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CHIEF COMPLAINT: AMS, concern for toxic alcohol ingestion PRESENT ILLNESS: Mr. [**Known lastname 27389**] is a 39 year old man with h/o EtOH and polysubstance abuse, seizure disorder, who was found to be unresponsive while visiting his partner in the ICU earlier today. . The patient was visiting his partner in the ICU...
0
1,061
CHIEF COMPLAINT: abdominal pain PRESENT ILLNESS: 78 yo Russian speaking F with h/o pulmonary HTN, CHF, OSA on home O2 who initially admitted on [**2139-5-18**] from home with vomiting, loss of appetite x 1 month. Diarrhea x 1 week. Per ED notes, pt also c/o RLQ/RUQ pain; rates pain as [**8-26**] lasting several days. ...
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27,180
CHIEF COMPLAINT: Bilateral Sub Dural Hematoma PRESENT ILLNESS: This is a 87 year old man with h/o CAD, s/p coronary artery bypass graft, sick sinus syndrome, s/p pacer insertion, AAA and cerebral aneurysm who presented to OSH with anorexia, nausea, and generalized weakness. He was recently noted to have been started o...
0
68,339
CHIEF COMPLAINT: Intracranial bleed PRESENT ILLNESS: 87 year-old French Creole speaking man with a history of HTN, Parkinson's disease was transferred from OSH with lethargy, difficulty speaking for 1 day and head CT with left basal ganglia hemorrhage for further management. Son reports that pt was fine when he went...
0
54,044
CHIEF COMPLAINT: ischemic left foot PRESENT ILLNESS: *-71y/o female initally evaluated ([**4-29**] ) at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital for left foot ischemia which became progressive over several days prior to admission with foot pain with walking. No resat pain.workup inclu...
0
91,128
CHIEF COMPLAINT: PRESENT ILLNESS: This 52 year old white female has a history of coronary artery disease. She is status post myocardial infarction eight years ago and reported feeling well since this myocardial infarction and catheterization at that time with medical management. She now presents with shortness of b...
0
65,020
CHIEF COMPLAINT: Leg Swelling PRESENT ILLNESS: 56 yo man with history of hypertension and diabetes who had recent bilateral total knee replacements on [**11-24**] for osteoarthritis presents with bilaterall swelling and pain in his lower extermities. Patient states that 2 days ago while at [**Hospital 38**] rehab he ...
0
78,768
CHIEF COMPLAINT: shortness of breath PRESENT ILLNESS: 64F active smoker with h/o CHF (EF 40% [**2103-12-12**])and COPD (on 3L at home when compliant) who presents with worsening dyspnea x 1 day. Patient reports a long standing history of COPD for which she has been on home oxygen. She reports that her breathing was ...
0
25,069
CHIEF COMPLAINT: Recurrent left lower quadrant pain, PRESENT ILLNESS: 74-year-old female with a recurrent left lower quadrant pain, status post recent hospitalization for a recurrent diverticulitis. For the last three years, she has had increasing left lower quadrant pain. It all started on a trip to [**Location (un) ...
0
32,485
CHIEF COMPLAINT: chest discomfort PRESENT ILLNESS: 64 year old spanish speaking female who was watching television when she had onset of pain in her left neck that radiated to left arm and left chest. It lasted approximately 10 minutes and then resolved. She was evaluated at outside hospital including cardiac cathet...
0
66,389
CHIEF COMPLAINT: Dizzyness PRESENT ILLNESS: Mr. [**Known lastname 349**] is an 89 year old man who presented with several months of dizziness, thirst, and increased urination. He was confused and found to be hyponatremic, head CT negative, CXR clear, UA negative. The patient is unable to recount a history due to word ...
0
80,293
CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 64 year old male with history of congestive heart failure, diabetes mellitus type II, status post aortic valve replacement and mitral valve replacement, on Coumadin. He was transferred from an outside hospital where he presented with nausea, vomiting and weakness and...
0
77,095
CHIEF COMPLAINT: Syncope, shortness of breath PRESENT ILLNESS: 89 F with history of breast cancer s/p lumpectomy in [**2145**], dementia, atrial fibrillation, PSVT, orthostatic hypotension and history of syncopal episodes and multiple falls with recent C2/3 spinous process fractures in [**10-5**], who presents after a...
1
23,420
CHIEF COMPLAINT: Dyspnea, orthopnea, and lower extremity edema PRESENT ILLNESS: Mr. [**Known lastname **] is a 61 year-old male admitted with fevers 102.6, leukocytosis and Congestive Heart failure SOB and weakness. An echocardiogram revealed endocarditis with vegetation seen on the mitral leaflet. His blood cultures...
0
25,843
CHIEF COMPLAINT: palpitations, shortness of breath PRESENT ILLNESS: The patient is a 61 year old white male with paroxysmal atrial fibrillation that is resistant to medical management. Symptoms have increased in severity and frequency recently and he is referred for surgical management. MEDICAL HISTORY: # Paroxysmal...
0
64,234
CHIEF COMPLAINT: acute cholesystitis PRESENT ILLNESS: This 70-year-old female presented to the [**Hospital3 3583**] ED on [**2103-12-7**] with the complaint of chest pain which was not resolved with sublingal nitroglycerine. Pt is s/p known to have severe coronary artery disease, which is not amenable to stenting and ...
0
81,879
CHIEF COMPLAINT: Low back pain PRESENT ILLNESS: 77 yo F w/ AF, htn, "enlarged heart," DM, hx UTI, multiple joint replacements, who transferred from [**Hospital **] w/ 1 week LBP (l-s and R paraspinal), nausea. UA + started on abx several days ago. l-s neg, CT abd w/o contrast showed no kidney stones. ESR [**Hospital 6...
0
71,184
CHIEF COMPLAINT: Status post PVI complicated by a pericardial effusion PRESENT ILLNESS: Patient is a 55 yo male with longstanding h/o atrial fibrillation and atrial flutter s/p afib ablation x 1, and aflutter ablation x 2 and multiple failed cardioversion attempts who was admitted today for a pulmonary vein isolation ...
0
18,972
CHIEF COMPLAINT: Weight gain since discharge on [**8-25**] and rash PRESENT ILLNESS: Pt is a 66 year old male with PMH of HTN, s/p knee surgeries, recently discharged from the hospital after treatment of pericardial effusion and anasarca. He was treated with a pericardial drain and diuresis with Lasix. He was discharg...
0
98,528
CHIEF COMPLAINT: Respiratory Distress PRESENT ILLNESS: This is a [**Age over 90 **] year-old (by record though actually 86 years-old per brother) male with history of Afib, HTN, CVA's and severe dememntia (nonverbal at baseline) who presented with respiratory failure. Per nursing home documentation the patient was sh...
0
80,162
CHIEF COMPLAINT: Shortness of breath PRESENT ILLNESS: 80M with a history of CAD s/p 5 vessel CABG in [**2098**], STEMI in [**2111**] multiple interventions the most recent being [**2113-8-22**] with PCI and BMS of native Lcx. He underwent implantation of dual chamber [**Company 1543**] pacemaker in [**2113-2-16**] due...
1
90,711
CHIEF COMPLAINT: Altered Mental Status PRESENT ILLNESS: 73yo m w/ hx of CAD s/p 4V CABG ([**2119**])and PCI w/ LAD stent, poorly controlled IDDM, HLD, COPD, and CKD (baseline cr 3.5)presented to [**Hospital3 **] Sunday AM after being found unresponsive at home. EMS FS at the scene was 63. In the [**Hospital3 5097**] E...
0
53,159
CHIEF COMPLAINT: Chest pain. PRESENT ILLNESS: The patient is a 46-year-old male admitted on [**2152-10-23**] to [**Hospital1 188**] with acute coronary syndrome and LMCA 80% thrombosis. The patient had an intra-aortic balloon pump placed immediately and underwent an urgent CABG the same day with LIMA to left anterior ...
0
89,423
CHIEF COMPLAINT: Right leg claudication. PRESENT ILLNESS: 55-year-old gentleman with severe peripheral vascular disease has had severe disabling claudication of his right lower extremity. He has some iliac disease, diffuse common femoral disease, a long segment right superficial femoral artery occlusion with reconstit...
1
50,046
CHIEF COMPLAINT: Hypothermia at Dilaysis PRESENT ILLNESS: The patient is a 84 y.o. female with h/o ESRD on HD recent admission for C diff colitis in [**2161-8-6**], a resident at [**First Name4 (NamePattern1) 4233**] [**Last Name (NamePattern1) **], admitted [**2161-9-22**] after she was found to be hypothermic during...
0
92,162
CHIEF COMPLAINT: Patient presented to ED s/p witnessed fall, unresponsive PRESENT ILLNESS: 80yo M s/p fall, non responsive, GCS 3 at OSH and [**Hospital1 18**]. MEDICAL HISTORY: Alzheimers Dememtia "Mini strokes" MEDICATION ON ADMISSION: ALLERGIES: Penicillins PHYSICAL EXAM: FAMILY HISTORY: Noncontributory SOCI...
1
50,701
CHIEF COMPLAINT: ESRD PRESENT ILLNESS: Mr. [**Known lastname 46505**] is a 50-year-old gentleman with end-stage renal disease and significant cardiac history. After an extensive workup and extensive discussion of the risks and benefits of the transplant, he strongly desired to proceed with a living-related renal trans...
0
3,423
CHIEF COMPLAINT: BRBPR PRESENT ILLNESS: Patient is a 77 yo M with multiple medical conditions including Stage IV NSCLC (adenocarcioma) s/p chemoradiation, CAD and PVD on [**Hospital **] transferred from [**Hospital6 **] ED for BRBPR. . Patient began having BRBPR last night. He presented to [**Hospital1 112**] ED and w...
0
81,937
CHIEF COMPLAINT: dyspnea/chest pain PRESENT ILLNESS: 56 year old male with past history of and recent hip replacement 2 weeks ago, transferred from [**Hospital6 33**] for bialteral PE's. He presented this morning with chest pain and syncope - fell forward on face. Found down, with pulse. EMS called and transfered to [...
0
22,588
CHIEF COMPLAINT: s/p NSTEMI PRESENT ILLNESS: Patient is an 87 year old woman with PMH of DM, HTN, and AFib s/p PPM admitted to [**Hospital3 4107**] on [**2175-8-15**] with non-healing gangreonous right fourth toe for consult regarding amputation. Patient was started empirically on vancomycin, levofloxacin, and flagyl ...
0
11,761
CHIEF COMPLAINT: head trauma s/p fall PRESENT ILLNESS: Patient is a 67 yo male with unknown PMH who suffered a [**9-19**] foot fall while on his boat. He struck his head on concrete and was believed to have been found 30 minutes later. Was in agonal breathing and was reportedly moving all four extremities. EMS attem...
1
23,594
CHIEF COMPLAINT: shortness of breath PRESENT ILLNESS: 44 y/o M w/no past med hx who was brought by EMS to the ED tonight c/o SOB and told them he did "a lot of cocaine". Per the ED triage note (as pt was unable to give further history once in the ED), he had SOB, was c/o feeling "antsy and jumpy", was diaphoretic, an...
0
95,118
CHIEF COMPLAINT: Trauma patient with multiple injuries including: 1.Left-retro-orbital hematoma 2.posterior right subgaleal hematoma 3.large midline frontal laceration to the skull 4.multiple facial fx 5.amputated Left(3rd) finger (DIP) PRESENT ILLNESS: 21 year old male s/p assault w/ a baseball bat and machette, init...
0
57,361
CHIEF COMPLAINT: Back/Chest Pain PRESENT ILLNESS: 74 yo male with HTN,PMIBI in [**2134**] demostrating mild reversible decrease in tracer uptake in inferolateral myocardial wall, with EF of 48%, who presented to Dr.[**Name (NI) 10962**] office with a complaint of back pain. The EKG from that office is unavailable, but...
0
49,096
CHIEF COMPLAINT: palpitations PRESENT ILLNESS: 85 year old female with history atrial fibrillation admitted for dofetilide initation. Has known history of mitral stenosis based on echocardiogram. MEDICAL HISTORY: Paroxysmal atrial fibrillation Rheumatic heart disease Moderate-to-severe mitral stenosis Hypertension H...
0
67,711
CHIEF COMPLAINT: Lower GI bleed. PRESENT ILLNESS: The patient is an 88-year-old male known to our hospital who was transferred here with a history of a lower GI bleed from an outside hospital. He was admitted there for five days in work-up for this lower GI bleed and both endoscopies from above and colonoscopy failed ...
1
23,094
CHIEF COMPLAINT: Altered mental status Diaphoresis Abdominal pain PRESENT ILLNESS: This 78 year old russian speaking female presented to the emergency department on [**2152-3-30**]. Her family memebers stated that she was found at home with altered mental status and diaphoresis. She is diabetic. Mental status improved...
0
56,844
CHIEF COMPLAINT: Diarrhea PRESENT ILLNESS: 31 y/o man with a PMH of relapsed AML who has received alloSCT x2 from his brother who presents today after a week of progressive diarrhea x 6 days with fevers today. Today c/o > 20 episodes copious non-bloody, yellow green watery diarrhea. He also c/o increased fatigue x 1 d...
1
39,230
CHIEF COMPLAINT: Worsening mental status and respiratory failure. PRESENT ILLNESS: 70 M with multiple lung co-morbidities including severe kyphoscoliosis resulting in severe restrictive physiology, severe sleep disordered breathing, hypoventilation syndrome, severe pHTN, chronic dHF who presents with worsening confusi...
0
10,445
CHIEF COMPLAINT: PRESENT ILLNESS: This is a 60-year-old man with CAD, PVD who had difficulty speaking after left carotid endarterectomy in [**2133-2-16**]. The patient has had bilateral carotid stenosis. On [**2-21**] while he was sitting in a chair he developed sudden onset of right arm and leg numbness, followed ...
0
59,283
CHIEF COMPLAINT: Right thigh hematoma. PRESENT ILLNESS: This is a 75 year old female a bioprosthetic mitral valve for rheumatic heart disease, with known chronic atrial fibrillation, anticoagulated. The patient traumatized her right thigh two days prior to admission and noted a small, bruised area which has increased...
0
62,259
CHIEF COMPLAINT: acute NSTEMI PRESENT ILLNESS: This 72 year old old male underwent laproscopic appendectomy on [**8-21**] at [**Hospital6 19155**] after acute episode of abdominal pain. He subsequently had post-operative EKG changesrevealing ST changes and he was started on The acute coronary syndrome protocol. His t...
0
2,981
CHIEF COMPLAINT: Ongoing chest pain and positive cardiac enzymes transfer for cardiac catheterization PRESENT ILLNESS: Pt is a 75 yo male with DM, ESRD, on HD for 18 months , HTN, high cholesterol, PAF, with dual chamber pacer for heart block, transferred to [**Hospital1 18**] for urgent cath due to ongoing CP and + c...
0
60,817
CHIEF COMPLAINT: Chest Pain PRESENT ILLNESS: 62 y/o male with abnormal EKG during stress test. Underwent cardiac cath which revealed three vessel disease. Referred for surgical revascularization. MEDICAL HISTORY: Diabetes Mellitus, Hypertension, Myocardial Infarction, Right Knee surgery MEDICATION ON ADMISSION: Topr...
0
19,696
CHIEF COMPLAINT: lightheadedness at clinic neutropenic fever myelodypslastic syndrome PRESENT ILLNESS: This is a 78 year old male with a history of aplastic anemia requiring chronic transfusions who presents from clinic where he was getting his labs drawn. Pt states that after getting his blood drawn, he became light...
0
48,727
CHIEF COMPLAINT: Fevers and shortness of breath. PRESENT ILLNESS: The patient is an 81-year-old man with a history of coronary artery disease, congestive heart failure, end-stage renal disease on hemodialysis, type 2 diabetes, peripheral vascular disease (numerous lower extremity bypass surgeries). He was admitted wi...
1
72,000
CHIEF COMPLAINT: hypoglycemia/ARF PRESENT ILLNESS: Mr. [**Known lastname 12543**] is a 70 yo M with DM2 and CKD baseline Cr 3.5-4.2 up to 9.0 [**6-28**] not on dialysis found by family to be altered with hypoglycemia now with ARF. He was given orage juice and milk by family. Pt vomited, unable to hold down food and fl...
0
72,364
CHIEF COMPLAINT: PRESENT ILLNESS: This 62 year old white male presented from his doctor's office following an electrocardiogram which revealed changes from previous electrocardiograms. He stated that he had been experiencing burning chest pain which was with exertion for the past three to four weeks. The pain also ...
0
80,462
CHIEF COMPLAINT: Agitation/MS changes/Aspirin Overdose PRESENT ILLNESS: 50F with history of refractory depression/anxiety (recent [**Doctor First Name **] hospitalization), HTN, DM, Breast CA who presents after aspirin injestion. Pt reports taking aspirin continuously last night into this morning. She is unable to qua...
0
40,088
CHIEF COMPLAINT: Mr. [**Known lastname 35123**] is a direct admission to the operating room for coronary artery bypass grafting and preadmission testing done [**2105-5-1**]. The patient's chief complaint was dyspnea on exertion, shortness of breath, and chest pain x 2 weeks. PRESENT ILLNESS: The patient is status pos...
0
45,191
CHIEF COMPLAINT: found down PRESENT ILLNESS: Patient is a 65 year old woman who was found down in [**Location (un) 583**] by the police early on the morning of admission. There were no obvious signs of trauma. She was unresponsive in the field and had a temperature of 31.9 rectal. She briefly awoke in the ED and could...
0
46,845
CHIEF COMPLAINT: S/P Fall, pericardial effusion PRESENT ILLNESS: 62F h/o CML on maintenance hydroxyurea in remission for 15 years with recent relapse, followed at [**Hospital1 **], who is s/p fall last night, found to have SAH/SDH and possible brain mets at OSH, as well as pericardial effusion. The patient reports pr...
0
16,476
CHIEF COMPLAINT: Vomiting, malaise, increasing LE edema PRESENT ILLNESS: Mrs. [**Known lastname 63845**] is a 80 year-old female with a history of chronic AF, diastolic CHF, DM, hyperlipidemia, CRI, who presents with increasing LE edema and erythema, x 10days. In addition to the erythema, the pt had blisters that burs...
0
7,651
CHIEF COMPLAINT: chest pain PRESENT ILLNESS: 79 yo female with PMH DM, hyperlipidemia, HTN admitted with one week history of chest pain and EKG changes. Pt states that CP started on Monday. It is intermittent and occurring with exertion. Sharp, substernal, radiating to right chest and back, [**10-25**], associated wit...
0
7,045
CHIEF COMPLAINT: Cholangitis, Afib w/ RVR (transfer from [**Hospital Unit Name 153**]) PRESENT ILLNESS: 87M h/o CVA on coumadin, PAF, porcine AVR initally presented to OSH with 5 days of fever (Tmax 104) and chills where he was found to have cholangitis. He was hypotensive at presentation with elevated LFTS (Tbili 4.7...
0
64,554
CHIEF COMPLAINT: Progressive dypnea on exertion PRESENT ILLNESS: 43 year old woman who has experienced progressive dyspnea on exertion. AN echocardiogram in [**1-14**] revealed moderate MR [**First Name (Titles) **] [**Last Name (Titles) **] with prolapse of the posterior mitral valve leaflet. A cardiac catheterizatio...
0
99,961
CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 58-year-old gentleman, who was going to an outside hospital for preoperative testing for right cataract surgery when his left prosthetic leg slipped and he fell hitting his back. He developed back pain, which persisted. He denied weakness, numbness, or bowel or bla...
0
24,816
CHIEF COMPLAINT: chest pain PRESENT ILLNESS: Mr. [**Known lastname 10743**] is a 59 M with history of HTN, HLD, and gout who is presenting with acute onset of chest pain that started the day of admission. The patient reports that he was walking around his apartment when he felt acute onset of upper midchest compressi...
0
39,569
CHIEF COMPLAINT: GI bleed PRESENT ILLNESS: 84M history of CAD s/p coronary stenting x 3 with the latest placed 4 weeks ago on Plavix, CHF, superficial bladder cancer s/p resection in [**2113-10-20**] and completed mitomycin chemo in [**Month (only) **], and diverticular disease 50 years ago with partial colectomy who ...
0
37,994
CHIEF COMPLAINT: shortness of breath PRESENT ILLNESS: 75 year old female with a past medical history of Rheumatic heart disease, atrial fibrillation-on Coumadin,type II Diabetes Mellitus, Hypertension, hyperlipidemia, and congestive heart failure who was admitted to an outside hospital for exacerabation of COPD/CHF wi...
0
89,180
CHIEF COMPLAINT: cough, chills PRESENT ILLNESS: The patient is an 84M w/ DM2, afib, HTN who was transferred from [**Hospital6 302**] per his request after presenting [**8-10**] with persistent cough and fevers x2days. He noted shaking chills after mowing his lawn 2days PTA and went to an urgent care clinic where he wa...
0
2,057
CHIEF COMPLAINT: PRESENT ILLNESS: This is an 85 [**Hospital **] nursing home resident with a history of cerebrovascular accident, coronary artery disease, status post coronary artery bypass graft who presents with shortness of breath and respiratory distress. The patient has been a nursing home resident for two year...
0
57,861
CHIEF COMPLAINT: Right hand weakness. PRESENT ILLNESS: The patient is a 63 year old right-handed African American man with past medical history of stroke in [**2147-1-26**] with right arm weakness, treated at [**Hospital 1263**] Hospital, with complete resolution and no residual symptoms, IDDM, tobacco abuse, obesity,...
0
65,437
CHIEF COMPLAINT: dyspnea PRESENT ILLNESS: This is a 25 year old woman with a history of asthma and Ehrlers-Danlos syndrome and currently undergoing IVF treatment who presents as a transfer from [**Hospital6 33**] with acute onset shortness of breath. She had 2 embryos implanted on Monday in her first cycle of IVF. She...
0
45,527
CHIEF COMPLAINT: Hypotension PRESENT ILLNESS: 83 year old female with a history of HTN, CKD, anemia presents to the ER with worsened bilateral hip pain. Apparently she fell on Friday and was seen at [**Hospital3 **] and discharged home after she had slipped on ice. She now has worsening bilateral hip pain and also R k...
0
18,519
CHIEF COMPLAINT: Elective surgery for kyphoscoliosis PRESENT ILLNESS: This is a 53-year-old woman without significant past medical history, who was in her usual state of health until about two months ago. On [**2120-5-31**], she suffered an L1 burst fracture and left rib fracture secondary to a fall from a ten foot l...
0
88,269
CHIEF COMPLAINT: Decreased responsiveness and respiratory distress PRESENT ILLNESS: Mr. [**Known lastname 27218**] is a 77yo M with history of COPD, DM and ischemic cardiomyopathy with EF of 10% ([**4-22**]) who was transferred to the cardiology service for ICD placement. . Patient was recently hospitalized at [**Hosp...
0
71,341
CHIEF COMPLAINT: left renal mass PRESENT ILLNESS: 53F s/p right radical nephrectomy 20years ago. Pathology was determined to be benign. She presented with a left exophytic renal mass in the lower pole of the left kidney. She underwent left partial nephrectomy. MEDICAL HISTORY: Diabetes mellitus diagnosed in [**212...
0
91,025
CHIEF COMPLAINT: 1. Acute bleed 2. Acute on chronic renal failure 3. Hypernatremia/Diabetes Insipidus PRESENT ILLNESS: 72yo male with h/o A Fib, HTN, AAA, CRI, L renal cysts, recent urosepsis treated with levofloxacin, who p/w an acute bleed from L kidney when INR was 4.6. Since admission, pt??????s INR and Hct have ...
0
48,990
CHIEF COMPLAINT: fever and abdominal pain PRESENT ILLNESS: The patient is a 65 year old male who was recently discharged from [**Hospital1 18**] on [**2107-4-1**] (please see discharge summary for details) with a known colovesical fistula, with the idea to continue bowel rest and antibiotics and return to [**Hospital1...
0
55,141
CHIEF COMPLAINT: respiratory distress, mental status change PRESENT ILLNESS: Ms. [**Known lastname 84176**] is a 25yo woman with history of anxiety and heroin abuse who was found apneic and unresponsive. Ms. [**Known lastname 84176**] has a long history of heroin abuse, which she usually takes intranasally. After tw...
0
18,975
CHIEF COMPLAINT: chest pain PRESENT ILLNESS: Mr. [**Known lastname 18801**] is a 48 yo M with a history DM, IGA nephropathy, hypertension who presented with chest pain and orthopnea. The patient reports that over the last 1 week he has been feeling unwell with decreased appetite and general malaise. He then reported t...
0
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