CRF:filling SharedTask @ CL4Health2026
Collection
Datasets for participants at the CRF:filling task of CL4Health2026. For more info visit the website https://sites.google.com/fbk.eu/crf
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In ED for abdominal pain localized in LUOGO mesogastric area for about 3 days, non-radiating, stabbing, intermittent.
Denies fever.
Denies nausea/vomiting.
Denies diarrhea, bowel habits regular (normochromic, normally formed stools).
Reports hyporexia over the last 2 days.
Denies weight loss.
Reports mild dysuria for about 3 days, no urinary frequency, no urinary urgency, no hematuria.
Denies changes in chronic cough.
Denies chest pain/palpitations.
Finally reports sensation of feeling cold with shivering when leaving home in the morning.
Language barrier.
Reports a very stressful period.
Has not taken antihypertensive therapy in the past 3 days.
SARS-CoV-2 vaccination: 3 doses
PMH
- Active smoker
- IA
- Type 2 DM
- Dyslipidemia
- Depression
Home medications: amlodipine, metformin 750 mg x 2, rosuvastatin/ezetimibe 20/10 mg, delorazepam 15 drops in the morning
Allergies: oral hypoglycemic that the patient does not recall
|
903116
|
TRIAGE: for one week, fever, productive cough, and influenza-like symptoms. At pre-triage T 38.2°C; has not taken antipyretic. This morning accidental fall as he reports slipping while sitting down on the stool. Denies head trauma, denies other complaints and symptoms.
VACCINATED 4 DOSES
MEDICAL EVALUATION:
Influenza-like symptoms for about 4 days with fever and productive cough, marked asthenia and diffuse bone pain.
Today fall to the ground with sacral trauma while attempting to sit on a chair; the patient reports decreased vision and therefore attributes the fall to misperception of the chair next to him. However, he was then unable to get up but was able to activate emergency services.
PMH:
- Arterial hypertension
- Diabetes mellitus on diet therapy
- Dyslipidemia
- DDD pacemaker for syncope and paroxysmal blocks on Holter
- Glaucoma with vision loss of the right eye
- Previous sacrococcygeal fistula
- Previous cholecystectomy
HOME MEDICATIONS: Pritor Plus 80/12.5 mg, cardioASA, Norvasc 5 mg, allopurinol 300 mg, Cardura 4 mg + 2 mg, Torvast 10 mg, Finastid 5 mg
ALLERGIES: not known
NUM_TELEFONO PARENTE
|
1036203
|
Patient recently discharged from our ED on 14/11 with diagnosis of portosystemic encephalopathy. Hb 10.
Since then, persistent psychomotor slowing, worsened this evening with onset of agitation, for which the patient took Zolpidem 1/2 tab. Also reports LOC with head trauma occurring while going to the bathroom tonight around 24:00. Finding of HR 30 bpm at home (by MSB; tracing unavailable).
In the afternoon one episode of bilious vomiting.
Bowel movement yesterday.
Completed SARS-CoV-2 vaccination (2nd dose 7/2021).
PMH
- Hypertension
- Dyslipidemia
- Obesity
- CAD
* 1994 coronary angiography performed for positive SPECT: RCA occlusion recanalized.
* In 2016 repeat coronary angiography for recurrence of angina and positive exercise test: chronically occluded RCA. Indication given for recanalization, multiple DES placed.
- COPD
- Known iron-deficiency anemia treated with transfusions: first detection in 2016: EGD and colonoscopy negative. 2/2018 admission to MECAU for typical chest pain: on labs Hb 8, no vitamin deficiencies and iron deficiency, TnT negative on all determinations. Transfused 2 units of PRBCs. EGD: cardial incontinence. Fecal Hb negative in 3 samples, therefore colonoscopy was deferred. Cardiology consult: maintain Hb 10 g/dl, intensified antianginal therapy. Hematology consult: recommended course with iron and Folina. Last CBC 9/2021: Hb 9.3 WBC 3790 PLTs 159000.
- Known vertebral compression fractures, prior vertebroplasty
- Abdominal ultrasound 6/2021: perihepatic fluid layer. Chest–abdomen CT 8/2021: hepatic cirrhosis, portal vein ectasia without signs of thrombosis, dilated splenic vein, splenomegaly, no focal hepatic lesions, bile ducts not dilated, mild perihepatic and perisplenic fluid layer, questionable thickening of the rectal walls. Rectoscopy performed: negative.
- 11/2021: hospitalization for hepatic encephalopathy, finding of esophageal varices F3 and congestive gastropathy, underwent banding and treatment with APC.
- lives with the PARENTE
ALLERGY TO LEVOFLOXACIN
tel PARENTE NOME_PERSONA NUM_TELEFONO
|
256860
|
Recently seen in ED from 1/3 to 2/3/23 for "ED visit for presyncope with consequent sliding of the knees on the floor, today. Denies head trauma".
PMH:
- Appendectomy
- Left TKA
- Eye surgery not otherwise specified, visually impaired
- Chronic AF
- Dyslipidemia
- COVID-19 infection May 2022
- Right saphenectomy
COVID-19 vaccination completed
Home medications: Coumadin, bisoprolol, Lasix 1 x 2, Luvion 1 at 16:00, Totalip
Tests of 1/3 WNL; INR 2.34
Knee X-ray R + L: severe right gonarthrosis
ECG done yesterday: known AF
ABG WNL
Daughter reports today malaise, retrosternal pain, reports palpitations. Symptoms lasting 20 minutes
Patient with visual deficit, bedridden. Reports similar symptoms for some months
For such symptoms, cardiology visit of 12/21/2022: permanent AF, intolerance to Targin containing codeine
Holter 9/2022 with average HR 80
TSH normal
Carotid ultrasound: ICA 35%
Atypical precordial pain with sporadic tachycardic palpitations
Dyspnea with mild exertion, no dyspnea at rest, no PND
ECG: AF EAS
9/22 cardiology visit
2019 hospitalization for heart failure
EF 62%
Mild–moderate MR
Mild dilation of the ascending aorta
Moderate AR
TTE: LV slightly dilated, concentric hypertrophy, EF normal (605)
Left atrium severely dilated
Mild MR, moderate TR
Right atrium dilated, RV of normal size
Mild–moderate TR PAS 25 +10
Aortic root normal
In the past NOAC discontinued for melena
Home medications: bisoprolol 2.5 mg 1 tab, Luvion 100 tao, Totalpid 20 1 tab, Lasix 1 tab x 2
Intolerance to Targin containing codeine
Vaccinated for COVID
|
1195646
|
Fell from approximately 2.5 meters. Brought by MSB without immobilization devices.
Reports attempted entry into his own home through the window at LUOGO no. 3, first floor, with consequent fall and trauma to the lower limbs and head. Denies thoracoabdominal trauma.
Found on the landing of his home; he reported a fall outside the dwelling, subsequently reported having dragged himself on his knees and having managed to reach the main door and then the landing.
He reported multiple versions of the event, with cocaine use in the evening.
PMH:
from chart:
TD
Psychiatric disorder with behavioral disturbance in TD. HCV+. (reported negativization without therapy).
Resident in a therapeutic community, history of TD with previous presentation for rhabdomyolysis in heroin and cocaine abuse
on 12721 peri-respiratory arrest in substance abuse, bilateral aspiration pneumonia with type 1 respiratory failure
followed by SERT of LUOGO, Dr. NOME_PERSONA
Home medications:
Duloxetine 60 mg at 08:00
Carbolitio 300 mg at 08:00 and 20:00
Lyrica 300 mg at 08:00 and 16:00
Tavor 5 mg at 08:00 and 16:00
Mirtazapine 30 mg at 16:00
Mirtazapine 30 mg x 3
Tavor 2.5 mg x 3
|
1804841
|
Accompanied by MSB.
In ED for dyspnea and difficulty ambulating for about 15 days.
Asthenia. No melena.
Hyporexia and hypoalimentation.
No fever. Cough without sputum.
No pain.
lives with the PARENTE
cognitively intact
Still active - until 15 days ago ambulation in outdoor spaces still possible - for the past 15 days ambulates at home only
Whole-body CT performed 11/2022 for follow-up one week ago.
PMH:
former smoker - 20 cigarettes/day
emphysema, pulmonary fibrosis
lung adenocarcinoma - diagnosis a few years ago - received oral chemotherapy until July 2022 - followed by Dr. NOME_PERSONA - at CT WB follow-up increase of nodular lesions 29 mm right basal pyramid and inferior horn of the right pulmonary hilum of 36 mm - right nodular lesion of 34 mm - pleural effusion of 20 mm on the right - not yet evaluated by the oncologist - 19/12 oncology visit followed by Dr. NOME_PERSONA.
gastric cancer - prior gastroresection - in 2006
TD:
none
Reported allergies: none
SARS-CoV-2 vaccination three doses
cell PARENTE NOME_PERSONA NUM_TELEFONO; personal cell PARENTE NUM_TELEFONO
home address LUOGO - LUOGO - LUOGO LUOGO /LUOGO - ground floor
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869076
|
In ED for onset after lunch of an episode of dizziness, visual blurring, sensation of heat with subsequent presyncope (unclear LOC), while seated. Denies trauma, in particular no head trauma. Placed supine by the PARENTE and by the PARENTE with rapid recovery. Reports palpitations after the syncope and mild sensation of dyspnea, unclear chest pain. Last Friday reported episode of bleeding of the oral cavity, self-resolved.
Last cardiology evaluation 9/2021: reported presyncopal sensation and tendency to hypotension, no precordial pain. Presyncopal episodes improved after discontinuation of beta-blocker (nebivolol) in brady-AF on the last Holter ECG of 3/2021. Repeat Holter ECG indicated, not yet performed. ASA discontinued since 3/2022.
PMH:
- Prostate adenocarcinoma treated with radical prostate-vesiculectomy with bilateral iliac–obturator lymphadenectomy in 2002.
- Consequent ureteral stenosis, underwent periodic calibrations with CV.
- ECD - TSA: fibrocalcific plaque on the right.
- CAD: 2011 PCI on Cx; 22/3/21 admission to cardiology for suspected unstable angina in known ischemic heart disease and newly detected AF; echocardiogram: LV of normal size, wall thickness, and global and segmental motion, normal filling pattern; coronary angiography: good result of previous angioplasty on a branch for the OM and critical, calcified stenosis of mid LAD treated with angioplasty + rapidly endothelializing stent.
- Prior AF underwent ECV in March 2019.
- Echocardiogram 3/2021: EF normal with normal LV, no diastolic dysfunction, LA dilated, right chambers normal. Mild MR, mild AR, and mild TR, PASP normal.
- Holter ECG 3/2021: AF with minimum HR 36 bpm, numerous pauses > 2 sec with max 3.21 sec (on beta-blocker).
- Arterial hypertension.
- Dyslipidemia.
- Hyperuricemia.
- Prior peptic ulcer on PPI therapy.
- ED TSA 2021: 40% stenosis at the right bulb and 45–50% at the left bulb.
Home meds:
- ASA 100 mg 1 tab
- Dabigatran 110 mg BID
- Amlodipine 5 mg 1 tab STOPPED, replaced with blopres 1 tab
- Rosuvastatin 20 mg 1 tab
No known drug allergies.
Vaccinated for SARS-CoV-2, 3 doses
PARENTE NUM_TELEFONO
|
715369
|
Presents to ED for presyncopal sensation and an episode of vertigo while with a PARENTE. Recent family bereavement; low mood in recent days. Denies NOME_PERSONA, dyspnea, or palpitations.
PMH:
- Hypertensive heart disease
- COPD GOLD III on LTOT since 2015. Last exacerbation 02/2020
- 2009 TURBT for bladder Ca
- February 2020 radiotherapy to right pulmonary nodule—pulmonary emphysema
- Cerebral aneurysm treated neurosurgically in 1999
- CKD
- AF cardioverted with medical therapy in 2008
- AAA prosthesis
- Moderate OSA
- Lung Ca followed at IRCCS NOME_PERSONA, recently treated with RT
- Left eye blindness
Home medications: ASA 100 mg, pantoprazole 20 mg, furosemide 25 mg, amlodipine 5 mg, metoprolol 100 mg 1/2 tab, losartan 50 mg, bronchodilator therapy per prior pulmonology indications.
No known allergies
Vaccinated for SARS-CoV-2 with 3 doses.
Tel PARENTE NUM_TELEFONO
|
854887
|
Patient in ED sent by the treating cardiologist Dr. NOME_PERSONA; unclear reason. Possible lower limb ischemia. Patient denies chest pain, denies dyspnea, denies fever. Adequate diuresis.
Reports 15 intervento Molinette for ambulazione peen, referred for calcifilassi.
Allergy to Zimox, intolerance to acarbose.
apr
Arterial hypertension
Former smoker
Hypercholesterolemia
Diabetes mellitus
CKD
Previous radical prostatectomy in 200 for prostate cancer
Sensorimotor polyneuropathy
Coxarthrosis
Chronic atrial fibrillation
ICD carrier
Ischemic heart disease with hypokinetic evolution
Last cardiology visit in review dated 21/01/2021: euvolemia, no clinical or instrumental signs of congestion, asymptomatic hypotension, pruritus of likely dietary origin — started Deltacortene.
Last echocardiogram in review: dilated LV, EF 25%, minimal MR, hypokinetic RV, mild TR, pas n.n.
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120579
|
Referred to the ED by the Ophthalmic Hospital.
On 17/4 episode of loss of consciousness occurred while the patient was going to the bathroom.
Preceded by dizziness and general malaise.
Prior episodes of vasovagal syncope; the episode on 17/4 per the patient is similar to previous ones.
No chest pain, dyspnea, or other symptoms.
Head and left facial trauma; reports having hit against the bidet.
Brief duration of LOC, rapid recovery of consciousness (presumably a few minutes).
No LOC nor emesis after the trauma; always GCS 15 after the trauma; only minimal epistaxis.
Presentation to ED LUOGO on 19/4; ophthalmology evaluation performed; performed:
- CT orbits: on the left, fracture of the medial wall and of the medial floor with entrapment of the inferior rectus muscle and, to a lesser degree, of the ipsilateral medial rectus; segmental irregularity of traumatic appearance of the lateral wall of the left maxillary sinus;
- CT brain: several punctate foci within the white matter (parenchymal contusive foci?).
Referred to this ED for Maxillofacial Surgery and neurological/neurosurgical evaluation.
PMH unremarkable; smoker; denies current pregnancy.
Menses ongoing; denies current pregnancy.
No known drug allergies; intolerance to dairy products.
PARENTE NUM_TELEFONO.
|
52473
|
Presents from Community LUOGO for fever and dyspnea
HPI: 02/2023 hospitalization in MIC for febrile respiratory failure
PMH:
- Intellectual disability. Post-meningitic epileptic encephalopathy with severe intellectual disability.
- Dysphagia. Prior aspiration pneumonia. Pureed diet and gelled water.
- Resident at Community LUOGO, bedbound.
- 05/2022 hospitalization for respiratory failure in decompensated congestive heart failure and sepsis. Blood culture positive for S. capitis; during hospitalization chest CT performed without evidence of inflammatory lesions.
- (11/20) Prior SARS-CoV-2 infection, subsequently 3 doses of COVID vaccine.
Home medications:
lactulose PRN
Eutirox 25 mcg
Depakin syrup 500 + 1000 + 500 mg
Mysoline 1 tab BID
Diazepam 5 drops BID
Entumin 3 drops BID
Lasitone 1 tab
Lasix 25 mg
Fluimucil 1 tab
Allergies: none reported.
Guardian (Mr. NOME_PERSONA): NUM_TELEFONO
Community supervisor (Mr. NOME_PERSONA; Mrs. NOME_PERSONA): NUM_TELEFONO
|
1402178
|
Presents to ED for a presyncopal episode at home during micturition, preceded by a sensation of dyspnea. Upon exiting the bathroom, new syncopal episode in front of PARENTE who partially supported him.
PARENTE reports head trauma. Denies angina.
PMH:
- from 16/12/22 to 30/12/22 CCU admission for NSTEMI (angioplasty performed and stent placed on LCx–obtuse marginal (OM) branch); subsequent completion with angioplasty. During hospitalization, associated COVID-19 infection.
- ED visits in Dec '22 and Feb '23 for a similar reason.
- Ex-smoker for 20 yrs
- IA
- T2DM
- Dyslipidemia
- Fibrosing interstitial lung disease, UIP pattern, autoimmunity negative. Nocturnal O2 therapy at 2 L/min and occasionally during daytime if needed
- Prior surgery for AAA
- BPH
Home medications: pantoprazole, metoprolol 1/4 x2, Urorec, ticagrelor x2, Deltacortene, CardioASA, Torvast, home O2 therapy 24/24 at 4 l/min
Allergies: DICLOFENAC (Fastum)
Phone PARENTE NUM_TELEFONO
|
1291971
|
In ED for onset about 1 week ago of nasal epistaxis, episodes of hemoptysis (coughing and saliva with blood-stained sputum), and hematuria (dark red urine). No fever. Occasional episodes of dyspnea not clearly characterized.
Significant weight loss (from 63 to 45 kg in 1 year).
PMH:
Type 2 DM
Hypertension
Lower-limb arterial Doppler ultrasound: bilateral femoropopliteal arteriopathy (moderate-grade stenosis but preserved patency of the common and deep femoral arteries). Superficial femoral arteries occluded with reduced flow from recanalization at the level of the popliteal arteries and at the level of the posterior and anterior tibial arteries
2/2022 SARS-CoV-2 infection with DVT
Home medications: Metformin and valsartan, Coumadin
Denies drug allergies
Patient vaccinated 3 doses
Lives with 2 elderly PARENTE, they do not have PARENTE
Tel PARENTE NUM_TELEFONO
|
766326
|
Presents with left-sided migraine-type headache and left ear pain
PMH
4/18 valvuloplasty; AF on DOAC; iron-deficiency anemia
- 5-2-21 In ED for episode of asthenia and dysarthria in regression in ED - head CT negative for acute findings.
- Most recent echocardiogram: Left ventricle of normal size and motion with concentric hypertrophy of the walls, EF 61%. Diastole not assessable due to mitral repair. No intracavitary masses detected. Left atrium severely dilated, biplane volume 145 cc, 83 cc/m2, without thrombi. Left atrial appendage without thrombi, with reduced flow velocity (outflow 24 cm/sec, inflow 22 cm/sec). Presence of spontaneous echo contrast in the left atrium and left atrial appendage. Interatrial septum intact, no shunt on color Doppler, nor after contrast injection (Voluven + air). Status post mitral repair with mild regurgitation, with mild stenosis (mean gradient 6 mmHg, functional area 1.4 cm2). Tricuspid aortic valve with mild regurgitation. Thoracic aorta of normal size, without significant plaques. Right-sided chambers of normal size. Mild tricuspid regurgitation. Inferior vena cava of normal size, normally collapsible. Estimated pulmonary systolic pressure normal, 17 mmHg. No pericardial effusion.
Home medications: Eliquis 5 mg BID; Lanoxin 0.125;
No drug allergies
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751803
|
Referred to ED by PCP for suspected heart failure decompensation and pneumonia.
On EMS arrival, NRB mask applied for desaturation (SpO2 85%).
History-taking difficult from the patient.
Reports cough for about one week. Fever (T up to 38–39). Also diarrhea.
From telephone conversation with PARENTE it appears: for about 15 days BLE edema; reported hyporexia and poor fluid intake; no fever; mild nonproductive cough; no dyspnea; no chest or abdominal pain; no GI symptoms.
Lives alone, not self-sufficient; assisted by PARENTE who lives nearby.
PMH
- Hypertension. TTE 2017: EF 60% - mild MR AR TR
- Paroxysmal AF on DOAC
- Hyperthyroidism
- Venous insufficiency of the lower extremities
Home medications: olmesartan 10 mg, bisoprolol 2.5 mg, edoxaban 60 mg, Tapazole 5 mg 1/2 tab
No known drug allergies
Phone PARENTE NUM_TELEFONO - NUM_TELEFONO
|
53833
|
In ED together with PARENTE. Today at lunch she ate cooked carrots and abundant fruit (peach, apricots, plums) with subsequent onset around 14:00 of diffuse colicky abdominal pain, more in the right quadrants. No nausea/vomiting, had a bowel movement this morning with soft stools (reports constipation in recent days for which she has been taking Movicol daily as prescribed by the treating physician). No fever.
Reports another recent episode of crampy abdominal pain after fruit intake.
PMH:
- left quadrantectomy for cancer with subsequent local recurrence treated with RT and hormone therapy
- hypertension;
- bronchogenic neoplasm of the left lower lobe;
- dyslipidemia;
- atheromatosis TSA;
- recent ED visit with diagnosis of AF (03/2023) with spontaneous restoration to SR, on that occasion started dabigatran and metoprolol, Cardioaspirin discontinued -- subsequent cardiology reassessment (26/6/2023) with discontinuation of dabigatran for epigastralgia, prescribed Lixiana 60 mg 1 tablet
- 06/07/2023 chest angio-CT performed for finding of mild dilation of the ascending aorta on ultrasound: aortic diameters (38 mm post-valvular, 28 mm sinotubular junction, 40 mm mid-ascending segment, 36 mm ascending-arch junction, 26 mm arch, 18 mm abdominal segment) - abdominal vessels normal - confirmed parenchymal consolidation area of the LLL arranged semi-circumferentially along the descending aorta - right apical micronodule - at the abdominal level mild diastasis of the right oblique muscles with partial herniation of the kidney, hepatic cyst 12 mm in S7, no other abnormalities
Home meds: triatec HCT 10/25 1 tablet in the morning, totalip., femara, metoprolol 100 mg 1/4 tablet x 2; Lixiana 60 mg 1 tablet
Allergy to paracetamol, NSAIDs (ibuprofen, nimesulide), amoxicillin, quinolones, colchicine (urticaria) - unclear whether intolerance to Contramal, the patient does not remember
habitually takes etoricoxib for pain
takes macrolides
PARENTE NUM_TELEFONO
|
1388062
|
Presents to the ED for cough associated with hemoptysis since Monday 13/2, no fever. Presence of white sputum with traces of blood. No other symptoms.
PMH: from chart
- lives with PARENTE
- cognitively intact, non-ambulatory, only bed-to-chair transfers, does not leave the house, not independent in ADL/IADL
- obese (weight approx. 125 kg)
- Hypertension
- Dyslipidemia
- Diabetes mellitus
- Paroxysmal AF, not on OAC
- CKD - Crsd 1.87 mg/dl
- Severe OSA not on CPAP/NIV due to intolerance / COPD on O2 therapy
- Polyarthrosis with inability to ambulate and poor mobilization
- History of peptic ulcer and GERD
- History of DVT
Home medications (from chart; unable to report therapy and does not have the complete list of current drugs with her, but reports they are the same as at the last ED visit)
Lasix 25 mg 1 tab x2
CardioASA 100 mg 1 tab
Totalip 20 mg
Olevia 1 capsule x 3
Foster 100/6 x 2
O2 1 L at night
baseline
insulin Humalog 20 UI - 20 UI - 20 UI
insulin Toujeo 28 UI
No known drug allergies
Vaccinated against SARS-CoV-2 - 4 doses
|
1312370
|
For about one week, malaise and onset of fever on Monday with a peak of 38.7 °C, spontaneously regressed after about one hour. New episode today with similar presentation.
Reports cough for about 10 days for which took an unspecified antibiotic and corticosteroid. Reports mild dysuria.
Denies chest pain. Also reports for about one week onset of bilateral lower-limb edema and mild dyspnea even with minimal exertion.
PMH
former smoker
hypertension
dyslipidemia
Obesity
Mild aortic stenosis in hypertensive heart disease
2019: left carotid endarterectomy; known TSA arteriopathy
prior gastric ulcer - GERD
thalassemia
polyarthritis on analgesic therapy
last cardiology visit 09/22: EF 64 % mild AS, mild–moderate MS and mild MR, mild TR,
Home medications
olprezide 40/12.5 mg 1 tab
cardiaspirina 1 tab
stilnox 10 mg
cholecalciferol 25,000 IU
cardura 2 mg
alprazolam 0.25 mg
lansoprazole 15 mg
atorvastatin 40 mg
dilzene 120 mg
movicol 1 bs
Reported allergies: nickel
SARS-CoV-2 vaccination complete, three doses
|
1270088
|
ED presentation for palpitations onset today at 9:00 AM.
No chest pain, no dyspnea.
No prior similar episodes.
Last meal at 9:00 AM today.
PMH
- Hypertension
- CKD likely predominantly chronic obstructive, due to bilateral vesicoureteral reflux, greater on the right
** 2000 Initiation of peritoneal dialysis
** 2001 peritonitic episode - culture positive for Sthapilococcus warnerii
** 2002 peritonitis due to Corynebacterium
** 07/2003 First kidney transplant in the right iliac fossa
** 05/2022 Second kidney transplant
- DM on insulin therapy
- CAD: 09/2021 Positive stress echocardiography in the inferoseptal region. Coronary angiography: non-critical atherosclerosis of LAD and RCA with indication for medical therapy.
- Perforated diverticulitis s/p sigmoidectomy (02/2022 - Surgery H S Giovanni Bosco)
- Prior cholecystectomy (1996)
- Hemorrhoidal disease treated with ligation
Home medications: ASA 100 mg, Mag2 2 bst, Calcium carbonate 1 g 2 co, Eskim 1000 mg x 2, Atenolol 50 mg, Calcitriol 0.25 mcg 1 co, Mycophenolate 500 mg x 2, Pantoprazole 40 mg, Tacrolimus 0.5+1 mg, Prednisone 5 mg, Amlodipine 5 mg, Furosemide 25 mg x 2, Binocrit 4000 U x 2/week, Linagliptin
Allergies: tramadol (cutaneous hypersensitivity)
SARS-CoV-2 vaccination series completed
|
1648479
|
In ED for progressively worsening dyspnea, worsened over the last 2 days, with marked orthopnea and exertional dyspnea. Occasional episodes of exertional chest pain.
No fever, no cough, no diarrhea, no anosmia or dysgeusia, no known contacts with SARS-CoV2-positive individuals.
Has undergone cardiology workup at another facility, was awaiting coronary angiography (see APR); currently in LUOGO staying with a PARENTE.
PMH
- Valvular heart disease. Cardiology visit and echocardiogram 02/2021 at LUOGO: on echo LV EF 50%, distal IVS–apex hypokinesis, moderate–severe aortic stenosis (mean gradient 40 mmHg, area 0.98), mild MR; ED evaluation recommended; on 6/02/2021 Cardiac Surgery evaluation at H LUOGO: severe AS confirmed with mean gradient 50 mmHg, coronary angiography advised in view of SVAO;
- severe obesity
- dyslipidemia
- former smoker, quit 11 years ago
- no known drug allergies
|
11911
|
In ED for epigastric–retrosternal pain for two days, since last night radiating to the entire back, continuous, partially regressed with paracetamol
No cough, no fever, mild dyspnea reported as baseline
Bowel movements regular with normal stool this morning, no vomiting
PMH
- Morbid obesity
- Smoking, dyslipidemia
- Prior hysterectomy + prior excision of adrenal adenoma
- SAD
- Cholelithiasis
- NIDDM
- Epilepsy (complex partial seizures and generalized seizures) secondary to head trauma; on MRI changes at the level of the left temporal lobe
- CAD:
* in January 2009 inferior STEMI, treated with PTCA + stent on RCA; echocardiogram with normal EF
* in December 2009 myocardial SPECT without evidence of inducible ischemia
Home medications: Vimpat 100 mg BID + Gardenale 100 + ASA + Triatec 10 in the evening +
Cardicor 5 mg + Metformin 850 mg 1+0+1 statin
VACCINE ALLERGY (cutaneous rash after the 3rd injection of SARS-CoV-2 vaccine)
|
1829184
|
Since this morning, onset of diffuse dorsolumbar pain radiating anteriorly to the epigastric/mesogastric region and to the chest, associated with nonspecific malaise. Denies dyspnea/chest pain/cold diaphoresis. Reports well-being in the preceding days, no fever. The PARENTE reports prior similar episodes. Denies recent trauma.
PMH
- early cognitive decline
- arterial hypertension;
- DM on insulin therapy;
- glaucoma;
- colostomy and mucous fistula;
- early senile dementia
- echocardiogram 3/2022: preserved EF, moderate aortic stenosis, minimal mitral and tricuspid regurgitation
- cardiology visit 6/2022: uncontrolled arterial hypertension, anxiety syndrome
Home medications: cotareg 320/25 mg, lispro 7+7, omegastatin 10 mg, cardioaspirina, cardiovasc 20 mg, toujeo 12 U, Azopt eye drops, pasaden 5 gtt x 3, nicetile 500 mg (until 5/11)
No known drug allergies
|
1009974
|
In ED for a transient episode of expressive aphasia lasting about 10 minutes in the presence of PARENTE, with subsequent spontaneous remission. In addition, the patient reports nausea and vomiting for about 2 days and pressure-like chest pain that the patient reports as entirely similar to previous episodes (history of chest pain) and different from previous ischemic ones. No profuse diaphoresis, no dyspnea, no fever or cough. Last night one episode of diarrhea; the PARENTE have had upper airway inflammation; rapid SARS-CoV-2 swabs performed: negative. No similar episodes in the past.
SARS-CoV-2 vaccination series completed.
PMH:
- bilateral hip prosthesis, cholecystectomy, hemicolectomy for diverticulosis
- atheromatosis of TSA without significant stenoses
- pacemaker for SSS, implanted 1990, replaced in 2007, in 2015, and in 2018 during hospitalization for heart failure and pocket infection
- FAP: 3 ablations (two in 2001 and 2017)
- CAD: 2015 coronary angiography for chest pain: LAD segment II 50%, Dg2 with indication for medical therapy. 09/2018 visit for chest pain, evidence of atrial fibrillation media penetranza. April 2019 hospitalization for unstable angina (PTCA + stent performed on mid and distal LAD for subocclusive stenosis)
Statin intolerance, no allergies
Patient phone NUM_TELEFONO
PARENTE phone NUM_TELEFONO
SARS-CoV-2 vaccination series completed
|
389015
|
Sent to the ED because the PARENTE reports finding him more confused than usual.
On questioning, difficult to obtain history; he first reports cramps in the lower limbs, then dyspnea, then asthenia.
PMH:
- CAD with multiple angioplasties, including for in-stent restenosis (last 12/2018). Multiple hospital admissions for heart failure, last in August 2022
- Chronic AF on DOAC
*On 6/7/2021 ED visit for brady AF and repolarization abnormalities, with finding of hyperkalemia
10/2021 hospitalization at LUOGO for heart failure in ischemic-arrhythmic cardiomyopathy
- BPH
- bilateral inguinal hernia repair
- peripheral vascular disease
- received anti-SARS-CoV-2 vaccination with 3 doses and prior infection in January 2022
Home medications:
- Lasix 2 tabs BID
- Luvion 100 1 tab
- Simvastatin 20 mg 1 tab
- Allopurinol 300 mg 1 tab
- Pradaxa 110 mg BID, l
- Dilatrend 6.25 mg 1 tab BID
- Tamsulosin 0.4 mg 1 tab
- Dutasteride 0.5 mg 1 tab
- Nitroderm 10 patch from 08:00 to 20:00
No drug allergies
PARENTE NUM_TELEFONO
|
1065330
|
In ED for acutely worsened respiratory distress.
until yesterday relatively better - still ambulated yesterday
Reports acute worsening of respiratory status overnight.
No fever, no cough, no sputum.
No chest pain, no abdominal pain.
Patient with ED visit on 22/2/2022 for palpitations for > 48 hours
Diagnosis of newly diagnosed atrial fibrillation; Lasix and emtroprololo 2.5 mg IV administered
At discharge
Recommended:
- stop bisoprolol - start metoprolol 100 mg 1/2 tab at 08:00 and 1/2 tab at 20:00, titratable based on HR per the primary care physician
- stop ASA
- start apixaban 5 mg 1 tab at 08:00 and 1 tab at 20:00 (PT delivered for 1 month)
- stop spironolactone - furosemide 25 mg 1 tab at 08:00
- in 7–10 days outpatient ECG check to assess HR trend through the primary care physician
- perform outpatient TTE through the primary care physician
- in about 3–4 weeks outpatient cardiology visit (for possible indication for ECV) and 24-hour Holter ECG outpatient with orders from the primary care physician
- blood tests in 7 days (CBC, creatinine, electrolytes, transaminases, cholestasis indices, coagulation)
new ED visit on 01/03 with increase of metoprolol 75 mg 1 tab x 2
lives alone
independent in ADLs and IADLs
independent in daily life
cognitively intact
PMH:
- Hypertension
- Overweight
- Dyslipidemia
- Atrial fibrillation with BBsin
- In 2016 hospitalization for hypertensive acute pulmonary edema and AF (concomitant to the episode and treated with pharmacological cardioversion with amiodarone) with noted hypokinetic cardiomyopathy; ED visit 22/02 with finding of EF 55%; TTE 05/21 EF 4% aciensia of the mid-distal portions of the septum and posterior wall; coronary angiography performed with single-vessel subcritical disease 2016
- Right lumbosciatalgia
Home medications:
- telmisartan 40 mg
- furosemide 25 mg 1 tab
- metoprolol 75 mg 1 tab x 2
- ezetimibe 10 mg
- Eliquis 5 mg 1 tab x 2
No known drug allergies
Completed anti-SARS-CoV-2 vaccination (2 doses - 2nd dose 20/2/2022)
Cell PARENTE NUM_TELEFONO
|
589001
|
In ED for progressively worsening dyspnea since yesterday.
Reports an episode of dyspnea last night while lying in bed, which resolved after assuming the sitting position within approximately 15 minutes. Subsequently reports lying down again and resting.
No fever.
No cough.
No GI symptoms.
No alterations in taste or smell.
Last week accidental fall to the ground with trauma to the RUE (X-rays of the involved region performed at H LUOGO: negative for post-traumatic lesions). In the following days onset of sacral pain.
Completed anti–SARS-CoV-2 vaccination (3/2021)
PMH
- Hypertension
- AF
- Dyslipidemia
- COPD, not on LTOT
- In 2017 breast cancer; nodulectomy performed; thereafter hormonal therapy initiated
- Vertebral compression fractures in osteoporosis
(History obtained in the absence of clinical documentation)
Home medications: apixaban 2.5 mg BID, digoxin 0.125 mg, bisoprolol 2.5 mg, rosuvastatin 5 mg, salmeterol/fluticasone, tamoxifen 20 mg, denosumab 60 mg IM (2 times/year)
Allergy to ASA
Phone PARENTE NUM_TELEFONO
|
437559
|
In ED for glycemic decompensation.
History not obtainable directly from the patient.
Yesterday 24/9 ED visit at GB for glycemic decompensation for a few days in the context of recent therapy change + fever. On PE: dehydration, afebrile. SARS-CoV-2 antigen test NEGATIVE. On ABG (arterial): Na 163 - other electrolytes within normal limits - glucose 250 - acid-base status normal - pO2 74. Patient discharged home (facility) with instructions for PO hydration, antibiotic therapy (Cefixoral 400 mg/day for 7 days), and diabetology visit scheduled Monday 27/9 next.
From telephone interview with the PARENTE it emerges: decline in general condition for ~1 week, psychomotor slowing, patient mute, no lateralizing deficit. Low-grade fever for ~24 hours about 2 days ago (T<38). No cough. No dyspnea. No GI symptoms. No urinary symptoms. No chest pain. Recent change of antihyperglycemic therapy by the treating physician (metformin stopped, dapagliflozin started).
SARS-CoV-2 vaccination completed (single dose in 3/2021)
Prior SARS-CoV-2 infection in 11/2020
PMH (History obtained from records and telephone interview with the PARENTE)
- Hypertension
- Type 2 DM
- AF on antiplatelet therapy
- Senile dementia with marked cognitive decline
- Lives in a group home
Home meds: pantoprazole 20 mg, ASA 100 mg, perindopril 4 mg, bisoprolol 1.25 mg, furosemide 25 mg 1/2 tab, simvastatin 20 mg, dapagliflozin 10 mg, trazodone 75 mg 1/3 + 1 tab, memantine 20 mg, lormetazepam 5 drops in the evening
No known drug allergies
Phone PARENTE NUM_TELEFONO
Phone group home NUM_TELEFONO
|
442220
|
The patient reports onset of retrosternal and epigastric pain radiating posteriorly, which began around 15:00 while she was seated on the bus returning from work. She describes the pain as burning, initially intermittent and subsequently becoming continuous, exacerbated by movement and deep inspiration. Denies dyspnea, palpitations, loss of consciousness, nausea, and vomiting. Denies consuming unusual or raw foods. Denies fever, cough; denies other complaints; reports well-being in recent days. Denies similar symptoms in the past.
PMH:
- active smoker (approximately 10–15 cigarettes/day)
- abstains from alcohol
- reports family history of CAD (reports PARENTE with MI)
- hypothyroidism
- reports being followed by hematology for light-chain disease (MGUS? multiple myeloma? cannot specify)
- prior hospitalization for bronchopneumonia
- bronchial asthma
- prior appendectomy
Home medications: Symbicort 2 puffs in the morning and 2 puffs in the evening and PRN
Denies drug allergies. Reports allergy to dog dander.
|
1546913
|
In ED for an episode of loss of consciousness with prodromal symptoms.
This morning: mild asthenia with nausea and headache. Last night took paracetamol for chronic general malaise (myalgia and bone pain). No fever.
Ate a light breakfast.
At work, while standing, mild malaise - while seated in the dining room, loss of consciousness with loss of posture and mild sialorrhea.
Regained consciousness, then a new episode of malaise.
LOC of short duration.
Upon recovery, malaise with nausea and sensation of epigastric pain, no confusional state.
No diarrhea. No melena.
No chest pain, no dyspnea, no palpitations.
No tonic-clonic jerks.
No sphincter incontinence.
No bite. Upward gaze.
Skin pale
First episode of LOC
Currently persisting nausea and asthenia
PMH:
IA
Sequelae of right humerus fracture
Home meds:
bivis
Reported allergies: none
SARS-CoV-2 vaccination: three doses
|
867924
|
sent from the port for respiratory distress, fever in known SARS-CoV-2 infection (known since 29/12)
patient arrived without accompanying therapy sheet ATTACHED
PMH
from previous ED visit
6/2020 hospitalization for hypokinetic cardiomyopathy newly found in AF of undeterminable onset + right basal consolidation treated with Tazocin, COVID negative -> discharged LUOGO
- relaxatio with elevation of the right hemidiaphragm, no surgical indications
- hypertension
- prior left knee prosthesis
- hearing loss
- in March 2022 ED visit for pain at the level of noted left NOME_PERSONA: reduced by taxis
relaxatio of the right hemidiaphragm without surgical indications, in November 2020 noted good psychophysical compensation, ED visit on that occasion for dyspnea
- SAD
- Prior left TKA
- Pemphigoid
- prior Clostridium difficile infection
Home meds bisoprolol 1.25 mg x 2, Kanrenol, Xanax 15 drops, Lanoxin 0, 250, Lasix 25 2 +1, Maalox, Prednisone 25 on Tue Thu Sat 1 tab, Mon Wed Fri and Sun 12, 5 mg, Ferrograd, lasxi 25 1 x 2, Pursennid,
allergies amoxicillin, intolerant to LMWH
tel PARENTE NUM_TELEFONO
|
941734
|
In ED for pain at the cervico-thoraco-lumbar spine for about 3 weeks, associated with burning pain starting from the 4th and 5th fingers of both hands and radiating toward the shoulders. Reports cervical spine MRI performed on 4/8 for this reason, showing multiple disc protrusions from C2 to C6. Betamethasone + diclofenac for 3 days was prescribed, with subjective improvement. Subsequently took paracetamol/codeine 500/30 mg x 3, however with recurrence of pain. Reports occasional pain at the left hemithorax, usually when leaning on that side, non-oppressive, not exertional, related to pressure applied to that area. Reports recent TTE performed for this reason: normal.
Denies trauma. Does not reliably deny physical exertion triggering the onset of the pain.
No fever, no cough, no dyspnea.
No nausea, no vomiting. Reports no bowel movements for about 3 days, last bowel movement 3 days ago after evacuative enema, passing flatus. No abdominal pain.
No other significant complaints.
PMH
- Hypertension
- Dyslipidemia
- Prior ischemic stroke
- Hypothyroidism
- BPH
Home medications
- Levothyroxine 100 mcg 5 days/week - 125 mcg 2 days/week
- Ramipril/HCTZ 5/12.5 mg
- Amlodipine 5 mg
- Atorvastatin 40 mg
- Tamsulosin 0.4 mg
- Ascriptin
ALLERGY TO PIPERACILLIN/TAZOBACTAM
|
522236
|
For two months episodes of oppressive chest sensation and presyncopal sensation, never LOC, for which ordered by PCP:
- 18/01/23 Cardiac Doppler echocardiography: LV not dilated, mildly hypertrophic with preserved EF; right chambers not dilated; intact interatrial septum; tricuspid valve with mild 2+ regurgitation and normal sPAP; no pericardial effusion; no intracavitary masses.
- 9/02/23 Doppler ultrasound of epiaortic vessels: diffuse atheromatosis bilaterally; right and left bulnare IMT 1 mm; carotids without hemodynamically significant stenosis; vertebral and subclavian arteries patent.
- 24-hour Holter ECG placed on 14/2/23 at CDC, currently ongoing
- 24-hour BP monitoring scheduled for next Thursday.
Today 14/2 recurrence of chest pain with mild exertion, partially resolved but not completely regressed with rest, therefore presents to the ED.
PMH
- colonic diverticulosis
- arterial hypertension
- dyslipidemia
- former smoker
- no family history of CAD
Denies drug allergies
SARS-CoV-2 vaccination with 4 doses
PARENTE: NUM_TELEFONO/NUM_TELEFONO
|
1303331
|
For several days influenza-like symptoms with cough and myalgias. Also abdominal pain related to long-standing constipation.
PMH:
- former smoker (stopped six months ago)
- centrilobular emphysema, mild interstitial lung disease, 2/2019 hospitalization at Cottolengo for respiratory failure
- apical hypertrophic cardiomyopathy EF 70%. 2019 coronary CT negative. Complete cardiology documentation currently unavailable.
- Colorectal adenocarcinoma of the rectosigmoid junction, stage 1, no metastases. Underwent LAR with lateral stoma in October 2020 with cholecystectomy + ileal resection, stoma placed. Subsequent recanalization. No indication for CT. Followed from the oncologic standpoint at OGB, Dr. NOME_PERSONA. Subsequent finding of cicatricial stenosis at the anastomotic site. Abdominal ultrasound scheduled, colonoscopy at OGB, oncologic re-evaluation. Latest visit on file 24/9/21.
- Lives with PARENTE
No drug allergies.
Completed full SARS-CoV-2 vaccination course with 3 doses.
PARENTE NUM_TELEFONO
|
644419
|
Reports persistent dyspnea since the recent discharge from the ED, denies angina
Visit with primary care physician scheduled for tomorrow
HPI
Last ED visit on 16.8 for initial heart failure
Advised increase of Dilzene from 1/2 tab x 2 to 1 tab x 2 and Lasix 2 + 1
PMH
- ED visit on 18/6/2022 for fever and productive cough; blood tests within normal limits; chest X-ray: fibrotic aspects as sequelae of radiation therapy in the left apical region; discharged home on 20/6 with levofloxacin and prednisone
- ED visit on 17/7 for dyspnea with worsening cough and sputum; finding of COPD exacerbation and rapid AF; prescribed home oxygen therapy, Deltacortene, aerosol therapy, increase of Dilzene
- ED visit on 3/8/2022 for dyspnea; chest X-ray: left apical fibrosclerosis with mild parenchymal retraction associated with peribronchitic phenomena of the lung bases; labs with inflammatory markers within normal limits
- 4/8/2022 pulmonology visit for renewal of PT Xoterna; spirometry not performed due to clavicle fracture about one month earlier
- Active smoker: 15 cig/day for 30 years, reports recent reduction
- Arterial hypertension
- Atrial fibrillation on NOAC
- PAD: femoral artery aneurysm 32 mm; thrombus occluding the deep femoral; superficial femoral occluded in the underlying segment; right popliteal ectatic, thrombosed; post-occlusive flows in TP; on the left, 18 mm ectasia of the common femoral, deep femoral stenosis 65%, popliteal aneurysm; prior left hypogastric (internal iliac) aneurysm with related surgery
- COPD not on LTOT (reported every other day, PRN)
- 11/2019 detection of suspected LUL pulmonary nodule; no surgical indications, therefore FNA not performed but only RT. In follow-up negative for disease progression for the moment
- BPH
- vaccinated for COVID, 3 doses
Home medications
Furosemide 25 mg 2 tabs + 1
Dilzene 60 mg 1 tab x 2
LIXIANA 60 mg
omeprazole
Totalip 20 mg
Xoterna (bronchodilator)
tamsulosin 0.4 mg - Avodart, Ventolin PRN
oxygen therapy 1 L/min 18 h/day (reported PRN)
No known drug allergies
PARENTE NUM_TELEFONO
PARENTE NUM_TELEFONO
|
1123345
|
In ED for fever since Sunday evening - 48 hours.
Max T 38.7°C without chills.
No cough, no new-onset sputum, no chest pain, no abdominal pain, bowel habits reported as normal with three bowel movements today and two yesterday.
Presence of skin eruptions on upper limbs and trunk and lower limbs - for two days - has not taken new medications - has not consumed new foods. No pruritus
Mild strangury and dysuria.
At the beginning of July ED visit for fever: finding of urinary tract infection - took agumtnin and Bactrim for 5 days - fever regressed; therapy tb completed on 06/07; EE 10 CRP and WBC 15,000
PMH:
- Hypertension
- Permanent AF not on OAC, underwent appendage closure - EF 50%
- Previous endocarditis due to MSSA/Enterococcus avium, in December 2021 on the tricuspid valve near EC with pulmonary embolization - vancomycin and gentamicin then shift to oxacillin and gentamicin - on 18/01 skin rash from oxacillin for which replaced with vancomycin; last TTE vegetation inariata on tricuspid valve, no vegetation on EC - TR moderate-severe
>>> 02/2022: last TEE; substantial resolution of the picture with remnants of the known endocarditic vegetation
- 2008 PM implantation for complete AV block; in 2013 generator change
- in 2018, following syncopal episodes, occlusion of the left venous system was found and therefore PM was positioned in the right infraclavicular site.
- in 2019, 2 revisions of the left infraclavicular pocket for lead dehiscence
- 1/2021 infection of the left infraclavicular pocket
- 4/2021 admission to Cardiac Surgery H molinette for chronic infection of the leads and left atrial thrombosis with mitral and tricuspid insufficiency, underwent mitral valve repair + tricuspid valve repair, removal of the atrial and ventricular leads of the PM previously implanted on the left, removing them from the cephalic vein via median longitudinal sternotomy; intraoperative culture positive for S. aureus. In April 2021 start of therapy with dalbavancin; last visit 6/10/21, surgical wound in order, PM pocket closed, cleansed.
- during the 4/2021 hospitalization evidence of chronic anemia Hb 7.5, underwent transfusion.
- Coronary CT 3/2021: no significant coronary atheromatosis
- 2010 TIA
- previous right inguinal hernioplasty
- previous appendectomy
Home meds:
- cardioasa
- bisoprolol 2.5 1 tab
- ramipril 2.5 mg
- esomeprazole 40 mg
- furosemide 1 tab
- spironolactone 25 mg 1 tab
No known drug allergies.
SARS-CoV-2 vaccination 4 doses - infection 01/2022 COVID-19
PARENTE NUM_TELEFONO; PARENTE: NUM_TELEFONO
|
782146
|
This morning, while standing (the PARENTE was changing her pyelostomy bag), onset of general malaise, blurred vision, nausea, and sweating, followed by LOC. No trauma, as she was supported by the PARENTE. Rapid recovery of consciousness; thereafter alert, oriented, and cooperative; she immediately recognized the surrounding environment. No clonic movements, no tongue biting. One evacuation of diarrheal stool after the episode.
No chest pain, no palpitations, no dyspnea before or after the syncope.
In the last 2 days low-grade fever; yesterday antigen test negative.
No cough or dyspnea.
Reports in the last 2 days abdominal pain at the hypogastrium–LLQ.
Occasional nausea and diarrhea, which she attributes to chemotherapy.
Intermittent gross hematuria, no other urinary symptoms.
Anti–SARS-CoV-2 vaccination: 3 doses
PMH
- Colorectal adenocarcinoma diagnosed in 2012. In 11/2012 anterior resection of the rectum + right salpingo-oophorectomy, laparoscopic. Adjuvant chemotherapy (XELOX). In 2016 disease recurrence; left hystero-adnexectomy and laparoscopic adhesiolysis performed. In 2018 recurrence with omental localizations evidenced after exploratory laparoscopy; JJ stents placed; subsequently pyelostomies fashioned in 2021 due to bladder invasion by disease. Chemotherapy restarted (FOLFIX and FOLFIRI). Followed by Oncology OSGB. Recent episodes of anemia (requiring blood transfusion) post-chemotherapy and partially related to episodes of hematuria. Last staging CT 7/2022: pulmonary mets stable (known since 2021), no PE, bladder finding stable (solid tissue infiltrating the bladder). Currently patient on active chemotherapy (last cycle completed approximately on 20/10).
- Prior appendectomy
- Prior traumatic fracture of the left clavicle
Home meds: none chronically - chemotherapy (trifluridine)
Allergies: CEFTRIAXONE - OXALIPLATIN (skin rash)
|
1028946
|
Presents to the ED on 04/05 for fever since 28/04 (max 38.8°C) associated with diffuse chest pain radiating to the back, shoulders, interscapular area, continuous, lasting about 2 days, not exertional, regressed with antibiotics and acetaminophen. Denies cough or dyspnea. Denies urinary symptoms. Denies GI symptoms. Denies anosmia and ageusia.
PCP contacted by phone, who prescribed amoxicillin/clavulanate 1 g twice daily taken from 29/04 until yesterday.
On that occasion CRP 11, Cr 2.3, AST 138, ALT 153, Cr 2.3.
Given the absence of abdominal symptoms, absence of respiratory failure, and the ultrasound finding of left basal pneumonia (radiographically occult), was discharged with levofloxacin 250 mg.
Today returns to the ED.
Persistence of low-grade fever but apparently improving compared with previous days.
Persistent absence of organ-specific symptoms suspicious for infection.
PMH:
-SARS-CoV-2 infection in 12/2020
-former smoker (quit 45 years ago)
-probable CKD recently detected (does not recall Cr values, reports nephrology visit scheduled)
-dyslipidemia
-hypertension
-obesity
-unspecified rheumatologic disease
-removal of uterine polyps
-cataract surgery right eye
-bilateral carpal tunnel surgery
Home medications: atenolol 100 mg, 1/2 tablet; doxazosin 4 mg (now stopped); simvastatin 10 mg; allopurinol 300 mg, 1/2 tablet; cholecalciferol; colchicine 1 mg twice weekly
Allergies: ASA
|
557234
|
Brought to ED by MSA for generalized seizure witnessed by bystanders who supported the patient; seizure still ongoing on EMS arrival. No trauma. Midazolam 5 mg intranasal administered with benefit. Subsequent postictal state with snoring respirations and desaturation.
The PARENTE denies fever and cough in recent days; habitual exertional dyspnea (one flight of stairs) noted for some time.
Vaccinated against SARS-CoV-2, two doses.
PMH: history obtained by phone with the PARENTE who is outside LUOGO; documentation unavailable
- lives alone, separated from PARENTE, one PARENTE, independent in ADLs/IADLs, initial cognitive decline
- former heavy smoker until age 50 yrs
- IA
- prior ischemic strokes, without sequelae
- prior carotid endarterectomy, side unknown (R vs L), and contralateral carotid stenosis
10/2020 carotid stenting
- ambulates with difficulty due to tendinopathy
Home medications (reported by PARENTE by phone): ASA 100 mg, Plavix 75 mg 1 tab, losartan 1 tab, Torvast 20 mg, tamsulosin 0.4 mg (DENIES COUMADIN USE, likely discontinued after carotid stenting of 10/2020)
Allergies: no known drug allergies
PARENTE NUM_TELEFONO
|
254019
|
Patient sent to the ED from the community due to blood noted in the diaper.
ALLERGIES: grasses; no known drug allergies
PMH:
- Patient residing in LUOGO for severe intellectual disability and behavioral disorder (followed by Dr. NOME_PERSONA--> NUM_TELEFONO)
- Tuberous sclerosis, followed by CMID OSGB (Dr. NOME_PERSONA) and by LUOGO Epilepsy, Molinette Hospital (Dr. NOME_PERSONA); known renal angiomyolipomas
- Multifactorial anemia
- IgA monoclonal gammopathy in B-cell lymphoma treated in 2018 with rituximab
- March 2021 SARS-CoV-2 pneumonia
- On 20/8/21 ED visit at G. Bosco Hospital for deterioration of general condition and doubtful seizure episodes. Repeat head CT: comparable to previous; plasma valproate level within limits. Hb 9.5 g/dL, PLT 91.
Discharged to the Community.
Home Medications: valproate 500 mg 2 tabs x 3 tabs in the evening, felbamate 600 mg 1 + 1/2 tab x 2, biperiden (Akineton) 4 mg 1 tab, risperidone 1 mg x3, carbamazepine 400 mg 1 tab + 1/2 tab + 1 tab, lansoprazole 30 mg 1 tab x2, clonazepam 2.5 mg/mL 15 gtt + 20 gtt + 20 gtt,, folic acid 5 mg 1 tab, calcifediol 8 gtt, promazine 10 gtt, Sideral 1 tab
Tel PARENTE--> NUM_TELEFONO
Tel Facility manager--> NUM_TELEFONO
|
521978
|
Pt. escaped from LUOGO at 15:00 to go to PARENTE, who alerted 112 to bring him back to the hospital. Transported to LUOGO due to proximity.
Similar episode on 5/02 (this year), brought back to LUOGO.
PMH (from chart)
- Hypertension
- Type 2 diabetes mellitus
- Severe obesity (height 180 cm, weight 120 kg)
- CKD (creatinine in 8/2021 1.7 mg/dl)
- Trophic ulcer of the left lower limb, followed at the V Montanaro Clinic
- Gastritis
- Past acute pancreatitis
- Past hospitalization at LUOGO for respiratory failure
- January 2021 ED presentation for fall to the ground and prolonged time on the ground due to inability to get up, finding of prerenal AKI and rhabdomyolysis, SARS-CoV-2 molecular swab positive. Admitted to Martini Hospital, subsequent rehabilitation at LUOGO. Discharged home in SOD. For some months progressive cognitive deterioration with memory gaps and decreased functional autonomy. Disability procedures initiated.
Home medications (from chart; the patient does not recall): furosemide, amlodipine, isosorbide mononitrate, bromazepam
Drug allergies: none reported
Tel PARENTE NUM_TELEFONO
Vaccinated 2 doses
|
1133867
|
Note written retrospectively to provide care to the patient.
The patient reports living alone, assisted by PARENTE. Reports about 10 days of nausea and food vomiting (approx. 3–4 episodes per day) with inability to eat and hydrate. Unable to report whether fever at home; reports bowel habits tending to constipation (last bowel movement 2 days ago, denies hematochezia, melena); denies chest pain, dyspnea, falls, and head trauma. Reports cough at home. Denies intake of foods or substances different from usual.
Spoke with PARENTE: reports prior fall with presyncope on 04/11 with presentation to Maria Vittoria Hospital (discharged with diagnosis of nocturnal dyspnea in HF exacerbation). Confirms vomiting for 10–15 days, reports having contacted the PCP who started levopraid from 11/12 (3 days) with slight improvement for 5–6 days, then reports recurrence of symptoms. Confirms constipation. Denies fever at home.
PMH from previous visit:
- CAD with STEMI 1 yr ago
- Hypertension
- Prior appendectomy
- Prior surgery for reported colon neoplasm in 2000
- Previous right PTA
- Diverticulosis
- Vaccinated, 3 doses SARS-CoV-2
Home medications:
- Furosemide 25 mg 1 tab at 08:00 and 1 tab at 16:00
- Laxative 1 sachet in the morning
- Pantoprazole 20 mg 1 tab in the morning
- Bisoprolol 2.5 mg 1 tab at 08:00
- Sereupin 20 mg 1 tab in the morning
- Venitrin patch 10 mg at 08:00
- Cardirene 75 mg 1 tab at 12:00
- Lasitone 25/37.5 mg 1 tab in the afternoon TUE-THU-SAT
- Ramipril 5 mg 1 tab at 20:00
- Solirem 1 tab in the evening
- Levopraid 50 mg 1 tab for 3 days
Denies drug allergies.
PARENTE number NUM_TELEFONO
|
1528915
|
Complains of dyspnea for approximately 4 days, worsened by the supine position, also present at rest.
Known lung cancer since 10/2019 with pericardial effusion (unclear localization of disease). Last echocardiogram 10/2020 (next scheduled for 2/7/21). At the echocardiogram in 6/2020 effusion of approximately 20 mm (much less in some areas). Unchanged in October. In 4/2021 chest CT performed: effusion of approximately 20 mm. On 10/6 CT: effusion 38 mm.
PMH:
- hypertension
- FAP
- chronic anemia
- pulmonary adenocarcinoma in follow-up. Last CT 10/6 pulmonary consolidation unchanged, pericardial effusion 38 mm, no secondary lesions. Unchanged infrarenal abdominal aortic aneurysm (37 mm), left common iliac (18 mm)
- known pericardial effusion (12/2019 circumferential effusion 25 mm maximum thickness)
Home medications: lansoprazole, Eliquis 2.5 mg twice daily, lercanidipine 1 tablet twice daily, metoprolol 100 mg 1 tablet x 1/2 tablet, Omnic 1 tablet
Denies allergies
PARENTE: NUM_TELEFONO
|
217148
|
In ED for dyspnea for a few days with fever.
Reported body temperature up to 39°C last night.
Lumbar and dorsal pain, no frank chest or abdominal pain.
No cough, no sputum, no focal symptoms reported.
Cognitively intact.
Reported independent in ADLs and IADLs.
Reported undergoing chemotherapy; last in June 2022.
SpO2: 82 at home – observed with home pulse oximeter at home.
PMH:
- Former smoker
- Hypertension
- Obesity
- Mild CKD (in March 2021 creatinine 1.2–1.4)
- April 2018 aortic valve replacement (Osp Molinette) with bioprosthesis and reconstruction of the mitral-aortic fibrous body with heterologous pericardial patch via sternotomy for infective endocarditis of the aortic valve due to S. gallolyticus. Postoperatively AF pharmacologically cardioverted. From 22/3/21 to 6/5/21 hospitalization at Osp Molinette for infective endocarditis on aortic bioprosthesis, underwent CCH procedure of replacement of the aortic bioprosthesis–aortic root–ascending aorta and respiratory failure from COVID-19 pneumonia (swab performed on 5/5/21 negative). During that hospitalization, findings of septic emboli in right parietal, bilateral temporo-insular, left occipital, and left cerebellar hemisphere.
- Cardiology visit 10/2/22: dyspnea with very mild exertion (NYHA II). LV slightly dilated; EF 38% with akinesis of septal and inferior apex. Homograft sequelae in normal position. Mild–moderate mitral regurgitation, aortic bioprosthesis in normal position, mild tricuspid regurgitation, visualization of a filamentous formation within the LV originating from the posterior apex and apparently extending into the ascending aorta confirmed on TEE. This filament causes restriction of the movement of one cusp with mild insufficiency. No indications for CCH. Coumadin started, apparently under the hypothesis of a thrombotic formation.
- 2019 enucleoresection of K left kidney
- COPD – November 2021 PFTs: restrictive defect (FEV1 69%) FVC 70%, mild reduction in DLCO, 6MWT normal.
- In 2008 radical prostatectomy and adjuvant pelvic RT for prostate ADK. In 2017 recurrence of neoplastic disease with lymph node and left pulmonary metastases, for which therapy with Enantone was started. PET showed uptake in the coccygeal area, left hemisancrum, right ilium, vertebral body of L1 and D10, and facet joints of C5; MRI SPINE JULY 2022: SECONDARY LESIONS d3 - l1 - l53 and l5 - RIGHT ILIAC BONES - s1; ongoing chemotherapy since April 2022 with taxanes via left PICC; home care activated – last chemotherapy at the beginning of July.
Home medications:
- Pantoprazole 20 mg x2
- Ramipril 5 mg at 08:00, furosemide 25 mg at 08:00
- FULCROSUPRA
- Coumadin per INR
- Enantone 3.75, 1 vial IM every 28 days
- Venlafaxine
- desametaone 64 drops
- Fentanyl 50 mcg/72 hours + Oramorph as needed
Allergies: no known drug allergies
SARS-CoV-2 vaccination in two doses
Reports COVID-19 infection twice – last at the beginning of 2022
CELL PARENTE NUM_TELEFONO
|
775844
|
In ED for abdominal pain localized to the upper quadrants for about 2 days.
No nausea/vomiting/diarrhea. Last bowel movement yesterday (normally colored stools).
No fever.
No respiratory symptoms.
No chest pain.
No frank urinary symptoms.
History obtained with the help of PARENTE; the patient does not exactly remember the reason for ED presentation.
SARS-CoV-2 vaccination: 4 doses
PMH (history obtained in the absence of clinical documentation)
- Hypertension
- T2DM
- Dyslipidemia
- Carotid atherosclerosis (right ICA stenosis 70%)
- AF
- Prior cholecystectomy for cholelithiasis
- In 10/2022 admission to Internal Medicine OSGB for acute pancreatitis; AF detected on that occasion, therefore started on DOAC
- In 1/2023 new admission to Internal Medicine H Carmagnola for acute pancreatitis
- Cognitive impairment
- Lives with a caregiver 24 h.
Home medications: pantoprazole 40 mg, barnidipine 10 mg, bisoprolol 1.25 mg, edoxaban 60 mg, empagliflozin 25 mg, atorvastatin 10 mg, melatonin 2 mg, haloperidol 7 drops x 2, Creon 10000 IU
No drug allergies
|
1204685
|
Sent from dialysis clinic for workup of abdominal pain since last night. Today blood cultures performed; ABG with respiratory alkalosis; fever; increased lipase.
See documentation held by the patient.
PMH
Admission on 29-7-22 to Nephrology for acute acalculous pancreatitis; VRE bacteremia. Treated with Tazocin and then gentamicin and daptomycin for isolation of VRE E. faecium.
COVID+ from 30/7 to 10/8/22
Pt on peritoneal dialysis,
diabetic,
ischemic heart disease,
prosthetic replacement of the ascending aorta,
peripheral arterial disease of lower limbs,
history of recurrent renal artery stenosis, underwent right angioplasty, with subsequent recurrence of stenosis, no longer indication to repeat the procedure
Recent positive QuantiFERON, currently on therapy with rifampicin
On therapy with Atorvastatin 20, Cardioasa, Lasix 500 1/2 in the morning and 1/4 in the afternoon, Lercadip 20, Metocal 1 tab BID, Nebivolol 5, Niferex 1 tab daily, Pantoprazole 20, Retacrit 6000 1 vial/week, Tresiba 14 U at lunch, kcl r, Rifadin 300 1 tab BID
Denies drug allergies
Pt vaccinated
Phone NUM_TELEFONO
|
1094186
|
HPI: Presents to the ED for onset of dyspnea and a sensation of heaviness in the retrosternal area radiating to the jugulum.
No fever, diarrhea, anosmia, ageusia. No change in the habitual cough in an active smoker.
Last cycle of chemotherapy performed on 04/19 (current year).
PMH:
- Heavy active smoker. Lives with PARENTE.
- Small-cell neuroendocrine carcinoma with lymph node + adrenal mets, on active chemotherapy with carboplatin + etoposide.
°°°Histologic exam: Ki-67 95% - TTF-1 +
°°°(04/21) Last oncology visit: fair general condition, no chemotherapy toxicity. ECOG 2 - Karnofsky 70. Staging CT scan scheduled on 04/29
- Arterial hypertension on treatment.
- Overweight.
- CKD stage III (creat 1.6 mg/dL).
- Early neurocognitive disorder.
°°°(02/21) Geriatrics visit: no indication for therapy. Only monitoring over time.
PARENTE NUM_TELEFONO
PARENTE NUM_TELEFONO
Home medications: Prednisone 25 mg 1/2 tab, Allopurinol 300 mg 1/2 tab, PPI, quetiapine 25 mg 1 tab, Promazine 15 gtt as needed.
Recent discontinuation of antihypertensive therapy (Lercanidipine 20 mg 1 tab + Telmisartan/HCTZ 1 tab).
|
52783
|
In ED for chest pain and finding of LBBB on ECG.
The patient reports last night at 04:00 onset at rest of substernal chest pain radiating posteriorly, oppressive in nature, lasting approximately 40 min; during the pain she reports having gone to the bathroom; while seated, onset of visual blurring and LOC; upon regaining consciousness, asymptomatic.
No palpitations, no dyspnea.
For about an hour, recurrence of chest pain but of markedly lower intensity than last night.
No fever, no organ-specific symptoms in recent days.
Denies current pregnancy with certainty.
SARS-CoV-2 vaccination: NOT received
PMH
- Non-smoker
- No HTN, No DM, No dyslipidemia
- No family history of CAD
- Previously underwent cardiology evaluations (ECG, TTE, and exercise stress testing) for sports reasons; reports results always normal; no known LBBB.
Home medications: none chronically
Allergies: clavulanic acid (takes amoxicillin)
|
878005
|
HPI: Since dinner time, sudden onset of shortness of breath; left hemithorax pain at the level of the 5th/6th intercostal space, stabbing in nature, partially exacerbated by palpation, lasting approximately 5–6 min; and pain and a sensation of numbness in the left upper limb.
Denies nausea, diaphoresis and/or palpitations.
For about 1 week reports onset of productive cough with yellowish sputum.
Denies fever, diarrhea, anosmia, ageusia.
PMH: (from history). Clinical documentation not available.
- Lives alone. Ex-smoker (quit 40 years ago).
- Hypertensive-ischemic heart disease, underwent multiple revascularizations (only dyspnea pre-CABG)
- (2002) CABG
- Subsequent revascularizations with PTCA. Stress test indicated, not performed.
- COPD in ex-smoker, not on therapy.
Home medications: Ramipril 2.5 mg 1 tab, Bisoprolol 1.25 mg, PPI, Indobufene at lunch, Atorvastatin 10 mg 1 tab, Amlodipine 10 mg 1 tab.
Allergies: ASA.
|
7660
|
ED presentation for fever for 5 days, associated with productive cough and dyspnea.
Rocefin IM started from 28/8.
PMH
- Hypertension
- HBV; HCV negative
- CAD with repeated PCI
- Peripheral arterial disease of the lower extremities, multiply treated: multiple revascularization procedures of LLE and RLE
- 04/2020 aneurysmal degeneration and infection of the right femoro-distal bypass, underwent in 06/20 revision of the bypass with a biological prosthesis type Omniflow2, complicated by hematoma near the knee, subsequently superinfected.
- 10/2020 RLE amputation in irreversible ischemia due to thrombosis of the right femoropopliteal bypass
- Ex TD
- Active smoker
- Type 2 diabetes mellitus, at least in part metasteroideo
- RA on therapy with MTX (in follow-up with Dr NOME_PERSONA)
- Hyperuricemia
- BPH
Home meds: pantoprazole 20 mg, alprazolam 1 mg 1 tab x2, Zaroxolyn 5 mg 1 tab, pregabalin 75 mg + 150 mg, bisoprolol 2.5 mg, clopidogrel 75 mg, Folina 5 mg, allopurinol 100 mg, amlodipine 5 mg, atorvastatin 20 mg, lorazepam 2.5 mg; Reumaflex 50 mg every Monday, Semaglutide 0.5 mg every Monday.
Allergies: denies
Lives with the disabled PARENTE. Separated, one PARENTE who lives with the PARENTE. One PARENTE.
Ambulation limited to bed–wheelchair transfers. Activation of territorial NOCC in progress.
NUM_TELEFONO PARENTE
|
1776696
|
In the ED for cough for 2 days; since today also dyspnea and oppressive chest pain.
PMH:
- Active smoker.
- Ischemic-hypertensive heart disease status post revascularization. Known LBBB.
°°°(2013) PCI + stent to mid LAD in 2013.
°°°(2021) Echocardiogram: EF 45% with apical septal dyskinesia, MR +.
°°°(03/2021) Outpatient cardiology visit: ischemic heart disease with status post PCI to LAD, newly detected LBBB, therapy modified (ivabradine added and beta-blocker increased but not tolerated, therefore continued bisoprolol only) and coronary angiography recommended.
- Previous COVID in 11/2020 u.s.
- Previous erysipelas ASSIn.
- Dyslipidemia.
- Hypertension.
- Vertebral collapse in osteoporosis.
- COVID 11/2020
Ongoing therapy: Pritor 20, cardioASA, bisoprolol 1.25
Doubtful allergy to Zitromax - cough from ACE-i
In menopause for 10 years
Not vaccinated
|
984975
|
Presents for dyspnea for about one week, no frank orthopnea or PND, reports marked weight gain (8 kg).
Also facial edema, rubor.
Never angina or palpitations.
Active smoker
Also reports about 14 days ago switch from Paroxetine to Venlafaxine 75 mg, then discontinued about one week ago due to onset of edema, rubor, dyspnea.
Two ED visits in Ciriè in recent days:
- 06/12 visit for dizziness. Head CT negative for SAH.
- 11/12 visit for worsening dyspnea, finding of heart failure, treated and discharged with indications to supplement therapy
PMH
- Lives alone, independent
- GERD with known hiatal hernia
- Alcohol use (10 glasses of wine per day for 20 years)
- Cardiovascular risk factors: active smoker (20/day for 30 years), spirometry negative in November 2023, overweight, dyslipidemic
- NSTEMI in 2022, treated with PCI and stenting LAD I-II-III and Cfx-MOP, EF 60% in 2022. Last Cardiology visit Molinette 08/2023
- SAH from rupture of anterior communicating artery aneurysm in 2016, last follow-up normal in March 2023
- Anxious-depressive syndrome
Home medications: Rosuvastatin/Ezetimibe, CardioSA; Doxazosin, Lexotan Telmisartan
No known allergies
A. Sapia m spec
|
1532363
|
In ED for worsening of gross hematuria over the last month.
Outpatient urologic visit performed and unsuccessful attempt at cystoscopy (not completed).
No fever.
No strangury/urinary frequency/urinary urgency.
In the last week nonproductive cough, no dyspnea. Ciprofloxacin prescribed yesterday by PCP.
No GI symptoms.
SARS-CoV-2 vaccination: 3 doses
PMH
- IA
- T2DM on insulin therapy
- Hypercholesterolemia
- CKD
- Ischemic heart disease (MI 1996)
- Atheromatosis of the TSA. TSA Doppler ultrasound 2020: 30-45% stenosis of the CI bilaterally
- Ischemic stroke in 2005 without sequelae
- VCC
- Venous insufficiency of the LE with organized saphenous vein phlebothrombosis, edema from lymphostasis
- BPH
- Bladder cancer known since 6/2021 (on cytology, high-grade urothelial carcinoma suspected - on cystoscopy, neoplastic vegetation on the left lateral wall), not treated with TURBT per patient’s wishes
- Lives alone. Helped by PARENTE. No longer independent in ADLs. Ambulates with a cane.
Home medications: clopidogrel 75 mg, atenolol 50 mg, amlodipine 5 mg, insulin in four injections (8+14+12 IU, long-acting 20 IU), atorvastatin 20 mg, tamsulosin 0.4 mg, pantoprazole 40 mg, oxybutynin 5 mg 1 tab x 2, sertraline 10 mg
ALLERGIES: PENICILLIN - contrast medium (MRI) - QUINOLONES (skin rash after the first administration, none with subsequent administrations)
Tel. NUM_TELEFONO
Tel. NUM_TELEFONO
|
1575341
|
ED visit for dyspnea since yesterday. Denies chest pain.
Reports low-grade fever and mild productive cough for 3–4 days.
Vaccination against LUOGO, 2nd dose in September 2021
PMH:
- Awaiting TURBT for bladder cancer (surgery scheduled 11/2/22).
- April 2021. Subacute anterior STEMI. On emergent coronary angiography after placement of an intra-aortic balloon pump, finding of critical 75% stenosis of the mid LAD and near-occlusion of the distal LAD; critical proximal RCA stenosis. PCI performed with 2 DES to the LAD. Evidence of periapical coronary microperforation. On echocardiography, small pericardial effusion and apical thrombosis. Discharged with LifeVest. Last Cardiology visit on 25/1/22: EF 33% in hypokinetic cardiomyopathy post ischemia
- September 2021, ICD (LUOGO) placed for primary prevention
- Left inguinal hernioplasty
- Former smoker: quit 1 year ago
- Hypertension
- CKD (on 28/1/22 creatinine 2.6)
- Dyslipidemia
|
710055
|
Presents to the ED for high fever preceded by shaking chills for two days, associated with cough
Vaccinated with 4 doses for SARS-CoV-2
PMH
- iron-deficiency anemia
- Type 2 diabetes mellitus
- Dyslipidemia
- CAD:
* in 2013 NSTEMI; on coronary angiography three-vessel coronary artery disease (LAD / OM / RCA) treated in 2 interventional cardiology sessions with PTCA + implantation of drug-eluting stents; on echocardiogram EF 50%
* in 2014 in-stent restenosis on OM, treated with drug-eluting balloon on LCx/OM + critical in-stent restenosis on RCA, treated with predilation + DEB; also noted critical stenosis of diagonal branch and PDA
* in February 2017 posterior STEMI; on coronary angiography in-stent subocclusion of OM; LAD and RCA without critical lesions; PTCA performed on OM; on echocardiogram EF 45%.
* in January 2018 hospitalization for unstable angina; on coronary angiography critical restenosis of LCx, treated with drug-eluting balloon
* 11/2019 PTCA + stenting on OM for critical restenosis - Noncritical supra-aortic trunk arteriopathy
- BPH
- Prior appendectomy
- Colon cancer operated in March 2023, with colostomy. Undergoing oral chemotherapy for positive lymphadenopathy
Home medications: pantoprazole 40 mg 1 tab, acetylsalicylic acid 100 mg, Lecadip 20 mg 1 tab, bisoprolol 1.25 mg 1 tab, Maoris 20/10 mg 1 tab, atorvastatin 40 mg, metformin 500 mg x 2, tamsulosin 0.4 mg, capecitabine 500 mg 3 tabs + 4 tabs
Denies drug allergies
Vaccination for SARS-CoV-2: 4 doses
PARENTE NUM_TELEFONO
|
1741529
|
TRIAGE: Accompanied by MSA for transient LOC with spontaneous recovery. Event preceded by blurred vision and dizziness. ECG performed by MSA negative. Denies chest pain, denies headache. At triage reports only asthenia and burning sensation.
Alert, conscious, and oriented to time and space. Hearing loss ++
Cincinnati negative
HGT 166
DISCUSSION WITH PARENTE:
During a meal, onset of nausea with a few bouts of vomiting, then reported blurred vision and subsequent LOC characterized by intense pallor and diffuse stiffening, with gaze directed upward.
Patient kept on the chair at the dining table until contact with 118; on advice of 118 placed on the ground with progressive return of color and consciousness. Not post-ictal, no tremors of the limbs, no morsus.
No chest pain, no palpitations; reported sensation of dyspnea during the malaise, for which 2 puffs were administered by PARENTE on suspicion of asthmatic-type exacerbation.
This morning SBP 175 mmHg, therefore Cardura restarted (not taken for a long time due to hypotension during the summer period).
COVID-VACCINATED 4 DOSES
PMH:
- COPD/asthma
- Obesity
- Hypothyroidism
- Hypertension
- Type 2 diabetes mellitus
- Insomnia
Home meds:
- Eutirox 75 mcg
- Foster 1
- Rulufta
- Salmetedur
- Micardis 80 mg
- Lasix 25 mg 2 tabs + 1 tab
- Repaglinide 0.5 mg 1 + 1 + 2 tabs
- Iron
- cardioASA
- Halcion 250 mcg 1/2 tab
ALLERGIES: none known
NUM_TELEFONO PARENTE
|
865037
|
Yesterday objective vertigo, nausea, vomiting. Currently asymptomatic
PMH:
- Former smoker (quit in 2002). Intermittent urinary incontinence. Independent in ADLs/IADLs.
- Hypertension.
- Pulmonary emphysema.
- T2DM managed with diet.
- Lung squamous cell carcinoma LSD (pT2 N1 G2 stage IIb) status post left pneumonectomy + adjuvant chemotherapy
°°°(2015) Left pneumonectomy + adjuvant chemotherapy with Carboplatin AUC + Vinorelbine.
°°°Chronic residual left pleural effusion.
°°°(09/20) Restaging CT: unchanged compared to the previous and oncologically negative.
°°°(07/23) Oncologic visit: follow-up negative. Follow-up visit in 1 year.
- (2002) Urothelial bladder carcinoma treated with cystectomy and neobladder creation - 6/2021 episode of gross hematuria while on low-dose ASA, subsequent abdominal CT and cystoscopy negative for disease recurrence
- (2007) AAA treated with endograft placement.
- 7/23 ED visit for anginal chest pain, TnT negative: after a long conversation with the PARENTE of the patient, preference to defer coronary angiography. Labs: Hb 14, Cr 0.8. Chest X-ray: status post left pneumonectomy
°Coronary CTA 1/2/22 LAD II 80%, first diagonal occluded, second diagonal critical at the ostium, RCA II-III 70%
- Sigmoid diverticulosis.
- Previous renal colic due to lithiasis.
- Past surgeries: bilateral inguinal hernia repair, tonsillectomy
Home medications:
Congescor, Foster, Incruse, Cardirene, rosuvastatin, Triatec, Nitroderm TTS.
Denies drug allergies
|
1630456
|
In ED for general malaise. Reports episodes of LE giving way associated with left-sided pulsating hemicranial headache; denies other deficits. Never fell to the ground, no trauma, in particular no head trauma. Denies syncope or LOC.
No fever. No cough or dyspnea. No chest pain. No palpitations.
No nausea, no vomiting or diarrhea. Reports occasional episodes of epigastric pain, stabbing in quality, of variable duration (from 2 h to days), difficult to characterize, pain occurring periodically since she underwent surgery (15 years ago) for epigastric hernia.
No urinary symptoms.
No other significant complaints.
Not vaccinated against SARS-CoV-2.
Denies previous SARS-CoV-2 infection.
PMH
- Arterial hypertension
- Hiatal hernia
- Chronic headache
- Sjögren syndrome
- Cervical spondylotic myelopathy
- Polyosteoarthritis
- Prior surgery for epigastric hernia (15 years ago), since then occasional episodes of epigastric pain
- ED visit on file from 2015 showing allergic reaction to bromazepam
(History obtained without documentation)
Home medications: amlodipine 5 mg, bromazepam (? archive shows allergy)
Allergy to PARACETAMOL, BROMAZEPAM, and other unspecified drugs (the PARENTE reports never having been able to understand which active ingredients the pt was allergic to)
|
501019
|
Presents to the ED accompanied by MSA reporting 2 days of oppressive retrosternal chest pain associated with worsening of chronic dyspnea and irritative cough. No fever. No urinary symptoms. Today also onset of diarrhea (5 episodes), no blood or mucus in the stools.
Reports having taken prednisone 5 mg 1 tab both yesterday and today with slight improvement of dyspnea and pain symptoms.
On 31/08 finding of INR 6.29; held for 2 days, dose reduced, recheck scheduled for tomorrow.
Upon arrival of the rescuers, tendency to hypotension noted; therefore NS 250 cc administered.
PMH:
- Type 2 diabetes mellitus
- Previous bilateral DVTs complicated by PE on OAC (2009 PE in bilateral infrapopliteal DVT, 2014 recurrence of massive PE and pulmonary infarction, therefore OAC resumed)
- Dyslipidemia
- SAD
- GERD
Home medications: coumadin per INR, metformin 500 mg 2 tabs/day, atorvastatin, (saxagliptin/dapaglifozin) 5/10 mg, trittico 75 mg 1/4, felison 15 mg, pantoprazole 40 mg
Allergies: no known drug allergies
Vaccination for SARS-CoV-2
PARENTE NUM_TELEFONO
|
1698819
|
In ED for epigastric pain of burning/cramping character for about 3 days, continuous.
Reports nausea and some episodes of vomiting.
Reports hyporexia.
The patient reports near-zero fluid intake in the past days due to vomiting always following the intake of minimal amounts of oral liquids.
Denies diarrhea. Bowel open to flatus. Last bowel movement 3 days ago, stools normal in form and color.
Denies fever.
Reports taking paracetamol 20 mg once daily for about 4 days, with temporary partial benefit.
Also reports taking metoclopramide.
Denies respiratory/urinary symptoms.
Reports symptoms similar to a previous episode of gastritis in 2021.
From conversation with the PARENTE it emerges: PARENTE of the patient affected by 'cyclic vomiting syndrome' presenting with similar symptoms.
SARS-CoV-2 vaccination: not performed
PMH
Active smoker
Denies alcohol use
Occasional use of illicit substances (THC)
In 2021 one ED visit in GB for epigastralgia in gastritis (E/ EGDS)
(History inferred in the absence of clinical documentation)
Home medications: none chronic
Denies known drug allergies
Phone PARENTE NUM_TELEFONO
|
1674634
|
Arrives to the ED for detection this evening of desaturation at home (SpO2 78% on NC 1 L/min) associated with dyspnea on minimal exertion and fever (Tmax 39) for about 7 days.
Also reports dysuria and urinary frequency.
Chronic productive cough not worsened in recent days; no chest or abdominal pain reported.
APP: recent hospitalization at O. San Luigi for COPD exacerbation treated with antibiotic therapy and steroid therapy, with subsequent positivity for C. albicans and S. aureus treated with a fluoroquinolone. Discharged home on LTOT 1 L/min 24 h/24 h. HRCT performed showing paraseptal emphysema of the upper lobes bilaterally and centrilobular emphysema diffusely distributed; extensive consolidative opacity in the RUL and RML and associated areas of bilateral basal ground-glass opacities.
APR:
- Lives at home with PARENTE, independent, former smoker (quit 11 yrs ago); 2nd dose SARS-CoV-2 vaccine (July 21)
- Arterial hypertension on pharmacologic treatment
- Ischemic heart disease (2017 PTCA + stent LCx + PTCA LAD for subcritical stenosis) last echocardiogram (09/21: global LV kinesis preserved, EF 62%, no dilation of RV and atria, ectasia of the ascending aorta (40 mm/26 mm/m^2))
- FAP on NOAC
- Dyslipidemia
- T2DM on oral hypoglycemics with good glycemic control
- Severe COPD
- Surgery for aneurysm of the distal aortic arch and of the descending thoracic aorta and abdominal aorta
- CKD (Cr 1.06, eGFR 60 on 09/21)
- Prior appendectomy, tonsillectomy, adenoidectomy, and unspecified mastoid surgery
Home medications (from discharge letter): bisoprolol 1.25 mg; Xarelto 20 mg 1 tab/day; Isoptin 120 mg 1 tab/day; Procoralan 5 mg 1 tab twice daily; pantoprazole 20 mg 1 tab/day; Jardiance 10 mg 1 tab/day; Rosumibe 1 tab; furosemide 25 mg 2 tabs + 1 tab/day; canrenone 50 mg; Foster 200+6 2 puffs/day;
ALLERGY TO contrast medium (diffuse erythema)
PARENTE Massimo NUM_TELEFONO
|
989490
|
Since Saturday 29/10 progressive exertional dyspnea, worsened today, since last night also present at LUOGO.
No angina, no palpitations.
No fever.
Last Wednesday reports an episode of pain at the shoulder girdle and upper back of long duration (several hours), resolved after ibuprofen.
In recent days hyporexia with marked reduction of fluid and caloric intake
PMH:
- Former smoker (quit about 30 years ago)
- Hypertension
- Intestinal neoplasm not well specified (does not remember exactly and documentation missing), operated in 2017, not treated with chemo or radiotherapy, previously followed by Dr. NOME_PERSONA; since after COVID no further follow-up
- Prior nephrolithiasis
- Chronic cervicalgia
- Reports intake of 1 glass of wine with meals
- Lives alone, independent in ADL and IADL, leaves home to do the shopping, has no PARENTE or PARENTE
- Vaccinated with 4 doses for SARS-CoV-2
Home meds: atenolol, quinapril/hydrochlorothiazide
No known allergies
PARENTE NUM_TELEFONO
Neighbor NUM_TELEFONO
|
1029779
|
Arrives in the ED sent from LUOGO in Settimo T.se for anasarca not responsive to diuretic therapy.
today metolazone 1 tablet administered
PMH:
- valvular heart disease: - 12/2009 worsening dyspnea + asthenia with severe intraprosthetic insufficiency with a highly eccentric regurgitant jet directed along the interatrial septum due to degeneration of the prosthetic cusps, dilated RV with massive TR --> on 19/5/2010 at CCH Rinaldi surgery of mitral bioprosthesis replacement with biological prosthesis NOME_PERSONA Peimount Magna 25 mm+
replacement of tricuspid valve with NOME_PERSONA Plus 29 mm. Placement of definitive epicardial lead VNdx. Postoperatively required CPAP and onset of third-degree AV block ---> implantation of PM Medtronic in sinc 3, mode VVIr. 1/2010 Echo: EF 50% mild AR
- diabetes
- hypertension.
- prior vaginal and rectal plasty
- prior benign mass of right salivary gland
- prior excision of back lipoma
- cholelithiasis
- hemorrhoids
- recurrent cystitis
- 1995 infectious endocarditis on mitral valve: underwent valve replacement with biological prosthesis BIOcor 29 mm associated with tricuspid plasty according to De Vega. During hospitalization AF for which OAC was started-
- From 1995 to 2009 good hemodynamic compensation
Current therapy: ceftriaxone 2 g, potassium canrenoate, normal saline x 3, enoxaparin 4000 x 2, insulin lispro 4+4+4, citalopram 8 drops, allopurinol 100, atenolol 50 mg x 2, pantoprazole 1, potassium chloride 1 x 3
Denies drug allergies
PARENTE NUM_TELEFONO
|
1704803
|
for 2 days dependent edema and dyspnea, no fever, no cough
independent in ADL and IADL but initial functional limitation. cognitively intact
HPI
discharged on 17.2 from MIC 2 with diagnosis of respiratory failure in heart failure and acute asthmatic bronchitis
PMH:
- Hospitalized from 8 to 15/11 for heart failure, treated with diuretics with benefit, no indication for further hemodynamic investigations, finding of MGUS
- hypertension
- dyslipidemia
- former smoker
- CAD: inferior MI in 1999, treated with PTCA on right coronary artery
- AAA last assessed in July 2022 at LUOGO. Mauriziano: 57 mm infrarenal fusiform aneurysm; considering morphology and age, surgery not indicated
- single-chamber pacemaker implantation (Abbott device) in June 2022 following syncope in Sick Sinus Syndrome. On that occasion, detection of atrial flutter of unknown duration, therefore dabigatran started
- right adrenalectomy 2013
- bilateral carotid stenosis (R 40%, L 45%)
- vaccinated for SARS-CoV-2, 4 doses
- COVID November 2022
Home meds:
pantoprazole 20 mg 1 tab at 08:00, furosemide 25 mg 3 tabs x 2 h 8-16, nitroglycerin patch 5 mg (08-20), ramipril 2.5 mg 1 tab at 08:00,
bisoprolol 2.5 mg 1 tab at 08:00, dabigatran 110 mg x 2 h 8-20, tamsulosin 0.4 mg 1 tab at 22:00, simvastatin 20 mg 1 tab at 22:00, ranolaziona 375 mg 1 tab x 2 h 8-20, lysine acetylsalicylate 75 mg 1 sachet at 12:00, ferrous sulfate/ascorbic acid 105 mg 1 tab at 12:00, macrogol 1 sachet at 08:00
No known allergies
NUM_TELEFONO home
cell PARENTE NUM_TELEFONO
cell PARENTE NUM_TELEFONO
|
1222739
|
In the ED for SARS-CoV-2 swab due to contact with a positive operatrice on 5/1 us. Reported sliding to the floor from bed with difficulty getting up; telemonitoring was contacted, which sent an operator and helped to get up from the floor. No head trauma, no other trauma. Mild chronic cough in a known smoker.
No fever.
Completed SARS-CoV-2 vaccination, 2 doses.
PMH (from records)
- Active smoker
- Ex TD
- Former alcohol abuse
- DM
- Multifactorial liver cirrhosis (alcohol, HCV, HBV) with marked thrombocytopenia and esophageal venous ectasias
- Peptic esophagitis + congestive gastropathy
- Cholelithiasis
- COPD + bronchiectasis
- Chronic laryngitis
- In 2000, polytrauma with left femur fracture, mandible fracture, head trauma, and bilateral rib fractures
- 5/2014 admission for ascitic decompensation
- 9/2014 left humerus fracture
- 3/2020 admission for post-traumatic SAH
- 8/2020 suspected epileptic seizure during fever; therefore no antiepileptic therapy initiated
- Lives alone. Followed by social workers in the community, assisted by OSS a few hours per day every day. No longer leaves home alone. Noted difficulty mobilizing the upper limbs due to prior trauma, with difficulty in extension movements of the limbs relative to the trunk
Home meds (from records): metformin 1000 mg, propranolol, lactulose - the patient reports having discontinued this therapy; currently takes rapid-acting insulin 12+14+14 IU and long-acting insulin 12/14 IU in the evening
Denies known drug allergies
|
975758
|
Presents to the ED for oppressive chest pain that began about 48 hours ago at rest. Pain reported as retrosternal with subsequent radiation to the jugulum, never resolved over the 48 hours (only intensity varied). The pain changes with position (decreases when supine) and is not associated with palpitations or dyspnea, not even with exertion. Not associated with vomiting or fever; reports general malaise and nausea. Pain reported as comparable to previous episodes of angina but of clearly lower intensity.
Vaccinated for SARS-CoV-2 (Pfizer, 2nd dose in June 2021)
PMH
- Former smoker
- Ischemic-valvular heart disease in Takayasu arteritis with hypokinetic evolution (EF 40%); underwent valve replacement with aortic bioprosthesis in 2017 for severe AR + replacement of the ascending aorta and 3 CABG.
July 2019 unstable angina, admission OSGB: on coronary angiography LM occlusion, stenosis at the anastomosis on the marginal of the sequential saphenous vein graft to PDA and OM, subocclusion at the ostium of the SVG to the LAD, critical stenosis of LAD II; paravalvular leak 2–3+. Treated with angioplasty + DES at the ostium of the graft to the LAD and DES on LAD II. Right femoral artery pseudoaneurysm, right DVT.
February 2021 recurrence of unstable angina, coronary angiography: occlusion of LM, venous graft, and RCA; subocclusive in-stent restenosis of the graft to the LAD; angioplasty performed on LAD; new coronary angiography scheduled at 6 months.
Echocardiogram 2/21: hypertrophic LV, LVEF 58%, left atrium and right chambers normal, aortic root and prosthetic tube normal, aortic bioprosthesis with leaflets minimally thickened, mitral valve with mild–moderate regurgitation
- Known LBBB
- Thalassemia trait
- Hypertension
- Graves disease treated with radioiodine therapy
- Previous pericarditis
- Takayasu arteritis known since 2017, followed at CMID
Home meds: levothyroxine 125 mcg, ramipril 5 mg (1 morning + 1/2 evening), bisoprolol 1.25 mg 1+1/2, pantoprazole 20 mg, Cardioaspirin, clopidogrel, prednisone 5 mg, lovastatin 20 mg, hydroxychloroquine 200 mg 4x/week, tocilizumab 1x/week
Dr. NOME_PERSONA (resident)
|
501481
|
HPI: For several days, progressively worsening dyspnea and orthopnea. Since last night, further worsening of dyspnea.
In triage, fever (Temp 38.2°C). Denies cough, anosmia, ageusia, diarrhea, nausea and/or vomiting.
Completed SARS-CoV-2 vaccination (2 doses).
PARENTE: NUM_TELEFONO
PMH:
- Former smoker
- Ischemic heart disease s/p multiple revascularizations
- (1982) Septal MI
- (1994) Exertional angina. Coronary angiography: LAD II occluded; underwent PCI + DES
- (2001) Angina. Coronary angiography: in-stent occlusion of LAD II; unsuccessful PCI; PCI + DES on RCA
- (2018) Scintigraphy: modest–moderate amounts of inducible ischemia, marginal relative to extensive anterior mid-apical and inferolateral necrosis
- (2020) Cardiology visit: asymptomatic for angina. Echocardiogram: EF 40%, hypo-akinesia of the apex, hypokinesia of the remaining segments
- PAD
- (2003) PTA + stent to right iliac artery
Home medications:
- Ranolazine 500 mg 1 tab BID
- Delapril/Indapamide 30/2.5 mg 1 tab
- Bisoprolol 1.25 mg 1 tab
- Bisoprolol 1.25 mg 1 tab
- Amlodipine 10 mg 1 tab
- Lipoff
- Cardirene 75 mg 1 tab
- Cilostazol 100 mg 1 tab
- Tamsulosin 0.4 mg 1 tab
- Metformin 500 mg
Allergies: none reported.
|
477326
|
Patient presents to ED for left hemithorax pain, stabbing and constrictive, onset around 9:30 today at rest, non-radiating, not modified by movements, deep inspiration, or palpation, never completely resolved, not associated with other symptoms. In the preceding days, similar episodes lasting a few minutes with spontaneous resolution. Denies fever, dyspnea, cough, vomiting, diarrhea.
PMH:
- Hypertension.
- CAD:
* 2014 inferoposterolateral STEMI, PTCA + DES on LCx and ostial LAD, LVEF 55%;
* 06/2017 repeat coronary angiography for dyspnea, finding hemodynamically non-significant stenoses of LAD II, LCx II, and RCA II; 2017 Holter: frequent PACs. 2017 echocardiogram LVEF 74%.
- AF on DOAC
- Graves disease with multinodular thyroid goiter and pleomorphic adenoma of the left parotid.
- BPH
- Appendectomy
Home medications: rivaroxaban 20 mg 1 tab, metoprolol 100 mg 1/2 tab, Tapazole 5 mg 1 tab every 2-3 days, olmesartan 40 mg 1 tab, tamsulosin 0.4 mg.
Allergies: none known.
Vaccinated for SARS-CoV-2 with 3 doses.
|
1126468
|
The patient reports recurrent epistaxis for about 1 week; this morning finding of severe thrombocytopenia (PLT 2000 /mcL) and anemia 7.4/dl.
No fever, dyspnea, cough, coryza, pharyngodynia, ageusia, anosmia, diarrhea, arthromyalgias, asthenia. No contacts with suspected or confirmed COVID cases.
PMH:
- Pacemaker for sick sinus syndrome (SSS)
- Prior AF treated with ECV
- Prior attempted AF ablation interrupted for VT/VF, and subsequent EPS with no further evidence of accessory pathway
- Prior heart failure
- Known mild anemia (the patient reports having had blood tests, currently unavailable, in 2020 showing mild anemia and platelets within normal range)
Wine with meals
No known allergies
Home medications:
- Lixiana 60 mg 1 tab at 12:00 (last administration yesterday at lunch)
- Lasix 25 mg 1 tab
- Lasitone 1 tab
- Ramipril 5 mg
- Amiodarone 200 mg
- Bisoprolol 1.25 mg 1 tab
- finastideì
NUM_TELEFONO
NUM_TELEFONO PARENTE
|
40103
|
Presents to the ED for right flank pain onset this morning associated with fever (T 38°C), nausea, no vomiting. No altered bowel habits.
About 15 days ago similar symptoms; medical on-call service alerted with indication for antibiotic therapy, the name of which he cannot report, and analgesic therapy with paracetamol.
No dyspnea, no cough, no diarrhea. Anosmia and ageusia present since 2011. No contacts with individuals with known positive swab for SARS-CoV-2.
On 28/01/2021 abdominal ultrasound performed, showing non-dilated bile ducts, very enlarged gallbladder with some stones at the neck, bilateral renal cysts, renal excretory tracts not dilated, no gross endoluminal expansile lesions.
Lives at home with the PARENTE, a PARENTE who lives in Monza
PMH
- Bladder polyps in urothelial carcinoma, underwent endoscopic resections and intravesical instillations
- Prostate cancer on hormone therapy
- Hypertension
- Previous meniscal surgery, complicated by subsequent PE
- Type 2 diabetes mellitus
- Permanent AF currently on rivaroxaban
Home medications: rivaroxaban 15 mg 1 tab, bisoprolol 5 mg 1 tab x 2, digoxin 0.125 mg 1 tab, ramipril 5 mg 1/2 tab, atorvastatin 20 mg 1 tab, polyunsaturated fatty acids 100 mg 1 tab dapagliflozin 10 mg 1 tab, lansoprazole 30 mg 1 tab, insulin lispro 12+18+18 U, insulin Levemir 32 U in the evening, Enantone 3.75 mg 1 tab
No known drug allergies
PARENTE NOME_PERSONA NUM_TELEFONO
Patient NUM_TELEFONO
|
47446
|
In ED for general malaise occurring during the night and characterized by cold sensation associated with tremors in all 4 limbs. Recorded Temp: normal. Reports detection of elevated blood pressure (BP 170/85).
About 10 days ago postprandial presyncopal episode (after a heavy meal) while seated; reports she had maintained the seated position for about 30 min; subsequently onset of bilateral visual blurring and mild objective vertigo; symptoms regressed after assuming the supine position; subsequently, in the supine position, elevated BP noted (about 150/90).
Denies headache.
Never chest pain, palpitations, or dyspnea.
Denies nausea/vomiting or diarrhea.
No urinary symptoms.
Denies weight gain or reduced appetite, denies bowel habit changes with constipation.
Completed SARS-CoV-2 vaccination (2nd dose 7/2021)
PMH (in the absence of clinical documentation)
- History of arterial hypotension (usually SBP 110)
- Atheromatosis TSA (right plaque with 35% stenosis)
- Hypothyroidism. No TSH reflex monitoring for >1 year
- Erosive gastritis
- Osteoporosis
- Low back pain
- Known migraine, occasional therapy with NSAIDs or paracetamol
Home medications: levothyroxine 100 mcg for 2 days/week - 125 mcg for 5 days/week, Riopan 2 times/day, pantoprazole 20 mg, aspirin 100 mg, Folina 5 mg, vitamin D
Reported drug allergies: none
|
255399
|
Brought to the ED by ALS EMS, found by neighbors on the ground in the street after loss of consciousness, with sphincter release and morsus. The patient does not recall the event; recalls the events before the loss of consciousness. Denies dyspnea, chest pain, palpitations. No fever or cough or other COVID-related symptoms.
PARENTE contacted: a neighbor reports having seen the patient collapse to the ground while going up to her home, with loss of consciousness. Placed in lateral position with rapid recovery of consciousness. The PARENTE reports two other episodes of loss of consciousness in the last 6 months, never investigated, without prodrome (one episode while she was seated on the sofa, with the patient suddenly slumping forward and losing consciousness).
Vaccinated against SARS-CoV-2, three doses; last dose administered yesterday (PFIZER).
PMH (from chart): Arterial hypertension
Home meds: antihypertensive, does not recall
Denies drug allergies
|
261156
|
ED presentation for progressive dyspnea over the last 7 days (but overall worsened after SARS-CoV-2 infection), associated with worsening dependent edema. No angina, mild nonproductive cough, no fever but chills.
In respiratory distress in the ED.
PMH:
- Smoker, overweight, diabetes mellitus on insulin therapy
- OSA
- Hypertension
- Sepsis due to right ureteral lithiasis 6/18, treated with right ureterorenoscopy and stone extraction about 15 days ago (nephrostomy removed) - durante il ricovero necessità
- CKD (Cr 12/22: 3)
Lives with PARENTE, partial independence in ADLs (walks with a walker) and carries out daily functions
SARS-CoV-2 vaccinated 3 doses - Infection 12/22
Home meds: PPI, Lasix 1 tab BID, atorvastatin 20 mg, CardioASA, Coverlam 10+5 mg, Adenuric, Folina 5 mg, nebivolol 5 mg, DiBase, Lantus 40 IU in the evening
PARENTE NUM_TELEFONO
|
1301226
|
In ED for atypical chest pain in the left hemithorax with pain also on palpation. Dyspnea with mild exertion
Vaccinated 2 doses. Second dose months ago
Recent ED visit on 4/6/21 with refusal of admission in patient with diagnosis of heart failure in hypokinetic cardiomyopathy
Denies fever, denies cough, and denies sputum
PMH:
- Dilated hypokinetic cardiomyopathy with normal coronaries, onset October 2020 with cardiogenic shock (required amines and mechanical support with Impella). FAP on DOAC. With improvement of compensation the patient self-discharged, EF 28%. Last visit at the heart failure clinic on 13/04/2021: reported poor adherence to therapy and to medical instructions; therefore he was discharged from the heart failure clinic.
In the recent June visit: "For about 4 days dyspnea on exertion with mild orthopnea, therefore today he presented to our ED. Picture of mild pulmonary overload confirmed on chest X-ray. Bogginess of the lower limbs
ECG: SR, HR 95, incomplete BBS + lateral T-wave inversions. Labs
creatinine 1.5 mg/dl, K+ 6, bilirubin 2.39, CRP 1.2. Troponin 0.04 ng/ml. Lactate 2. In conclusion: picture of decompensation in known dilated hypokinetic cardiomyopathy with normal coronaries. FAP theoretically on DOAC.
Hospitalization for decongestion proposed to the patient, which he refused. It is suggested to intensify diuretic therapy with FUROSEMIDE 25 mg 2 tablets in the morning and 2 tablets in the afternoon and to take metolazone 5 mg 1 tablet twice weekly. Check electrolytes and creatinine in 15 days.: history difficult to reconstruct,
Denies pathologies except severe aortic insufficiency due to reported rheumatic disease,
Denies allergies
Former smoker
Severe aortic insufficiency in rheumatic carditis
History of substance abuse in youth, now denies
Arterial hypertension
Home medications theoretically prescribed: amiodarone 200 mg, enalapril 5 mg 1/4 tab, h 14, spironolactone 25 mg, bisoprolol 1.25, furosemide 25 mg 1 tab x 2, apixaban 5 mg x 2 at the last evaluation during ED access agreed increase of furosemide to 25 MG 2 TABS x 2, METOLAZONE 5 MG x 2/week, suspension of aldactone for one week for hyperkalemia 6
Allergies: denies
Therapy unclear at the time of today's visit
|
433849
|
in ED, managed by MSB. Since yesterday onset of some episodes of yellow loose stools, not associated with fever, nor abdominal pain nor nausea/vomiting. Additionally the PARENTE reports urine leakage from the catheter with questionable hematuria.
Foley catheter replaced on 14/03 (this month).
Recent ED visit for malfunction of the Foley catheter; irrigations performed; returned home.
PMH:
- lives with the PARENTE, not self-sufficient, only bed–wheelchair transfers
- recent admission to Internal Medicine for syncope, PE, hydronephrosis in urinary retention
- Parkinson’s disease with early dysautonomia on therapy with Madopar and Jumex with associated dysphagia
- thyroid goiter
- TSA: diffuse, non-significant thickening
- previous near-syncope episode from postprandial sitting
- displaced fracture of left humerus
- valvular heart disease with severe mitral and tricuspid regurgitation associated with moderate-to-severe pulmonary hypertension without cardiac surgical indications
Home meds:
- Madopar NUM_TELEFONO
- bisoprolol
- PPI
- tonterodina
- apixaban
- Talofen 10 gtt
- Dibase every 20 days
ALLERGIES: none known
Vaccinated against SARS-CoV-2, 5 doses
NUM_TELEFONO PARENTE
|
1190743
|
ED presentation for onset of tremors around 06:20, witnessed by PARENTE.
PARENTE applied oxygen.
During the episode patient remained alert throughout.
Afebrile on 118 assessment.
No significant symptoms in the preceding days, including dyspnea, fever, cough, dysuria.
PMH:
- COPD on oxygen therapy as needed (30 min in the evening, not every day
- hypertension,
- chronic gastritis
- Recent hospitalization for anemia
- Left frontoparietal ischemic stroke (12/21)
- Right femur fracture, underwent osteosynthesis with nail (02/23); subsequent PT at FBF
- Gout
- SAo mild with minimal associated insuff.
Home meds: relvar 1 puff, rolufta 1 puff, pantoprazole 20 mg, ramipril 5 mg 1/2 tab, sertraline, amlodipine 10 mg 1/2 tab, allopurinol 300 mg, vitamin B complex, bimatoprost 1 drop OD, furosemide 25 mg 1 tab, ferrous sulfate, dutasteride,
Allergies: none known.
PARENTE NUM_TELEFONO
Lives in LUOGO with PARENTE. Partially independent in ADL/IADL
|
1729936
|
Presents to the ED for diffuse abdominal and chest pain. Reports herpes zoster in recent days.
PMH:
- Hypertension
- Dyslipidemia
- Subcritical carotid vasculopathy
- CKD stage V on dialysis, urine output preserved
- Thrice-weekly dialysis
- CAD. Three-vessel coronary artery disease; PCI with drug-eluting stent of the mid LAD and PL branch of the LCx, and PCI with drug-eluting stent on the proximal RCA (reported recent admission to Cardiology for angioplasty, 3 weeks ago)
- COPD on LTOT 2 L/min
- Benign pituitary adenoma
- Anxiety disorder with prior panic attacks
- BPH
- Hiatal hernia
Home medications: ASA 100 mg, atorvastatin 20 mg, mcg x 2, pantoprazole 20 mg, Movicol, bromazepam PRN, nitroglycerin 0.3 mg tab PRN, Renvela 1/2 sachet twice daily, Trimbow 2 inhalations twice daily, Urorec, Avodart, nebulization with 1 vial Fluibron and Clenil, Nobistar 1/2 tab, Monoket 20, 1/2 tab three times daily, clopidogrel, Disepavit 1 injection 2 times/week (Monday, Friday), Parsabiv, Binocrit
Denies known drug allergies.
|
1608637
|
In ED for intermittent palpitations. No chest pain.
Additionally over the last few days fever, associated with minimally productive cough.
04/2023 ED visit for the same reason, discharged with diagnosis of paroxysmal AF; subsequent cardiology visit with indication to start DOAC (edoxaban) and stop ASA.
11/2023 ED visit for a similar reason, with finding of spontaneous restoration of SR. Holter ECG and subsequent cardiology visit indicated.
PMH:
- former smoker, hypertension, dyslipidemia
- right leg amputation due to accident
- CAD, multiple treatments on RCA in 2001, 2002, 2004, 2005. Recurrence in 2013, 2015 and 2018 of three-vessel disease LAD+LCx+RCA.
Echocardiogram: LV not dilated, hypertrophic, segmental wall motion preserved, EF 68%, mild MR and TR.
01/21 exercise stress test negative for inducible ischemia
01/23 Coronary angiography: good result of previous PCI on LAD and PL; known CTO of RCA
Home medications: irbesartan 150 mg, amlodipine 5 mg, pantoprazole 40 mg, Tenormin 1/2 tablet, edoxaban 60 mg, atorvastatin 20 mg, allopurinol 1/2 tablet
No known allergies
SARS-CoV-2 vaccination 4 doses
|
1501125
|
In ED for onset of palpitations at approximately 15:15 today 1/12.
The patient reports sensation of retrosternal pain/discomfort associated with palpitations, radiating to the bilateral mandibular region, similar to that occurring in 5/2021, after which hospitalization for coronary angiography followed (PTCA+stent performed).
Denies dyspnea.
Denies fever or cough in recent days.
Denies GI/urinary symptoms.
SARS-CoV-2 vaccination: 2 doses + prior SARS-CoV-2 infection
PMH
- Former smoker
- IA
- Overweight
- Hypertriglyceridemia
- Previous episode of paroxysmal AF (first documented in 2019) on DOAC. Outpatient ECV performed 1 month after the first episode of AF for which she had presented to the ED.
- CAD
* Coronary CT May 2019: no significant lesions
* Hospitalization in 5/2021 for elective coronary angiography following an episode of bilateral jaw discomfort; at coronary angiography critical LAD disease treated with PTCA+DES. Therapy with ASA + clopidogrel initiated, discontinued at 12/2021, continued DOAC only
* TTE (24/11/22): normal
- Hypothyroidism
- H. pylori+ gastritis
- Right hystero-adnexectomy for fibroid
Home medications: ramipril/HCT 5/12.5 mg, olmesartan/amlodipine 40/10 mg, atenolol 100 mg 1/4 tab, dabigatran 150 mg x 2, rosuvastatin/ezetimibe 20/10 mg, levothyroxine 125 mcg, pantoprazole 20 mg
Allergies: denies
|
940868
|
In ED for onset this morning at approximately 09:00, at rest, of retrosternal chest pain, non-radiating, stabbing, that varies with position (reports relief maintaining a forward-flexed posture of the trunk - no difference in supine or semi-upright), pain not increased with palpation, increased during deep inspiratory efforts. Pain never subsided up to the time of today's visit. Reports difficulty performing deep breaths due to the pain. No frank dyspnea.
In recent days diffuse musculoskeletal pains treated with paracetamol (about 1000 mg 2 times/day).
Reports subjective sensation of fever, but temperature never measured.
Denies cough.
Denies GI symptoms.
Reports since this morning anosmia and ageusia.
Last intake of paracetamol this morning at approximately NUM_TELEFONO.
Denies prior SARS-CoV-2 infection.
Not yet vaccinated against SARS-CoV-2.
PMH
- Overweight
Home meds: none chronic
No known drug allergies
Patient phone NUM_TELEFONO
|
142068
|
From triage it appears: in ED sent by PCP for worsening of clinical status in recent UTI due to Klebsiella pneumoniae. In recent days fever (T up to 38). At triage tachycardic pulse, BP 90/45 mmHg, T 37.1. Presence of indwelling Foley catheter with reduced urine output, about 50 ml, presence of debris inside the catheter.
On exam patient slowed, reports sensation of heat and cold in recent days with evidence of fever.
Denies cough or dyspnea.
Denies GI symptoms.
Denies pain involving any body region.
Denies changes in urine in the Foley catheter.
The PARENTE confirms APP.
SARS-CoV-2 vaccination: NOT vaccinated.
PMH
- AF
- 2015 TURP for BPH and subsequent urethrotomy for urethral stricture, indwelling Foley catheter
- 9/2019 left femoropopliteal DVT
- 5/2019 partial thrombosis of v. LUOGO left
- 2015 left peritrochanteric femur fracture (reduction and fixation with PFNA nail)
- Osteoarthritic degeneration with incomplete osteophytosis at L3-L4 and complete from L4 to S1
- 2017 excision of cutaneous basal cell carcinoma
- Hospitalization in 10/2019 for acute lumbar hematoma onset after positional change, hematology management, started LMWH then switched to edoxaban
- Hospitalization in 3/2022 for heart failure and UTI due to NOME_PERSONA MR, treated with antibiotic therapy (meropenem) and IV diuretic. Discharged on 7/4 with instruction to continue ciprofloxacin 250 mg BID until 15/4
- From records, mobilization of the patient with hoist and wheelchair
Home medications: edoxaban 15 mg, diltiazem 60 mg BID, furosemide 500 mg 1/4 tablet BID, nitroglycerin 5 mg 8 --> 20, pantoprazole 20 mg, methylprednisolone 2 mg, pregabalin 25 mg BID, tamsulosin 0.4 mg, haloperidol 4 gtt, alprazolam 1 mg 1/2 tablet, lactulose, cholecalciferol 20 gtt, fentanyl 50 mcg every 3 days
No known drug allergies
tel. PARENTE NUM_TELEFONO
|
679259
|
In ED for orbital hematoma and lacerated-contused wound of the eyelid margin.
Fell and struck the nightstand.
On NOAC
PMH:
- vaccinated against SARS-CoV-2 (last dose 05/2021)
- Former smoker. Former factory worker
- Follicular lymphoma grade 3A, treated with chemotherapy, followed at Molinette, last staging CT in 11/2019 (no pathologic-appearing lymph nodes, no pulmonary lesions, at the level of the left lower lobe area of parenchymal consolidation, pericardial effusion 17 mm, remainder unremarkable)
- Permanent AF
- IA
- Hypokinetic cardiomyopathy
** admission at MIC OGB in January 2020 for type 2 IR in heart failure decompensation and hemoptysis on NOAC for FAP. Coronary angiography: no significant lesions. TTE with EF 29%, mild-moderate central MR. On TTE March 2021: EF 50%. At the last cardiology visit 04/2021: AF, asymptomatic and well compensated.
** 05/2021 admission to cardiology for sustained VT, underwent electrical cardioversion and implantation of dual-chamber ICD, EF 35%.
- COPD
- Overweight
- BPH
No known drug allergies.
|
515764
|
Presents to ED on PCP recommendation. On 6/6, follow-up chest X-ray for pulmonary silicosis with finding of right pleural effusion. Pleural effusion already present in January 2023, underwent thoracentesis with subsequent finding of hydropneumothorax due to rigid lung. Thoracic surgery visit 2/2/23: reviewed chest X-ray with right parieto-basal hydropneumothorax with maximum thickness of 8 cm, abundant pleural effusion in the postero-basal region, also consolidation with air bronchogram on the left; no indication for more invasive procedures; repeat chest X-ray recommended if clinical worsening.
For about one week, worsening dyspnea, orthopnea, and productive cough with whitish sputum. 2 weeks ago a febrile episode. No chest or back pain.
Vertiserc started 2 days ago for vertiginous syndrome.
Lives alone at home with PARENTE upstairs, ambulates with a cane.
PMH:
- pulmonary silicosis (former foundry worker)
- moderate COPD with asthma-like features
- Type 2 DM
- BPH
- SAD
- prior inguinal hernioplasty
- resection of bladder polyp in March 2023
Vaccinated for SARS-CoV-2 with 5 doses
Allergies: NKDA
Home meds: Zoloft 50 mg 1/2 tab, Lyrica 75 mg 1 tab BID, Xatral 10 mg 1 tab, Lasix 25 mg 1 tab, Trajenta 5 mg 1 tab, metformin 1000 mg 1 tab, Relvar 1 puff, Contramal 10 drops 2 times x 2, Vertiserc 24 mg 1 tab x 2 (for 2 days), iron and folic acid
PARENTE NUM_TELEFONO
|
1426718
|
TRIAGE: The patient is brought by MSA for decline in general condition caused by low fluid intake for a few days. Arousable to stimulus. RR 18 SpO2 94% RA BP 110/60 HR 74. No use of accessory muscles.
No other symptoms or complaints. Request for respite admission. NUM_TELEFONO PARENTE
MEDICAL ASSESSMENT: markedly debilitated patient, not able to provide history details.
Rattling breathing, cold extremities. Sounds due to secretions in the large airways.
During interview with PARENTE, patient already in poor condition; speaks little, predominantly bedbound although able to sit during the day. Since yesterday reduced urine output, marked asthenia and complete bed confinement, cyanotic extremities and rattling breathing
PMH (from electronic history):
-lives with PARENTE, partially independent in ADLs/IADLs
-prior cerebral ischemia with deficit fbc sx
-CAD
-2011 abdominal aortic replacement
-2011 BPAC and mitral valve repair.
-COPD in active smoker (last hospitalization for exacerbation 12/2021)
-secondary epilepsy, previously on therapy with Tolep now discontinued
-prior syncopal episodes
-inguinal hernioplasty
-polyvascular disease
-Barrett’s esophagus and ipogastrica stenosis
-hemolytic anemia treated with corticosteroids
-colon polyposis; prior melena requiring transfusions
-dyslipidemia
-cholecystectomy
-staghorn lithiasis
-8/2020 admission at H. Cottolengo for pneumonia
-suspected mamillated bladder lesion (CT 8/2020 not investigated due to patient refusal)
- 12/2021 Admission for accidental fall with finding during hospitalization of NSTEMI in subacute phase. On inpatient echocardiogram: EF 35% with apical akinesis. Severe left atrial dilation. Right atrium dilated. TAPSE 14 mm. Estimated PASP 48 mmHg. Fibrosclerosis of the aortic valve cusps.
-active SOD
Home medications (from MIC letter 2022): Pantoprazole 20 mg, bronchodilators, furosemdie 25 mg x2, ASA 100 mg, atoravstatian 409 mg, calcium lefolinate, iron, vitamin B12Atorvastatin 40 mg, CardioASA, Prednisone 25 mg, Furosemide 25 mg x2.
ALLERGIES: heparin
NUM_TELEFONO PARENTE
|
1567924
|
In ED for:
Since this morning at 09:30 vertex headache, "frying" type; reported dyspnea and global chest pain and generalized asthenia, and reported difficulty with ambulation.
Diffuse tremors and chills without evidence of fever.
Well until last night. No evident inflammatory symptoms.
Lives with PARENTE
Ambulates with help/support - ambulates outside. Eats independently, washes independently, goes to the bathroom independently.
Supervision by PARENTE
PMH:
- Hypertension
- Critical bilateral ICA stenosis: left ICA 85% and left ECA 65% - right ICA 25%
- Alzheimer’s disease - amnesia for events - interacts and recognizes
- In 2017 critical LAD stenosis treated with PCI+stent
- Hospitalization for ischemic stroke in October 2020 with global slowing and uses a cane
Home medications:
- pantoprazole
- memantine
- Duoplavin
- valsartan
- Lercadip as needed
No known drug allergies
Vaccinated with 3 doses for SARS-CoV-2
|
1717352
|
ED visit for onset of swelling and hyperemia on the dorsal surface of the L leg for 5 days.
Reports trauma at that site.
ED visit on 21/5: Presents for onset of dyspnea and orthopnea for about 10 days, worsened tonight. Denies fever, cough, or chest pain. Labs show evidence of microcytic anemia.
PMH:
- COPD in a former smoker
- Valvular heart disease: severe AS associated with severe depression of LV systolic function (EF 30%); TAVI proposed and refused by the patient (05/23)
- Prior left basal pneumonia (hospitalized at LUOGO)
- Prior hemicolectomy for colon cancer (2006)
- Chronic multifactorial anemia; FOBT + with finding of angiodysplasias of the cecum and ascending colon, treated with coagulation (05/23)
- Recent hospitalization at Med H Oftalmico for heart failure in chronic multifactorial anemia and aortic stenosis
Home medications: pantoprazole 20 mg, aspirin 100 mg, formoterol/glycopyrronium/budesonide 2 puffs x 2, folic acid 5 mg, zolpidem 10 mg, furosemide/spironolactone 25/37 mg 1 tab, ferrous sulfate 1 tab
Allergies: none known
|
1774125
|
Presents to the ED for fever and diffuse arthralgias for three days
Denies cough, chest pain, dyspnea, and urinary symptoms
The PARENTE report difficulty managing at home
Discharged on 10/01 from Medicine with diagnosis of right basal pneumonia in s, myelodysplastic (Hb on 09/01 7,2 gr/dl)
PMH:
- Type 2 diabetes mellitus
- Dyslipidemia
- Myelodysplasia (refractory cytopenia without excess blasts), followed by
Hematology H LUOGO; periodic red blood cell transfusions at
LUOGO transfusion unit of Maria Vittoria
- Hospitalized in General Surgery from 21/02 to 03/03/2022 for acalculous cholangitis with abdominal collection as sequelae of cholecystectomy for acute gangrenous cholecystitis, complicated by intra-abdominal collection and pleural effusion.
New hospitalization in MIC 2nd floor at the end of March 2022 for fever
- Mitral valvular heart disease (moderate regurgitation and mild stenosis)
Echocardiogram 10/2022: EF 66% Vs nn SAo leive, IM moderata, lieve SM; elevated ventricular filling pressure
Home meds: pantoprazole 20 mg, Lasix 1 tab, Luvion 50 mg 1 tab, Metformin 1000 mg x 2, Cardicor 1,25, Trulicity 1,5 once weekly, Binocrit 40000 2x/week (Tuesdays and Fridays)
ALLERGY TO FOLIC ACID
SARS-CoV-2 vaccinated, 3 doses.
PARENTE NUM_TELEFONO
|
1599285
|
History obtained from interview with patient and PARENTE contacted by telephone (number NUM_TELEFONO)
In ED because two days ago onset of bilateral cyanosis of the toes extending to the foot (PARENTE reports similar episodes in the past but limited to the toes) not associated with pain or cold lower limb and regressed over the course of the day; also onset of rest tremor of the right upper limb starting at the shoulder (no similar episodes in the past) associated with paresthesias ("electric shock"), no pain, no cold limb, no reported strength deficits; also, again two days ago onset of dorsal retroscapular pain not well specified in character and duration, with recurrent course, not associated with trauma. Also reports dyspnea with increased RR. No fever, no cough, no chest pain.
Recent ED visit on 22/11 for exertional dyspnea and retrosternal chest pain that resolved spontaneously, asymptomatic in the ED. Discharged home
RECENT HOSPITALIZATION IN CARDIOLOGY OGB DISCHARGED 8/11/2022;
during hospitalization
> NSTEMI underwent coronary angiography with mid Cx occlusion and subocclusive stenosis of LAD I - II, both treated with PCI and DES, EF post-procedure 45%
> bradiFA underwent pacemaker implantation
> pre-discharge echocardiogram EF 60%
> SARS-CoV-2 pneumonia
> episode of delirium during hospitalization
PMH
- former smoker
- prior inguinal hernioplasty
- appendectomy
- hypothyroidism
- CAD. Ischemic heart disease with critical proximal LAD stenosis and Dg II
underwent PTCA and DES in 2008; in 2010 new coronary angiography critical distal Cx stenosis treated with DES;
- CKD (2/2022 creat 1.3)
- early cognitive decline
- chronic anemia (Hb 11)
- prior SARS-CoV infection and superinfection with C. difficile
Home medications:
Lixiana 30 mg 1 tab
ASA 100 mg 1 tab for 1 month from 8/11/22
Clopidogrel 75 mg for 12 months from 11/2022
Pantoprazole 20 mg 1 tab
Ramipril 2.5 mg 1 tab
Atorvastatin 40 mg 1 tab daily
Bisoprolol 2.5 mg 1 tab
Eutirox 75 mcg in the morning alternating with 100 mcg
Denies allergies
vaccinated 3 doses
|
882572
|
HISTORY DIFFICULT TO OBTAIN
For 4 days diffuse pain, more localized to the thoracic spine, sometimes in the epigastrium and sometimes a sensation of constriction at the jugulum.
Associated protean symptomatology, localized at the auricular level, frontal region, lower limbs; worsening of known psoriasis.
Associated dyspnea with minimal exertion.
Lives with PARENTE affected by intellectual disability; spends the day in a wheelchair.
Help from a PARENTE and a caregiver 2 times a week.
No apparent help when PARENTE or caregiver not present.
Anti-SARS-CoV-2 vaccination: 4 doses
PMH (from records)
- IA.
- Obesity
- Permanent AF. Known RBBB.
- Valvular heart disease. Moderate AS.
- Left atrial appendage closure with AMULET device in a patient with previous stroke episodes of cardioembolic etiology with severe anemia in erosive gastropathy while on anticoagulants (February 2023)
- Prior TIA
- 7/2022 ischemic stroke of the left corona radiata, presenting with right upper-limb strength deficit, without gross sequelae (patient reports persistence of minimal right upper-limb strength deficit)
- COPD in active smoker (10 cigarettes/day)
- Lower-limb neuropathy (repeated falls)
- Hepatic steatosis
- Cholelithiasis
- Psoriasis
- SAD
- Excision of basal cell carcinoma/epithelioma of the nasal tip
- Prior OD cataract surgery
- From 09/30/22 to 10/07/22 hospitalization at Ophthalmic Hospital for repeated falls and type 2 respiratory failure in SARS-CoV-2 infection
- At the end of 10/2022 hospitalization at Internal Medicine, 8th floor, for bilateral pleural effusion and pulmonary consolidation (documentation missing)
- Lives at home with PARENTE; not independent in ADLs; spends most of the time in a wheelchair; ambulates with a walker for very short distances
Discharge medications from Cardiology: pantoprazole 20 mg, enoxaparin 6000 x 2, pregabalin 75 mg x 2, foster, folic acid, escitalopram 10 drops after dinner
Allergies: aspirin (reported by the patient but unable to specify the type of allergy)
NO ALLERGIES REPORTED IN THE CARDIOLOGY DISCHARGE LETTER
Tel PARENTE NUM_TELEFONO
|
1228581
|
INTERVIEW WITH THE PATIENT
Reports diffuse myalgias and marked asthenia for about one week, in the absence of clear perceived signs suspicious for infection (no headache, no pharyngodynia, no cough, no abdominal pain; bowel habit known as constipated, no dysuria). Associated difficulty drinking with lateral leakage of water from the left oral commissure (no frank objective facial deficit); no cough during intake of liquids.
At triage, evidence of fever (37.7 °C).
The patient reports being able to help the elderly PARENTE until last week; to walk with a walker.
Caregiver present mostly for cleaning, a few hours a day, not every day.
INTERVIEW WITH PARENTE:
Confirmed what was reported by the PARENTE. Added slightly laterodeviated posture toward the left when seated.
Voice perhaps lower and slightly hoarse.
VACCINATED 3 DOSES
PMH
- Hypertension
- Hypothyroidism
- Parkinson's disease not on treatment
Home medications: ramipril ? mg, Eutirox 75 mcg (2 days a week 50 mcg)
no known drug allergies
PARENTE NUM_TELEFONO
|
1144059
|
In ED for persistent dizziness and headache for approximately 7 days, constant.
Onset of symptoms one evening with onset of vertiginous syndrome - upon awakening persistent headache
Headache NRS 8 at the sphenoidal sinus - and frontal
No back pain - no cervical pain
Functional limitation - no visual changes
No LOC.
First episode of this nature
Constant pain in recent days - worsened in the last 3 days
Symptom onset as dizziness with vertigo syndrome and postural instability - symptoms worsen with positional changes but apparently spontaneous onset
No tinnitus, no hearing loss
First episode
Never other similar episodes previously
No fever - no cough - no cervical or cranial trauma
Supplements taken
Has not taken analgesics
First episode of this type
PMH:
none reported
Home meds: none reported
Reported allergies: none
Denies pregnancy
LMP last week
|
2136
|
Brought to the ED by EMS for worsening dyspnea with scant productive cough with whitish sputum. Dyspnea worsened in the supine position. Denies chest pain, denies fever at home.
Patient with ED visit on 16/02/23 for dyspnea; labs (WBC 15,220, CRP 1.32, creatinine 1.52, platelets 96,000) and chest X-ray showed a known consolidation in the left upper lobar bronchial region contouring the initial segment of the descending thoracic aorta (suspicious for a productive lesion). Discharged home with recommendation to increase oxygen therapy.
Workup already underway for suspected lung neoplasm, for which home oxygen therapy 1 L/min already prescribed.
Baseline chest CT 25/01/23: in the high right mediastinal region, inseparable from the pulmonary artery and aortic arch, a 43 x 48 x 35 mm mass with liquefactive changes, with concomitant 14 mm nodular lesion involving the middle lobe. Findings of centrilobular emphysema with traction bronchiectasis on the right. Ectasia of the ascending aorta (43 mm).
PMH:
- COPD in an active smoker
- Hypertension
- Chronic ischemic heart disease; echocardiogram never performed.
- Mild CKD (08/22 creatinine 1.45)
- AAA (10/2022: maximum diameter 48 mm with true lumen approximately 27 mm)
- Bladder carcinoma; in 2010 underwent radical cystectomy + prostatectomy + neobladder creation
- Prior TB
- Known cholelithiasis
- Known nephrolithiasis
- Vaccinated for SARS-CoV-2
Home meds: pantoprazole 20 mg, triatec/HCT 5/25 mg, cardioasa, bisoprolol 2.5 mg, furosemide 25 mg 1 tab, allopurinol 300 mg, rolufta (umeclidinium) 55 mcg, onbrez (indacaterol).
Allergies: none known.
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1314566
|
Reports cramp-like pain in the hypogastric, midline prepubic area, radiating to the R testicle, with onset in August 2021 (after administration of the third dose of SARS-CoV-2 vaccine) but in recent days recurrent and increased. Previously presented to PCP who recommended colonoscopy, negative. Denies fever, no cough, no diarrhea (last bowel movement this morning), mild strangury.
The patient also reports low back pain, not associated with the above pain.
PMH
- SARS-CoV-2 vaccination: 3 doses
- Depression. Followed at CSM Falchera by Dr. Festa. Three prior admissions to SPDC (last admission at SPDC GB about 10 years ago).
- IA
- Tachycardia, not further specified
- Hypertriglyceridemia
Home medications: bisoprolol 2.5 mg once daily, zofenopril 30 mg once daily, ASA 100 mg, fenofibrate, quetiapine 100 mg in the morning + 300 mg RP in the afternoon + 100 mg in the evening, Tavor 2.5 mg 1/2 tablet in the morning + 1 tablet in the evening, flurazepam 30 mg in the evening
Allergies: DENIES - reports cutaneous rash appearing after the third dose of SARS-CoV-2 vaccine
|
1229756
|
Since approximately 04:00, sensation of palpitations, preceded by nausea
in apr
hypertension
-dyslipidemia
-overweight
-AF already underwent ECV 12/2020 and 5/2021
-known SV extrasystoles
-mild-moderate OSA
-Echocardiogram 10/2020: IVs, EF 66%, mild inferobasal hypokinesia; coronary CTA: coronary arteries within normal limits, pulmonary artery ectasia. At the cardiology visit of 11/20 possible prior myocarditis episode
-SAD
-hypothyroidism
No known drug allergies
visit yesterday for paroxysmal AF treated with ECV and discharged with indication for therapy with flecainide and bisoprolol (since December approximately 4 visits for similar reason, underwent ECV)
Home medications: citalopram, Eutirox, COUMADIN (currently switching to rivaroxaban), bisoprolol, 15:13 enalapril, Lodoz, flecainide 1/2 tab x 2 (since yesterday)
reports having taken flecainide 50 mg at home
SARS-CoV-2 vaccination already completed in May
|
165324
|
In ED for 10-day onset of dyspnea on exertion progressively worsening to dyspnea at rest, associated with orthopnea (habitually sleeps with 2 pillows) and mild cough, no fever. Known dependent edema, not worsened. Denies chest pain.
PMH:
- Obese
- Type 2 DM on insulin therapy
- Hypertension. Echo 2020: EF 65%, grade I diastolic dysfunction, dilated LA, RA normal, mild MR, trace TR
- BPH with prostatic adenoma
- CKD stage V from diabetic nephropathy awaiting initiation of dialysis - left AVF created 1 month ago -. Last creatinine 4.6 12/2021 with metabolic acidosis, hypocalcemia, hyperphosphatemia, secondary hyperparathyroidism, anemia
- Venous disease of the lower limbs and trophic ulcers. Vascular Surgery evaluation 07/02/2022: lower limbs normothermic and normally perfused with femoral and popliteal pulses present bilaterally, dorsalis pedis on the right and posterior tibial on the left palpable. No current indications.
Home meds:
- sevelamer 1 sachet twice daily
- Lasix 25, 1 tablet
- amlodipine 10 mg, 1 tablet
- Abasaglar 15 IU SC
- Ferrograd
- Cardura 4 mg, 1 tablet
- Metocal 1250 mg, 1 tablet
- calcitriol 0.25 mcg, 1 tablet
- Apidra 8–10 IU breakfast + 8–12 IU lunch and dinner
- Binocrit 4000, 1/week
- allopurinol 300 mg
- sodium bicarbonate 1 tablet twice daily
No drug allergies
Vaccinated for SARS-CoV-2, 3 doses
|
587713
|
ED presentation for anterior and posterior epistaxis since this morning at 08:00.
PMH:
- T2DM
- Aortic valvulopathy (last TTE in February 2022: EF 49%, moderate aortic valve stenosis, mild MR (transmitral flow morphology of grade III diastolic dysfunction).
- Left pulmonary lobectomy for carcinoid with subsequent PE.
- Prior episode of decompensated heart failure
- Previously resected melanomas
- AF on OAC
- Hypertension
- Appendectomy
- Tonsillectomy
- Hysterectomy with adnexectomy for unspecified reasons
- Hypertriglyceridemia
- CKD, eGFR 34
Home medications:
- Coumadin 5 mg per INR (1/2 tab usual dosage)
- insulin lispro 4 + 4 U (lunch, dinner)
- insulin Toujeo 15 U
- clonidine 5 mg TD /week
- digoxin 0.0625 mg 2 tabs
- furosemide 500 mg 1/4 tab
- furosemide 25 mg x 3
- lercanidipine 10 mg
- pantoprazole 20 mg
- metoprolol 100 mg
- zaroxolin 5 mg 1/2 tab
- allopurinol 300 mg 1/2 tab
Allergies: none known
|
1742772
|
In the ED for an episode of chest and left arm pain since this morning
Reports since this morning intermittent episodes of chest pain of about 20 minutes' duration, localized, non-radiating, occurring spontaneously and resolving spontaneously after about 30 minutes — no clear correlation with exertion, not modified by posture, pressure, or respiration, no associated red flag symptoms.
Concomitant episodes of left arm pain, also intermittent, constant since 15:00, likewise without modification or correlation with exertion or arm movement.
These pains have appeared for about one week with a worsening course, without particular triggering factors, two–three episodes/day.
Denies fever, dyspnea, palpitations, hemoptysis, cold sweating, nausea, emesis.
Pain described as burning, not pesp.
PMH:
- Hypertension with poorly controlled BP
- Diabetes mellitus on insulin therapy
- Former heavy smoker — 40 cigarettes/day for 30 years
- Overweight — dyslipidemia
- History of gastric ulcer
- Family history of cardiovascular events
Home medications:
- Injectable insulin
- Losartan
- Norvasc
No allergies
|
235068
|
HPI: At 9:30 this morning, onset of cold diaphoresis, left-sided pulsatile headache, sense of chest oppression and at the jugular region lasting about 20 min while at work (tube preforming) after an altercation at work.
BP measured at 170/80 mmHg.
During triage wait, new onset of similar pain, currently in remission.
Denies fever, dyspnea, diarrhea, anosmia, ageusia.
PMH:
- Ischemic heart disease
°°°(2019) Coronary angiography: critical OM1 disease not suitable for revascularization and subcritical LAD II (30–40%)
°°°(2021) NSTEMI. Coronary angiography: long stenosis of LAD I–II with negative functional assessment, PTCA + DES on distal LAD. Post-discharge TTE: EF 56%, no segmental amolie, MR 1+, AR 1+, mild TR.
°°°(03/2021) Cardiology visit for precordial pain radiating to the jugular with dizziness and cold diaphoresis since discharge: therapy with ranolazine started and indication for 24-hour Holter ECG + myocardial scintigraphy.
- Arterial hypertension
- T2DM
- Overweight
- Hypertriglyceridemia
- Previous right pyeloplasty for congenital renal malformation.
Home medications:
Atenolol 100 mg 1/2 tab, Ramipril/Amlodipine 5/5 mg 1 tab, Rosuvastatin/Ezetimibe 20/10 mg 1 tab, Fenofibrate 200 mg 1 tab, Omega-3 1 capsule twice daily, Clopidogrel 75 mg 1 tab, CardioASA 100 mg 1 tab, PPI, Ranolazine 375 mg 1 tab twice daily, Metformin 1000 mg 1 tab twice daily, Forxyga 1 tab at lunch
|
1207
|
Patient presenting to the ED because since yesterday he has had an episode of chest pain associated with dyspnea, currently regressed.
The pain did not resemble previous ischemic pain; rather stabbing in nature, without radiation.
PMH (from history, documentation missing):
- smoker
- hypertensive
- dyslipidemia
- in 2005 PTA + stent
- in 2014 inferior STEMI treated with PCI
- in 2015 cerebellar stroke
- in 2017 angina; coronary angiography negative
- AF on NOAC
- on 17/3/2018 procedure for right carotid stenosis, underwent carotid bypass (follow-up performed on 30/3/2018 with good outcome of carotid TEA)
Home medications:
- pantoprazole 20 mg
- ranolazine 375 mg 1 tab x 2
- metoprolol 100 mg 1/4 x 2
- ramipril 5 mg x 2
- Venitrin patch 10 mg
- cetirizine 10 mg
- ASA 100 mg 1 tab
- Lixiana 60 mg 1 tab
- atorvastatin 40 mg
- amlodipine 10 mg
- furosemide 25 mg 2 tabs
ALLERGIES: denies
|
442295
|
Presents for urinary retention and bowel closed to stool since last evening
recent admission to Internal Medicine for respiratory failure in hypokinetic cardiomyopathy and right pleural effusion + severe mitral regurgitation
scheduled in June for cardiology evaluation for ICD implantation; will also be contacted to schedule right heart catheterization and implantation of LUOGO
Received SARS-CoV-2 vaccination with 4 doses.
APR:
Known hypokinetic CAD (three-vessel and left main coronary artery disease, prior percutaneous revascularizations. Recent coronary angiography for NSTEMI complicated by EPAC > good outcome of prior PTCA+DES, known CTO of Cx. EF 34%). numerous admissions for hypertensive EPA
PM
DM on mixed therapy (insulin + oral hypoglycemics)
arterial hypertension
dyslipidemia
peripheral vasculopathy
overweight
former smoker
2014 vocal cord neoplasm, operated
previous admission at Cottolengo Hospital for EPA; on that occasion finding of right pleural effusion drained; due to finding of activated mesothelial cells, thoracic surgery evaluation scheduled, performed on 6/4 and concluded with indication for diagnostic-therapeutic thoracoscopy (pre-admission performed on 11/4).
Allergies: AMOXICILLIN
td pantoprazole 20, bisoprolol 2.5, Lasix 25, ASA, canrenone 50, tamsulosin 0.4, dapagliflozin, sacubitril(valsartan, Torvast 40, insulin
|
1818952
|
Progress note written retrospectively to provide care to the patient
In ED with ALS for CPA.
Orotracheal intubation reported with GCS 4 at home; patient arrives not intubated with CPR in progress (no LUCAS).
PMH:
- Lives with PARENTE
- Smoker (quit about 2 weeks ago at the time of hospitalization), with diagnosis of COPD with severe obstructive defect
- Arterial hypertension
- Dyslipidemia
- Osteoporosis
- Prior road traffic accident with L1 trauma and pelvic fracture for which she wears an orthopedic brace
- Right pleuritis at age 10
- Depressive syndrome
- Recent hospitalization from 31/03 to 06/04/2021 for pericarditis at Cardiology of OSGB and discharged with medical therapy; hospitalization for COPD exacerbation in 6/22
*CT chest-abdomen: pulmonary emphysema and anomalous venous return.
*TTE: preserved EF 55%, no wall motion abnormalities
*Coronary CT: diffuse calcifications, mixed stenosis
*Coronary angiography (06/04): no significant disease
- Completed full vaccination course
Home medications:
- ASA 100 mg 1 tab
- Bisoprolol 2.5 mg 1 tab, amlodipine 5 mg 1 tab, ramipril + HCT 5 + 25 mg 1 tab
- Atorvastatin 20 mg 1 tab
- Pantoprazole 20 mg 1 tab
- Paroxetine 20 mg 1 tab
- Laventair 1 puff
No known allergies
PARENTE NUM_TELEFONO
PARENTE NUM_TELEFONO (communicate with PARENTE)
|
1590345
|
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in Data Studio
Dataset description
This dataset contains the train unannotated clinical notes for the CRF:filling Shared Task at CL4Health2026.
The clinical notes have been collected, anonymized and annotated at the San Giovanni Bosco (SGB) hospital, Turin, Italy.
There are two splits, each representing a different language: en (English) and it (Italian). English data has been automatically translated from Italian.
Each example (2667 in total) in the dataset is composed by:
document_id: clinical note identifierclinical_note: the note reporting on the patient's clinical history
For more info visit the website https://sites.google.com/fbk.eu/crf
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