diff --git "a/app.py" "b/app.py"
--- "a/app.py"
+++ "b/app.py"
@@ -258,8 +258,8 @@ def predict_icd(text_input, model_name, label_count):
     
     return html_output, visualized_text
 
-sample_texts = {"Sample summary 1": "service medicine allergies nsaids sulfa sulfonamide antibiotics attending chief complaint transfer from neurosurg to micu for acute renal failure major surgical or invasive procedure ivc filter placement central line placement arterial line placement hemodialysis intubation mechanical ventilation history of present illness 85m with prior dvt htn and ckd was admitted to nebh with decreased appetite and le swelling found to have extensive dvt and acute on chronic rf was started on heparin gtt and yesterday was noted to have a right facial droop and increased dysarthria r sided weakness and somnolence he developed what appeared to be a r sided seizure and then a grand mal seizure in the ct scanner at the osh he was intubated for airway protection and transferred to to the neurosurgery service he was noted to be hypotensive after intubation without sedation prior to transfer and was started on neo an aline was placed also prior to transfer this morning the neurosurgery attending asked that the micu take over his care given the complexity of his medical problems on eval he was intubated and sedated does not follow commands not on sedation although received mg of iv ativan within the past hours for possible seizure per his son who is at his bedside he was doing well until about months ago at which point they noticed a pound weight loss and hematuria bladder cancer was discovered and he had a cystoscopic removal of tumor weeks ago his son noted that he was increasingly tired w decreased appetite and le swelling he fell and hit his head about week ago but his son noticed only a small cut and so did not have him evaluated over the week prior to admission he became unable to walk and needed a wheelchair to get around past medical history htn thoracic and abdominal aortic aneurysm h o transitional cell bladder cancer ckd h o lumbar laminectomy tertiary hyperparathyroidism bph dvt in the past s p ivc filter placement bilateral cataracts s p removal glaucoma s p l tkr unclear per records pvd fem bipass social history was living independently prior to weeks ago physical exam admission exam general intubated and sedated bites down on ett heent sclera anicteric pinpoit pupils oropharynx clear neck supple jvp not elevated no lad lungs clear to auscultation bilaterally no wheezes rales ronchi cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext cool feet bilaterally w eschar on r great toe lle swelling w edema not able to palpate pedal pulses doplerable lle dp pt and r dp pertinent results admission labs 58pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct 58pm blood neuts lymphs monos eos baso 58pm blood pt ptt inr pt 58pm blood glucose urean creat na k cl hco3 angap 58pm blood alt ast ck cpk alkphos amylase totbili 58pm blood ck mb ctropnt 38am blood ck mb ctropnt 23pm blood ck mb ctropnt 58pm blood albumin calcium phos mg 58pm blood free t4 58pm blood tsh 58pm blood phenyto 08pm blood type art po2 pco2 ph caltco2 base xs 08pm blood lactate radiology studies ct head on admission findings a mixed but predomitly hyperdense collection overlies the entire left cerebral hemisphere measuring up to mm in greatest transverse dimension and extending along the left tentorium it is consistent with a predomitly acute subdural hematoma this exerts mass effect upon the left hemisphere predomitly in the frontal and temporal lobes with effacement of the underlying cerebral sulci and mild left frontal edema there is a mild rightward shift of the anterior falx septum pellucidum and third ventricle there is mild mass effect upon the left lateral ventricle no intraventricular hemorrhagic extension and no parenchymal hemorrhage is identified prominence of the cerebral sulci is compatible with age related involutional change periventricular regions of hypodensity are compatible with chronic microvascular ischemic change no fracture is identified the paranasal sinuses and mastoid air cells are well aerated the orbits are unremarkable endotracheal and nasogastric tubes are noted impression large acute subdural hematoma along the convexity and tentorium with mass effect as described above ct head on for follow up findings an evolving subdural hematoma along the left cerebral convexity again likely extends along the left tentorium cerebelli minimal mm rightward midline shift is unchanged ventricular and sulcal caliber is unchanged and no new intracranial hemorrhage is identified moderate to severe periventricular white matter hypodensity is consistent with chronic small vessel ischemic changes atherosclerotic calcifications involve the cavernous carotids and intracranial vertebral arteries bilaterally the imaged portions of the paranasal sinuses appear well aerated impression evolving left cerebral convexity subdural hematoma with unchanged minimal mass effect stable compared to the ct from mri head findings areas of slow flow and restricted diffusion are seen in the right posterior parietal periatrial region with high signal on diffusion images and low signal on adc map indicative of acute infarcts small acute infarcts are also seen in right parietal and left frontal lobes there is subacute subdural hematoma identified extending from frontal to occipital region on the left with a maximum width of approximately cm to cm at the convexity with indentation on the sulci increased signal along the sulci may indicate small amount of subarachnoid hemorrhage or stasis of the csf secondary to subdural small amount of subdural collection is also seen along the left side of the tentorium there is no midline shift seen moderate to severe brain atrophy and moderate changes of small vessel disease are identified there is no midline shift sagittal t2 images were obtained to evaluate the brainstem but are limited by motion changes of cervical spondylosis are visualized which are further evaluated with cervical spine mri bilateral basal ganglia lacunes are seen impression small areas of restricted diffusion in the left frontal lobe right parietal lobe and left periatrial region suggestive of embolic infarcts left sided subdural hematoma extending from frontal to occipital region with obliteration of adjacent sulci no midline shift brain atrophy and small vessel disease mri c spine impression limited study due to motion multilevel degenerative change is seen moderate spinal stenosis at c4 and mild to moderate spinal stenosis at c5 and c6 with extrinsic indentation on the spinal cord postoperative changes with posterior bony bar at c3 slightly indenting the spinal cord atrophic changes in the spinal cord at c3 level echos the left atrium is elongated left ventricular wall thicknesses and cavity size are normal there is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal inferior and inferolateral walls the remaining segments contract normally lvef right ventricular chamber size and free wall motion are normal the ascending aorta is mildly dilated the descending thoracic aorta is mildly dilated the aortic valve leaflets are mildly thickened but aortic stenosis is not present there is no aortic valve stenosis mild aortic regurgitation is seen the mitral valve leaflets are structurally normal there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion impression normal left ventricular cavity size with mild regional systolic dysfunction c w cad pda distribution dilated ascending and descending thoracic aorta mild pulmonary artery systolic hypertension the left atrium is elongated left ventricular wall thicknesses and cavity size are normal there is mild regional left ventricular systolic dysfunction with hypokinesis of the inferior and inferolateral walls the remaining segments contract normally lvef right ventricular chamber size and free wall motion are normal the ascending aorta is mildly dilated the aortic valve leaflets are mildly thickened but aortic stenosis is not present mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened trivial mitral regurgitation is seen the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion compared with the prior study images reviewed of a prominent left pleural effusion is now identified and the estimated pulmonary artery systolic pressure is lower left ventricular wall motion is similar lower extremity cath comments access via lfa via 4f catheter imaging of the distal aorta with a omniflush catheter at l1 revealed mild aortic disease with no renal artery stenosis the iliacs were very tortuous on both sides but without flow limiting lesions the cfa s were without lesions imaging of the right leg with a slip cath in the right sfa revealed a mid sfa 10cm occlusion there was a high grade popliteal lesion and single vessel run off to the foot via a peroneal there was only very faint filling of plantars and dp referral to vascular surgery for right leg bka final diagnosis right sfa occlusion with severe infra popliteal disease renal us impression probably no hydronephrosis ct abdomen and pelvis follow up findings cc of contrast was administered through g tube there is no contrast extravasation extensive pneumoperitoneum is again noted however this is unchanged from the prior examination from the previous day there is bilateral pleural effusion small in quantity not significantly changed from the prior study the unenhanced liver and spleen appear unremarkable there is bilateral hydronephrosis and mild hydroureter this is likely on the basis of the significant wall thickening seen in the urinary bladder aneurysmal abdominal aorta at the diaphragmatic crura is unchanged from prior study with atherosclerotic changes the gallbladder appears dilated though unchanged from the prior study again noted is prominence of the left psoas muscle with an area of hypodensity which may represent fluid collection however infection cannot be excluded there is no evidence of bowel dilatation ivc filter is again noted there are degenerative endplate changes in the thoracolumbar spine impression no evidence for g tube extravasation no interval change in enlargement of the left psoas muscle with hypodense collection in the left flank while this may represent old hematoma a loculated infected collection cannot be excluded and intravenous contrast would be necessary for additional evaluation again noted mild bilateral hydronephrosis which is likely secondary to significant bladder wall thickening unchanged pneumoperitoneum ct chest impression dilated ascending aorta and thoracoabdominal junction bilateral psoas hematoma much larger on the left extending in the retroperitoneum labs on discharge chms added agap wbc hct plt all have been stable over the last several days estgfr click for details ck mb trop t comments ctropnt called 303am ctropnt ctropnt ng ml suggests acute mi ca mg p alt ap tbili alb ast ldh dbili tprot lip serum asa etoh acetmnphn benzo barb tricyc negative comments positive tricyclic results represent potentially toxic levels therapeutic tricyclic levels will typically have negative results tsh free t4 phenytoin pt ptt inr fibrinogen of note in microbiology pt only grew albicans in urine otherwise all cultures were negative without any obvious organism brief hospital course year old gentleman with cri htn bladder ca and known r transferred from nebh with subdural hematoma seizures and new acute on chronic renal failure requiring dialysis he was transfered to our neurosurgical service then micu for evaluation of altered mental status and sepsis altered mental status ams began with the development of a sdh after treatment of extensive lle dvt with a heparin gtt the patient was transfered to the micu on neurosurgery was the initial primary team then consulting and based on family discussions and repeat head imaging no intervention was performed his neurologic status did improve over time but persistent deficits lead to subsequent neurologic consultation the following problems were addressed by the neurology team for his encephalopathy toxic metabolic work up identified the following possible etiologies yeast uti pna r le necrosis l dvt esrd on hd his sedating medications were limited a repeat routine eeg demonstrated no evidence of subclinical sz activity mri of the brain however demonstrated small areas of restricted diffusion in the left frontal love right parietal love and left periatal region suggestive of embolic infarcts improving sdh for his strokes mri of the brain demonstrated actute embolic infarcts a subsequent tte on demonstrated regional left ventricular systolic dysfunction consistent with coronary artery disease a left atrial thrombus cannot be excluded by tte if clinically indicated a tee would better assess for this possibility no significant change from prior carotid ultrasound noted less than stenosis in the right and left internal carotid arteries mra was held due to concern for acute on chronic renal disease the patient was placed on asa to treat the embolic strokes after consultation with neurosurgery for his quadraparesis mri of the c spine multilevel degenerative change is seen with moderate spinal stenosis at c4 and mild to moderate spinal stenosis at c5 and c6 with extrinsic indentation on the spinal cord and postoperative changes with posterior bony bar at c3 slightly indenting the spinal cord atrophic changes in the spinal cord at c3 level the patient was transferred to the micu minimally responsive to stimuli on intermittent ativan he was intubated for airway protection and maintained on pressure support with minimal requirements his altered mental status was attributed to a combination of new subdural hematoma which remained stable throughout admission and resulting seizure activity on transfer he is responsive to questions with the appropriateness of his garbled answers uncertain as treatment for the seizures he was started on keppra and should be continued on this until neurology follow up is arranged the dose is keppra mg subdural hematoma after discovery of an extensive dvt of the lle at an osh the patient was started on a heparin gtt he subsequently developed right facial droop and increased dysarthria r sided weakness and somnolence he developed what appeared to be a r sided seizure and then a grand mal seizure in the ct scanner at the osh he was intubated for airway protection and transferred to to the neurosurgery service he was noted to be hypotensive after intubation without sedation prior to transfer and was started on neo heparin was stopped due to head bleed and ivc filter placed the patient developed a subdural hematoma at the outside hospital presumed secondary to heparin therapy for a dvt neurosurgery was the initial primary team then consulting and based on family discussions and repeat head imaging no intervention was performed the hematomas were stable on transfer see below for seizure treatment related to hematoma seizures the patient developed right sided seizures likely due to his subdural hematoma as confirmed by eeg and neuro consult the patient was started on ativan dilantin and keppra for seizure control he will be tapered off of dilantin transitioned to keppra and the ativan held acute on chronic renal failure acute on chronic kidney failure likely due to contrast induced nephropathy despite pretreatment with ivf and bicarb the patient was admitted with temporary hd line in place after days of hd he was seen by our renal service and dialyzed once through the temporary line with no further indication for dialysis at the time of transfer the patient developed a fever of unknown origin and the temperary hd line was pulled due to concern that it would be seeded by infection he subsequently developed fluid overload resistent to medical therapy nephrology then saw him and placed a permanent hd line and received regular hd he develops moderated hypotension during hd but was otherwise asymptomatic the plan is to continue monday and thursday dialysis indefinitely for now the renal team will directly contact the receiving rehab facility about dialysis information pneumonia gram suggestive of infection treated with days of vanc zosyn followed by unasyn with a resolution of white count and no fevers early in the admission he did have another infection of unclear source which resulted in sepsis and a second transfer to the micu see below for details of that infection right toe eschar unable to palpate doppler pulses and concern is for arterial insufficiency vascular consulted follow recs suggested nitropaste only no intervention given bleed and contraindication for heparin due to intermittant hypotension the nitropaste was discontinued he went for catheterization which demonstrated severe diffuse disease not amenable to stenting due to prior sdh patient was not a candidate for anticoagulation prelim report on us showed sfa occlusion with reconstitution distal to popliteal dvt the patient was found to have extensive dvt and acute on chronic rf was started on heparin gtt and subsequently developed a sdh the heparin was stopped and an ivc filter was placed in he does not have signs of pe with good oxygenation on room air hematuria insetting of change of and care the patient also has a history of bladder cancer urology saw patient earlier in admission several u as were positive for yeast infection the patient had a prolonged course of oral fluconazole and topical miconazole the yeast infection cleared on subsequent u a but per urology recs he is to complete a day course of fluconazole the end date of fluconazole is days from day of discharge on he should not have his foley changed once at rehab as it was placed with cystoscopy and is a difficult change he should follow up with urology in weeks after his fluconazole is completed for reevaluation of need for foley in setting of arf he does still make small amounts of urine inability to swollow possibly multifactorial with left sided sdh and acute embolic areas of infarction in addition to severe cervical spinal stenosis speach and swallow evaluation occurred on more than one occasion and he was unable to protect his airway and did not have a gag reflex after a significant amount of time with an ng tube and multiple conversations with the son her received a g tube he is receiving tube feeds and reached his goal rate hypotension developed within two days of g tube placement and in the setting of penile instrumentation etiology could be from a number of cuases including bleeding in the setting of his recent g tube placement hypovolemia perhaps increased vagal tone from bladder distention sepsis from gangrenous foot and acs a ct of his abdomen demonstrated a fluid collection that was not consistent with blood by but could not differentiate between sterile fluid collection or an abscess without contrast the patient received fluid boluses narcan to reverse the potential effects of the 1mg of i v morphine the patient received in addition the patient had blood and urine cultures the urine culture wa positive for bacteria and wbcs rbcs the patient remained persistently hypotensive despite ivf and was transferred to the micu for concern for urosepsis see below for micu course anemia hct in setting of hemodilution and hematuria no further hematuria overnight after foley replaced by urology iron studies were obtained and were consistent with anemia of chronic disease the hct remained stable thrombocytopenia resolved micu admission patient was transferred to micu on for hypotension in the setting of concern for sepsis with a possible complication of the g tube placement imaging did not show problems with the g tube placement and patient became afebrile and resolved leukocytosis on vanc zosyn fluconazole surgery followed and determined that the g tube was safe to use pressures were map and sbp in 90s higher than pressures on admission pressure throughout the course of hospitalization have not been greater than sbp sepsis his hypotension that resulted in transfer to the micu was likely urosepsis although no organism was ever grown in culture other sources could have been the intraabdominal fluid collection although surgery consulted and did not think it was an infection he responded to a course of vanco and zosyn and should complete a two week course of the antibiotics the end date is he had a midline placed for abx administration he recovered quickly without any need for pressure support he was not dialyzed during this time because of his hypotension but has been dialyzed the last two days prior to discharge and was run even he maintained his bps during this time pneumoperitoneum on ct scan during imaging while working up his hypotension ct revealed pneumoperitoneum around the g tube placement he had a benign abdomen exam and it was not thought to be cause of his hypotension his tube feeds were initially held but with surgery following along were restarted several days prior to discharge he quickly reached goal and did not have high residuals svt the day prior to discharge the patient developed transient episodes of svt with rates of the episodes last approximately minutes and were asymptomatic to the patient he maintained a normal blood pressure during these episodes most of the episodes broke with vagal manuevers or with a spontaneous pvc we started diltiazem for rate control at a very low dose as to not drop his blood pressures he tolerated the diltiazem well and should be continued on it in summary y o m who presented after anticoagulated dvt resulted in sdh also found to have old strokes now with resultant quadraparesis had seizures that were treated with keppra also initially had a pneumonia s p treatment while receiving imaging during workup of these above issues developed acute on chronic renal failure and started on hd now due for monday and thursday dialysis had workup of ischemic feet showed diseased vasculature but no intervention done no infection of necrotic toes was recovering well but after g tube placement had hypotension likely from sepsis of unclear etiology although urine most likely source has known yeast infection in bladder urology following and has permanent foley cath in is being treated with vanco and zosyn and fluconazole for sepsis had svts treated with diltiazem so once at rehab he should continue his antibiotic course of vanco zosyn and fluconazole he can start pt ot he should follow up with neuro urology and his pcp medications on admission oxycodone calcitrol prilosec mentax avocat flomax timoptic travatan dyazide vitamin d vitamin b12 on transfer lorazepam mg iv once duration doses order date iv access temporary central access icu location left subclavian date inserted order date lorazepam mg iv q4h seizure activity hold if oversedated order date ml ns continuous at ml hr order date magnesium sulfate gm iv once duration doses order date ml ns bolus ml over mins order date norepinephrine mcg kg min iv drip titrate to sbp 100mmhg order date ml ns bolus ml over mins order date pantoprazole mg iv q24h order date ml ns bolus ml over mins order date phenytoin mg iv q8h hold am dose until trough level back order date acetaminophen mg pr q4h prn fever or pain order date piperacillin tazobactam na g iv once duration doses awaiting id approval id approval is required for this order order date calcium gluconate gm ml d5w iv once duration doses order date pneumococcal vac polyvalent ml im asdir order date chlorhexidine gluconate oral rinse ml oral use only if patient is on mechanical ventilation order date sodium chloride flush ml iv q8h prn line flush peripheral line flush with ml normal saline every hours and prn order date influenza virus vaccine ml im asdir follow influenza protocol document administration in poe order date sodium chloride flush ml iv prn line flush temporary central access icu flush with 10ml normal saline daily and prn order date insulin sc per insulin flowsheet sliding scale order date vancomycin mg iv once duration doses order date discharge medications latanoprost drops one drop ophthalmic hs at bedtime timolol maleate drops one drop ophthalmic times a day lidocaine mg patch adhesive patch medicated one adhesive patch medicated topical qd apply to mid back heparin porcine unit ml solution one injection times a day calcium carbonate mg ml mg suspension one po tid times a day miconazole nitrate powder one appl topical tid times a day as needed cholecalciferol vitamin d3 unit tablet two tablet po daily daily aspirin mg tablet one tablet po daily daily acetylcysteine mg ml solution one ml miscellaneous q6h every hours as needed for cough simvastatin mg tablet two tablet po daily daily ipratropium bromide solution one inhalation q6h every hours lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr daily daily levetiracetam mg ml solution five hundred mg po bid times a day fluconazole mg tablet one tablet po q48h every hours for days monitor for interaction with statin watch for ck elevation or rhabdo vancomycin in dextrose gram ml piggyback one gram intravenous hd protocol hd protochol through piperacillin tazobactam gram recon soln one intravenous twice a day through insulin lispro unit ml solution per sliding scale subcutaneous asdir as directed please see sliding scale epoetin alfa unit ml solution at hemodialysis injection asdir as directed verapamil mg tablet one tablet po q12h every hours discharge disposition extended care facility rehab center discharge diagnosis deep venous thrombosis subdural hemorrhage seizure disorder end stage renal disease on hemodialysis svt treated with vagal maneuvers discharge condition vital signs were stable sbp occassionally drops to 80s but pt is without change in mental status patient with g tube in place patient is communicative with non verbal signs afebrile completing course of antibiotics discharge instructions you were admitted initially at with decreased appetite and leg swelling you were found to have extensive dvt and acute on chronic renal failure you were later noted to have right sided weakness and somnolence developed what appeared to be a right sided seizure and then a grand mal seizure you were intubated for airway protection and transferred to here we treated you for your seizures we found that they were likley caused by a large subdural hematoma in your brain you also developed renal failure and needed to start hemodialysis he placed a gtube in your stomach to feed you we also needed to treat you for a severe infection that caused your blood pressure to get low you were on antibiotics and improved you will now continue to recover at rehabilitation complete your course of antibiotics and work on your strength please return to the hospital or call your doctor if you have temperature greater than shortness of breath worsening difficulty with swallowing chest pain abdominal pain diarrhea or any other symptoms that you are concerned about followup instructions please call to make an appointment with dr urologist for follow up weeks after discharge please call to make and appointment with dr neurology for follow up for weeks after discharge md completed by ", 
-                "Sample summary 2": "date of birth:               sex:   m service medicine allergies percocet erythromycin base a c e inhibitors nsaids attending chief complaint fevers rigors major surgical or invasive procedure dialysis bilateral hematoma and right lower quadrant hematoma incision and drainage left arm picc placement history of present illness year old male with a history of end stage renal disease of unknown etiology on hd htn prior history of hodgkin s disease gout peptic ulcer disease hypothyroidism depression presenting with fevers after right subclavian hd line was placed by transplant surgery days prior to admission mr went for his first hd treatment after new line placement day prior to admission with temps to he also developed rigors this morning and presented to his fever climbed to and was given vancomycin blood cultures from his hd line and was given fluid boluses and was then transferred to given that his nephrologist and transplant team are here in the ed his heart rates were in the 130s with a rectal temperature of he was visibly in rigors and not endorsing any pain otherwise he received tylenol and ativan for his rigors zosyn was added on to his vancomycin transplant team pulled his hd line and tip was sent for culture an ekg done in the ed showed st elevations in avf and lead iii with st depressions in v1 and v2 however these resolved on repeat ekg set of troponins was elevated to with no prior troponins to compare to ck mb was of normal fraction cards was consulted and they felt the troponin elevation was in the setting of chronic renal failure and demand ischemia in setting of tachycardia aspirin was given they did not recommend anticoagulation in setting of demand iv vancomycin was redosed and l of iv fluids were given vitals in the ed were hr bp rr satting ra past medical history chronic renal failure cr baseline followed by dr at no kidney biopsy hypertension hodgkin s disease s p chemotherapy with and radiation reportedly as a result of chemo treatment left him with numbness below the waist depression with one prior psych hospitalization h o suicidal attempt with narcotics overdose left eye blindness evaluated in ed on with functional overlay back pain right flank pain requiring chronic narcotics as per pt unknown etiology hypothyroidism gout tear post radiation pancreatitis chronic anemia social history pt lives with his wife and his children he is on disability used to work as emt pt denies tobacco alcohol or illicit drug use family history father s p renal transplant hypertensive nephropathy mother depression and alcohol dependence two sons ages and with renal dysplasia no history of deafness or cystic kidney disease physical exam admission physical exam vs hr 120s bp ra rr temp gen in nad lying in bed heent anicteric oropharynx clear cardiac tachycardic no murmurs appreciable chest old suture evident from prior line placement pulm clear in anterior fields abd soft and nontender ext no edema noted discharge physical exam vs tm tc bp hr rr s02 ra gen lying in bed comfortable apparing cardiac muffled s1 and s2 rrr systolic murmur at the apex as well as llsb cardiac friction rub present lungs crackles at the bases but otherwise clear abdomen mod firm and distended two incision sites in rlq and llq show staples in place without drainage minimal tenderness around rlq incision ue significant erythema and swelling in lue le dp radial pulses trace swelling in bilat le pertinent results admission results cbc wbc rbc hgb hct mcv mch mchc rdw plt ct neuts lymphs monos eos baso coags pt ptt inr pt chem glucose urean creat na k cl hco3 angap lfts alt ast ck cpk alkphos totbili lytes calcium phos mg abx vanco lactate cardiac markers 58pm blood ctropnt 42am blood ck mb mb indx ctropnt 37am blood ck mb ctropnt 00pm blood ck mb ctropnt 55am blood ck mb ctropnt 01pm blood ck mb ctropnt 51pm blood ck mb ctropnt 12am blood ck mb ctropnt 27am blood ck mb ctropnt 36am blood ck mb ctropnt 40am blood ck mb ctropnt 59am blood ck mb ctropnt relevant results 55am blood esr 55am blood crp 15pm blood aca igg aca igm 30am blood aca igg aca igm 30am blood lupus pos 58pm blood lipase 55am blood lipase 20am blood lipase 30am blood hapto 55am blood hba1c eag 55am blood triglyc hdl chol hd ldlcalc 27am blood hbsag negative hbsab positive hav ab positive 27am blood hcv ab negative micro pm blood culture final report blood culture routine final staph aureus coag consultations with id are recommended for all blood cultures positive for staphylococcus aureus and species final sensitivities staphylococcus species may develop resistance during prolonged therapy with quinolones therefore isolates that are initially susceptible may become resistant within three to four days after initiation of therapy testing of repeat isolates may be warranted sensitivities mic expressed in mcg ml staph aureus coag clindamycin s erythromycin s gentamicin s levofloxacin s oxacillin s trimethoprim sulfa s aerobic bottle gram stain final reported by phone to at 35pm on gram positive cocci in clusters anaerobic bottle gram stain final gram positive cocci in clusters pm catheter tip iv aerobic anaerobic final report wound culture final staph aureus coag colonies staphylococcus species may develop resistance during prolonged therapy with quinolones therefore isolates that are initially susceptible may become resistant within three to four days after initiation of therapy testing of repeat isolates may be warranted sensitivities mic expressed in mcg ml staph aureus coag clindamycin s erythromycin s gentamicin s levofloxacin s oxacillin s trimethoprim sulfa s cardiology tte the left atrium is elongated the right atrium is moderately dilated no atrial septal defect is seen by 2d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity is moderately dilated lv systolic function appears depressed ejection fraction percent secondary to severe hypokinesis of the inferior septum inferior free wall and posterior wall there is no ventricular septal defect right ventricular chamber size is normal with depressed free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic stenosis no masses or vegetations are seen on the aortic valve but cannot be fully excluded due to suboptimal image quality mild aortic regurgitation is seen the mitral valve appears structurally normal with trivial mitral regurgitation there is no mitral valve prolapse no masses or vegetations are seen on the mitral valve but cannot be fully excluded due to suboptimal image quality no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality no masses or vegetations are seen on the pulmonic valve but cannot be fully excluded due to suboptimal image quality there is no pericardial effusion impression no obvious vegetation but suboptimal study tee no atrial septal defect is seen by 2d or color doppler left ventricular wall thickness cavity size and global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets appear structurally normal with good leaflet excursion no masses or vegetations are seen on the aortic valve no aortic regurgitation is seen the mitral valve leaflets are structurally normal no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no vegetations or abscess normal biventricular systolic function mild mitral regurgitation radiology u s r hd graft patent right upper extremity av graft with no stenosis no evidence of abscess u s rue and r ij nonocclusive thrombus seen in the mid right internal jugular vein no evidence of perigraft abscess of hd graft u s bilateral hips no hip joint effusion on the left or right side slight asymmetry of psoas muscle on the right suspicious for a psoas paraspinal process mri bilateral thighs bilateral heterogeneous fluid collections in the iliacus muscles most consistent with abscesses right greater than left fluid fluid levels with areas of t1 hyperintensity suggest the presence of internal hemorrhage and or proteinaceous debris collection on the right extends into the iliopsoas bursa with associated myositis and small area of focal fluid near the rectus femoris origin no evidence of hip effusions ct of pelvis large right and small left iliac muscle abscess with percutaneous drain in place on the right right iliac abscess extends inferiorly distal to the inguinal ligament but does not reach the iliopsoas insertion site at the lesser trochanter left iliac muscle abscess ends about cm distal to the inguinal ligament ct of pelvis right iliopsoas pigtail catheter removal and subsequent washout now with packing surgicell gauze in place and a skin staple closure over it this was confirmed with the description in the operative note as well as with at on right subcutaneous fat fluid collection with air fluid level and hematocrit suggestive of hematoma extensive subcutaneous gas likely postoperative although gas producing infection cannot be ruled out pelvic arteriogram pelvic arteriograms without signs of active bleeding no embolization was performed l groin u s there is a x x cm collection with a fluid fluid level within the left groin suggestive of a hematoma there is no internal vascularity there is no connection with the underlying vessels the underlying left common femoral artery and vein demonstrate normal waveforms and are patent abd u s multiple superficial hypoechoic fluid collections in the right lower quadrant adjacent to the incision one of which measures cm with complex features located above the right inguinal fold raising question of abscess this site has been marked for possible aspiration although not definitely amenable to drainage given internal echoes abd ct two fluid collections in the right anterior abdominal wall one may be residual hematoma the other may be fluid infection is not excluded multiple locules of air within the right iliacus muscle some of which may be post operative the remaining may be related to surgical packing with surgicel a small amount of air may be intraperitoneal persistent large amount of air in the anterior abdominal wall fascititis is not excluded heterogeneous attenuation of the left iliacus muscle may reflect residual hematoma at the site but no locules of air within the left iliacus small amount of free fluid within the pelvis mrv chest without contrast no findings of svc thrombosis no contrast was administered due to diminished gfr reidentification of nonocclusive chronic appearing thrombosis in the mid right jugular vein better appreciated on the previously performed ultrasound moderate left pleural effusion and pericardial effusion abdominal ultrasound a cm fluid collection in the subcutaneous fat of the right lower quadrant tte the left atrium is normal in size the estimated right atrial pressure is 15mmhg left ventricular wall thicknesses and cavity size are normal there is moderate regional left ventricular systolic dysfunction with basal to mid akinesis of the inferior wall there is mild hypokinesis of the remaining segments lvef the estimated cardiac index is normal 5l min m2 right ventricular chamber size is normal with mild global free wall hypokinesis the diameters of aorta at the sinus ascending and arch levels are normal the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve leaflets are structurally normal mild mitral regurgitation is seen the pulmonary artery systolic pressure could not be determined there is a moderate sized pericardial effusion no right ventricular diastolic collapse is seen there is brief right atrial diastolic collapse there is significant accentuated respiratory variation in mitral tricuspid valve inflows consistent with impaired ventricular filling compared with the prior study images reviewed of there is a moderate sized pericardial effusion without frank tamponade ekg sinus tachycardia left bundle branch block since the previous tracing of there is probably no significant change tte the left atrium is mildly dilated the estimated right atrial pressure is 20mmhg left ventricular wall thicknesses are normal the left ventricular cavity size is normal there is moderate to severe global left ventricular hypokinesis lvef right ventricular chamber size is normal with depressed free wall contractility the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse the estimated pulmonary artery systolic pressure is normal there is a moderate sized pericardial effusion there are no echocardiographic signs of tamponade no right ventricular diastolic collapse is seen there is brief right atrial diastolic invagination compared with the findings of the prior study images reviewed of the pericardial effusion is slightly smaller tte the estimated right atrial pressure is 10mmhg there is mild regional left ventricular systolic dysfunction with basal to mid inferoseptal inferior and inferolateral hypokinesis overall left ventricular systolic function is mildly depressed lvef right ventricular chamber size is normal with borderline normal free wall function there is a moderate sized pericardial effusion no right ventricular diastolic collapse is seen there is brief right atrial diastolic collapse there is significant accentuated respiratory variation in mitral tricuspid valve inflows consistent with impaired ventricular filling compared with the prior study images reviewed of the pericardial effusion size is similar without tamponade the left ventricular systolic function may be slightly improved upper extremity us with doppler short segment of nonocclusive thrombus along the left basilic picc in the upper arm discharge labs 24am blood wbc rbc hgb hct mcv mch mchc rdw plt ct 24am blood pt ptt inr pt 24am blood glucose urean creat na k cl hco3 angap 24am blood calcium phos mg brief hospital course year old with a complicated medical history including prior hodgkins htn pud hypothyroidism depression hx of lupus anticoagulant requring warfarin use and esrd of unclear etiology on transferred from osh to ed on two days prior to presentation the patient had a right ij tunneled hd line placed placed by dr transplant surgery one day prior to presentation went to hd with fevers had rigors morning of presentation on and went to mssa line sepsis patient was initially admitted directly to the micu for concern of line sepsis in the setting of fevers and rigors transplant surgery was notified and removed newly placed subclavian line osh blood cultures grew staph aureus and patient was started on vancomycin while sensitivities were pending blood cultures at were taken prior to antibiotic administration these cultures also grew gram positive cocci patient continued to spike intermittent fevers surveillance cultures were taken daily while in the micu a tte was completed and did not indicate any valvular abnormalities however it did show focal areas of hypokinesis and a depressed ef as noted below tee was arranged with cardiology and showed no vegetations on day of transfer to floor patient was also started on nafcillin as cultures came back mssa plan was complete a week course of antibiotics for mssa bacteremia with nafcillin being used while in hospital and then transition to cefazolin with hemodialysis once patient was discharged as noted below abx were changed for days to emperic vanco cefepime due to concerns for thigh and abdominal abscess but patient was transitioned back to nafcillin ciprofloxacin and flagyl once the culture data from these thigh abdomen collections was negative the patient was transitioned from nafcillin to cefazolin prior to discharge cefazolin ciprofloxacin and flagyl were to be continued until cefazolin to be given with hd grams on monday and wednesday and g on friday was contact directly regarding the cefazolin as it was left out of his discharge medication list pericardial effusion patient had mrv of chest to evaluate for clot burden which revealed an incidental pericardial effusion pulsus physiology was difficult to detect as patient had av graft in right extremity and a picc line in his left extremity a tte was subsequently perfromed to characterize the effusion more carefully and revealed a cm pericardial effusion without evidence of tamponade though brief right atrial collapse was noted a repeat tte hours later revealed a slightly smaller effusion with only right atrial involution appreciated a third tte was performed on the day of discharge approximately houurs later which again showed a slightly smaller pericardial effusion with noted brief right atrial diastolic collapse a copy of the most recent tte report was sent with the patient at to communicate with him regarding follow up the patient is to have repeat ttes on and a follow up cardiology appointment was made for the patient on troponin leak on admission patient had ekg changes concerning for cardiac ischemia initial troponins were elevated although ck mb was within normal limits cardiology was notified in the ed and said that the troponin level was consistent with esrd and demand ischemia as patient was tachycardic for a prolonged period however tte demonstrated inferior wall hypokinesis with ef of which made it appear that the patient had a cardiac event prior to admission and still had elevated troponins from this event because of no renal clearance pt was started on full strength asa high dose atorvastatin beta blocker and kept on heparin drip which had already been started for below coagulation issues cardiology initially planned to perform cardiac catheterization during his hospitalization but tee done to evaluate for endocarditis a few days after initially tte no longer showed evidence of hypokinetic wall segments and showed and ef bringing back to the forefront the idea that perhaps the patient had not had a cardiac event and had merely spilled troponins in the setting of some coronary disease exacerbated by tachycardia septic physiology and esrd decision was made for no coronary intervention and atorvastatin dose was decreased in setting of elevated lfts troponins continued to slowly trend down although never really resolved during the hospitalization likely secondary to his esrd late in this hospital course the troponins were no longer followed heparin was stopped as patient developed hematomas as per below and it was felt that the risk to bleeding was more significant that risk of clotting ttes were performed per above the last tte on day of discharge revealed an ef of cardiology follow up per above esrd renal was notified upon admission and patient received a line holiday while in the micu receiving abx electrolytes were monitored plan was for patient to restart normal mwf schedule using mature graft of r upper extremity however ptt was on morning of planned graft access and infectious disease was also concerned about the possibility that graft infected in the setting of bacteremia as a result a temporary l subclavian tunneled hd catheter was placed by ir and used for two hd sessions while ptt was brought under better control and u s of r vascular graft was done to r o infection u s showed no evidence of perigraft abscess of fluid collection so graft was used for hd starting on temporary hd line was removed after successful use of the graft pt was continued on mwf hd schedule for throughout his hospitalization antibiotics to be given at hd after discharge as per above coagulopathy at time of admission pt was on therapeutic warfarin with presenting inr of per patient report he was on this medication because of anti phospholipid hypercoag state that had been discovered at hospital as part of a work up to determine why he kept clotting off hd access grafts fistulas pt warfarin was held at presentation to because of need for multiple procedures and pt was placed on heparin gtt this was continued through much of hospitalization but pt still developed multiple thrombotic complications in the icu difficulty threading a l ij line led team to believe there must be a clot in the l ij additionally a non occlusive thrombus in r ij at site of recent central line was found on u s pt later developed significant r hip thigh pain with some swelling ultra sound of the area showed and asymmetry that was suspicious for a psoas paraspinal process as a result f u mri of the r hip thigh was performed and showed bilateral heterogeneous fluid collections in the iliacus muscles most consistent with abscesses right greater than left fluid fluid levels with areas of t1 hyperintensity suggest the presence of internal hemorrhage and or proteinaceous debris collection on the right extends into the iliopsoas bursa with associated myositis and small area of focal fluid near the rectus femoris origin because patient was febrile with significant pain in the area ct guided ir drainage of r thigh abscesses were performed on with drain placed in the r side a follow up ct on showed persistence of fluid and in light of continuing fevers and concern for permanent neurologic damage to nerve structures in the area orthopedic surgery took pt to the or to debride the abscesses during surgery these were found to be hematomas r l from the or pt was transferred to the tsicu due to hypotension sbp down to the s and complications from bleeding which continued to ooze during surgery preventing initial closure of the wound in the tsicu mr was placed on peripheral pressors initially due to access issues and was also transfused blood products due to hct drop and hypotension also he had an elevated white count and fevers left femoral line was placed on additionally was switched from nafcillin to vancomycin cefepime on with suggestion of a day course switch made at id s suggestion due to concern of possible infected hematomas at sites of abscesses these abx continued until slightly longer than initially planned because concern for a wound infection had developed in the interim as noted below pressors d c d morning of and the pt s vs remained stable and afebrile had pelvic arteriograms performed to assess for possible bleeds which were negative went back to the or on to have packing removed from washout on cultures ultimately negative from this source and hematomas seemed to have spontaneously formed while on heparin gtt pt was transfered back to the floor but shortly thereafter developed pain in l groin and significant rlq pain with surrounding skin erythema induration and dusky changes ultra sound of l groin showed a small hematoma which had formed at site of femoral line removal the day before there was no vessel aneurysm and the hematoma was not connected to other vascular structures so since small no intervention was undertaken ultra sound of abdomen showed multiple superficial hypoechoic fluid collections in the rightnlower quadrant adjacent to the recent surgical incision one of which measured cm withcomplex features located above the right inguinal fold raising question of abscess a ct of abdomen with contrast showed two fluid collections in r ant abdominal wall one likely hematoma with the other containing fluid that could not have infection excluded because pt has having recurrence of fever spikes there was concern for post surgical abscess orthopedics took pt back to the or on for i d of the wound and found it to be a hematoma not abscess cultures were sent but like previous hematoma cultures remained negatived the heparin gtt was eventually disconinued as the risk of bleeding was considered greater than the risk of clotting hematology was consulted as an inpatient but had low suspicion for a hypercoaguable state the patient was discharged with the contact information to make a follow up appointment so that his possible anti phospholipid syndrome could be evaluated more appropriately as an outpatient pain control pt with significant pain control issues during hospitalization mostly related to pain at sites of various hematoma formations initially pain was controlled with iv morphine but this was ultimately changed to dilaudid because of pt s poor renal function dilaudid pca was initiated when difficulty controlling pain with iv pushes pt then started on long acting oxycontin which was uptitrated in effort to provide more consistent pain control dilaudid pca weaned as long acting pos uptitrated and pt ultimately transitioned over to po dilaudid for breakthrough pain as better control was achieved the patient was eventually transitioned to oxycontin for pain control the patient reported significantly improved pain late in his hospital course left upper extremity thrombosis the day prior to discharge the patient had left upper extremity swelling and mild surround erythema an us was ordered for evaluation of a thrombosis and revealed a short segment of nonocclusive thrombus along the left basilic picc in the upper arm per report good flow was noted around the picc line the picc line was pulled as it was considered the most likely source of the thrombosis no anticoagulation was persued due to above issues and due to its non occlusive nature and thought that it would resolve after the picc line was removed medications on admission albuterol allopurinol mg daily nephrocaps caps daily calcium acetate mg daily citalopram mg daily vicodin levothyroxine mcg daily morphine mg daily pantoprazole mg daily trazodone mg qhs venlafaxine mg daily coumadin alternating colace senna discharge disposition extended care facility discharge diagnosis primary diagnosis mssa methicillin sensitive staphylococcus aureus bacteremia bilateral psoas and right lower quadrant hematomas pericardial effusion myocardial ischemia secondary diagnoses end stage renal disease possible lupus anticoagulant anti phospholipid antibody syndrome discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions mr you were admitted to with a bloodstream infection that was most likely from your tunneled hd line blood cultures revealed a bacteria called staphylococcus aureus that was sensitive to the antibiotic nafcillin you were treated with nafcillin throughout most of your stay but were transitioned to cefazolin prior to discharge you will need to continue cefazolin as instructed below on admission to the hospital you were also on coumadin for a possible diagnosis of anti phospholipid antibody syndrome as you subsequently developed several hematomas during your hospitalization this medication was discontinued and the hematology service was consulted the diagnosis of anti phospholipid antibody syndrome is difficult to make as an inpatient you will need to follow up with the hematology department as an outpatient and the information has been provided below the following changes were made to your medications start cefazolin grams with hemodialysis on mondays and wednesdays and grams with hemodialysis on fridays you will need this antibiotic for a total of two weeks from stop this medication on stop taking vancomycin which you were admitted on from the outside hospital your senna was increased from tablet by mouth twice a day for constipation to tablets twice a day for constipation stop taking the cefazolin that you were admitted on and continue as directed above stop taking morphine sulfate mg intravenously every four hours for pain start taking oxycontin mg by mouth every hours start taking docusate sodium mg by mouth twice a day for constipation start taking atorvastatin mg by mouth once a day for hyperlipidemia start taking ciprofloxacin mg by mouth once a day for days start this medication on and stop on start taking metronidazole mg by mouth every eight hours for days you will need one dose the evening of otherwise you will need to take this medication three times a day from to start taking trazodone mg by mouth at night as needed for insomnia start taking nephrocaps b complex vitamin c folic acid tab by mouth daily start taking calcium acetate mg take two capsules three times a day with meals start taking sevelamer carbonate mg take one tablet by mouth three times a day with meals start taking nitroglycerin mg tablets take one tablet every five minutes as needed for chest pain do not exceed tablets in a minute period given the severity of your renal failure you will also need to receive epoetin alfa with dialysis this medication will not appear on your medication list in the following documents as it was dosed and administered according to protocols no other changes were made to your other medications while in the hospital and you should continue taking all other medications as previously prescribed followup instructions please keep all follow up appointments as below please call the hematology oncology department at to establish a follow up appointment in the hemostasis and clinic for further evaluation of the possible anti phospholipid antibody syndrome please call the orthopedics department at to make a follow up appointment the appointment should be for approximately one month from the date of discharge and should be made with the the nurse practitioner please keep the infectious disease appointment as below department infectious disease when monday at am with md building lm bldg campus west best parking garage below are instructions for the labs that will need to be sent to the infectious disease department prior to your appintment on outpatient antibiotic regimen and projected duration and dose cefazolin 2g with dialysis on mo we 3g with dialysis on friday start date stop date required laboratory monitoring lab tests cbc bun crea lfts esr and crp frequency qweekly all laboratory results should be faxed to infectious disease r ns at patient will need weekly monitoring of his pericardial effusion with a transthoracic echocardiogram please communicate this information to the md completed by ",
+sample_texts = {"Sample summary 1": "date of birth:               sex:   f service medicine allergies levofloxacin attending chief complaint dyspnea pneumonia major surgical or invasive procedure et tube change arterial line placement right ij line placement ir guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness year old woman with history of asthma copd dm hypothyroidism with recent history significant for worsening dyspnea over past three months status post four courses of antibiotics and steroids for presumed copd exacerbation presenting to hospital on with acute worsening dyspnea intubated for respiratory distress and transferred to for further management as noted above she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids she presented to osh on with worsening dyspnea and had a fever to 103f and was started on ceftriaxone azithromycin for pneumonia and copd exacerbation she developed an increasing oxygen requirement however and initially required nasal canula on l o2 but later required face mask on l on her cxr which initially was read as negative for infiltrate progressively worsening with increasingly prominent diffuse bilateral infiltrates right greater than left she also had a negative chest cta with an oxygen requirement that was rising and worsening dyspnea she was transitioned to vanc zosyn levo and then vanc zosyn ceftaz ceftaz started levo on because of an allergy to levofloxacin it is unclear why she received double coverage for gram negatives she was also given methylprednisolone dose mg iv q8 then mg iv q8 afterward on she was admitted to the icu and intubated electively for hypoxia and sob sputum culture grew staph aureas that was mrsa per report influenza viral screen was negative phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol which had to be uptitrated for sedation she was transferred to on based on her family s wishes on arrival her ventilator settings were vt 500cc fio2 peep she was on phenylephrine at and rapidly weaned off her vs were vent past medical history copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s p lumpectomy h syndrome per pcp social history she does not smoke or drink she lives with her husband family history non contributory physical exam vitals t bp p r o2 general intubated obese arousable heent ett sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs soft inspiratory wheezes bilaterally no rales or rhonchi cv regularly irregular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 36pm type art temp rates tidal vol peep o2 po2 pco2 ph total co2 base xs aado2 req o2 intubated intubated 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw 22pm plt count 22pm pt ptt inr pt 09pm blood ck cpk ck mb notdone ctropnt 41pm blood ck cpk ck mb notdone ctropnt 00am blood ck cpk ck mb notdone ctropnt 50am blood caltibc ferritn trf 00pm blood fibrino 13am blood ret aut 15pm blood hapto 24am blood triglyc 27am blood triglyc 41am blood tsh 10am blood hba1c spep trace abnormal band in gamma region based on ife see separate report identified as monoclonal igg kappa now represents by densitometry roughly mg dl of total protein upep multiple protein bands seen with albumin predominating based on ife see separate report negative for bence protein immunofixation urine no definite m protein seen negative for bence protein bal flow cytometry there is an immuonphenotypically abnormal cd138 cd56 cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid the significance of this finding in the context of an acute viral illness is unclear although a reactive process is favored a lymphoproliferative disorder can not be ruled out repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated bal bronchial washings cytology negative for maligt cells many neutrophils pulmonary macrophages lymphocytes and few multinucleated giant cells rare fungal organisms present consistent with species pm bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final ml oropharyngeal flora immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at within week if additional testing is needed rapid respiratory viral antigen test final this is a corrected report respiratory viral antigen test is uninterpretable due to the lack of cells positive for swine like influenza a h1n1 virus by rt pcr at state lab previously reported as respiratory viral antigens not detected specimen screened for adeno parainfluenza influenza a b and rsv refer to respiratory viral culture for further information reported by phone to dr 12p am urine source catheter legionella urinary antigen final negative for legionella serogroup antigen pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final oropharyngeal flora absent pseudomonas aeruginosa sparse growth pseudomonas aeruginosa cefepime i ceftazidime r ciprofloxacin r gentamicin s meropenem s piperacillin r tobramycin s am blood culture source line a line blood culture routine preliminary parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus and species sensitivities performed on request aerobic bottle gram stain final reported by phone to dr 0800am budding yeast urine cx yeast cta chest no evidence of pe consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia atelectasis is in the bases of the lungs given the fact that there is no cardiomegaly or pleural effusions diffuse ground glass opacity is probably not cardiogenic in origin could be resolving noncardiogenic pulmonary edema or drug reaction reactive mediastinal lymphadenopathy ct chest overall improvement in extent of diffuse multifocal bilateral ground glass opacities with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe unchanged mediastinal lymphadenopathy likely reactive signs of anemia bulky left adrenal fatty pancreas tiny liver hypodensity too small to characterize cta chest no pulmonary embolism marked interval worsening of multifocal bilateral ground glass opacities with new areas of consolidation in the bilateral lower lobes and right upper lobe likely reflecting progression of infectious process ct chest impression multifocal bilateral airspace opacities in the lungs grossly unchanged from the prior study tte the left atrium and right atrium are normal in cavity size suboptimal image quality agitated saline contrast injection at rest x did not demonstrate early appearance of contrast in the left atrium there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be quantified there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function no definite intracardiac shunt identified tte the left atrium is normal in size left ventricular wall thickness cavity size and global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion there is an anterior space which most likely represents a fat pad impression normal global and regional biventricular systolic function no diastolic dysfunction or significant valvular disease seen mild pulmonary hypertension tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no vegetations seen suboptimal quality study normal global and regional biventricular systolic function ct head no acute intracranial pathology air fluid level seen in the sphenoid sinuses which may be the result of long term intubation or nasal feeding tube ct head no acute intracranial process if there is a high clinical concern for an infarct an mri with diffusion is recommended abd x ray findings a percutaneous feeding tube is present overlying the midabdominal region a non obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 00am differential neuts lymphs monos eos baso 00am chemistry renal glucose glucose urean creat na k cl hco3 angap 00am antibiotics vanco 16pm brief hospital course year old woman with history of asthma copd dm hypothyroidism presenting to osh with acute on chronic dyspnea treated with antibiotics for pneumonia and intubated for worsening hypoxia and transferred for further management respiratory failure pneumonia she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates her course was notable for progressive worsening of her respiratory status during her osh hospitalization along with development of bilateral infiltrates at the time of transfer her cxr large a a gradient and low pao2 fio2 were thought to be consistent with ards acute lung injury and mechanical ventilation settings targeted low tidal volumes and high respiratory rate however despite this her lung was compliant with low peak inspiratory pressures she was also very peep dependent culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin zosyn and then zosyn was discontinued and she was given a course of solumedrol because of her history of question copd a respiratory viral screen performed at the osh was negative and was repeated at the initial dfa test was negative but the sample was sent to the state lab and there it was positive for h1n1 the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt she continued to require high peep with hypoxia if peep was lower than diuresis was tried several times with minimal change in peep linezolid was switched back to vancomycin given concern for lactic acidosis id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a day course a picc line was placed on for long term antibiotics oseltamivir was discontinued on vanco was discontinued gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation and a trach was placed by ip on sedatives eventually weaned off on and transitioned to fentanyl gtt and valium which too were weaned off to a mcg patch q72 hours this should be weaned further at her facility under the direction of the accepting md patient was transitioned to lasix iv boluses until cr and bun bumped then prn to keep her i os even although sputum cx with persistence of pseudomonas per id this was thought to represent colonization pt finished her day course of meropenem on single lumen picc was placed after a day line holiday afib with rvr patient developed af with rvr and hypotension chads score no evidence of pe on cta chest or right heart strain on echo normal atria she was started on hep gtt and amio loaded she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib heparin was discontinued at time of trach placement long term anticoagulation was not started as she is considered low risk s p conversion she was continued on amiodarone and asa volume overload the patient was volume overloaded after about week in the icu lasix gtt was started to have a smoother diuresis as bolus doses of 40mg iv lasix made her transiently hypotensive she was restarted on lasix gtt in setting of pressors which were eventually weaned off she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped then transitioned to prn lasix boluses to keep i os even of note she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing please give iv lasix 160mg prn to keep fluid balance even fungemia patient began to spike fevers almost one month into her hospitalization she was started on oral fluconazole on due to persistent yeast positive urine cultures despite changing out foley catheters rij placed was pulled however blood cultures from a line grew out yeast presumptively not c albicans on her a line and picc were pulled id was re consulted and recommended switching to micafungin ophthalmology was consulted and did not see evidence of endopthalmitis tte was suboptimal but without e o endocarditis id did not think tee needed as blood cx grew c paraipsilosis changed to fluconazole iv to complete day course of antifungal last dose repeat blood cultures including mycolytic cultures showed no growth to date up until left arm weakness patient was noted to be moving all extremities except the left upper voluntarily on concern was for emoblic event given af as well as fungemia ct head was done which showed no acute process and a tte was without vegitations pt later observed to be moving all extremities and withdrawing to painful stimuli in l arm so no further work up pursued vaginal bleeding she was noted to have vaginal bleeding after a week in the hospital she was evaluated by ob gyn who could not find evidence of further bleeding a pelvic ultrasound was a very limited study but did not find any pathology she should follow up as an outpatient with her ob gyn for further workup hypertriglyceridemia tg elevated to in setting of propofol gtt pt initially switched to fentanyl and midazolam with improvement in tg she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation atyical bal pathology tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138 cd56 cell population on flow cytometry significance unclear in in the context of an acute viral illness and a reactive process was favored although a lymphoproliferative disorder could not be ruled out repeat bronch on with path read of lymphocytes alveolar macrophages neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization cytology negative for maligt cells diabetes required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control hypothyroidism continued levothyroxine communication patient husband is h son is c medications on admission singulair mg qhs prevacid mg daily levothyroxine mg daily d flonase sprays eat nostril daily advair on inh albuterol nebs prn janumet metformin and sitagliptin discharge medications lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig puffs inhalation q4h every hours albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q4h every hours as needed for shortness of breath or wheezing aspirin mg tablet sig one tablet po daily daily meropenem mg recon soln sig five hundred mg intravenous q8h every hours for days last dose on fluconazole in saline iso osm mg ml piggyback sig four hundred mg intravenous once a day for days last dose on fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please remove am of fentanyl mcg hr patch hr sig one patch hr transdermal q72h every hours for days please place amiodarone mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for sores acetaminophen mg tablet sig tablets po q6h every hours as needed for fever chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane times a day docusate sodium mg ml liquid sig one hundred ml po bid times a day hold for loose stools senna mg tablet sig tablets po bid times a day as needed for constipation lactulose gram ml syrup sig thirty ml po tid times a day as needed for constipation insulin glargine unit ml cartridge sig forty units subcutaneous once a day insulin regular human unit ml insulin pen sig sliding scale as below subcutaneous every six hours adjust as needed amp d50 units units units units units units units units units notify m d heparin porcine unit ml solution sig units injection tid times a day discharge disposition extended care facility discharge diagnosis primary h1n1 swine flu pneumonia superinfection with mrsa pneumonia pseudomonas ventilator associated pneumonia parapsilosis fungemia line infection secondary copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd syndrome left breast cancer s p lumpectomy discharge condition stable on vented trach discharge instructions you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation you likely had swine flu which was complicated by mrsa pneumonia you later also developed a pseudomonas pneumonia you had a complicated icu course but your ventilator was able to be weaned down gradually given your continued need for respiratory support however a tracheostomy was placed and a peg tube in your stomach for nutrition lastly you were treated for a fungal blood infection as you are more stable now you are being discharged to a rehab for further care of note you had an episode of vaginal bleeding however you were examined by ob gyn with a negative pelvic ultrasound and no evidence of any more bleeding you should follow up with ob gyn as an outpatient for further evaluation antibiotic courses are as follows meropenem last dose fluconazole last dose most of your other medications were changed please refer to your new medication list and take all medications as prescribed please call your doctor or come to the ed if you develop chest pain difficulty breathing fevers dizziness loss of consciousness bleeding or any other concerning symptoms followup instructions please follow up with your pcp following your discharge from rehab his office number is please also schedule follow up with ob gyn on discharge from rehab the office number at is completed by ", 
+                "Sample summary 2": "date of birth:               sex:   m service neurology allergies nkda chief complaint multifocal pontine and cerebrellar infarcts major surgical or invasive procedure pt arrived intubated trach peg multiple bals history of present illness per admitting resident information for the note was taken from the medical records from as well as the patient s daughter hpi year old male with significant medical problems including afib noncompliant on coumadin cad s p stent placement x6 chf with diastolic dysfunction htn morbid obesity alcoholism and dm was transferred from for possible intervention following cva briefly he presented to ed by ambulance on the morning of complaining of days of general malaise and abdominal pain and one bout of emesis he was prompted to call the ambulance after an episode of near syncope during micturition as well as tinnitus he was noted to be hypotensive upon arrival to the ed which resolved following fluid boluses work up in the ed with a head ct showed likely old parietal infarct and possible area of low attenuation in the central pons infarct ct of the abdomen and chest showed no evidence of aortic dissection on presentation his inr was pt 5s and ptt 1s at 35am on he was noted to have transient slurring of his speech with normal upper and lower extremity strength tone and sensation bilaterally he also had labile blood pressures becoming hypertensive to at his speech was still slurred with decreased lue and lle strength tone and sensation were normal and intact at that time at he began to have an expressive language difficulty along with his slurred speech his tongue was noticed to deviate to the right with right facial drooping as well as drooping of the right side of his mouth he also had a poor cough and difficulty clearing his secretions lue and lle strength were decreased to tone in lue and lle was flaccid sensation was intact at on his gag reflex was absent and his lue strength was still with flaccid tone at he was unable to keep his right eye closed against resistance and his lue and lle sensation was decreased mri and mra of the head and neck on the morning of showed possible basilar artery thrombosis with multiple infarcts in the brainstem and cerebellar hemispheres he was note to have abssent gag later in morning and he was intubated prior to arrival in icu for airway protection past medical history atrial fibrillation cad s p stent placement x6 htn chf with diastolic dysfunction morbid obesity alcoholism with enlarged liver dm borderline not on medications sleep apnea r eye blindness since childhood psh s p stent placement at r cea at social history social security disability habits long standing alcoholic and smoker daughter unable to quantify family history htn physical exam on admission t afebrile bp hr irregular o2sat on ventilator gen lying in bed intubated drowsy heent nc at anicteric neck no tenderness to palpation normal rom supple no carotid or vertebral bruit cv afib with heart rate 80s no murmurs gallops rubs lung decreased air entry on left abd bs soft nontender ext no edema cyanosis neurologic examination mental status intubated drowsy however follows commands such as opening eyes moving limbs other exam diificult owing to intubated status cranial nerves pupils equally round and reactive to light to mm bilaterally extraocular movements intact bilaterally no nystagmus trapezius normal bilaterally slight facial droop on right but difficcult to characterise given intubated status motor limited owing to intubated and sedated status he was actively moving his right arm and leg was not actively moving his left ul however partially cooperated with power testing he was noted to have full power in all major muscle groups on right and was antigravity on lul in deltoids and triceps but not against resistance same was noted in lll in ip and hamstrings sensation withdraws to pain bl reflexes hyper reflexic throughout l more than r with left toe downgoing and right toe mute coordination unable to test gait deferred neurological exam at time of discharge awake alert peg and tracheostomy in place brief general exam obese l subclavian line cta b no m g r obese soft abdomen nttp edematous in yues and les non pitting pt nods and shakes head but irreproducibly to questions and requests does not follow commands reproducibly titubation after nodding his head persists for seconds eomi 2mm b l brisk symmetric face tongue to midline responds to mimicking spontaneous fingermovement in l hand noxious stim to rue leads to withdrawal flexor of the lue to noxious bilaterally l foot wiggles toes spontaneously r to noxious only responds with grimace toes extensor bilaterally pertinent results admission labs wbc rbc hgb hct mcv mch mchc rdw glucose urea n creat sodium potassium chloride total co2 anion gap calcium phosphate magnesium pt ptt inr pt hypercoagulability evaluation prothrombin mutation negative factor v leiden negative crp mini bal gram stain final per 1000x field polymorphonuclear leukocytes per 1000x field gram negative rod s per 1000x field gram positive cocci in pairs respiratory culture final ml commensal respiratory flora sputum gram stain final this is a corrected report pmns and epithelial cells 100x field gram stain indicates extensive contamination with upper respiratory secretions bacterial culture results are invalid please submit another specimen previously reported as pmns and epithelial cells 100x field per 1000x field gram negative rod s per 1000x field gram positive rod s per 1000x field gram positive cocci in pairs respiratory culture final sparse growth commensal respiratory flora catheter tips no significant growth no significant growth pending blood cultures bottle staphylococcus coagulase negative isolated from one set only gram stain gram positive cocci in clusters bottle no growth bottle no growth bottle no growth bottle no growth bottle no growth bottle pending bottle pending urine cultures no growth mrsa screens no mrsa isolated discharge labs imaging mri a head and neck impression extensive confluent and multifocal infarcts involving the inferomedial aspect of both cerebellar hemispheres with signal characteristics suggesting that these are late acute or early subacute and correspond to the infarcts demonstrated on the study performed one day earlier no associated hemorrhage herniation or evidence of obstructive hydrocephalus abnormalities involving the vertebral arteries bilaterally with possible origin stenosis on the right and distal occlusion thrombosis on the left given the clinical context the latter in particular could reflect impacted embolic material from a more proximal source the 2d tof and the cranial portion of the enhanced cervical mra both suggest very poor flow in the distal left vertebral artery as well as throughout the basilar artery and its branches including the superior cerebellar vessels bilaterally which may relate to the embolic event above there is no finding on these sequences to specifically suggest vertebral arterial dissection which in general would not account for the bilaterality of the cerebellar hemispheric findings relatively mild atherosclerotic disease involving particularly the left common and internal carotid arteries with no flow limiting stenosis there is no flow limiting stenosis in the intracranial anterior circulation focal cystic encephalomalacia and surrounding gliosis involving the left frontovertex likely related to previous embolic infarct chest x ray impression ap chest reviewed in the absence of prior chest radiographs et tube is in standard placement left pic line tip projects over the anticipated location of the mid svc mediastinum and left hemithorax are very abnormal suggesting extensive mediastinal adenopathy and pleural abnormality perhaps lingular collapse overall the findings are strongly suggestive of extensive maligcy alternatively there could be widespread hemorrhage in both mediastinum and left pleural space right lung clear no pneumothorax ct torso impression et tube approximately cm above the carina left thyroid lobe nodule clinical correlation is recommended small bilateral pleural effusions and lower lobe consolidation versus atelectasis aspiration can have a similar appearance mediastinal and hilar lymph nodes measuring up to cm in short axis diameter these may be reactive but are nonspecific coronary artery calcifications and vascular calcifications trace pericardial effusion chest x ray severe cardiomegaly is stable widened mediastinum mainly due to increase in the mediastinal fat as seen in prior ct from is unchanged et tube remains at the level of the thoracic inlet right ij catheter tip is in the upper svc left retrocardiac opacities have improved consistent with improving previously large areas of atelectasis there is no pneumothorax or large pleural effusions chest x ray indication lymphadenopathy findings endotracheal tube terminates above the thoracic inlet level and could be advanced several centimeters for standard positioning cardiomediastinal contours remain widened based upon review of recent ct torso this appears to be due to extensive mediastinal lipomatosis mild volume overload is present dense left retrocardiac opacity has developed likely a combination of atelectasis and effusion transthoracic echo the left atrium is dilated the right atrium is moderately dilated there is mild symmetric left ventricular hypertrophy the left ventricular cavity is moderately dilated due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded lv systolic function appears depressed the right ventricular cavity is dilated with depressed free wall contractility the aortic valve leaflets are mildly thickened the aortic valve is not well seen there is no aortic valve stenosis significant aortic regurgitation is present but cannot be quantified the mitral valve leaflets are mildly thickened mitral regurgitation is present but cannot be quantified there is a trivial physiologic pericardial effusion impression poor technical quality due to patient s body habitus both ventricles are dilated and hypokinetic however exact function and size cannot be determined mitral and aortic regurgitation unable to quantify pulmonary artery systolic pressure could not be determined unable to assess if lv thrombus eeg impression this is a mildly abnormal extended routine eeg in the waking state there is occasional theta and delta frequency slowing in the right temporal regions and to a lesser degree there was also mild left temporal slowing consisting of theta frequencies the cardiac rhythm was irregularly irregular with frequent pvcs there were no epileptiform features on this study ct head findings there is no intracranial hemorrhage multifocal hypodensities within the pons and the cerebellum are consistent with the prior infarcts and are better assessed on previous mri left frontal area of cystic encephalomalacia is unchanged otherwise current white matter differentiation of the hemispheres is maintained the ventricles are unchanged in size and configuration there is no uncal or transtentorial herniation there are no fractures there is opacification of scattered ethmoid air cells and mucosal thickening of the sphenoid sinus and maxillary sinuses the mastoid air cells are under pneumatized and opacified impression no intracranial hemorrhage evolving pontine and cerebellar infarcts mastoid air cell opacification and paranasal sinus disease labs at time of discharge cbc 56a pt ptt inr brief hospital course mr is a year old gentleman with a past medical history including atrial fibrillation non compliant on coumadin inr diastolic dysfunction hypertension diet controlled dm and cad s p stenting who initially presented to with tinnitus and presyncope and was transferred to the when he was discovered to have multifocal infarcts involving the pons and both cerebellar hemispheres in the setting of poor posterior circulation he was admitted to the stroke service in the icu from to neuro following his arrival to the an mri and angiography of the head and neck was performed to better characterize the lesions the studies demonstrated extensive confluent and multifocal infarcts involving the pons and inferomedial aspect of both cerebellar hemispheres the strokes appreared in the context of abnormalities in the vertebral arteries possible origin stenosis on the right and distal occlusion thrombosis on the left with poor flow in the basilar artery and its branches including the superior cerebellar vessels there was no associated hemorrhage herniation or evidence of obstructive hydrocephalus the heparin drip initiated at was continued with an initial ptt goal of and subsequent goal of following the placement of a peg coumadin was started with a target inr of two to three the patient s neurological examination remained relatively constant he appeared alert and interactive he could follow basic midline and appendicular requests eg stick out your tongue and lift your right arm there was evidence of gaze evoked nystagmus he could voluntarily shake is head yes and no in addition to moving the distal aspect of his left upper extremity and left toes occasionally clonus was noted in the left upper extremity a bilateral extensor response was observed cvs the patient was monitored by telemetry which demonstrated chronic atrial fibrillation metoprolol was given for rate control and cardioprotection however minimal doses of the beta blocker were used in an attempt to allow a target systolic blood pressure of to a statin was continued per the patient s cardiologist and pcp aspirin and plavix were not necessary for prophylaxis for his cardiac stents and thus these meds were not started as the appearance of the vessel occlusions and infarcts were suggestive of embolic phenomena from a proximal source a transthoracic echocardiogram was performed due to the technical challenges of the study the presence of an lv thrombus could not be explored there is no comment regarding the presence of asd pfo and vegetations note was made of the irregularly irregular rhythm as noted above following the placement of the peg coumadin was started for the atrial fibrillation inr goal of ptt goal while bridging is resp upon arrival mr had an endotracheal tube placed to protect the airway the ett was transitioned to trach in the course of the hospitalization he required mmv respiratory support due to having been noted to have episodes of apnea while on trach mask these occured o n only and were of 30s min duration repeat hct on was performed to evaluate for pontine hemorrhage possibly affecting the respiratory centers this was negative it was felt that etiology was most likely due to pontine infarction will need further monitoring and weaning as tolerated if apneic episodes do not recur id in the course of the hospitalization the patient developed persistent fevers the peak wbc count was the bronchealveolar lavage revealed commensal respiratory flora urine cultures were repeatedly negative one of six blood cultures grew coagulase negative staph and the result was thought to reflect contamination two mrsa screens were negative two sputum cultures were negative and gram stains were considered contaminated by upper respiratory secretions two of three catheter tip cultures were negative iv tip catheter culture grew vre no blood cultures were positive vancomycin was discontinued and he was started on linezolid for a seven day course day with last day of although daily chest x rays failed to reveal clear evidence of the condition treatment with ciprofloxacin cefuroxime and vancomycin was initiated to treat presumed ventilator associated pneumonia he completed day course of ciprofloxacin and cerfuroxime and vancomycin on heme onc there was some concern that the patient could be hypercoaguable analyses for factor v leiden and the prothrombin gene mutation were negative it might be worth conducting a more thorough study eg protein c protein s anticardiolipin ab etc for potential coagulopathy in the non acute setting because the initial chest x ray was thought to show findings concerning for maligcy a ct torso was done the study showed non specific possibly reactive mediastinal and hilar lymph nodes measuring up to cm in short axis diameter there were also small bilateral pleural effusions and lower lobe consolidation versus atelectasis no further investigatory studies were pursued abd gi ultimately on a peg was placed by the interventional radiology service to provide nutrition tube feeds were administered endo insulin was administered by sliding scale with a goal of maintaining normoglycemia renal prior to discharge the lasix was restarted for diastolic dysfunction intermittently however was eventually discontinued due to no oxygen requirement rehabilitation the physical and occupational therapy teams participated in the patient s care code full hcp medications on admission coumadin 10mg qd simvastatin 80mg qd plavix 75mg qd lasix 40mg qd doxazosin 1mg qd nitroglycerin prn chest pain discharge medications chlorhexidine gluconate mouthwash sig one ml mucous membrane times a day miconazole nitrate powder sig one appl topical times a day white petrolatum mineral oil ointment sig one appl ophthalmic prn as needed as needed for dry eyes bisacodyl mg suppository sig one suppository rectal hs at bedtime as needed for constipation famotidine mg tablet sig one tablet po bid times a day simvastatin mg tablet sig two tablet po daily daily nystatin unit ml suspension sig five ml po qid times a day as needed for thrush glucagon human recombit mg recon soln sig one recon soln injection q15min as needed for hypoglycemia protocol multivitamin tx minerals tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig one tablet po tid times a day linezolid mg tablet sig one tablet po q12h every hours last day dextrose gm iv prn hypoglycemia protocol sodium chloride flush ml iv q8h prn line flush peripheral line flush with ml normal saline every hours and prn heparin flush units ml ml iv prn line flush picc heparin dependent flush with 10ml normal saline followed by heparin as above daily and prn per lumen outpatient lab work patient will need inr monitoring to goal inr of cbc monitoring should be peroformed on weekly basis until inr is stable coumadin mg tablet sig one tablet po once a day insulin nph regular human unit ml suspension sig thirty u nph subcutaneous twice a day am and hs for nph and as per sliding scale regular discharge disposition extended care facility rehab center discharge diagnosis primary embolic strokes secondary atrial fibrillation cad htn chf discharge condition hemodynamically stable on ventilator support for tracheostomy neurological exam at time of discharge remarkable for awake alert eyes open tracks past midline mimicks as permitted by motor status but does not reproducibly follow verbal commands brainstem reflexes intact eomi nystagmus on b l gaze perrl 2mm face symmetric but weak able to stick out tongue scm b l is motor reflexes r paraplegia frimaces to noxious trace l finger and l toe movement dtrs increased on l mute on r toes extensor bilaterally discharge instructions you were admitted to after having suffered severe strokes to your cerebellum and your pons parts of your brain you were left with significant neurological deficits at time of discharge you were treated with medicatoins to treat your strokes in addition you had a course complicated by a lung infection and blood infection you were treated with antibiotics because you could not breathe on your own or eat on your own you underwent placement of a breathing tube tracheostomy and feeding tube peg you were started on multiple medications please take them as prescribed you were discharged to a rehabiliation facility for further treatment of your breathing and stroke should you develop any symptoms of concern to you please call your doctor or go to emergency room followup instructions neurology provider md phone at 1pm please call the office of dr danka to set up a follow up appointment after your discharge from rehabilitation completed by ",
                 "Sample summary 3": "date of birth:               sex:   f service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint nausea vomiting major surgical or invasive procedure cerebral angiogram with coiling history of present illness 67f fell off step stool days ago and possible loc had laceration on back of head with much bleeding did not seek medical attention at that time has been nauseaous and vomiting since that time daughters brought to osh found diffuse sah and possible r mca distribution loaded with dilantin and transferred to ed and possible r mca distribution loaded with dilantin and transferred to ed past medical history high cholesterol social history married has three children family history parents deceased sister and children alive and well physical exam hunt and grade gcs e v motor o t bp hr r18 o2sats96 gen wd wn comfortable nad heent pupils eoms neck in hard collar extrem warm and well perfused no c c e neuro mental status awake and alert cooperative with exam normal affect orientation oriented to person place and date recall objects at minutes language speech fluent with good comprehension and repetition naming intact no dysarthria or paraphasic errors cranial nerves i not tested ii pupils equally round and reactive to light to mm bilaterally visual fields are full to confrontation iii iv vi extraocular movements intact bilaterally without nystagmus v vii facial strength and sensation intact and symmetric viii hearing intact to finger rub bilaterally ix x palatal elevation symmetrical sternocleidomastoid and trapezius normal bilaterally xii tongue midline without fasciculations motor normal bulk and tone bilaterally no abnormal movements tremors strength full power throughout no pronator drift sensation intact to light touch bilaterally toes downgoing bilaterally on the day of discharge alert and oriented to person place and time patient has full strength and sensation eoms are intact 2mm with brisk reaction bilaterally no pronator drift the patient ambulate with a steady gait and is out of bed to the chair this morning eating breakfast the patient ambulate independently and is out of bed to the pertinent results cta head impression subarachnoid hemorrhage seen on head ct ct angiography of the head demonstrates a x mm aneurysm at the anterior communicating artery with irregular contour study date of pm sinus bradycardia non diagnostic inferior q wave pattern may be a normal variant but cannot exclude prior inferior myocardial infarction left ventricular hypertrophy with marked repolarization abnormalities consistent with left ventricular strain pattern no previous tracing available for comparison read by intervals axes rate pr qrs qt qtc p qrs t ct cspine impression no evidence of acute fracture or dislocation of the cervical spine chest portable ap study date of pm impression mild lingular and bibasilar atelectasis no focal consolidation ct head impression post embolization of the acomm aneurysm sah stable cta head impression interval coiling of anterior communicating artery aneurysm there is no evidence of large vessel occlusion or significant vasospasm the coil pack obscures the aneurysm itself and some adjacent vessels of the anterior circle of persistent moderate hydrocephalus with intraventricular hemorrhage echo the left atrium is elongated no atrial septal defect is seen by 2d or color doppler there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal regional left ventricular wall motion is normal left ventricular systolic function is hyperdynamic ef there is a very mild resting left ventricular outflow tract obstruction there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the ascending aorta is mildly dilated the aortic arch is mildly dilated the aortic valve leaflets appear structurally normal with good leaflet excursion there is no valvular aortic stenosis the increased transaortic velocity is likely related to high cardiac output no aortic regurgitation is seen the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be determined there is no pericardial effusion cta head w w o c recons study date of am impression no evidence to suggest vasospasm in the intracranial arterial vasculature further evolution of the subarachnoid and intraventricular hemorrhage 30pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct 45pm blood neuts lymphs monos eos baso 30pm blood plt ct 30pm blood pt ptt inr pt 25am blood glucose urean creat na k cl hco3 angap 30pm blood glucose urean creat na k cl hco3 angap 12am blood glucose urean creat na k cl hco3 angap 43am blood glucose urean creat na k cl hco3 angap 16am blood glucose urean creat na k cl hco3 angap 41am blood glucose urean creat na k cl hco3 angap 01am blood glucose urean creat na k cl hco3 angap 20pm blood glucose urean creat na k cl hco3 angap 51am blood glucose urean creat na k cl hco3 angap 48pm blood glucose urean creat na k cl hco3 angap 45pm blood glucose urean creat na k cl hco3 angap a normal variant but cannot exclude prior inferior myocardial infarction left ventricular hypertrophy with marked repolarization abnormalities consistent with left ventricular strain pattern no previous tracing available for comparison brief hospital course ms is a year old woman who was admitted to the nsicu under the care of dr on after a fall with ct findings of sah and acomm aneurysm she was on dilantin for seizure prophylaxis a ua showed a uti and she was started on cipro seh had some heart block on ekg and some bradycardia in the icu she received a dilantin bolus for a low drug level on she underwent a cerebral angiogram with coiling immediately post angio she was lethargic a head ct was obtained which was stable as patient awoke from sedation her exam was stable on her dilantin level was cardiology consult was called for persistant htn and bradycardia they noted 3sec sinus pauses episodes of sinus arrest with ventricular escape with heart rate to 30s but sbp was stable at ekg showed changes consistent with left ventricular hypertrophy vs cerebral t waves consistent with sah they felt that her bradycardia and htn were consistent with effect from her sah they asked that her calcium channel blocker be stopped which it was on on at she was noted to have a new left facial droop and she was lethargic she had some right deltoid and grasp weakness this strength exam has varied during her admission cta was ordered there was no increase in ventricular size and no concern for vasospasm she was transfered to dr service on her icu course was uneventful she had serial tcds as of which have showed no evidence of vasospasms nimodipine was discontinued secondary to bradycardia and hypotension she completed her course of cipro for urinary tract infection the patients serum sodium was and her serum bun of on patient was transferred to the step down unit in stable condition the patient has a cta consistent with no evidence to suggest vasospasm in the intracranial arterial vasculature and further evolution of the subarachnoid and intraventricular hemorrhage the patient s serum sodium was and her serum bun of on the patients serum sodium was and her serum bun of on routine laboratory blood work was sent and a serum sodium was and her serum bun of sodium chloride tablets grams po bid were initiated for hyponatremia po intake was encouraged her floor course was otherwise uneventful now the day of discharge she is afebrile vital signs were stable and neuro exam stable she is tolerating a good oral diet and her pain is well controlled the patient has had a bowel movement and is voiding without difficulty the patient s serum sodium was and her serum bun of the patient had a point rise in her serum sodium since the day prior while on the sodium chloride tablets the patient will go home on this medication for days at a lower dose of gram with follow up with her primary care this week for follow up of hyponatremia elevated bun and hypertension she is set for discharge home the patient s daughter has concerns about the patients ability to amubulate around the house independently physical therapy assesed the patient prior to discharge the patient was able to ambulate independently but slowly she was able to climb up and down stairs the patient did not need assistance or use of cane or walker but continued to have high level balance and endurance difficulties it was recommended that the patient be discharged home with a course of physical therapy at home for high level balance and endurance the patients daughter was called at home and this was discussed in ma was contact at they will contact the patient either or tuesday medications on admission none discharge medications hydralazine mg tablet sig one tablet po q6h every hours disp tablet s refills acetaminophen mg tablet sig two tablet po q6h every hours as needed for pain do not exceed grams tylenol in hours bisacodyl mg tablet sig two tablet delayed release e c po daily daily as needed for constipation hold for loose stools disp tablet delayed release e c s refills oxycodone mg tablet sig tablets po every six hours as needed for pain do not drive while taking this medication di not take if lethargic disp tablet s refills docusate sodium mg capsule sig one capsule po tid times a day disp capsule s refills senna mg tablet sig one tablet po bid times a day hold for loose stools disp tablet s refills sodium chloride gram tablet sig one tablet po every twelve hours for days please follow up at your primary care physicians to follow your sodium level this week disp tablet s refills outpatient lab work please draw a chem wednesday to monitor bun slightly elevated the day of discharge and serum sodium trending down currently day of discharge while on sodium tablet repleation follow up with your primary care this week please make an appointment with your primary care physcian this week after having your labs drawn on wenesday to follow up your slightly elevated bun and low trending serum sodium and to eveluate further need of sodium chloride tablets po every hours and hypertension and initiation of hydralazine for treatment of high blood pressure during your hospital stay outpatient physical therapy physical therapy at home for high level balance and endurance discharge disposition home discharge diagnosis subarachnoid hemorrhage anterior comunicating artery aneurysm ruptured urinary tract infection bradycardia hyponatremia hypertension discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent activity status ambulatory independent no use of walker or cane able to perform stairs independently continues to have high level balance endurance issues discharge instructions angiogram with embolization coiling ofanterior communicating artery medications continue all other medications you were taking before surgery unless otherwise directed you make take tylenol or prescribed pain medications for any post procedure pain or discomfort what activities you can and cannot do when you go home you may walk and go up and down stairs you may shower let the soapy water run over groin incision rinse and pat dry your incision may be left uncovered unless you have small amounts of drainage from the wound then place a dry dressing or band aid over the area that is draining as needed no heavy lifting pushing or pulling greater than lbs for week to allow groin puncture to heal after week you may resume sexual activity after week gradually increase your activities and distance walked as you can tolerate no driving until you are no longer taking pain medications what to report to office changes in vision loss of vision blurring double vision half vision slurring of speech or difficulty finding correct words to use severe headache or worsening headache not controlled by pain medication a sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg trouble swallowing breathing or talking numbness coldness or pain in lower extremities temperature greater than 5f for hours new or increased drainage from incision or white yellow or green drainage from incisions bleeding from groin puncture site sudden severe bleeding or swelling groin puncture site lie down keep leg straight and have someone apply firm pressure to area for minutes if bleeding stops call our office if bleeding does not stop call for transfer to closest emergency room angiogram with embolization coiling of anterior communicating followup instructions please follow up with dr in weeks with a mri mra of the brain protocol please call to make this appointment please follow up with you primary care physician this week as your serum bun has been slightly elevated and your serum sodium is has been trending slightly low you will be given a prescription to have your lab studies drawn and please follow up with you primary care by friday to dicuss you were also started on a medication for high blood pressure hydralazine please discuss further management of your hypertension at that time completed by md addendum this entire discharge summary is a duplicate of the discharge summary from earlier today with addendum added to brief hospital course as patient will have physical therapy at home for high level balance and endurance"}
 
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