impression: no evidence of pneumothorax. no evidence of pneumonia. no evidence of pleural effusion. no evidence of mass. bronchopulmonary findings: right upper lobe: there is a <1CUI> periosteal reaction </1CUI> , which is most consistent with a fracture. left pleura: there is a small left pleural effusion. right pleura: there is a small right pleural effusion. pericardium: there is no pericardial effusion. echocardiagram: the echocardiogram is unremarkable. peripheral vessels: there is no evidence of deep vein thrombosis. abdomen: there is a small amount of ascites. li |
| C2674949 | 2. cerebral palsy. 3. <1CUI> chromosome 3q29 deletion syndrome </1CUI> . 4. s/p [**last name (un) 3338**] [**name10 (nameis) 3339**] [**last name (un) 3340**] [**unit/telephone/fax (3) 3341**] [**2018-10-01**]. [**first name1**] [**name2 (mf) **] [**initials (namepattern1) **] [**doctor first name **] [**doctor initials **] [**doctor title (un) **] [**doctor company (un) **] [**2018-10-01**] [**06:30:33**] signed electronically on [**2018-10-01**] at 10:45:40 am discharge diagnosis: cerebral palsy, chromos |
| C2675014 | mild hyperandrogenism. cervical ultrasound showed a normal-sized uterus and cervix, with no evidence of a mass. the patient had a normal pelvic exam. the patient's <1CUI> mullerian aplasia and hyperandrogenism </1CUI> was discussed with her and she was referred to [**hospital 414**] endocrinology for further evaluation and management. # social history: no social history. # family history: no family history. # physical exam: perrla. vitals: t 98.8, hr 64, bp 100/70, rr 12 gen: wnht, nad, no lymphadenopathy, no rashes heent: mmm, eomi, no oropharyngeal lesions, no thyromegaly, no laryngeal lesions cv: rrr, no murmurs lungs: ctab abd: soft, nt/nd, no mass, no hepatosplenomegaly |
| C2675211 | 2. pulmonic valve replacement. 3. lymphedema. 4. <1CUI> episodic ataxia, type 6 </1CUI> . 5. chronic knee pain. 6. hypertensive renal disease. 7. hyperlipidemia. 8. gerd. social history: 1. etoh: n/v/e. 2. tobacco: n/v/e. 3. illegal drugs: n/v/e. family history: noncontributory. physical exam: vitals: 95.4 16 60 16 100%ra 18 gen: well appearing man in nad. heent: pupils eomi, anicteric sclerae. no jvd. lungs: cta/cta bilaterally. abd: soft, nt |
| C2675336 | 11. peripheral arterial disease. 12. pulmonary arterial hypertension. 13. peripheral vascular disease. 14. <1CUI> chromosome 15q11-q13 duplication syndrome </1CUI> . 15. gastritis. 16. cystic fibrosis. 17. chronic kidney disease. 18. hypertension. 19. diabetes melitus. 20. asthma. 21. chronic obstructive pulmonary disease. 22. osteoarthritis. 23. carpal tunnell syndrome. 24. otosclerosis. 25. gastritis. 26. hypertension. 2 |
| C2675369 | 2. 22q11.2 duplication syndrome. 3. <1CUI> chromosome 22q11.2 duplication syndrome </1CUI> . 4. 22q11.2 duplication syndrome. 5. 22q11.2 duplication syndrome. discharge condition: good. discharge instructions: 1. take all medications as prescribed. 2. follow up with your primary care physician in [**2013-07-17**]. 3. follow up with your cardiologist in [**2013-07-17**]. 2. follow up with your primary care physician in [**2013-07-17**]. 3. follow up with your cardiologist in [**2013-07-17**]. social history: no smoking. family history: no history of heart disease. physical exam: vital signs: t 98 |
| C2674723 | 3. chronic lymphocytic leukemia. 4. hypo <1CUI> plast </1CUI> ic left heart syndrome. 5. cerebral palsy. 6. anemia. 7. cmv. 8. aplastic anemia. 9. alps. social history: 1) 1p (1st cousin), 2) 2p (2nd cousin), 3) 3p (3rd cousin), 4) 4p (4th cousin), 5) 5p (5th cousin), 6) 6p (6th cousin), 7) 7p (7th cousin), 8) 8p (8th cousin), 9) 9p (9th cousin), 10) 10p (10th cousin) 2) 1) 1c1 3) 2) 2c1 4) 3) 3c1 5) 4) 4c1 6) 5) 5c1 7) 6) 6c1 8) 7 |
| C2674737 | sig: one (1) tablet po bid for 7 days. disp:*7 tablets(10mg)* refills:*0* discharge disposition: extended care discharge diagnosis: 1. right lower extremity fracture 2. <1CUI> finger abnormalities </1CUI> 3. hypopituitarism 4. hyperparathyroidism discharge condition: good. discharge instructions: 1. follow up with your primary care physician. 2. follow up with your endocrinologist. 3. follow up with your orthopedic surgeon. 4. follow up with your neurologist. 5. follow up with your primary care physician to have your thyroid labs checked. 6. you will need to have your wound cared for daily. 7. you will need to have your blood pressure and thyroid labs checked. 8. you should avoid heavy lifting, bending, or straining. 9. you should avoid driving for one month. |
| C2674853 | on [**2016-11-17**] he was transferred to [**hospital1 123**] where he was admitted to the [**hospital unit name **]. his workup for his chest pain was negative for acute coronary syndrome, and he was found to have a right atrial enlargement, with a right ventricular systolic pressure of 42 mmhg. he was also found to have a 3.5 cm <1CUI> periosteal reaction </1CUI> in the left ribs. his left hilar lymph nodes were enlarged. he was treated with antibiotics for possible osteomyelitis and was started on coumadin for his atrial fibrillation. his chest pain resolved with medication. on [**2016-11-21**] he was transferred to [**hospital2 123**] for further evaluation of his chest pain. his chest pain resolved with medication and he was discharged home on [**2016-11-23**]. his chest pain was thought to be secondary |
| C2675014 | discharge date: [**2013-07-20**] date of birth: [**1975-06-26**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 209**] chief complaint: vaginal bleeding and uterine mass. major surgical or invasive procedure: hysterectomy history of present illness: 52 year old female with history of <1CUI> mullerian aplasia and hyperandrogenism </1CUI> , presented to the [**hospital1 18**] on [**2013-07-17**] with 2 days of vaginal bleeding. the patient had been followed by her primary care physician for her mullerian aplasia and hyperandrogenism. she had been on hormone replacement therapy for her hyperandrogenism. on the day of presentation, she had been taking her hormone replacement medications as |
| C2675021 | pupils are equal and reactive to light. extraocular muscles are intact. the patient has <1CUI> narrowed palpebral fissures </1CUI> . the patient has a right facial droop. the patient has a left-sided weakness. the patient has no dysarthria, ataxia, or weakness. brief hospital course: the patient was transferred from [**hospital 100**] to the [**hospital 712**] for a ct scan of the head. the ct scan of the head showed no evidence of hemorrhage. the patient was transferred to the [**hospital 1016**] for further management. the patient was seen by the neurologist and was diagnosed with a right cerebral hemispheric infarction. the patient was transferred to [**hospital 1007**] for further management. the patient was seen by the neurologist and was diagnosed with a right cerebral hemispheric infarction. the patient was transferred to [**hospital 1007**] |
| C2675074 | 2. carotid artery disease. 3. dysphagia. 4. hypothyroidism. 5. hypercholesterolemia. 6. hypotension. 7. hyperglycemia. 8. hypertriglyceridemia. 9. <1cui> <1CUI> enlarged peripheral nerve </1CUI> <1cui>. 10. hyperlipidemia. 11. hypercalcemia. 12. hyperkalemia. 13. hypernatremia. 14. hyperphosphatemia. 15. hypoalbuminemia. 16. hyperuricemia. 17. anemia. 18. elevated liver enzymes. 19. elevated creatinine. 20. hyperuricemia. 21. elevated calcium. 22. elevated sodium. 23. elevated potassium. 24. elevated creatin |
| C2675211 | on [**2019-03-06**] the patient was seen by dr. [**last name (stitle) **] in the [**location (un) 34**] clinic. the patient's [**last name (un) 35**] was reviewed and the patient was noted to have had an episode of ataxia the previous day. the patient's eeg was reviewed and was noted to be normal. the patient was seen by the neurology team and was noted to have had a prior episode of ataxia and was diagnosed with <1CUI> episodic ataxia, type 6 </1CUI> . the patient was started on keppra and was instructed to follow up with the neurology team. the patient was seen by the [**hospital unit name 37**] team and was instructed to follow up with the [**hospital unit name 37**] team. the patient was seen by the [**hospital unit name 38**] team and was instructed to follow up with the [**hospital unit name 38**] team. |
| C2675336 | discharge date: [**2011-08-15**] date of birth: [**1972-01-26**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 3785**] chief complaint: seizures major surgical or invasive procedure: none history of present illness: this 38 year old man with a history of <1CUI> chromosome 15q11-q13 duplication syndrome </1CUI> , seizures, and mental retardation was transferred from [**hospital 1234**] to the [**hospital1 234**] for further management of seizures. the patient had been admitted to [**hospital 1234**] on [**2011-08-11**] for evaluation of a recent seizure. he had been seen in the emergency room at [**hospital 12 |
| C2675369 | discharge date: [**2011-03-17**] date of birth: [**1961-01-13**] sex: f service: cardiothoracic allergies: patient recorded as having no known allergies to drugs attending:[**attending info 419**] chief complaint: <1CUI> chromosome 22q11.2 duplication syndrome </1CUI> major surgical or invasive procedure: balloon atrial septostomy replacement history of present illness: this is a 49-year-old woman with a history of chromosome 22q11.2 duplication syndrome, who presented with a cough and fever. she had a recent 6 week history of cough and fever, with a recent episode of coughing up blood. she was seen in the [**doctor first name 4**] in the past with an episode of coughing up blood and was found to have |
| C2675547 | the patient was started on 2000 mg of dexamethasone and 100 mg of solumedrol, with a plan to wean these medications over the next few days. he was also given 100 mg of lasix for his edema. the patient's right upper extremity weakness improved and he was able to move his arm against gravity and walk without assistance. the patient's condition improved and he was transferred to the icu on [**2013-09-03**] for further management. the patient was transferred to the floor on [**2013-09-06**] and was continued on dexamethasone and solumedrol. the patient's condition improved and he was discharged on [**2013-09-09**]. discharge diagnoses: 1. multi-drug resistant staphylococcus aureus sepsis. 2. <1CUI> slender long bones with narrow diaphyses </1CUI> . 3. hypotension. 4. respiratory |
| C2675558 | 3. chronic renal insufficiency. 4. proteinuria. 5. hyperkalemia. 6. hypercalcemia. 7. <1CUI> nephroblastomatosis </1CUI> . 8. ckd. 9. hypertension. 2. chronic renal insufficiency. 3. proteinuria. 4. hyperkalemia. 5. hypercalcemia. 6. nephroblastomatosis. 7. ckd. 8. hypertension. 2. chronic renal insufficiency. 3. proteinuria. 4. hyperkalemia. 5. hypercalcemia. 6. nephroblastomatosis. 7. ckd. 8. hypertension. 2. chronic renal insufficiency. 3. proteinuria. 4. hyperkalemia. 5. hypercalcemia. 6. nephroblastomatosis. 7. |
| C2675590 | physician dispensing: 1. 10 mg levothyroxine sodium tablet, [**2021-07-09**] 30 tablet(s) of 10 mg(s) dispensing/refills: *2 refills* discharge disposition: extended care discharge diagnosis: <1CUI> anophthalmia, true </1CUI> discharge condition: good discharge instructions: please contact dr. [**last name (stitle) **] at [**telephone/fax (2) 375**] if you have any questions or concerns. follow up with dr. [**last name (stitle) 376**] in [**city 377**] in [**month discharge date 378**] for mri of brain. follow up with dr. [**last name (stitle) 379**] in [**city 377**] in [**month discharge date 378 |
| C2675627 | discharge date: [**2015-03-12**] date of birth: [**1951-04-23**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 430**] chief complaint: melena, abdominal pain, diarrhea major surgical or invasive procedure: colonoscopy history of present illness: 55 yo f with <1CUI> acholia stool </1CUI> , melena, abdominal pain, diarrhea, fevers and chills, vomiting, diarrhea, h/o gastric bypass surgery in 2009, h/o gastroenteritis in 2013. past medical history: 1. 2013: gi infection with diarrhea, vomiting, fevers, chills, melena, acholia stool, abdominal pain, treated with antibiotics, discharged to |
| C2675904 | family history: mother had a [**lastname 7821**] at <1CUI> age </1CUI> 37 and had a hysterectomy at age 45. brother died at age 25 from a motor vehicle accident. physical exam: the patient is an obese male with a bp of 140/80, hr of 90, rr of 20, o2 sats of 90% on room air. heent: anicteric, perrl, eomi, mmm. neck: supple, no jvd, no lymphadenopathy. chest: cta, no wheezes, no rales. abd: soft, nt, nd, no organomegaly. ext: no edema, no clubbing, no cyanosis, no erythema. neuro: a&ox3, no focal neuro signs. pertinent results: [**2015-11-23**] 04:15am blood wbc-10.1 rbc- |
| C2675920 | 4. anemia. 5. <1CUI> anisopoikilocytosis </1CUI> . 6. iron deficiency. 7. chronic myelogenous leukemia. 8. pertussis. 9. tuberculosis. 10. pertussis. 11. hepatitis c. 12. lyme disease. 13. syphilis. 14. hiv. 15. cmv. 16. ebv. 17. hcv. 18. hepatitis b. 19. adenovirus. 20. adenovirus. 21. cryptococcus. 22. pcp. 23. aspergillus. 24. cryptococcus. 25. cryptococcus. 26. cryptococcus. 27. cryptococcus. 28. aspergillus. 29. asperg |
| C2675993 | discharge date: [**2013-07-16**] date of birth: [**1945-01-27**] sex: m service: [**hospital unit name **] allergies: penicillins / sulfa / aspirin / vancomycin attending:[**attending info 1223**] chief complaint: pancreatic cancer major surgical or invasive procedure: pancreaticoduodenectomy history of present illness: 84 yo m with a history of pancreatic ca, last seen in [**2007**] with an elevated ca-19-9 and ct scan showing a mass in the head of the pancreas. the patient was seen at [**hospital 1127**] where he underwent a ct guided biopsy of the mass which showed a <1CUI> squamous cell carcinoma of the pancreas </1CUI> . he was then referred to [**hospital1 1224**] for further management. |
| C2676032 | discharge date: [**2014-11-27**] date of birth: [**1967-05-18**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1784**] chief complaint: <1CUI> craniofaciofrontodigital syndrome </1CUI> , abdominal pain major surgical or invasive procedure: none history of present illness: 40 y/o female with a history of craniofaciofrontodigital syndrome (cffd), hypertension, hyperlipidemia, hypothyroidism and polycystic ovarian disease, presented to the emergency department with abdominal pain. patient states that she has been experiencing abdominal pain for the past 3 weeks, which has been associated with nausea, vomiting, diarrhea, fever and decreased urine output. she states that the pain is located in the right lower |
| C2675547 | 3. <1CUI> slender long bones with narrow diaphyses </1CUI> . discharge condition: good. discharge instructions: 1. you should contact your primary care physician with any questions or concerns. 2. you should avoid any strenuous activities for the next two weeks. 3. you should avoid any weight lifting or bending for the next two weeks. 4. you should avoid any deep water activities for the next two weeks. 5. you should avoid any activities that cause pain. 6. you should avoid any activities that cause shortness of breath. 7. you should avoid any activities that cause dizziness or lightheadedness. 8. you should avoid any activities that cause nausea or vomiting. 9. you should avoid any activities that cause constipation. 10. you should avoid any activities that cause diarrhea. 11. you should avoid any activities that cause pain. 12. you should avoid any activities that cause shortness of breath. 13. you should avoid any activities that cause dizziness or lightheadedness |
| C2675558 | discharge date: [**2014-03-25**] date of birth: [**1978-02-25**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 103**] chief complaint: <1CUI> nephroblastomatosis </1CUI> major surgical or invasive procedure: nephrectomy history of present illness: 41 y/o female with a history of nephroblastomatosis was transferred to [**hospital1 17**] for a nephrectomy. patient was born with 2 kidneys and had a normal ultrasound in infancy. at 16 years of age, she had a renal ultrasound which showed multiple nephrocalcinosis, 4-5 mm in size. she had a renal biopsy which showed nephroblastomatosis. she was seen at [**hospital1 28**] and was |
| C2675590 | sex: f service: cardiothoracic history of present illness: ms. [**last name (stitle) **] is a 38 year old woman who was transferred from [**hospital 205**] with a diagnosis of <1CUI> anophthalmia, true </1CUI> . she was seen by [**hospital1 142**] and [**hospital 142**] and underwent a mri scan of the head and neck which showed no evidence of ocular tissue, optic nerve, chiasm or optic tracts. she was transferred to [**hospital 142**] for further evaluation. physical examination: on admission to the [**hospital 142**] she was afebrile. she had a normal heent examination with no evidence of globe, optic nerve, chiasm or optic tracts. the right ear canal was clear. the left ear canal was clear with a 10 decibel hearing loss. past medic |
| C2675627 | discharge date: [**2011-02-10**] date of birth: [**1953-02-28**] sex: m service: general surgery history of present illness: mr. [**lastname 3116**] is a 58 year old man with a history of <1CUI> acholic stool </1CUI> and melena who was transferred to the surgical service for an exploratory laparotomy. he was admitted to [**hospital 142**] in [**2011-02-02**] with a 2 day history of acholic stool and melena. he was transferred to [**hospital 142**] on [**2011-02-03**] and had a ct of the abdomen which showed a small amount of free fluid in the pelvis and a 5 cm mass in the rectum. on [**2011-02-04**] he underwent a colonoscopy |
| C2675904 | discharge date: [**2011-03-22**] date of birth: [**1979-01-25**] sex: f service: cardiothoracic history of present illness: this 31 y <1CUI> ear o </1CUI> ld female with 11p13-p12 deletion syndrome (wagro) presented to the [**hospital1 12**] with cough, fever, and chest pain. she had been seen at [**hospital 474**] and [**hospital 475**] for these symptoms, but had not been seen at the [**hospital1 12**]. she had a chest x-ray at [**hospital 474**] which was interpreted as showing a right lower lobe pneumonia. she was started on antibiotics, but her symptoms worsened and she was sent to the [**hospital1 12**] for further evaluation. she had a repeat chest x-ray at |
| C2675920 | the patient was transferred to the [**hospital unit name 103**] for further management. patient was transferred to [**hospital1 19**] for further management. past medical history: 1. copd 2. <1CUI> anisopoikilocytosis </1CUI> 3. hypercholesterolemia 4. hypertriglyceridemia 5. gerd 6. htn 7. hyperlipidemia 8. obesity 9. dementia 10. chronic renal insufficiency 11. chronic anemia 12. hypothyroidism social history: 1. lives with spouse 2. retired [**last name (un) 1766**] worker 3. no tobacco, alcohol, or illicit drug use family history: non-contributory review of systems: general: increasingly somnolent |
| C2675993 | discharge date: [**2014-09-15**] date of birth: [**1947-12-06**] sex: f service: [**hospital unit name **] history of present illness: the patient is a 67 year old female with a history of a <1CUI> squamous cell carcinoma of the pancreas </1CUI> . the patient underwent a whipple procedure with a pancreatectomy on [**2014-09-10**]. she was taken to the operating room for a right hemicolectomy with a loop ileostomy. she was transferred to the floor on [**2014-09-12**]. she is now transferring to [**hospital 25**] for further care. family history: the patient's father died of pancreatic cancer at age 60. social history: the patient is a retired teacher. she is married with two children and two grandchildren. rea |
| C2676026 | the patient's vision was 20/200 od and 20/200 os. the patient was referred to ophthalmology for further evaluation. the patient's neurological exam was otherwise unremarkable. the patient was referred to [**hospital 327**] for further evaluation of his <1CUI> optic nerve dysplasia </1CUI> . # social history: the patient lives in [**state 701**] and is married. he has three children, two of whom are adults and one is a child. the patient is a construction worker and works in [**state 701**]. # family history: the patient's father died of a heart attack at age 50. the patient's mother died of breast cancer at age 65. the patient's brother died of a heart attack at age 48. # physical exam: the patient's height was 72 inches and his weight was 198 pounds. the patient's blood pressure was 120/80. the patient's heart rate was 74. the |
| C2676032 | 102721 |||| 19304 |||| 12555 |||| echo_report |||| 2019-06-05 00:00:00.0 |||| |||| patient/test information: indication: <1CUI> craniofaciofrontodigital syndrome </1CUI> . test: transthoracic echocardiogram. technical/interpretive findings: 2d: the left ventricular cavity is moderately dilated. the left ventricular wall is thin. the left ventricular ejection fraction is 20%. the left ventricular free wall is severely hypertrophied. 2d: the aortic root is mildly dilated. 2d: the aortic valve leaflets are mildly thickened. there is no aortic regurgitation. 2d: the mitral valve leaflets are mildly thickened. 2d: there is mild mitral regurgitation. 2d: the pulmonary |
| C2675459 | 11) dysphagia 12) malnutrition 13) chronic renal insufficiency 14) chronic obstructive pulmonary disease 15) cognitive impairment 16) seizure disorder 17) <1CUI> adenylate kinase deficiency, hemolytic anemia due to </1CUI> 18) factor xiii deficiency 19) anemia 20) thrombocytopenia 21) hypoproteinemia social history: the patient lives with his wife in [**location 1127**]. he is a former smoker and does not drink. family history: the patient is married and has two children. his father died of a heart attack at 57 years of age. physical exam: vitals: 98.6, 130/70, 18, 97% gen: the patient is a 70 year old man who is in no acute distress. heent: perrla, eomi, anicteric sclerae, |
| C2675547 | 6. pitting edema. 7. <1cui> <1CUI> slender long bones with narrow diaphyses </1CUI> . 8. hyperesthesia of the left upper extremity. 9. hyperesthesia of the left lower extremity. 10. hyperesthesia of the right lower extremity. 11. hyperesthesia of the right upper extremity. 12. hyperesthesia of the left upper extremity. 13. hyperesthesia of the right lower extremity. 14. hyperesthesia of the left lower extremity. 15. hyperesthesia of the right upper extremity. 16. hyperesthesia of the left upper extremity. 17. hyperesthesia of the right lower extremity. 18. hyperesthesia of the left lower extremity. 19. hyperesthesia of the right upper extremity. 20. hyperesthesia of the left upper extremity. 21. hyperesthesia of the right lower extremity. 22. hyper |
| C2675558 | 2. hypertrichosis. 3. <1CUI> nephroblastomatosis </1CUI> . 4. microscopic hematuria. 5. hypercalcemia. 6. hypokalemia. 7. hypocalcemia. 8. hyperphosphatemia. 9. hyperuricemia. discharge condition: good. discharge instructions: 1. please call your primary care physician if you have any fever, chills, or vomiting. 2. please call your primary care physician if you have any pain, swelling, or redness around your wounds. 3. please call your primary care physician if you have any questions or concerns. 4. please call your primary care physician if you have any new onset of weakness, numbness, or vision changes. 5. please take your medications as prescribed by your primary care physician. 6. please follow up with your primary care physician in [**doctor first name 12**] for a follow-up visit. 7. please follow |
| C2675562 | 3. scoliosis. 4. spina bifida. 5. <1CUI> unossified sacrum </1CUI> . 6. vertebral fracture. 7. degenerative changes. 8. osteoporosis. 9. kyphosis. [**2018-04-23**] disp: prn 3. draining catheter: patient is a 72 year old woman with a history of spina bifida who has had a drainage catheter in place since [**2018-04-14**]. she is to be discharged to home with the catheter in place. the drainage catheter is to be changed as needed. discharge instructions: please follow up with your primary care physician for further instructions. pain control: your pain should be controlled with your medications. if you have any concerns or questions, please call the doctor. followup instructions: please follow up with [**doctor first name 5 |
| C2675590 | 110976 |||| 18430 |||| 2568 |||| radiology_report |||| 2018-06-26 10:17:00.0 |||| c11 chest (portable) |||| |||| clip # 43-2696 actual report |||| date: [**2018-06-26**] 10:17 am chest (portable) [**clip number (radiology) 43-2696**] reason: chest pain and cough. [**clip number (radiology) 43-2696**] ______________________________________________________________________________ underlying medical condition: 62 year old male with <1CUI> anophthalmia, true </1CUI> , right side. reason for this examination: chest pain and cough. ______________________________________________________________________________ final report indication |
| C2675627 | sig: one (1) capsule bid. discharge disposition: extended care discharge diagnosis: <1CUI> acholic stool </1CUI> discharge condition: stable discharge instructions: follow up with your primary care physician in two weeks. followup instructions: follow up with your primary care physician in two weeks. please take the medication as prescribed. please call your primary care physician or come to the emergency department if you have any fever, chills, abdominal pain, or any other concerning symptoms. please call your primary care physician or come to the emergency department if you have any changes in your bowel movements. please call your primary care physician or come to the emergency department if you have any changes in your stool color. please call your primary care physician or come to the emergency department if you have any changes in your appetite. please call your primary care physician or come to the emergency department if you have any changes in your weight. please call your primary care physician or come to the emergency department if you have |
| C2675904 | discharge date: [**2013-03-21**] date of birth: sex: f service: [**hospital unit name 48**] allergies: patient recorded as having no known allergies to drugs attending:[**attending info 1215**] chief complaint: 20 y <1CUI> ear o </1CUI> ld female with 20 year history of wagro/chromosome 11p13-p12 deletion syndrome and cystic kidney disease who presents with a 2 day history of abdominal pain, fever, and vomiting. major surgical or invasive procedure: lr s/p appendectomy history of present illness: 20 year old female with 20 year history of wagro/chromosome 11p13-p12 deletion syndrome and cystic kidney disease who presents with a 2 day history of abdominal pain, fever, and vomiting. the patient was seen in the emergency |
| C2675920 | the patient was started on intravenous furosemide and was transferred to the floor. on postoperative day 2, the patient's urine output was increased, and the patient developed a new onset of fever to 101.6. the patient's white count was 13.4, hemoglobin was 10.4, and platelet count was 143. the patient's creatinine was 1.2, and bun was 24. the patient was transferred to the icu for further evaluation. the patient was found to have a new onset of anemia with a hemoglobin of 9.3 and a hematocrit of 28.2. the patient's red blood cell count was 2.76, and the patient's reticulocyte count was 1.9. the patient was found to have <1CUI> anisopoikilocytosis </1CUI> . the patient's reticulocyte count was 1.9, and the patient's red blood cell count was 2.76. the patient was given 2 units of pack |
| C2675993 | the patient was started on chemotherapy with gemcitabine and 5fu, and his pain was improved. the patient's liver function was followed with serial transaminases, which showed a gradual improvement. the patient had a negative ct scan of the abdomen and pelvis on [**2010-03-10**], and a repeat pet scan on [**2010-04-05**] which showed no evidence of metastatic disease. the patient was continued on gemcitabine and 5fu. 2. <1cui> <1CUI> squamous cell carcinoma of the pancreas </1CUI> . 3. hypertension. 4. hypercholesterolemia. 5. hyperlipidemia. 6. gerd. 7. hyperuricemia. 8. osteoporosis. 9. hypothyroidism. 10. chronic back pain. 11. copd. 12. coronary artery disease. 13. mitral valve pro |
| C2676026 | there is no evidence of aneurysm or arteriovenous malformation. the right basilar artery is mildly tortuous. the right vertebral artery is tortuous. there is no evidence of aneurysm or arteriovenous malformation. the left vertebral artery is mildly tortuous. there is no evidence of aneurysm or arteriovenous malformation. the left internal carotid artery is normal. the right internal carotid artery is normal. impression: the patient has a normal carotid artery ultrasound. [**2014-10-28**] 08:45am discharge diagnoses: 1. <1CUI> optic nerve dysplasia </1CUI> 2. cerebral vasospasm 3. cerebral hemorrhage 4. hypertension 5. hyperlipidemia 6. hypothyroidism 7. hypoparathyroidism 8. vitamin b12 deficiency |
| C2676032 | the patient was also noted to have a small left-sided pleural effusion. the patient was seen by dr. [**last name (stitle) 1545**] on [**2013-05-10**] who noted that the patient had a history of <1CUI> craniofaciofrontodigital syndrome </1CUI> . the patient was referred to dr. [**last name (stitle) 1546**] for further evaluation. the patient was seen by dr. [**last name (stitle) 1547**] on [**2013-05-13**] who noted that the patient had a craniofaciofrontodigital syndrome, with a history of mild intellectual disability, short stature, cardiac anomalies, mild dysmorphic features, cutis laxa, joint hyperlaxity, wrinkled palms and soles and skeletal anomalies. the patient was also noted to have a small left-sided pleural effusion. 1. portosystemic shunt: the patient was |
| C2675459 | 5. chronic lymphocytic leukemia. 6. chronic kidney disease. 7. hypertension. 8. hyperlipidemia. 9. 1,2-dihydroxyphenobarbital. 10. <1CUI> adenylate kinase deficiency, hemolytic anemia due to </1CUI> . 11. osteoporosis. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. |
| C2675547 | the patient was admitted to [**hospital 140**] for a total hip replacement on [**2013-02-13**]. on [**2013-02-14**], the patient was transferred to [**hospital 471**] for a complete blood count and an electrolyte panel. the patient was transferred to [**hospital 471**] for a complete blood count and an electrolyte panel. the patient's labs were significant for a white blood cell count of 15.5 and a hemoglobin of 12.3. the patient was transferred to the [**doctor first name 7**] floor for further evaluation. the patient's labs were significant for a white blood cell count of 15.5 and a hemoglobin of 12.3. the patient was transferred to the [**doctor first name 7**] floor for further evaluation. the patient was seen in the [**hospital unit name 3**] and was diagnosed with <1CUI> slender long bones with narrow diaphyses </1CUI> . the patient was seen |
| C2675558 | pt is currently on 250mg of aspirin daily. pt is on lasix 20mg bid for the last 6 years for renal impairment secondary to <1CUI> nephroblastomatosis </1CUI> . pt is on furosemide 20mg bid for the last 6 years for renal impairment secondary to nephroblastomatosis. pt is on lisinopril 20mg bid for the last 6 years for hypertension secondary to nephroblastomatosis. pt is on furosemide 20mg bid for the last 6 years for renal impairment secondary to nephroblastomatosis. pt is on furosemide 20mg bid for the last 6 years for renal impairment secondary to nephroblastomatosis. pt is on furosemide 20mg bid for the last 6 years for renal impairment secondary to nephroblastomatosis. pt is on furosemide 20mg bid for the last 6 |
| C2675627 | discharge date: [**2014-07-11**] date of birth: [**1967-09-27**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 460**] chief complaint: h/o melena major surgical or invasive procedure: none history of present illness: 61 yo m with <1CUI> acholic stool </1CUI> , melena, and jaundice. past medical history: 1. 1981-1983: hcv 2. 1984-1987: hcv 3. 1987-1990: hcv 4. 1990-1991: hcv 5. 1991-1992: hcv 6. 1992-1993: hcv 7. 1993-1994: |
| C2675904 | pertinent results: 1. echocard <1CUI> iogra </1CUI> m: normal left ventricular systolic function. 2. eeg: 24 hour video eeg: no ictal or non-ictal events seen. 3. 1. ct abdomen and pelvis: no evidence of peritoneal or retroperitoneal abscesses, liver abscesses, or bowel obstruction. 4. 2. ct chest: no evidence of mediastinal or hilar lymphadenopathy. 5. 3. ct head: no evidence of intracranial abscesses, tumors, or cerebral edema. 6. 4. ct neck, chest, abdomen, and pelvis: no evidence of metastases. 7. 5. labs: wbc 10.6, hct 31.9, plt 121, neut 74.8, lymph 15.6, mono 2.8, eos 1.6, baso 1.4, ne |
| C2675920 | 4. anemia: 1. iron deficiency anemia. 2. <1CUI> anisopoikilocytosis </1CUI> . 3. chronic blood loss. 4. increased erythropoietin. 5. increased ferritin. 6. increased transferrin. 7. decreased reticulocyte count. 8. decreased red blood cell count. 9. decreased hematocrit. 10. decreased hemoglobin. - 2008: anemia, iron deficiency. - 2007: anemia, iron deficiency, chronic blood loss, anisopoikilocytosis. - 2006: anemia, iron deficiency, chronic blood loss, anisopoikilocytosis, hypertransferrinemia. - 2005: anemia, iron deficiency, chronic blood loss, anisopoikilocytosis. - 2004: anemia, iron def |
| C2675993 | 2. chronic pancreatitis. 3. <1CUI> squamous cell carcinoma of the pancreas </1CUI> . 4. gastrointestinal hemorrhage. 5. hypertension. 6. hyperlipidemia. 7. hypothyroidism. 8. gastric ulcer. 9. hiatal hernia. 10. obesity. 11. hypercholesterolemia. 12. hypoproteinemia. 13. hyperkalemia. 14. hyperglycemia. 15. hypertriglyceridemia. 16. hypocalcemia. 17. hypophosphatemia. 18. hypernatremia. 19. hypercalcemia. 20. hypotension. 21. anemia. 22. thrombocytopenia. 23. neutropenia. 24. hypoproteinemia. 25. hypocal |
| C2676026 | the patient was transferred to the [**hospital unit name 46**] for further management. the patient was seen by [**hospital1 268**] ophthalmology for further evaluation of her <1CUI> optic nerve dysplasia </1CUI> . the patient was diagnosed with optic nerve dysplasia with a right optic nerve hypoplasia. the patient was seen by [**hospital1 268**] ophthalmology for further evaluation of her optic nerve dysplasia. the patient was diagnosed with optic nerve dysplasia with a right optic nerve hypoplasia. the patient was seen by [**hospital1 268**] ophthalmology for further evaluation of her optic nerve dysplasia. the patient was diagnosed with optic nerve dysplasia with a right optic nerve hypoplasia. the patient was seen by [**hospital1 268**] ophthalmology for further evaluation of her optic nerve dysplasia. the patient was diagnosed with optic n |
| C2676032 | sex: f service: cardiothoracic history of present illness: this is a 21-year-old female with a known diagnosis of cantu <1CUI> craniofaciofrontodigital syndrome </1CUI> who presented to the emergency room on [**2018-01-26**] with fever, chills, cough, and shortness of breath. the patient was seen in the emergency room and was found to have an elevated temperature of 100.9, tachycardia, and tachypnea. she was also found to have a heart rate of 140 and a blood pressure of 116/70. her chest x-ray was significant for a right middle lobe pneumonia. she was started on a course of antibiotics and was admitted to the hospital for further management. past medical history: the patient has a known diagnosis of cantu craniofaciofrontodigital syndrome. the patient has a history of seizures which have |
| C2675547 | diffuse osteopenia. 2. <1CUI> slender long bones with narrow diaphyses </1CUI> . 3. osteoporosis of the spine. 4. diffuse osteopenia of the pelvis. 5. multiple sclerotic metastases. 6. a left pleural effusion. 7. a 2.5 cm left renal mass. 8. a 2.5 cm right renal mass. 9. 2.5 cm right adrenal mass. 10. a left hydronephrosis. 11. a right hydronephrosis. 12. a left hepatic cyst. 13. 1.7 cm left lobe liver mass. 14. 2.3 cm right lobe liver mass. 15. 1.2 cm liver mass. 16. a 2.2 cm spleen mass. 17. a 2.2 cm spleen mass. 18. 2.5 cm right ovarian mass. 19 |
| C2675558 | sig: one (1) tablet po bid for 14 days. discharge disposition: extended care discharge diagnosis: <1CUI> nephroblastomatosis </1CUI> discharge condition: stable discharge instructions: 1. you should call your doctor if you have any of the following: - fever - vomiting - diarrhea - pain - changes in your urine 2. you should call your doctor if you miss a dose of the medication. 3. you should call your doctor if you have any questions. discharge instructions for the family: please take your medication as prescribed by your doctor. please take the medication as prescribed by your doctor. if you have any questions, please call your doctor. please call your doctor if you have any of the following: - fever - vomiting - diarrhea - pain please call your doctor if you miss a dose of the medication. please call your doctor if you have any questions. please call your doctor if you have |
| C2675562 | aortic valve: normal aortic valve leaflets. mitral valve: normal mitral valve leaflets. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. pericardium: no pericardial effusion. conclusion: this is a 65-year-old male with a history of [**hospital1 2**] who was admitted for the management of his chronic heart failure. his heart failure is stable. he is also known to have a [**last name (un) 158**] of <1CUI> unossified sacrum </1CUI> . his cardiac status is stable and his [**last name (un) 158**] is stable. he is to be followed up in clinic. discharge diagnoses: 1. chronic heart failure. 2. [**first name4 (namepattern1) 435**] 3. [**first name4 (namepattern1) 436**] 4. [**first name4 (namepattern |
| C2675590 | sex: m service: history of present illness: the patient is a 39 year old male with a history of <1CUI> anophthalmia, true </1CUI> , who was admitted to [**hospital 157**] on [**2019-03-14**] for a ct scan of his head and neck. he was found to have a right-sided optic nerve sheath meningioma and was transferred to [**hospital 421**] for further management. past medical history: anophthalmia, true. physical examination: the patient is a well-developed male in no acute distress. he has no palpable or visible eyes. reason for this examination: to evaluate the patient's optic nerve sheath meningioma. final diagnosis: optic nerve sheath meningioma. dispensing/pharmacy information: discharge medications: |
| C2675627 | discharge date: [**2010-07-14**] date of birth: [**1955-09-23**] sex: f service: medicine history of present illness: the patient is a 55-year-old female who presented to the emergency room with a 2-day history of abdominal pain and loose, <1CUI> acholic stool </1CUI> s. she was diagnosed with possible appendicitis, but a ct scan was negative for this condition. the patient was admitted for further evaluation. past medical history: the patient is a former smoker who quit 15 years ago. she has a history of esophageal varices and has been followed by her primary care physician. she also has a history of acholic stools, which has been treated with metronidazole. the patient has no other significant medical history. social history: the patient is a retired teacher who lives with her husband. she has no alcohol or drug use. she |
| C2675904 | 5. physical therapy: the patient is to follow up with outpatient physical therapy for range of motion, strengthening, and ambu <1CUI> latio </1CUI> n. 6. diagnostic tests: the patient was to have a [**hospital1 15**] us to assess for hydronephrosis. 7. medications: the patient was to continue on his medications as follows: a) pantoprazole 40 mg p.o. bid for gastroesophageal reflux disease. b) furosemide 20 mg p.o. qd for hypertension. c) levothyroxine 25 mcg p.o. qd for hypothyroidism. 8. diet: the patient was to follow a low salt diet. 9. discharge instructions: the patient was to follow up with his primary care physician for follow-up of his medical conditions. 10. follow-up appointments: the patient was to |
| C2675920 | a repeat bone marrow biopsy on [**2011-04-14**] showed a normal bone marrow with trilineage hematopoiesis. the patient was continued on chemotherapy. the patient's blood counts, including the <1cui> <1CUI> anisopoikilocytosis </1CUI> <1cui> , improved with chemotherapy and the patient was discharged on [**2011-04-23**]. 3. pulmonary: the patient was admitted to the hospital with a left lower lobe pneumonia. 4. gastrointestinal: the patient had a history of melena and was found to have a gastric ulcer. 5. urologic: the patient had a history of bladder cancer and had a ureteral stent placed on [**2011-04-16**]. 6. neurologic: the patient was found to have a right frontal lobe contusion. 7. psychiatric: the patient |
| C2675973 | sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: 1. <1cui> <1CUI> open operculum </1CUI> 2. gastroesophageal reflux disease discharge condition: good. discharge instructions: 1. please call your doctor if you have any shortness of breath, chest pain, or difficulty swallowing. 2. please take all medications as prescribed. 3. please eat a soft food diet for 2 weeks. 4. please do not take any nsaids for pain. if you have pain, please call your doctor. 5. please follow up with your doctor in 2 weeks. 6. please do not eat any fatty or spicy foods for 2 weeks. 7. please do not drink alcohol for 2 weeks. 8. please do not smoke. 9. please do not drive or operate heavy mach |
| C2675993 | 2. chronic pancreatitis. 3. <1CUI> squamous cell carcinoma of the pancreas </1CUI> . 4. history of 2 episodes of melena. 5. history of variceal bleeding. 6. history of hernia repair. 7. history of pneumothorax. social history: 1. lives with wife, no children. 2. eats out 2-3 times per week. 3. drinks 1-2 glasses of wine per day. 4. no tobacco. family history: non-contributory. physical exam: vital signs: t 98.4 bp 144/82 hr 79 rr 20 98%ra gen: nad, no jvd, no lymphadenopathy heent: perrla, eomi, mmm, no oral lesions, no neck lymphadenopathy cv: rrr, no murmurs, rubs, or gallops |
| C2676026 | the patient was discharged with the following instructions. please follow up with your primary care physician in one week. 1. you have a condition called <1CUI> optic nerve dysplasia </1CUI> . 2. you have a condition called hydrocephalus. 3. you have a condition called cerebral atrophy. 4. you have a condition called ventriculomegaly. 5. you have a condition called chiari malformation. 6. you have a condition called spinal cord dysgenesis. 7. you have a condition called spinal cord cyst. 8. you have a condition called syringomyelia. 9. you have a condition called cerebral palsy. 10. you have a condition called optic nerve dysplasia. 11. you have a condition called seizures. 12. you have a condition called developmental delay. 13. you have a condition called autism. 14. you have a condition called cerebral white matter abnormality. 15. you have a condition called cerebral |
| C2676032 | 3. <1CUI> craniofaciofrontodigital syndrome </1CUI> . 4. congenital heart disease. 5. small right kidney. discharge condition: good. discharge instructions: please follow the following instructions. 1. take your medications as prescribed. 2. you are to follow up with your cardiologist and dr. [**last name (stitle) **] in [**city **] at [**telephone/fax (2) 161**]. 3. please call dr. [**first name10 (namepattern1) 113**] if you have any concerns, chest pain, shortness of breath, or fever. 4. you are to take your blood pressure and weight daily and keep a log of this. 5. please call the [**telephone/fax (2) 161**] if you have any questions or concerns. 6. you are to follow up with dr. [**first name10 (namepattern1) 113**] at [**telephone |
| C2676198 | the patient was treated with 3000 units of heparin, and the patient was placed on coumadin for anticoagulation. the patient was also started on a 24-hour holter monitor to monitor for any cardiac arrhythmias. the patient was started on a nasal oxygen cannula and placed on a low-flow oxygen. the patient was also started on a continuous infusion of furosemide for fluid management. 2. <1CUI> elevated serum igf1 </1CUI> : the patient's serum igf1 was elevated, and the patient was started on a somatostatin analog to suppress the production of igf1. 3. hyperkalemia: the patient's serum potassium was elevated, and the patient was started on a potassium-binding resin. 4. elevated creatine kinase: the patient's serum creatine kinase was elevated, and the patient was started on a statin. 5. hyperlipidemia: the patient's serum cholesterol was elevated, and the patient was |
| C2676443 | the left radial artery was not visualized. there is a suggestion of a left radial shaft fracture. the left radial head is dislocated. there is a suggestion of <1CUI> proximal radio-ulnar synostosis </1CUI> . there is no evidence of a left carpal fracture. brief hospital course: the patient was admitted to the [**hospital1 49**] on [**2016-06-22**] for surgical repair of the left radial head fracture. he underwent an open reduction of the fracture and internal fixation of the radial head. he had a successful surgery and was transferred to the [**hospital unit name 115**] for postoperative care. past medical history: the patient is a 37 year old man with a history of multiple left radial head fractures. he has a history of alcohol abuse and is currently sober. he is a smoker and has a history of a left radial shaft fracture. social history: the patient is a married man with 2 children. he is currently unemployed |
| C2676770 | on [**11-14**] the patient was transferred to [**hospital1 4**] for further evaluation and management. on [**11-17**] the patient was transferred to [**hospital1 1**] for further evaluation and management. the patient was admitted to the [**doctor first name **] [**last name (un) 39**] service with the diagnosis of <1CUI> mental retardation with hypotonia and facial dysmorphism </1CUI> . the patient was seen by dr. [**last name (un) 39**] and dr. [**last name (un) 40**] for an initial evaluation. on [**11-19**] the patient was transferred to [**hospital1 7**] for further evaluation and management. the patient was seen by dr. [**last name (un) 41**] and dr. [**last name (un) 42**] for an initial evaluation. on [**11-20**] the patient was transferred to [**hospital1 2**] for further evaluation and management. the patient |
| C2676973 | the patient was discharged to home on the day of surgery with no complications. followup with [**last name (stitle) 311**] in [**location (un) 312**] is recommended. the patient was transferred to the [**hospital unit name 313**] for further evaluation of her right ear. the patient's right ear was found to have a dilated internal auditory canal consistent with a <1CUI> bulbous internal auditory canal </1CUI> . the patient's right ear was found to have no meningitis or mastoiditis. the patient's left ear was found to have no meningitis or mastoiditis. the patient's left ear was found to have no meningitis or mastoiditis. the patient's left ear was found to have no meningitis or mastoiditis. the patient was discharged with a diagnosis of otitis media. the patient's right ear was found to have no meningitis or mastoiditis. the patient was discharged with a diagnosis of otitis media. the patient's left ear was found to |
| C2677167 | 2. pulmonary artery system: the pulmonary arteries are unremarkable. 3. pericardium: there is no evidence of pericardial effusion. 4. peripheral vessels: there is no evidence of peripheral arterial or venous stenosis or occlusion. 5. <1CUI> lymphedema, cardiac septal defects, and characteristic facies </1CUI> : the patient has generalized lymphedema, with bilateral upper and lower extremity edema. the patient has a large atrial septal defect, with a left-to-right shunt. the patient has a characteristic facies, with a round face, prominent forehead, flat nasal bridge, broad nasal tip, epicanthal folds, thin upper lip, and a cleft chin. 6. gastrointestinal tract: the gastrointestinal tract is unremarkable. 7. bone and joints: there is no evidence |
| C2677180 | he has a history of seizures. he has a history of multiple episodes of vomiting. he has a history of hypotonia, poor muscle tone, and developmental delays. he has a history of <1cui> <1CUI> microcephaly, congenital </1CUI> <1cui>. he has a history of cleft lip and palate. he has a history of constipation. he has a history of frequent urinary tract infections. he has a history of failure to thrive. he has a history of gastroesophageal reflux. he has a history of frequent vomiting. he has a history of frequent diarrhea. he has a history of frequent respiratory infections. he has a history of frequent ear infections. he has a history of frequent urinary tract infections. he has a history of failure to thrive. he has a history of gastroesophageal reflux. he has a history of frequent vomiting. he has a history of frequent diarrhea. he has a history of frequent respiratory infections. |
| C2677326 | 2. <1CUI> epileptic encephalopathy, early infantile, 4 </1CUI> . this is a rare genetic disorder characterized by recurrent seizures, encephalopathy, and intellectual disability. the patient has been on numerous antiepileptic medications with little to no effect on his seizures. 3. hypothyroidism. the patient has been on levothyroxine for this condition. 4. respiratory distress syndrome. 5. otitis media. 6. pneumonia. 7. peripheral arterial disease. 8. cardiac arrest. 9. arrhythmias. 10. pulmonary embolus. 11. gastroesophageal reflux disease. 12. carcinoma of the lung. 13. bile du |
| C2677328 | mri of the brain on [**2018-11-22**] revealed diffuse white matter hypomyelination with no evidence of active demyelination. the patient was referred to [**doctor first name 2**] neurology for further evaluation. 1. <1cui> <1CUI> brain hypomyelination </1CUI> . 2. multiple sclerosis. 3. seizure disorder. 4. cerebral vasculitis. 5. [**hospital1 2**]-overwhelming infection. 6. hypertension. 7. hyperlipidemia. 8. hyperglycemia. 9. hypothyroidism. 10. hypoparathyroidism. 11. vitamin d deficiency. 12. [**hospital1 2**]-overwhelming infection. 13. anemia of chronic disease. 14. iron deficiency anemia. 15. hypocalcemia. 16. hypercal |
| C2676443 | 3. right radial head fracture. 4. <1CUI> proximal radio-ulnar synostosis </1CUI> . 5. no evidence of rotator cuff tear. 6. no evidence of fracture. 7. no evidence of joint effusion. 8. no evidence of intra-articular fracture. 9. no evidence of osteochondritis dissecans. brief hospital course: 71 y/o female with r wrist pain after fall. pt was admitted to the floor. during her hospital course, she had a chest x-ray which showed a fracture of the right radial head. she had a ct scan of the right wrist which showed a proximal radio-ulnar synostosis. she had a right wrist arthroscopy which showed a radial head fracture, synostosis of the distal radio-ulnar joint, and a fracture of the radial styloid. during her hospital course, she also had a right wrist arthroscopy which showed a radial head fracture, synostosis of the |
| C2676770 | date of birth: [**1981-04-01**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**attending info 160**] chief complaint: 1. 1. increased sedation 2. decreased urine output 3. decreased oral intake 4. decreased muscle tone 5. decreased respiratory rate 6. decreased heart rate 7. decreased bp 8. increased sweating 9. increased pain 10. decreased ability to move extremities major surgical or invasive procedure: none history of present illness: 25 yof with known [**1cui> <1CUI> mental retardation with hypotonia and facial dysmorphism </1CUI> 3751**] who was admitted to the [**hospital 1734**] in [**20 |
| C2676973 | 4. discharge date: [**2014-04-17**] discharge disposition: extended care discharge diagnosis: 1. tracheostomy tube placement 2. cerebral infarction 3. hypoxic brain injury 4. <1CUI> bulbous internal auditory canal </1CUI> 5. left atrial myxoma discharge condition: good discharge instructions: 1. follow up with your primary care physician in [**location (un) 2641**] 2. follow up with your neurologist in [**location (un) 2641**] 3. follow up with your cardiologist in [**location (un) 2641**] 4. follow up with your pulmonologist in [**location (un) 2641**] 5. follow up with your ent in [**location (un) 2641**] 6. follow up with your infectious |
| C2676974 | the right ear tympanic membrane is not visible. the left ear tympanic membrane is not visible. the left ear mastoid air cells are not visible. the left ear cholesteatoma is intact with no evidence of infection. the left ear <1cui> <1CUI> hypoplasia of the cochlea </1CUI> <1cui> is not visible. the left ear external auditory canal is patent. the right ear tympanic membrane is not visible. the right ear mastoid air cells are not visible. the right ear cholesteatoma is intact with no evidence of infection. the right ear external auditory canal is patent. the left ear middle ear is clear. the left ear tympanic membrane is not visible. the left ear mastoid air cells are not visible. the left ear cholesteatoma is intact with no evidence of infection. the left ear external auditory canal is patent. the right ear middle ear is clear. the right ear tympanic membrane is not visible. the right ear mastoid air cells are not visible. |
| C2677180 | 3. hydrocephalus. 4. seizures. 5. cerebral palsy. 6. <1CUI> microcephaly, congenital </1CUI> . 7. [**hospital unit name 42**] s/p 1989. 8. cerebral arteriovenous malformation. 9. neuroblastoma. 10. [**first name4 (namepattern4) 1675**] tumor. 11. [**first name4 (namepattern4) 1675**] tumor. 12. [**last name (namepattern3) **] cyst. 13. [**first name4 (namepattern4) 1675**] cyst. 14. [**first name4 (namepattern4) 1675**] cyst. 15. [**last name (namepattern3) **] cyst. 16. [**first name4 (namepattern4) 1675**] cyst. |
| C2677209 | 3. hypertension. 4. hyperlipidemia. 5. hypothyroidism. 6. chronic renal insufficiency. 7. osteoporosis. 8. fracture of the left distal radius. 9. <1CUI> contractures of the metacarpophalangeal joints </1CUI> . 10. chronic low back pain. 11. chronic obstructive pulmonary disease. 12. hyperparathyroidism. 13. gastroesophageal reflux disease. social history: the patient lives with her husband and is a retired school teacher. she enjoys playing the piano, reading, and traveling. family history: the patient is a non-smoker. she had a father with a history of coronary artery disease and a brother who died of a myocardial infarction at age 48. she also had a brother who died of a myocardial infarction at age 42. physical exam: on admission, the patient's vital signs |
| C2677326 | pt was transferred to [**hospital 127**] for further management. 1. <1CUI> epileptic encephalopathy, early infantile, 4 </1CUI> . pt has a history of seizures since age 2 weeks. he was initially treated with valproic acid and phenobarbital. he had a seizure in the [**hospital 127**] picu on [**2015-03-21**] and was transferred to [**hospital 127**] for further management. he was started on levetiracetam and topiramate. he was admitted to the [**hospital unit name **] for further management. 2. respiratory failure. pt was admitted to [**hospital 127**] for respiratory failure. 3. cardiomyopathy. pt has a history of cardiomyopathy. he was transferred to [**hospital 127**] for further management. 4. |
| C2676198 | sig: one (1) vial (20 mg/ml) injection (100 mg) subcutaneously (s/c) qd (every day) for 30 days. disp:*30 dose [**2018-12-28**] 06:00:00 am* 100 mg injection (100 mg) refills:*0* discharge disposition: home with service discharge diagnosis: 1. hypertension 2. hypercholesterolemia 3. <1CUI> elevated serum igf1 </1CUI> 4. hyperlipidemia 5. hyperglycemia 6. hypothyroidism discharge condition: stable. discharge instructions: 1. follow up with your primary care physician. 2. follow up with your endocrinologist. 3. follow up with your cardiologist. 3. take your medications as prescribed. 4. follow up with |
| C2676443 | aortic arch calcification. no evidence of aortic dissection. no evidence of aortic regurgitation. no evidence of mitral regurgitation. 2. <1CUI> proximal radio-ulnar synostosis </1CUI> . 3. right 3rd metacarpal fracture. 4. right wrist sprain. 5. right knee contusion. 6. left knee effusion. 7. left ankle effusion. 8. left 4th metacarpal fracture. 9. left 2nd metacarpal fracture. 10. right 2nd metacarpal fracture. 11. right 1st metacarpal fracture. 12. left 1st metacarpal fracture. 13. right acromioclavicular joint sprain. 14. right distal 3rd rib fracture. 15. left distal 3rd rib fracture. 16. left subclavian vein thromb |
| C2676770 | history of present illness: this is a 16-year-old male with a history of <1CUI> mental retardation with hypotonia and facial dysmorphism </1CUI> who was admitted to the hospital on [**2011-01-04**] with a 2-day history of fever, headache, sore throat, and cough. he was transferred to the [**hospital1 157**] for further evaluation and treatment. he was found to have a left-sided pneumonia, which was treated with antibiotics and supportive care. past medical history: the patient has a history of mental retardation with hypotonia and facial dysmorphism. he also has a history of cleft palate, long neck, narrow chest, tapered fingers, and unusual facial features. social history: the patient is from [**country 2751**], and his family is from [**country 2751**]. the patient lives with his parents. he is a student, but he |
| C2676973 | 4. cranial nerve palsy. 5. hearing loss. 6. tympanic membrane perforation. 7. <1CUI> bulbous internal auditory canal </1CUI> . 8. meningioma. past medical history: 1. history of malignant melanoma of the skin. 2. history of thyroid cancer. 3. history of kidney cancer. 3. family history: no significant family history. 4. social history: lives with husband. no tobacco. 5. physical exam: vital signs: 100.2 t, 166/84, 100% on room air. gen: well-appearing, alert, and oriented. heent: perrl, eomi, mmm, anicteric sclerae, no mass or lesion noted. brief flexible laryngoscopy: normal vocal cords. pertinent results: [**2015-09-21**] |
| C2676974 | he has had a number of surgeries to address his cochlear implant. he has had a number of surgeries to address his cochlear implant. the patient is a [**hospital1 1623**] with a history of multiple surgeries including a cochlear implant. he has a history of a cochlear implant, which has been explanted. the patient has a history of multiple surgeries including a cochlear implant. the patient is a [**hospital1 1623**] with a history of multiple surgeries including a cochlear implant. he has a history of multiple surgeries including a cochlear implant. he has a history of multiple surgeries including a cochlear implant. he has a history of multiple surgeries including a cochlear implant. past medical history: 1. <1CUI> hypoplasia of the cochlea </1CUI> . 2. multiple surgeries for cochlear implant. 3. seizure disorder. social history: the patient lives in [**state 772**] with his parents |
| C2677167 | discharge date: [**2014-03-18**] date of birth: [**1953-11-28**] sex: f service: cardiothoracic history of present illness: this is a 58-year-old female with a history of <1CUI> lymphedema, cardiac septal defects, and characteristic facies </1CUI> who presented with a recent onset of chest pain, shortness of breath, and fatigue. the patient is a known case of irons-bianchi syndrome. she was referred to the cardiothoracic surgical service for evaluation of her chest pain. the patient was seen in the outpatient clinic and had a transthoracic echocardiogram, which demonstrated a large atrial septal defect with a right-to-left shunt. she was admitted for further evaluation and possible surgical correction of her defect. past medical history: irons-bianchi syndrome lymphedema pre |
| C2677209 | the patient was transferred to [**hospital 142**] for further management. past medical history: 1. hypothyroidism 2. osteoporosis 3. chronic pain syndrome 4. <1CUI> contractures of the metacarpophalangeal joints </1CUI> 5. hypertension 6. hyperlipidemia 7. gerd social history: the patient is a retired teacher and lives with his wife. he is a non-smoker and drinks alcohol socially. family history: non-contributory physical exam: the patient was afebrile, had a pulse of 72 and a bp of 140/60. he was in no acute distress. his head, eyes, ears, nose and throat were normal. his neck was supple without lymphadenopathy or thyromegaly. the patient's chest was clear to auscultation bilaterally. his abdomen was soft, nontender, nondistended without organomegaly. his extremities were |
| C2676198 | sig: one (1) injection, subcutaneous 100 mcg/2 ml(25 mcg/kg) every 24 hours for 7 days. discharge disposition: extended care facility: [**hospital 3302**] - [**hospital 3302**] rehabilitation and healthcare center discharge diagnosis: 1. cerebral infarction - left hemisphere. 2. hypothyroidism. 3. <1CUI> elevated serum igf1 </1CUI> . discharge condition: good. discharge instructions: 1. please take all medications as prescribed by your physician. 2. please follow up with your primary care physician in 7-10 days. 3. please follow up with your endocrinologist in 7-10 days. 4. please follow up with your neurologist in 7-10 days. 5. please follow up with your surgeon in 7-10 days. |
| C2676443 | the patient had an uncomplicated postoperative recovery. he was discharged home on postoperative day #3. he was started on plavix and aspirin for the [**first name4 (namepattern4) 1151**] coronary artery disease and the [**first name4 (namepattern4) 1151**] <1CUI> proximal radio-ulnar synostosis </1CUI> . he was instructed to follow up with his cardiologist in [**location (un) 1152**] and to return to the [**hospital1 1153**] for follow-up in [**location (un) 1152**] days. 1. proximal radio-ulnar synostosis: the patient had a history of this condition and was seen by the hand surgeon. he was recommended for surgical intervention which he declined. 2. aortic valve stenosis: the patient was referred to the cardiothoracic surgeon for further evaluation. 3. hypertension: the patient was started on atenolol 25mg po |