trustworthiness
Collection
Datasets for the anonymous epistemic trustworthiness submission. • 4 items • Updated
document_id_it large_stringclasses 289
values | clinical_note_it large_stringclasses 286
values | document_item large_stringlengths 8 111 | document_id_en large_stringclasses 289
values | clinical_note_en large_stringclasses 286
values | item large_stringclasses 134
values | ground_truth large_stringclasses 181
values | options listlengths 2 5 |
|---|---|---|---|---|---|---|---|
1323973_it | In dea per arrossamento cutaneo, edema e dolore gamba sx. Riferisce che i sintomi erano presenti da circa 2-3 gg, peggiorati nelle ultime 24 ore.
Nega traumi. Nega punture di insetti.
Nega immobilizzazione prolungata recente, nega interventi chirurgici recenti, nega viaggi di lunga durata recenti.
Riferisce febbre ieri... | 1323973_serum creatinine kinase | 1323973_en | In Emergency Department for skin redness, edema and pain in left leg. Reports that symptoms have been present for about 2-3 days, worsened in the last 24 hours.
Reports no trauma. Reports no insect bites.
Reports no recent prolonged immobilization, no recent surgery, nor recent long-term travel.
Reports fever yesterday... | serum creatinine kinase | unknown | [
"measured",
"unknown"
] |
132042_it | Paz 15enne. visitata in presenza del PARENTE. orfana di PARENTE da circa 4 anni, vive con il PARENTE. iscritta al liceo turistico. buona rete amicale e affettiva. cognitività integra. il PARENTE è in pensione e si occupa della PARENTE in modo fattivo.
gli scorsi giorni, litigio su istanze adolescenziali: la paziente vo... | 132042_living alone | 132042_en | 15-year-old patient, examined in the presence of the RELATIVE. Orphaned of a RELATIVE approximately 4 years ago, lives with the RELATIVE. Enrolled in a tourism-focused high school. Good social and emotional support network. Cognitive function intact. The RELATIVE is retired and provides active care for the patient.
In ... | living alone | n | [
"y",
"n",
"unknown"
] |
782931_it | pz torna in ps, dopo aver abbandonato questa mattna, per
cervicalgia e trauma gnocchio dx in incidente stradale bassa dinamica avvenuto questa mattina.pz alla guida del furgone rif di aver tamponato un automobile davanti. pz non indossava cintura di sicurezza,nega trauma cranico, nega pdc, racconta l'accaduto. rif in... | 782931_pale skin during the episode | 782931_en | Patient returns to the Emergency Department after leaving earlier this morning, for neck pain and right knee trauma following a low-speed motor vehicle collision that occurred this morning. Patient was the driver of a van and reports rear-ending the vehicle in front. Patient was not wearing a seatbelt, denies head trau... | pale skin during the episode | unknown | [
"y",
"n",
"unknown"
] |
647046_it | Paziente di 62 anni condotto in PS per compasa di impaccio dell'eloquio, confusione e incoordinazione movimenti.
APR:
- familiarità per patologie cerebrovascolari e oncologiche
- ipertensione arteriosa
- HIV+
- polimialgia reumatica
- Ca vescicale noto dal 2011; luglio 2021 riscontro di voluminosa formazione vescicale,... | 647046_chronic metabolic failure | 647046_en | 62-year-old patient brought to the Emergency Department for onset of slurred speech, confusion, and uncoordinated movements.
Past medical history:
- Family history of cerebrovascular and oncologic diseases
- Arterial hypertension
- HIV positive
- Polymyalgia rheumatica
- Known bladder cancer since 2011; July 2021 detec... | chronic metabolic failure | unknown | [
"certainly chronic",
"possibly chronic",
"certainly not chronic",
"unknown"
] |
893897_it | In dea per dispnea dalla notte scorsa. Non dispnea nei giorni scorsi.
Riferisce in associato h 4.00 circa comparsa a riposo di dolore toracico retrosternale oppressivo, non irradiato, della durata di circa 2-3 h, regredito spontaneamente.
Nega febbre.
Nega variazioni della tosse cronica.
Nega franco incremento degli ed... | 893897_cardiovascular diseases | 893897_en | In Emergency Department for dyspnea since last night. No dyspnea in the past few days.
Reports experiencing with onset at about 4:00 a.m. of oppressive, non-radiating retrosternal chest pain at rest, lasting about 2-3 hours, resolved spontaneously.
Reports no fever.
Reports no changes in chronic cough.
Reports no incre... | cardiovascular diseases | y | [
"y",
"n",
"unknown"
] |
861151_it | In DEA per dolore toracico.
Insorgenza spontanea. Non sforzi fisic particolari, non traumai
Dolore toracico insorto da circa 4 gg.
Dolore a livello emitorace destra e sinistro.
Dolore cosatnte tutto il giorno sempre presente,m peggiora con il respiro e con la presisone e con il movimento del tronco.
NRS 5
Ha assunto 2... | 861151_blood pressure | 861151_en | Presented at the Emergency Department for chest pain.
Spontaneous onset. No particular physical exertion, no trauma.
Chest pain onset approximately 4 days ago.
Pain in the right and left hemithorax.
Pain is constant throughout the day and worsens with breathing, on pressure, and with trunk movement.
NRS 5
Took 2 Brufen... | blood pressure | unknown | [
"hypotensive",
"normotensive",
"hypertensive",
"unknown"
] |
535035_it | PA 123/70 mmHg, FC 100 R, spO2 75% in aa, fr 20 apm, GCS 15. TC 36°C
posizionata MV 35%, SPO2 92%.
eo:
toni parafonici ritmici
murmure diffusamente ridotto, espirio prolungato
stato anasarcatico con edema della parete addominale, aass, glutei, aaii; cute diffusamente eritematosa, non orticaria
addome globoso per adipe... | 535035_ph | 535035_en | BP 123/70 mmHg, HR 100 R, spO2 75% in room air, RR 20 breaths/min, GCS 15. Temp.: 36 degrees Celsius
Venturi mask 35% applied, SpO₂ 92%.
Cardiovascular exam:
muffled rhythmic heart sounds.
Lung exam: diffusely reduced breath sounds, prolonged expiratory phase.
Anasarca with edema of the abdominal wall, upper extremiti... | ph | 7.31 | [
"measured",
"unknown"
] |
987763_it | in PS condotto da MSA per possibile episodio di perdita di coscienza ,trovato vigile disorientato TS con rilascio sfinterico. Paziente con nota demenza senile. NOn sa riferire sintomi nè cosa è accaduto, non ricorda con chi vive.
Non lamenta dolore nè dispnea.
Si contatta la PARENTE: da venerdì scorso comparsa di febb... | 987763_pulmonary embolism | 987763_en | brought to ER by Advanced Rescue Vehicle for possible episode of loss of consciousness, found alert but disoriented, history of sphincter incontinence. Patient with known senile dementia. Cannot report symptoms or what happened, and does not remember who he lives with.
No complaints of pain or dyspnea.
The RELATIVE is... | pulmonary embolism | unknown | [
"y",
"n",
"unknown"
] |
1323973_it | In dea per arrossamento cutaneo, edema e dolore gamba sx. Riferisce che i sintomi erano presenti da circa 2-3 gg, peggiorati nelle ultime 24 ore.
Nega traumi. Nega punture di insetti.
Nega immobilizzazione prolungata recente, nega interventi chirurgici recenti, nega viaggi di lunga durata recenti.
Riferisce febbre ieri... | 1323973_pregnancy | 1323973_en | In Emergency Department for skin redness, edema and pain in left leg. Reports that symptoms have been present for about 2-3 days, worsened in the last 24 hours.
Reports no trauma. Reports no insect bites.
Reports no recent prolonged immobilization, no recent surgery, nor recent long-term travel.
Reports fever yesterday... | pregnancy | unknown | [
"y",
"n",
"unknown"
] |
1795974_it | in ps per aggressione da parte di persona sconosciuta con una testata e un pugno provocando un trauma a livello della piramide nasale e dello zigomo sin. presenta flc non sanguinante senza sanguinamento.
lieve cefalea
| 1795974_chronic pulmonary disease | 1795974_en | In the Emergency Department for assault by an unknown person with a headbutt and a punch, causing trauma to the nasal pyramid and the left cheekbone. Presents with a non-bleeding laceration.
Mild headache.
| chronic pulmonary disease | unknown | [
"certainly chronic",
"possibly chronic",
"certainly not chronic",
"unknown"
] |
1143513_it | APP: passaggio in DEA il 30/04 per dolore epigastrico. Rilievo laboratoristico-strumentale di pancreatite litiasica, indicazione chirurgica ad eseguire colangioRMN.
Agli esami laboratoristici incremento della bilirubina diretta e degli enzimi di citolisi e colestasi epatica.
All'ETG addome: colecisti normodistesa, con... | 1143513_history of allergy | 1143513_en | History of present illness: Emergency Department visit on 04/30 for epigastric pain. Laboratory and instrumental findings consistent with biliary pancreatitis, surgical indication to perform MR cholangiography.
Laboratory tests show elevated direct bilirubin and increased cytolytic and cholestatic liver enzymes.
On abd... | history of allergy | n | [
"y",
"n",
"unknown"
] |
121138_it | Presa in carico, si presenta
A. vie aeree pervie, vco, rallentata
B. eupnoico in AA, sat 97%, no utilizzo di muscolatura accessoria
C. polsi radiali validi bil, fc 60 bpm R, PAO 115/70 mm/hg, cvp funzionante
D. GCS 15, no deficit di lato, collaborante, si accompagna ai servizi per urinare, collaborante
E. TC 36.4, cut... | 121138_eye deviation during the episode | 121138_en | Admitted, presents
A. airway patent, alert, slowed
B. eupneic on room air, SpO₂ 97%, no use of accessory muscles
C. radial pulses palpable bilaterally, HR 60 bpm regular, BP 115/70 mmHg, functioning peripheral IV
D. GCS 15, no lateralizing deficits, cooperative, walks to the bathroom to urinate, cooperative
E. T 36.4, ... | eye deviation during the episode | unknown | [
"y",
"n",
"unknown"
] |
460954_it | ---------- CONSULENZA per la richiesta di: VISITA PSICHIATRICA del: 07/NUM_TELEFONO:23 ----------
Consulente: Dr.ssa NOME_PERSONA il: 07/NUM_TELEFONO:38
paziente di 60 anni in cura pressocsmdi LUOGO con ladr.ssa Festa per distimiain trattamento con tritticoe rivotril. Storia di depressione in famiglia ... | 460954_problematic family context | 460954_en | ---------- CONSULTATION regarding the request for: PSYCHIATRIC EVALUATION of: 07/PHONE_NUMBER:23 ----------
Consulting physician: Dr. PERSONS_NAME on: 07/PHONE_NUMBER:38
60-year-old patient under treatment at the mental health center of LOCATION with Dr. Festa for dysthymia, treatment with tricyclic an... | problematic family context | unknown | [
"y",
"n",
"unknown"
] |
963_it | Paziente preso in carico, giunge per dispnea e diarrea da giorni.
A: vie aeree pervie, vigile e orientata.
B: eupnoico in aa, spo2 87%aa, FR 14 atti min/circa. Posizionato CN 3L/min con spo2 stabile a 93%.
C: polso pieno e valido non tachicardico, cute calda e asciutta. FC 75 ritmica, PAO 110/80; eseguito ECG +ematochi... | 963_blood pressure | 963_en | Patient admitted, presents with dyspnea and diarrhea that has lasted several days.
A: airways patent; alert and oriented.
B: eupneic on room air, SpO₂ 87%a, RR 14 breaths/min approximately. Placed on nasal cannula 3 L/min with stable SpO₂ at 93%.
C: full and strong pulse, not tachycardic, skin warm and dry. HR 75 regul... | blood pressure | normotensive | [
"hypotensive",
"normotensive",
"hypertensive",
"unknown"
] |
1103640_it | Pz che viene in Ps in quanto riferisce di essere andato a letto , di essersi addormentato, e poi di essersi trovato a terra , senza saperne il motivo
Ha battuto il capo, il naso e la mano dx
In anamnesi ( desunta da data base )
APR:
esofagite
2015 fr femore dx
erniajatale
epatite C
ipertensione
fibrillazione atriale ... | 1103640_respiratory rate | 1103640_en | Patient presenting to the Emergency Department after reporting that they went to bed, fell asleep, and then found themselves on the ground, without knowing the reason.
They sustained trauma to the head, nose, and right hand.
Medical history (obtained from database):
Past medical history:
esophagitis
2015 right femur fr... | respiratory rate | unknown | [
"bradypneic",
"eupneic",
"tachypneic",
"unknown"
] |
661135_it | Uomo di 72 aa familiarità, ex fumo, ipertensione arteriosa, obesità.
CAD nota: 30/11/2021 ricovero in cardiologia per eseguire coronarografia per sospetta angina da sforzo( da tempo angor e dispnea da sforzo), inoltre, dal 23/11/2021 riscontro di FA, avviato dabigatran.
Alla coro malattia trivasale: DX diminuitiva crit... | 661135_cardiac ultrasound, any abnormality | 661135_en | 72-year-old male, family history, former smoker, arterial hypertension, obesity.
CAD note: 11/30/2021 hospitalization in cardiology to perform coronary angiography for suspected exertional angina (for some time angina and dyspnea upon exertion), in addition, from 11/23/2021 finding of AF, dabigatran started.
Coronary a... | cardiac ultrasound, any abnormality | y | [
"y",
"n",
"unknown"
] |
776908_it | Buone condizioni generali. GCS 15, orientato nel T-S e collaborante.
PA 130/85
FC 85
SO2 98% in AA
TC apiretico
FR 14 apm
Toni cardiaci validi e ritmici
MV diffusamente presente e senza rumori aggiunti
Addome piano, trattabile, non dolente nè dolorabile, OI nei limiti, peristalsi +. Blumberg e Murphy negativi. Non mass... | 776908_head or other districts trauma | 776908_en | Good general condition. GCS 15, oriented in time and space and cooperative.
BP 130/85 mmHg
HR 85 bpm
SpO₂ 98% on room air
Temp.: afebrile
RR 14 breaths per minute
Heart sounds normal and regular
Breath sounds diffusely present, without added sounds
Abdomen flat and soft, not tender or painful; bowel sounds within norma... | head or other districts trauma | unknown | [
"y",
"n",
"unknown"
] |
709578_it | ---------- CONSULENZA per la richiesta di: VISITA CARDIOLOGICA del: 02/NUM_TELEFONO:58 ----------
Consulente: Dr.ssa NOME_PERSONA Sara il: 02/NUM_TELEFONO:58
Donna di 72 anni.
FDR-CV: ipertensione arteriosa, sovrappeso
Iposodiemia cronica nota (il fgilio non sa riferire dettagli ma segnala costante ip... | 709578_ecg, any abnormality | 709578_en | ---------- CONSULTATION regarding the request for: CARDIOLOGY EXAMINATION of: 02/PHONE_NUMBER:58 ----------
Consulting physician: Dr. Sara PERSONS_NAME on: 02/PHONE_NUMBER:58
72-year-old woman.
Cardiovascular risk factors: arterial hypertension, overweight
Known chronic hyponatremia (the son is unable... | ecg, any abnormality | y | [
"y",
"n",
"unknown"
] |
643686_it | ALTRI E NON SPECIFICATI TRAUMATISMI DI GINOCCHIO,GAMBA,CAVIGLIA E PIEDE (TRAUMAT GAMBA SAI)
| 643686_blood glucose | 643686_en | OTHER UNSPECIFIED KNEE, LEG, ANKLE AND FOOT INJURIES (LEG INJURY NOS)
| blood glucose | unknown | [
"measured",
"unknown"
] |
1722312_it | Buone condizioni generali. GCS 15, orientata nel T-S e collaborante.
PA 130/65
FC 89 R
SO2 98% in AA
TC apiretica
FR 19 apm
Toni cardiaci validi e ritmici
MV diffusamente presente e senza rumori aggiunti
Addome piano, trattabile, diffusamente dolente e dolorabile soprattuto in mesogastrio, OI nei limiti, peristalsi +.... | 1722312_improvement of patient’s conditions | 1722312_en | Good general condition. GCS 15, oriented in time and space and cooperative.
BP 130/65 mmHg
HR 89 bpm, regular
SpO₂ 98% on room air
Temp.: afebrile
RR 19 breaths per minute
Heart sounds normal and regular
Breath sounds diffusely present, without added sounds
Abdomen flat and soft, diffusely tender and painful, especiall... | improvement of patient’s conditions | unknown | [
"y",
"n",
"unknown"
] |
1500842_it | Preso in carico da collega ortopedico.
Accesso in DEA per trauma alla caviglia dx ieri pomeriggio.
Eseguito Rx segmentario ndr.
Al momento della dimissione, il PARENTE contattato telefonicamente ha riferito impossibilità di riaccoglierla a domicilio per difficile gestione domiciliare
APR (da storico):
- Ipertensione ... | 1500842_antihypertensive therapy | 1500842_en | Admitted by an orthopedic colleague.
Admitted to the Emergency Department for trauma to the right ankle yesterday afternoon.
A segmental X-ray was performed, with no abnormalities detected.
At the time of discharge, the RELATIVE contacted by phone reported an inability to take the patient back home due to difficult ho... | antihypertensive therapy | y | [
"y",
"n",
"unknown"
] |
1000632_it | Scritto a posteriori per prestare assistenza. Presa in carico:
A cosciente, vie aeree pervie
B eupnoica in O2 M.Venturi 35% SpO2 96%, no utilizzo dei muscoli accessori della respirazione
C polsi radiali validi, ritmici, isosfigmici FC 73 b/min PAO 145/85 mmhg
D GCS 15 eloquio normofasico fluente
E cute normotermica, ... | 1000632_history of alcohol abuse | 1000632_en | Written retrospectively to provide assistance. Admitted:
A: conscious, airway patent.
B: eupneic on O₂ via Venturi mask 35%, SpO₂ 96%, no use of accessory respiratory muscles.
C: radial pulses strong, regular, equal; HR 73 bpm; BP 145/85 mmHg.
D: GCS 15, speech fluent and normal.
E: skin normothermic, dry; Temp.: 37.3 ... | history of alcohol abuse | unknown | [
"y",
"n",
"unknown"
] |
427866_it | POSTUMI DI TRAUMATISMI INTRACRANICI SENZA MENZIONE DI FRATTURA DEL CRANIO (POSTUMI TR INTRACRANICO)
| 427866_improvement of dyspnea | 427866_en | AFTER-EFFECTS OF INTRACRANIAL TRAUMA WITHOUT MENTION OF SKULL FRACTURE (AFTER-EFFECTS OF INTRACRANIAL TRAUMA)
| improvement of dyspnea | unknown | [
"y",
"n",
"unknown"
] |
1803820_it | Paziente di 78 anni condotto in PS per impaccio dell'eloquio ed ipostenia dell'arto sup dx.
APR:
- Ipertensione arteriosa, Obesità, Dislipidemia, Ex fumatore (stop 3 mesi fa)
- modico consumo alcolico (ha sospeso 3 mesi fa)
- BPCO
- Stenosi Ao moderata (ultimo ETT 02/23), eseguita visita cardiologica a febbraio 2023, a... | 1803820_agitation | 1803820_en | 78-year-old patient brought to the ER for speech impediment and weakness of the right upper limb.
Past Medical History:
- Arterial hypertension, Obesity, Dyslipidemia, Former smoker (stopped 3 months ago)
- moderate alcohol consumption (stopped 3 months ago)
- COPD
- Moderate Ao stenosis (last ETT 02/23), cardiological... | agitation | n | [
"y",
"n",
"unknown"
] |
681196_it | Pz in PS per morso di cane (piccola taglia, animale di persona non nota) lateralmente al ginocchio sx. Incidente occorso ieri. In sede visibili superficiali segni del morso, non edema, non rossore. Dolore esacerbato dai movimenti del ginocchio.
| 681196_acute coronary syndrome | 681196_en | Patient in ER for dog bite (small size, animal of unknown person) laterally to the left knee. Incident occurred yesterday. Superficial signs of the bite visible on examination, no edema, no redness. Pain exacerbated by knee movements.
| acute coronary syndrome | unknown | [
"y",
"n",
"unknown"
] |
1187128_it | Donna di 84 anni. Non allergie note.
FDR-CV: ipertensione arteriosa, dislipidemia, DM in dietoterapia.
Prolasso uterino.
CAD nota . Triplice BYPASS 20 anni fa presso LUOGO.
Ricovero a 1/23 per STEMI infero-posteriore + destro esordito con EPA e BAV III -> alla coro in urgenza occlusione trombotica di CDx ostio-pross... | 1187128_leukocytes | 1187128_en | 84-year-old woman. No known allergies.
Cardiovascular risk factors: arterial hypertension, dyslipidemia, diabetes mellitus managed with diet therapy.
Uterine prolapse.
Known coronary artery disease. Triple BYPASS 20 years ago at LOCATION.
Hospitalization in 01/2023 for inferoposterior and right STEMI with onset marked... | leukocytes | 12.89 | [
"measured",
"unknown"
] |
567561_it | Paziente vigile, orientato T/S, collaborante
Cute e mucose idratate. Nega dolore al momento della visita (NRS=0)
PAO:130/90 mmHg - FC: 120 bpm R - SatO2: 97%AA - T: 37.5°C
EOC: toni tachicardici, ritmici, pause apparentemente libere
EOP: MV diffusamente presente, non grossolani rumori aggiunti
EOA: addome teso, scarsam... | 567561_situation description, like coughing, prolonged periods of straining, sudden abdominal pain, phlebotomy | 567561_en | Patient alert, oriented to time/place, cooperative
Hydrated skin and mucous membranes. Reports no pain at the time of the visit (NRS = 0)
BP: 130/90 mmHg - HR: 120 bpm R - SatO2: 97%on room air - T: 37.5°C
Cardiac examination: tachycardic, rhythmic tones, apparently free pauses
Pulmonary examination: diffusely present ... | situation description, like coughing, prolonged periods of straining, sudden abdominal pain, phlebotomy | unknown | [
"y",
"n",
"unknown"
] |
386669_it | Verso le ore 14.00 verosimile ipostenia emilato dx descritta come difficoltà nell' afferrare gli oggetti e impossibilità a stare in stazione eretta, sbandamneto a sx, per due volte caduto dalla sedia sul lato sx. La PARENTE ha riferito lieve deviazione della rima buccale. Rif. dal pz che non riusciva a focalizzare bene... | 386669_influenza and various infections | 386669_en | At around 2:00 p.m., probable right-sided weakness, described as difficulty grasping objects and inability to stand upright, with veering to the left, and twice falling from the chair onto the left side. The RELATIVE reported slight deviation of the oral commissure. Reported by the patient inability to focus clearly on... | influenza and various infections | unknown | [
"y",
"n",
"unknown"
] |
1500842_it | Preso in carico da collega ortopedico.
Accesso in DEA per trauma alla caviglia dx ieri pomeriggio.
Eseguito Rx segmentario ndr.
Al momento della dimissione, il PARENTE contattato telefonicamente ha riferito impossibilità di riaccoglierla a domicilio per difficile gestione domiciliare
APR (da storico):
- Ipertensione ... | 1500842_poly-pharmacological therapy | 1500842_en | Admitted by an orthopedic colleague.
Admitted to the Emergency Department for trauma to the right ankle yesterday afternoon.
A segmental X-ray was performed, with no abnormalities detected.
At the time of discharge, the RELATIVE contacted by phone reported an inability to take the patient back home due to difficult ho... | poly-pharmacological therapy | y | [
"y",
"n",
"unknown"
] |
1596874_it | pte presa in carico, giunge in dea per riscontro di febbricola e ipotensione
A: vie aeree pervie, pte vigile, cosciente
B: eupnoica in O2t con cn 2 l/min espansione toracica bilaterale, no utilizzo dei muscoli accessori
C: cute asciutta e normotermica, si posiziona cvp 18 g su arto superiore sinistro e/ee+ega arterio... | 1596874_administration of oxygen/ventilation | 1596874_en | Patient admitted, arrives in the Emergency Department for low-grade fever and hypotension
A: clear airways, patient alert, conscious
B: eupneic on oxygen therapy via nasal cannula at 2 L/min; bilateral chest expansion; no use of accessory muscles.
C: skin dry and normothermic; 18G peripheral IV placed in the left upp... | administration of oxygen/ventilation | y | [
"y",
"n",
"unknown"
] |
382962_it | Paziente condotta in PS per peggioramento della parola, cefalea, instabilità posturale, deambulazione.
Completata vaccinazione antiSARS CoV2 (JJ monodose 6/2021)
APR:
- Ipertensione arteriosa
- Sindrome di Arnold Chiari. Seguita c/o H Molinette. In programma RM encefalo a breve (non ancora effettuata) e successiva v ... | 382962_history of allergy | 382962_en | Patient brought to ER due to worsening speech, headache, postural instability, and difficulty walking.
Completed SARS CoV2 vaccination (J&J single dose 6/2021)
Past Medical History:
- Arterial hypertension
- Chiari malformation. Followed at Molinette Hospital. Brain MRI scheduled shortly (not yet performed), followed... | history of allergy | n | [
"y",
"n",
"unknown"
] |
1203238_it | In DEA per peggioramento della dispnea per sforzi minimi e e tosse da circa una settimana. Eseguito ciclo di ABT (non meglio specificato) . Nega febbre e/o angor.
APR ( da storico)
- Vaccinato COVID 3 dosi
- Ex forte fumatore
- BPCO in LTOT domiciliare (enfisema severo, 2 L/min per 24h)
- Ipertensione arteriosa
- I... | 1203238_chronic metabolic failure | 1203238_en | In the Emergency Department for worsening dyspnea on minimal exertion and cough for approximately one week. Completed a course of antibiotic therapy (not further specified). Denies fever and/or angina.
Past medical history (from records)
– COVID vaccination, 3 doses
– Former heavy smoker
– Chronic obstructive pulmona... | chronic metabolic failure | certainly chronic | [
"certainly chronic",
"possibly chronic",
"certainly not chronic",
"unknown"
] |
1456139_it | Paziente noto, si veda ultima lettera di dimissione
Accesso in DEA per astenia e fiato corto, con riscontro di ipotensione. Ha eseguito
EE: PCR 17 WBC > 15mila CrS 2.4
TC AC: Rispetto al precedente studio del 28/07/2023, in presenza di catetere a doppio J, correttamente posizionato, si osserva marcato rigonfiamento del... | 1456139_pulmonary embolism | 1456139_en | Known patient, see last discharge letter
Admitted to the Emergency Department for asthenia and shortness of breath, with evidence of hypotension. The following tests were performed:
Laboratory tests: CRP 17; WBC > 15,000; serum creatinine 2.4.
CT scan of the abdomen with contrast: Compared with the previous study dated... | pulmonary embolism | unknown | [
"y",
"n",
"unknown"
] |
1624085_it | Accesso in DEA per epigastralgia da 2 giorni in maniera continua.
Inoltre dolore toracico che non sa definire 4 giorni in maniera continua.
Inoltre dolore caviglia sn, senza traumi associati.
APR:
-BPCO in ex fumatore (ha smesso 40 anni fa) in OssigenoTp /24 ore a 2/min
-noto BBsn
-FA permanente
-plurimi ricovero per ... | 1624085_anticoagulants or antiplatelet drug therapy | 1624085_en | Presented to the Emergency Department for epigastric pain ongoing for the past 2 days.
Also, chest pain that the patient cannot define, ongoing for 4 days.
Also left ankle pain, with no associated trauma.
Past medical history:
- Chronic obstructive pulmonary disease in a former smoker (quit 40 years ago), on long-term... | anticoagulants or antiplatelet drug therapy | y | [
"y",
"n",
"unknown"
] |
1281662_it | Paziente di 29 anni che giunge in PS per riscontro verso le h 13 di deviazione rima buccale.
Vaccinazione antiSARS CoV2: 3 dosi
APR
- Non fumo
- Non Ipertensione arteriosa-dislipidemia
- Non familiarità per malattie CV
- storia di coliche renali con riferiti calcoli
- riferita cervicalgia con talora formicolio all'ar... | 1281662_anticoagulants or antiplatelet drug therapy | 1281662_en | 29-year-old patient who presents to the Emergency Department around 1 p.m. for deviation of the oral commissure.
Anti–SARS-CoV-2 vaccination: 3 doses
Past medical history
– Non-smoker
– No arterial hypertension or dyslipidemia
– No family history of cardiovascular disease
– History of renal colic with reported kidney... | anticoagulants or antiplatelet drug therapy | n | [
"y",
"n",
"unknown"
] |
210362_it | Accesso in DEA ieri sera per episodi di emoftoe in concomitanza con accessi di tosse nella giornata di ieri con riferita emissione di quantità di sangue lievemente aumentata rispetto a quella abituale. Riferisce emoftoe quotidiana mattutina durante episodi di tosse dalla dimissione di ottobre 2020, quando era stata ric... | 210362_chronic pulmonary disease | 210362_en | Presented to the Emergency Department last night for episodes of hemoptysis in conjunction with coughing fits yesterday, with a reported emission of slightly increased amounts of blood compared to usual. Reports daily morning hemoptysis during coughing episodes since discharge in October 2020, when she was hospitalized... | chronic pulmonary disease | certainly chronic | [
"certainly chronic",
"possibly chronic",
"certainly not chronic",
"unknown"
] |
477616_it | ---------- CONSULENZA per la richiesta di: CONSULENZA NEUROCHIRURGICA del: 06/NUM_TELEFONO:46 ----------
Consulente: Dr.ssa NOME_PERSONA il: 06/NUM_TELEFONO:11
Paziente di 55 anni. Trovato oggi pomeriggio a casa privo di coscienza. Intubato dal 118 e trasportato rpresso nostro DEA. Alla TC encefalo emo... | 477616_compression ultrasound (cus), any abnormality | 477616_en | ---------- CONSULTATION regarding the request for: NEUROSURGICAL CONSULTATION of: 06/PHONE_NUMBER:46 ----------
Consulting physician: Dr. PERSONS_NAME on: 06/PHONE_NUMBER:11
55-year-old patient. Found unconscious at home this afternoon. Intubated by 118 and transported to our Emergency Department. On b... | compression ultrasound (cus), any abnormality | unknown | [
"y",
"n",
"unknown"
] |
52762_it | In dea per dispnea da qualche giorno, riferisce dispnea da sforzo e ortopnea.
Nega febbre (riferisce di averla misurata), ma rilevata Tc circa 38 a domicilio.
Riferisce tosse cronica senza variazioni (tosse che presenta da qualche anno).
Nega disturbi GI, non dolore addominale, non diarrea, un episodio di vomito isolat... | 52762_history of allergy | 52762_en | In Emergency Department for dyspnea that has lasted several days, reports dyspnea on exertion and orthopnea.
Denies fever (reports having measured it), but Temp.: approximately 38 degrees Celsius recorded at home.
Reports chronic cough without changes (cough that has been present for a few years).
Reports no GI disorde... | history of allergy | n | [
"y",
"n",
"unknown"
] |
637941_it | Algie emicostato dx persistenti verso K8-K10 in corrispondenza dell'ascellare media e anteriore in trauma 7 gg fa, non rumori aggiunti all'EOP
EOP: eupnoico, non cianosi periferica, nega tosse, MV+/+ senza rumori aggiunti.
EOCV: nega angor, toni ritmici, pause libere, non segni d’IC destra né sinistra, non segni di TVP... | 637941_blood alcohol | 637941_en | Persistent right hemithorax pain extending to K8-K10, corresponding to the mid and anterior axillary regions, following trauma 7 days ago. No additional sounds on pulmonary examination
Pulmonary examination: eupnoeic, no peripheral cyanosis, reports no cough, vesicular murmur +/+ with no additional sounds.
Cardiovascul... | blood alcohol | unknown | [
"measured",
"unknown"
] |
1750279_it | Rivalutazione clinica
vigile orientato collaborante
asintomatico
alvo canalizzato alle feci (già 2-3 evacuazioni di feci semiformate normocromiche in mattinata)
PAO 110/60 mmhg, FC 80 bpm R, FR 16 apm, SPO2 96% in AA, apiretico
EOP: MV ridotto a livello bibasale
EOC: toni ritmici validi
EOA: addome globoso per adipe, t... | 1750279_blood pressure | 1750279_en | Clinical reassessment
alert oriented cooperative
asymptomatic
bowel movements resumed (already 2–3 bowel movements of semi-formed normochromic stool this morning)
BP 110/60 mmHg, HR 80 bpm regular, RR 16 breaths/min, SpO₂ 96% on room air, afebrile
Chest exam: breath sounds reduced at bibasilar level
Cardiac exam: heart... | blood pressure | normotensive | [
"hypotensive",
"normotensive",
"hypertensive",
"unknown"
] |
352393_it | pz di 69 anni in condizioni cliniche generali gravemente scadute: disidratato, cachettico, cianotico e dispnoico. già valutato durante un recente accesso al DEA per quadro di sichemia critica cronica degli arti inferiori rapidamente peggiorata con riscontro di quadro di S. di Leriche (occlusione cronica aorto-bisiliaca... | 352393_serum creatinine kinase | 352393_en | 69-year-old patient in severely deteriorated general clinical condition: dehydrated, cachectic, cyanotic and dyspneic. Already evaluated during a recent Emergency Department visit for a picture of chronic critical ischemia of the lower limbs with rapid worsening and finding of Leriche syndrome (chronic aorto-bisiliac o... | serum creatinine kinase | > 9330 | [
"measured",
"unknown"
] |
295478_it | DISORDINI DEI LIQUIDI E DEGLI ELETTROLITI NON CLASSIFICATI ALTROVE (DIS ELETTROLIT/LIQU NAS)
| 295478_ab ingestis pneumonia | 295478_en | FLUID AND ELECTROLYTE DISORDERS, NOT ELSEWHERE CLASSIFIED (FLUID/ELECTROLYTE DISORDER, NOS)
| ab ingestis pneumonia | unknown | [
"y",
"n",
"unknown"
] |
12953_it | Paziente giunge in ps. presenta diplopia campo visivo dx
A: vie aeree pervie, vigile e orientato,
B: eupnoico in aa,
C: polso pieno, valido e non tachicardico, cute calda ed asciutta.
D: pupille isocoriche isocicliche
E: testa piedi nulla da segnalare
wseguito esami ematici
PARAMETRI: pao: 148/85mmHg spo2: 97% fc 91... | 12953_level of consciousness | 12953_en | Patient arrives in the emergency room with diplopia in the right visual field
A: airways patent, alert and oriented,
B: eupneic on room air,
C: full, strong and non-tachycardic pulse, skin warm and dry.
D: isochoric isocyclic pupils
E: head-to-toe examination unremarkable
Blood tests performed
VITAL SIGNS: BP: 148/8... | level of consciousness | A | [
"A",
"V",
"P",
"unknown"
] |
1286408_it | in DEA per comparsa di edema della lingua
A: vie aeree pervie, no tirage, no cornage, no disfonia
B: eupnoico in aa; no utilizzo muscolatura accessoria; no rumori respiratori, fr 12 atti/min, spo2 97%
C: polsi radili pieni, validi e isosfigmici pao 135/70, fc 71 - posizionato cvp arto sup.dx ed e/ti ematochimici; e/to... | 1286408_administration of fluids | 1286408_en | In the Emergency Department for onset of tongue edema
A: airway patent, no retractions, no stridor, no dysphonia
B: eupneic on room air; no use of accessory muscles; no respiratory sounds, RR 12 breaths/min, SpO₂ 97%
C: radial pulses full, strong and symmetrical BP 135/70, HR 71 – peripheral IV placed in the right uppe... | administration of fluids | y | [
"y",
"n",
"unknown"
] |
780560_it | ERNIA INGUINALE MONOLATERALE O NON SPECIFICATA,SENZA MENZIONE DI OSTRUZIONE O GANGRENA (ERNIA INGUINALE UNILAT)
| 780560_severe anemia | 780560_en | UNILATERAL OR UNSPECIFIED INGUINAL HERNIA, WITHOUT MENTION OF OBSTRUCTION OR GANGRENE (UNILATERAL INGUINAL HERNIA)
| severe anemia | unknown | [
"y",
"n",
"unknown"
] |
82397_it | RX RACHIDE LOMBOSACRALE
RX ANCA DX
Esiti di protesi totale d'anca a destra senza segni di mobilizzazione rispetto al precedente studio del 01/04/2021.
Quadro di coxartrosi a sinistra con irregolarità degenerative sclerosi del tetto acetabolare. Testa femorale di sinistra normoconformata, in sede. Non evidenti lesioni o... | 82397_administration of fluids | 82397_en | LUMBOSACRAL SPINE X-RAY
RIGHT HIP X-RAY
Sequelae of total hip prosthesis on the right with no signs of mobilization compared to the previous study of 04/01/2021.
Clinical picture of coxarthrosis on the left with degenerative irregularities and sclerosis of the acetabular roof. Left femoral head normally shaped, in plac... | administration of fluids | unknown | [
"y",
"n",
"unknown"
] |
889166_it | Da 3 giorni dolore in sede dorsale e al fianco sinistro.
Di tipo continuo. Esordito a riposo ma accentuato dai movimenti. Attualmente NRS 8/10.
Assunto paracetamolo senza beneficio.
Alvo regolare. Non disuria o stranguria. Diuresi attiva.
Non traumi recenti.
Inoltre comparsa di edemi declivi con peggioramento negli... | 889166_chronic renal failure | 889166_en | For the past 3 days, pain in the back and left flank.
The pain is continuous. Began at rest but accentuated by movements. Currently NRS 8/10.
Took paracetamol without improvement.
Regular bowel function. No dysuria or stranguria. Active diuresis.
No recent trauma.
Additionally, onset of dependent edema with worsenin... | chronic renal failure | certainly chronic | [
"certainly chronic",
"possibly chronic",
"certainly not chronic",
"unknown"
] |
1463718_it | Uomo 83 aa
dislipidemico iperteso
Nota IRC pre terminale in FU osp Mauriziano- manca documentazione
Esiti di stroke 2002 con esito di plegia sinistra
Cad nota con pregressa PCI. Non documentazione recente. Ultima visita cardio 3/23 FE 57% con ipo siv e p inferiore.
Modesta autonomia nelle ADL e IADL anche per limitaz... | 1463718_hemoglobin | 1463718_en | 83-year-old man
Dyslipidemia and hypertension
Known near end-stage chronic kidney disease, previously followed up at Mauriziano Hospital—documentation unavailable.
History of stroke in 2002 with residual left-sided plegia.
Known coronary artery disease, with a history of percutaneous coronary intervention. No recent d... | hemoglobin | unknown | [
"measured",
"unknown"
] |
298965_it | In DEA per ideazione anticonservativa; inoltre riferisce saltuario dolore all'emitorace sx di cui non sa precisare le caratteristiche; il dolore dura circa 2 minuti, insorge sia a riposo che durante la deambulazione.
Numerosi passaggi PS per varie ragioni (dispnea, scompenso cardiaco, FA, ansia), ultimo passaggio in... | 298965_history of allergy | 298965_en | Presentation to the Emergency Department for suicidal ideation; additionally reports intermittent left-sided chest pain, unable to further characterize it; the pain lasts approximately 2 minutes and occurs both at rest and during ambulation.
Multiple Emergency Department visits for various reasons (dyspnea, heart fail... | history of allergy | n | [
"y",
"n",
"unknown"
] |
1187128_it | Donna di 84 anni. Non allergie note.
FDR-CV: ipertensione arteriosa, dislipidemia, DM in dietoterapia.
Prolasso uterino.
CAD nota . Triplice BYPASS 20 anni fa presso LUOGO.
Ricovero a 1/23 per STEMI infero-posteriore + destro esordito con EPA e BAV III -> alla coro in urgenza occlusione trombotica di CDx ostio-pross... | 1187128_concussive head trauma | 1187128_en | 84-year-old woman. No known allergies.
Cardiovascular risk factors: arterial hypertension, dyslipidemia, diabetes mellitus managed with diet therapy.
Uterine prolapse.
Known coronary artery disease. Triple BYPASS 20 years ago at LOCATION.
Hospitalization in 01/2023 for inferoposterior and right STEMI with onset marked... | concussive head trauma | unknown | [
"y",
"n",
"unknown"
] |
568647_it | P.te preso in carico in degenza L8 per idronefrosi bilaterale in sospetta calcolosi.
V/C/O e collaborante. Eupnoica in aa con FR di 14 apm circa. Polsi radiali isosfigmici, validi e non tachicardici. CVP as dx in sede, pervio e funzionante da cui infionde CaCl 1 fl in SF 100 cc. GCS 15, no deficit di lato. Apiretica, ... | 568647_level of autonomy (mobility) | 568647_en | Patient admitted to L8 ward for bilateral hydronephrosis with suspected stones.
Alert, conscious, oriented, and cooperative. Eupneic on room air with RR of about 14 breaths/min. Radial pulses palpable, isosphygmic, and not tachycardic. Peripheral IV in the right upper extremity in place, patent and functioning, throug... | level of autonomy (mobility) | walking with auxiliary aids | [
"walking independently",
"walking with auxiliary aids",
"walking with physical assistance",
"bedridden",
"unknown"
] |
1387943_it | Vigile orientata collaborante
PAO 125/85 mmhg, FC 68 bpm, SpO2 100%, T° 36.8
EOP: MV diffuso
EOC. toni ritmici
EOA: addome piano trattabile, dolente in fossa iliaca sinistra, dolorabile in fossa iliaca destra e sinistra, NOME_PERSONA neg, NOME_PERSONA neg, NOME_PERSONA neg, peristalsi vivace
Non edemi declivi
Cute cald... | 1387943_body temperature | 1387943_en | Alert, oriented, cooperative
BP 125/85 mmHg, HR 68 bpm, SpO₂ 100%, Temp.: 36 degrees Celsius
Pulmonary examination: diffuse vesicular breath sounds
Cardiac examination: rhythmic heart sounds
Abdominal examination: flat, soft abdomen, tender in the left iliac fossa, painful on palpation in the right and left iliac fossa... | body temperature | normothermic | [
"hypothermic",
"normothermic",
"hyperthermic",
"unknown"
] |
651155_it | In DEA per astenia generalizzata, dispnea per minimi sforzi presente da alcune settimane.
Nega tosse o febbre o qualsiasi altro sintomo sospetto infettivo (non disuria, non diarrea, non dolore addominale, non cefalea). Inoltre mai dolore toracico; neanchge presenza di cardiopalmo.
Dispnea non acuta ma esordio gradual... | 651155_cardiovascular diseases | 651155_en | At the Emergency Department for generalized asthenia, dyspnea on minimal exertion present for a few weeks.
Denies cough, fever, or any other suspected infectious symptoms (no dysuria, no diarrhea, no abdominal pain, no headache). Also, no chest pain; no palpitations.
Non-acute dyspnea but gradual onset; worse in the ... | cardiovascular diseases | y | [
"y",
"n",
"unknown"
] |
1500842_it | Preso in carico da collega ortopedico.
Accesso in DEA per trauma alla caviglia dx ieri pomeriggio.
Eseguito Rx segmentario ndr.
Al momento della dimissione, il PARENTE contattato telefonicamente ha riferito impossibilità di riaccoglierla a domicilio per difficile gestione domiciliare
APR (da storico):
- Ipertensione ... | 1500842_situation description, like coughing, prolonged periods of straining, sudden abdominal pain, phlebotomy | 1500842_en | Admitted by an orthopedic colleague.
Admitted to the Emergency Department for trauma to the right ankle yesterday afternoon.
A segmental X-ray was performed, with no abnormalities detected.
At the time of discharge, the RELATIVE contacted by phone reported an inability to take the patient back home due to difficult ho... | situation description, like coughing, prolonged periods of straining, sudden abdominal pain, phlebotomy | unknown | [
"y",
"n",
"unknown"
] |
1813094_it | Richiesta consulenza ortopedica per frattura polso sinistro.
Riferito incidente auto contro moto
il paziente viaggiava in moto a riferita bassa velocità, riferito impatto frontale
Indossava il casco, nega trauma cranico, riferisce caduta sul polso, nega trauma colonna bacino
Al mio arrivo paziente vigile, orientato e... | 1813094_active neoplasia | 1813094_en | Request for orthopedic consultation for left wrist fracture.
Reported car accident against motorcycle
the patient was traveling on a motorcycle at reported low speed, reported frontal impact
Wearing a helmet, denies head trauma, reports fall on the wrist, denies trauma to the pelvic column
Upon my arrival, the patien... | active neoplasia | unknown | [
"certainly active",
"possibly active",
"certainly not active",
"unknown"
] |
1071944_it | Prosegue medicazioni quotidiane.
Applicazione 2 volte al dì su ferita e glande di Connettivina Plus Crema.
Controllo come da programma Martedì p.v. (20/9/2022).
| 1071944_chronic respiratory failure | 1071944_en | Daily wound care continued.
Apply Connettivina Plus Cream twice daily to the wound and the glans.
Follow-up as scheduled next Tuesday (09/20/2022).
| chronic respiratory failure | unknown | [
"certainly chronic",
"possibly chronic",
"certainly not chronic",
"unknown"
] |
661135_it | Uomo di 72 aa familiarità, ex fumo, ipertensione arteriosa, obesità.
CAD nota: 30/11/2021 ricovero in cardiologia per eseguire coronarografia per sospetta angina da sforzo( da tempo angor e dispnea da sforzo), inoltre, dal 23/11/2021 riscontro di FA, avviato dabigatran.
Alla coro malattia trivasale: DX diminuitiva crit... | 661135_blood calcium | 661135_en | 72-year-old male, family history, former smoker, arterial hypertension, obesity.
CAD note: 11/30/2021 hospitalization in cardiology to perform coronary angiography for suspected exertional angina (for some time angina and dyspnea upon exertion), in addition, from 11/23/2021 finding of AF, dabigatran started.
Coronary a... | blood calcium | unknown | [
"measured",
"unknown"
] |
105476_it | Paziente preso in carico, in DEA per persitente di febbre e peggioramento della dispnea in noto paziente con positività covid19
A: vie aeree pervie, vigile, cosciente orientato.
B: eupnoico, spo2 96% o2 2 L/min, FR 16 atti min/circa. No utilizzo della muscolatura accessoria.
C: polso pieno e valido non tachicardico, c... | 105476_respiratory rate | 105476_en | Patient taken into care, in the Emergency Department for persistent fever and worsening dyspnea in a patient known to be COVID-19 positive
A: airway patent, alert, conscious and oriented.
B: eupneic, SpO₂ 96% on O₂ 2 L/min, RR 16 breaths/min approximately. No use of accessory muscles.
C: full and strong pulse, not tac... | respiratory rate | eupneic | [
"bradypneic",
"eupneic",
"tachypneic",
"unknown"
] |
394397_it | A: vie aeree pervie
B: SAO2 97% AA, FR 18 apm, MV diffuso non ra
C: PAO 170/100, FC 170 AR, cute calda ben perfusa, polsi presenti tachiaritmici, toni tachiaritmici validi, non soffi
D GCs 15 non deficti di lato
E succulenza bimalleolare
ECG: FA con FC media 160 bpm, QRS stretto, sottoST DII-aVF
POCUS:
- torace: s. ... | 394397_blood in the stool | 394397_en | A: clear airways
B: SAO2 97% on room air, RR 18 apm, diffuse breath sounds no rhonchi.
C: BP 170/100, HR 170 AR, warm well-perfused skin, tachyarrhythmic pulses present, valid tachyarrhythmic tones, no murmurs
D: GCs 15 no unilateral motor and sensory deficits
E: bilateral ankle edema
ECG: AF with mean HR 160 bpm, nar... | blood in the stool | unknown | [
"pos",
"neg",
"unknown"
] |
1201050_it | Si prende in carico pz.
Vie aeree pervie.
Eupnoica, espansione toracica bilaterale, no rumori respiratori, FR 15 atti/min, SpO2 100% in aa.
Polsi validi, FC 95 bpm, PAO 95/60 mmHg, cvp pervio, si infonde idratazione con RA 500 cc come da IM.
GCS 15, pupille isocoriche e isocicliche, pz disorientata, apiretica.
Cute nor... | 1201050_administration of oxygen/ventilation | 1201050_en | Patient admitted.
Clear airways.
Eupnoeic, bilateral chest expansion, no respiratory sounds, RF 15 breaths/min, SpO2 100% on room air.
Pulses strong, HR 95 bpm, BP 95/60 mmHg, peripheral IV patent; Lactated Ringer's 500 mL infusion initiated per physician order.
GCS 15, isochoric and isocyclic pupils, patient disorient... | administration of oxygen/ventilation | n | [
"y",
"n",
"unknown"
] |
883132_it | Accesso in DEA per episodi di dolore toracico dopo sforzi lievi e a riposo con durata circa 5 minuti che peggiora con l'inspirio, già presente da 2-3 ma con incremento della frequenza nelle ultime 2 settimane. Ultimi episodi stanotte e stamattina a riposo, durato alcuni minuti, associato a dispnea e regredito spontanea... | 883132_history of allergy | 883132_en | Presented to the Emergency Department for episodes of chest pain after mild exertion and at rest lasting about 5 minutes that worsens with inhalation, already present for 2–3 [months] but with an increase in frequency in the last 2 weeks. Most recent episodes during the night and this morning at rest, lasting several m... | history of allergy | y | [
"y",
"n",
"unknown"
] |
1509420_it | Paziente condotta per dolore addominale e plurimi episodi di vomito.
Si colloquia con il PARENTE, il quale riferisce di vivere con la paziente. Riferisce questo pomeriggio intorno alle ore 16.00 di essere rientrato a domicilio e di aver trovato la paziente che lamentava dolore addominale descritto come continuo ai quad... | 1509420_homelessness | 1509420_en | Patient brought in for abdominal pain and multiple episodes of vomiting.
Discussion held with the RELATIVE, who reports living with the patient. Reports that this afternoon at around 4:00 p.m. he returned home and found the patient complaining of abdominal pain described as continuous in the upper quadrants; reports 2–... | homelessness | unknown | [
"y",
"n",
"unknown"
] |
1396734_it | Paziente preso in carico, giunge in DEA per febbre persistente e tosse con escreato.
P.te LOC, vie aeree pervie.
eupnoica in AA , torace normoespanso, non utilizzo muscolatura accessoria.
Cute asciutta, eutermica, normocromica. Polsi radiali validi, ritmici e tachicardici.
GCS 15, eloquio libero e fluente, non defi... | 1396734_presence of dyspnea | 1396734_en | Patient admitted, arrives at Emergency Department for persistent fever and cough with sputum.
Patient alert, oriented and cooperative, clear airways.
eupnoeic on room air, normal chest expansion, no use of accessory muscles.
Skin dry, normal temperature, normal color. Radial pulses present, rhythmic and tachycardic... | presence of dyspnea | n | [
"y",
"n",
"unknown"
] |
1203238_it | In DEA per peggioramento della dispnea per sforzi minimi e e tosse da circa una settimana. Eseguito ciclo di ABT (non meglio specificato) . Nega febbre e/o angor.
APR ( da storico)
- Vaccinato COVID 3 dosi
- Ex forte fumatore
- BPCO in LTOT domiciliare (enfisema severo, 2 L/min per 24h)
- Ipertensione arteriosa
- I... | 1203238_carotid sinus massage | 1203238_en | In the Emergency Department for worsening dyspnea on minimal exertion and cough for approximately one week. Completed a course of antibiotic therapy (not further specified). Denies fever and/or angina.
Past medical history (from records)
– COVID vaccination, 3 doses
– Former heavy smoker
– Chronic obstructive pulmona... | carotid sinus massage | unknown | [
"pos",
"neg",
"unknown"
] |
354519_it | Vigile collaborante
SpO2 93% AA TC 36
Walking test: SpO2 93% -> 88%
PV ematochimici
RX torace: polmonite
Tampone molecolare SARS-CoV2 positivo
EGA arteriosa in AA: pH 7.38 pO2 64 pCO2 35 HCO3 20 lac neg Na 138 K 3.35
ECG: RS, asse intermedio, atipie aspecifiche della ripolarizzazione
ECO mirata in urgenza:
- in R5-R6... | 354519_poly-pharmacological therapy | 354519_en | Alert, cooperative
SpO₂ 93% on room air Temp.: 36 degrees Celsius
Walking test SpO₂ 93% -> 88%
Blood chemistry tests reviewed
Chest X-ray: pneumonia
Molecular swab for SARS-CoV-2 positive
Arterial blood gas on room air: pH 7.38 pO₂ 64 pCO₂ 35 HCO₃ 20 lactate negative Na 138 K 3.35
ECG: sinus rhythm, intermediate axis,... | poly-pharmacological therapy | unknown | [
"y",
"n",
"unknown"
] |
210362_it | Accesso in DEA ieri sera per episodi di emoftoe in concomitanza con accessi di tosse nella giornata di ieri con riferita emissione di quantità di sangue lievemente aumentata rispetto a quella abituale. Riferisce emoftoe quotidiana mattutina durante episodi di tosse dalla dimissione di ottobre 2020, quando era stata ric... | 210362_pulmonary scintigraphy, any abnormality | 210362_en | Presented to the Emergency Department last night for episodes of hemoptysis in conjunction with coughing fits yesterday, with a reported emission of slightly increased amounts of blood compared to usual. Reports daily morning hemoptysis during coughing episodes since discharge in October 2020, when she was hospitalized... | pulmonary scintigraphy, any abnormality | unknown | [
"y",
"n",
"unknown"
] |
1754455_it | Giunto in PS - MeCAU accompagnato da MSA 025 per FA di nuova insorgenza
PV allegati
A - LOC , vie aeree pervie
B - eupnoico espansione torace bilaterale, no utilizzo muscoli accessori,
C - polsi radiali validi bilateralmente, cute asciutta, refill capillare < 2 sec, Presenta CVP 18 G polso sx, E / ematici + EGA v... | 1754455_dementia | 1754455_en | Arrived at the Emergency Department – MeCAU accompanied by advanced life support unit 025 for new-onset atrial fibrillation
Prior vital signs attached
A – alert, airway patent
B – eupneic, bilateral chest expansion, no use of accessory muscles,
C – radial pulses palpable bilaterally, skin dry, capillary refill < 2 se... | dementia | unknown | [
"y",
"n",
"unknown"
] |
71236_it | Tampone antigenico rapido positivo di 5 giorni fa presso la LUOGO eseguito per comparsa di sintomi tre gg prima di astenia
Recente assunzioen di atbterapuia per infezione delle vie urinarie
dalla esecuzioen di tampone rapido - prescrizione da parte del curante di terapia steroide - deltacorterne 25 mg 1 co per 6 gg po... | 71236_dementia | 71236_en | Rapid antigen swab positive 5 days ago at LOCATION, performed for onset of asthenia 3 days earlier.
Recent antibiotic therapy for urinary tract infection.
Following performance of the rapid swab, prescription by the primary care physician of steroid therapy: Deltacortene 25 mg 1 tablet for 6 days, then tapering; Azith... | dementia | n | [
"y",
"n",
"unknown"
] |
472721_it | Pz preso in carico
Vie aeree pervie, cosciente
Eupnoico Spo2 95% aa
Polsi radiali pieni isosfigmici FC 70 PAO 114/70
Cute asciutta no pallida no sudata
Vigile collaborante GCS 15
TC 37
P/ CVP E/ematici
E/ ECG
e/medicazione arto sup sx con connettivina per presenza di escoriazione
Presenta xerosi cutanea diffusa app... | 472721_blood pressure | 472721_en | Patient taken into care
Airways clear, conscious
Eupnoeic, Spo2 95% on room air
Radial pulses full and symmetric; HR 70 bpm; BP 114/70 mmHg.
Skin dry, not pale, not diaphoretic.
Awake, cooperative, GCS 15.
Temp.: 37 degrees Celsius
Peripheral venous catheter placed; blood tests obtained.
ECG performed.
Left upper limb ... | blood pressure | normotensive | [
"hypotensive",
"normotensive",
"hypertensive",
"unknown"
] |
1230384_it | PAO 131/84 Spo2 97%aa fc 64
EOP: MV bilaterale, sibili espiratori.
EOC toni ritmici validi, pause apparentemente libere. polsi normoisosfigmici. no edemi declivi
EOA: addome piano, trattabile, lievemente dolente alla palpazione in tutti i campi. NOME_PERSONA- NOME_PERSONA - (riferito alvo stititico)
presenza di cisti... | 1230384_heart rate | 1230384_en | BP 131/84 SpO2 97% on room air HR 64
Pulmonary examination: bilateral breath sounds, wheezing on exhalation.
Cardiac examination: valid rhythmic tones, apparently free pauses. normal pulses. no peripheral edema
Abdominal examination: abdomen flat, palpable, slightly tender to palpation in all areas. PERSONS_NAME- PER... | heart rate | normocardic | [
"bradycardic",
"normocardic",
"tachycardic",
"unknown"
] |
382962_it | Paziente condotta in PS per peggioramento della parola, cefalea, instabilità posturale, deambulazione.
Completata vaccinazione antiSARS CoV2 (JJ monodose 6/2021)
APR:
- Ipertensione arteriosa
- Sindrome di Arnold Chiari. Seguita c/o H Molinette. In programma RM encefalo a breve (non ancora effettuata) e successiva v ... | 382962_neurodegenerative diseases | 382962_en | Patient brought to ER due to worsening speech, headache, postural instability, and difficulty walking.
Completed SARS CoV2 vaccination (J&J single dose 6/2021)
Past Medical History:
- Arterial hypertension
- Chiari malformation. Followed at Molinette Hospital. Brain MRI scheduled shortly (not yet performed), followed... | neurodegenerative diseases | y | [
"y",
"n",
"unknown"
] |