update

chatgpt.py

@@ -179,14 +179,10 @@ def submit_text_and_respond(edited_text, api_key, username, selected_title, hist
     print(response)
     if isinstance(response, str):
         history.append((edited_text, response))
-        # Generate conversation ID for evaluation
-        conversation_id = f"{username}_{datetime.now().strftime('%Y%m%d_%H%M%S')}"
-        return history, "", conversation_id, edited_text, response
+        return history, ""
     doctor_response = response['doctor_response']
     history.append((edited_text, doctor_response))
-    # Generate conversation ID for evaluation
-    conversation_id = f"{username}_{datetime.now().strftime('%Y%m%d_%H%M%S')}"
-    return history, "", conversation_id, edited_text, doctor_response
+    return history, ""
 
 def set_initialize_button(api_key_input, username_input):
     message = asyncio.run(initialization(api_key_input, username_input))
@@ -206,58 +202,60 @@ def start_recording(audio_file):
     except Exception as e:
         return f"Failed to transcribe: {str(e)}"
 
-# Evaluation functions
-def save_evaluation(conversation_id, user_input, bot_response, rating, feedback, expert_name, categories):
-    """Save evaluation data to a JSON file"""
+# Patient Sample Evaluation functions
+def save_patient_evaluation(patient_id, patient_input, ai_summary, rating, feedback, expert_name, categories, sentence_comments=None):
+    """Save patient sample evaluation data to a JSON file"""
     timestamp = datetime.now().isoformat()
     
     evaluation = {
         "timestamp": timestamp,
-        "conversation_id": conversation_id,
+        "patient_id": patient_id,
         "expert_name": expert_name,
-        "user_input": user_input,
-        "bot_response": bot_response,
+        "patient_input": patient_input,
+        "ai_summary": ai_summary,
         "overall_rating": rating,
         "feedback": feedback,
-        "categories": categories
+        "categories": categories,
+        "sentence_comments": sentence_comments or []
     }
     
     # Create evaluations directory if it doesn't exist
-    eval_dir = "evaluations"
+    eval_dir = "patient_evaluations"
     if not os.path.exists(eval_dir):
         os.makedirs(eval_dir)
     
     # Save to JSON file
-    eval_file = os.path.join(eval_dir, f"evaluation_{timestamp.replace(':', '-')}.json")
+    eval_file = os.path.join(eval_dir, f"patient_eval_{patient_id}_{timestamp.replace(':', '-')}.json")
     with open(eval_file, 'w', encoding='utf-8') as f:
         json.dump(evaluation, f, ensure_ascii=False, indent=2)
     
     # Also append to a master CSV file for easier analysis
-    csv_file = os.path.join(eval_dir, "evaluations_master.csv")
+    csv_file = os.path.join(eval_dir, "patient_evaluations_master.csv")
     file_exists = os.path.isfile(csv_file)
     
     with open(csv_file, 'a', newline='', encoding='utf-8') as f:
         writer = csv.writer(f)
         if not file_exists:
-            writer.writerow(['timestamp', 'conversation_id', 'expert_name', 'overall_rating', 
-                           'medical_accuracy', 'clinical_relevance', 'communication_clarity', 
-                           'safety_considerations', 'feedback'])
+            writer.writerow(['timestamp', 'patient_id', 'expert_name', 'overall_rating', 
+                           'medical_accuracy', 'clinical_relevance', 'completeness', 
+                           'clarity', 'feedback', 'sentence_comments_count'])
         
         writer.writerow([
-            timestamp, conversation_id, expert_name, rating,
+            timestamp, patient_id, expert_name, rating,
             categories.get('medical_accuracy', ''),
             categories.get('clinical_relevance', ''),
-            categories.get('communication_clarity', ''),
-            categories.get('safety_considerations', ''),
-            feedback
+            categories.get('completeness', ''),
+            categories.get('clarity', ''),
+            feedback,
+            len(sentence_comments) if sentence_comments else 0
         ])
     
-    return f"Evaluation saved successfully at {timestamp}"
+    return f"Patient evaluation saved successfully at {timestamp}"
 
-def submit_evaluation(conversation_id, user_input, bot_response, overall_rating, 
-                     medical_accuracy, clinical_relevance, communication_clarity, 
-                     safety_considerations, feedback, expert_name):
-    """Process and save the evaluation"""
+def submit_patient_evaluation(patient_id, patient_input, ai_summary, overall_rating, 
+                            medical_accuracy, clinical_relevance, completeness, 
+                            clarity, feedback, expert_name, sentence_comments):
+    """Process and save the patient evaluation"""
     if not expert_name.strip():
         return "Please enter your name before submitting evaluation."
     
@@ -267,15 +265,26 @@ def submit_evaluation(conversation_id, user_input, bot_response, overall_rating,
     categories = {
         'medical_accuracy': medical_accuracy,
         'clinical_relevance': clinical_relevance,
-        'communication_clarity': communication_clarity,
-        'safety_considerations': safety_considerations
+        'completeness': completeness,
+        'clarity': clarity
     }
     
-    result = save_evaluation(conversation_id, user_input, bot_response, 
-                           overall_rating, feedback, expert_name, categories)
+    # Parse sentence comments
+    parsed_comments = []
+    if sentence_comments.strip():
+        for line in sentence_comments.strip().split('\n'):
+            if ':' in line:
+                sentence_num, comment = line.split(':', 1)
+                parsed_comments.append({
+                    'sentence_number': sentence_num.strip(),
+                    'comment': comment.strip()
+                })
+    
+    result = save_patient_evaluation(patient_id, patient_input, ai_summary, 
+                                   overall_rating, feedback, expert_name, categories, parsed_comments)
     
     # Reset form after successful submission
-    return result, "", 0, 0, 0, 0, 0, ""
+    return result, "", 0, 0, 0, 0, 0, "", ""
 
 def get_conversation_for_evaluation(history):
     """Get the last conversation pair for evaluation"""
@@ -288,23 +297,23 @@ def get_conversation_for_evaluation(history):
     
     return user_input, bot_response
 
-def export_evaluations():
-    """Export evaluation data for analysis"""
-    eval_dir = "evaluations"
-    csv_file = os.path.join(eval_dir, "evaluations_master.csv")
+def export_patient_evaluations():
+    """Export patient evaluation data for analysis"""
+    eval_dir = "patient_evaluations"
+    csv_file = os.path.join(eval_dir, "patient_evaluations_master.csv")
     
     if not os.path.exists(csv_file):
-        return None, "No evaluation data found."
+        return None, "No patient evaluation data found."
     
-    return csv_file, f"Evaluation data exported. Total evaluations in file."
+    return csv_file, f"Patient evaluation data exported."
 
-def get_evaluation_stats():
-    """Get basic statistics about evaluations"""
-    eval_dir = "evaluations"
-    csv_file = os.path.join(eval_dir, "evaluations_master.csv")
+def get_patient_evaluation_stats():
+    """Get basic statistics about patient evaluations"""
+    eval_dir = "patient_evaluations"
+    csv_file = os.path.join(eval_dir, "patient_evaluations_master.csv")
     
     if not os.path.exists(csv_file):
-        return "No evaluation data available."
+        return "No patient evaluation data available."
     
     try:
         import pandas as pd
@@ -313,16 +322,22 @@ def get_evaluation_stats():
         total_evaluations = len(df)
         avg_overall_rating = df['overall_rating'].mean() if 'overall_rating' in df.columns else 0
         avg_medical_accuracy = df['medical_accuracy'].mean() if 'medical_accuracy' in df.columns else 0
+        avg_completeness = df['completeness'].mean() if 'completeness' in df.columns else 0
         
         expert_count = df['expert_name'].nunique() if 'expert_name' in df.columns else 0
+        patient_count = df['patient_id'].nunique() if 'patient_id' in df.columns else 0
+        total_sentence_comments = df['sentence_comments_count'].sum() if 'sentence_comments_count' in df.columns else 0
         
         stats = f"""
-📊 **Evaluation Statistics**
+📊 **Patient Evaluation Statistics**
 
 - **Total Evaluations**: {total_evaluations}
+- **Patients Evaluated**: {patient_count}
 - **Average Overall Rating**: {avg_overall_rating:.2f}/5
 - **Average Medical Accuracy**: {avg_medical_accuracy:.2f}/5
+- **Average Completeness**: {avg_completeness:.2f}/5
 - **Number of Experts**: {expert_count}
+- **Total Sentence Comments**: {total_sentence_comments}
 - **Latest Evaluation**: {df['timestamp'].iloc[-1] if not df.empty else 'N/A'}
         """
         return stats
@@ -332,9 +347,9 @@ def get_evaluation_stats():
         with open(csv_file, 'r', encoding='utf-8') as f:
             lines = f.readlines()
             total_evaluations = len(lines) - 1  # Subtract header
-            return f"Total evaluations: {total_evaluations} (Install pandas for detailed stats)"
+            return f"Total patient evaluations: {total_evaluations} (Install pandas for detailed stats)"
     except Exception as e:
-        return f"Error reading evaluation data: {str(e)}"
+        return f"Error reading patient evaluation data: {str(e)}"
 
 def update_methods(chapter):
     return gr.update(choices=interview_protocols[chapter], value=interview_protocols[chapter][0])
@@ -480,7 +495,7 @@ with gr.Blocks(css=css) as app:
             submit_button.click(
                 submit_text_and_respond,
                 inputs=[transcription_box, api_key_state, username_input, selected_title, state, chatbot_type_state],
-                outputs=[chatbot, transcription_box, conversation_id_state, eval_user_input_state, eval_bot_response_state]
+                outputs=[chatbot, transcription_box]
             )
 
             # download_button.click(
@@ -525,14 +540,10 @@ with gr.Blocks(css=css) as app:
                 outputs=[predefined_option_text, markdown_display, selected_title]
             )
 
-            # Evaluation Module
+            # Patient Sample Evaluation Module
             with gr.Box():
-                gr.Markdown("## 🔬 Expert Evaluation Module")
-                
-                # Hidden fields to store conversation data for evaluation
-                conversation_id_state = gr.State("")
-                eval_user_input_state = gr.State("")
-                eval_bot_response_state = gr.State("")
+                gr.Markdown("## 🏥 Patient Sample Evaluation Module")
+                gr.Markdown("Evaluate AI-generated patient summaries based on patient data")
                 
                 with gr.Row():
                     expert_name_input = gr.Textbox(
@@ -546,16 +557,34 @@ with gr.Blocks(css=css) as app:
                         scale=1
                     )
                 
+                # Patient Data Display (based on selected sample)
+                with gr.Accordion("📋 Patient Input Data", open=True):
+                    patient_input_display = gr.Textbox(
+                        label="Original Patient Data",
+                        interactive=False,
+                        lines=6,
+                        value="Select a patient sample above to view data"
+                    )
+                
+                # AI Summary Display
+                with gr.Accordion("🤖 AI Generated Summary", open=True):
+                    ai_summary_display = gr.Textbox(
+                        label="AI Patient Summary",
+                        interactive=False,
+                        lines=8,
+                        value="AI summary will appear here"
+                    )
+                
                 # Overall Rating
                 overall_rating = gr.Slider(
                     minimum=1,
                     maximum=5,
                     step=1,
-                    label="Overall Rating (1=Poor, 5=Excellent)",
+                    label="Overall Quality Rating (1=Poor, 5=Excellent)",
                     value=0
                 )
                 
-                # Category-specific ratings
+                # Category-specific ratings for patient summaries
                 with gr.Row():
                     medical_accuracy = gr.Slider(
                         minimum=1,
@@ -573,74 +602,109 @@ with gr.Blocks(css=css) as app:
                     )
                 
                 with gr.Row():
-                    communication_clarity = gr.Slider(
+                    completeness = gr.Slider(
                         minimum=1,
                         maximum=5,
                         step=1,
-                        label="Communication Clarity",
+                        label="Completeness",
                         value=0
                     )
-                    safety_considerations = gr.Slider(
+                    clarity = gr.Slider(
                         minimum=1,
                         maximum=5,
                         step=1,
-                        label="Safety Considerations",
+                        label="Clarity & Organization",
                         value=0
                     )
                 
                 # Detailed feedback
                 feedback_text = gr.Textbox(
-                    label="Detailed Feedback",
-                    placeholder="Please provide specific feedback about the response...",
-                    lines=4
+                    label="Overall Feedback",
+                    placeholder="Please provide specific feedback about the AI summary...",
+                    lines=3
                 )
                 
-                # Current conversation display (readonly)
-                with gr.Accordion("Current Conversation", open=False):
-                    current_user_input = gr.Textbox(
-                        label="User Input",
-                        interactive=False,
-                        lines=2
-                    )
-                    current_bot_response = gr.Textbox(
-                        label="Bot Response",
-                        interactive=False,
-                        lines=3
+                # Sentence-by-sentence comments
+                with gr.Accordion("📝 Sentence-by-Sentence Comments", open=False):
+                    gr.Markdown("""
+                    **Instructions**: Provide specific comments for individual sentences in the AI summary.
+                    Format: `Sentence Number: Your comment`
+                    
+                    Example:
+                    ```
+                    1: Good introduction but missing patient age
+                    3: Incorrect medication dosage mentioned
+                    5: Excellent summary of symptoms
+                    ```
+                    """)
+                    sentence_comments = gr.Textbox(
+                        label="Sentence Comments",
+                        placeholder="1: Comment for first sentence\n2: Comment for second sentence\n...",
+                        lines=6
                     )
                 
                 # Submit evaluation button
                 submit_eval_button = gr.Button(
-                    "Submit Evaluation",
+                    "Submit Patient Evaluation",
                     variant="primary",
                     size="large"
                 )
             
-            # Connect evaluation functionality
-            def update_eval_display(conversation_id, user_input, bot_response):
-                """Update the evaluation display with current conversation"""
-                return user_input, bot_response
+            # Connect patient evaluation functionality
+            def update_patient_eval_display(selected_title):
+                """Update the evaluation display with selected patient data"""
+                if not selected_title:
+                    return "No patient selected", "No AI summary available"
+                
+                for option in options:
+                    if option["title"] == selected_title:
+                        patient_id = option["title"].replace("Patient:", "")
+                        return option["text"], option["note"]
+                
+                return "Patient data not found", "AI summary not found"
             
-            # Update evaluation display when new conversation happens
-            submit_button.click(
-                fn=update_eval_display,
-                inputs=[conversation_id_state, eval_user_input_state, eval_bot_response_state],
-                outputs=[current_user_input, current_bot_response]
+            # Update evaluation display when patient selection changes
+            predefined_option_radio.change(
+                fn=update_patient_eval_display,
+                inputs=[predefined_option_radio],
+                outputs=[patient_input_display, ai_summary_display]
             )
             
-            # Handle evaluation submission
+            # Handle patient evaluation submission
+            def submit_patient_eval_wrapper(selected_title, overall_rating, medical_accuracy, 
+                                          clinical_relevance, completeness, clarity, 
+                                          feedback_text, expert_name_input, sentence_comments):
+                if not selected_title:
+                    return "Please select a patient sample first.", "", 0, 0, 0, 0, 0, "", ""
+                
+                patient_id = selected_title.replace("Patient:", "")
+                patient_input = ""
+                ai_summary = ""
+                
+                for option in options:
+                    if option["title"] == selected_title:
+                        patient_input = option["text"]
+                        ai_summary = option["note"]
+                        break
+                
+                return submit_patient_evaluation(
+                    patient_id, patient_input, ai_summary, overall_rating,
+                    medical_accuracy, clinical_relevance, completeness, clarity,
+                    feedback_text, expert_name_input, sentence_comments
+                )
+            
             submit_eval_button.click(
-                fn=submit_evaluation,
+                fn=submit_patient_eval_wrapper,
                 inputs=[
-                    conversation_id_state,
-                    eval_user_input_state,
-                    eval_bot_response_state,
+                    selected_title,
                     overall_rating,
                     medical_accuracy,
                     clinical_relevance,
-                    communication_clarity,
-                    safety_considerations,
+                    completeness,
+                    clarity,
                     feedback_text,
-                    expert_name_input
+                    expert_name_input,
+                    sentence_comments
                 ],
                 outputs=[
                     evaluation_status,
@@ -648,38 +712,39 @@ with gr.Blocks(css=css) as app:
                     overall_rating,
                     medical_accuracy,
                     clinical_relevance,
-                    communication_clarity,
-                    safety_considerations,
+                    completeness,
+                    clarity,
+                    sentence_comments,
                     expert_name_input
                 ]
             )
 
-            # Admin Panel for Evaluation Management
+            # Admin Panel for Patient Evaluation Management
             with gr.Box():
-                gr.Markdown("## 📈 Evaluation Analytics")
+                gr.Markdown("## 📈 Patient Evaluation Analytics")
                 
                 with gr.Row():
                     refresh_stats_button = gr.Button("Refresh Statistics", variant="secondary")
                     export_data_button = gr.Button("Export Data", variant="secondary")
                 
                 evaluation_stats_display = gr.Markdown(
-                    value="Click 'Refresh Statistics' to view evaluation data.",
+                    value="Click 'Refresh Statistics' to view patient evaluation data.",
                     label="Statistics"
                 )
                 
                 export_file_output = gr.File(
-                    label="Download Evaluation Data",
+                    label="Download Patient Evaluation Data",
                     visible=False
                 )
                 
                 # Connect admin functions
                 refresh_stats_button.click(
-                    fn=get_evaluation_stats,
+                    fn=get_patient_evaluation_stats,
                     outputs=[evaluation_stats_display]
                 )
                 
                 export_data_button.click(
-                    fn=export_evaluations,
+                    fn=export_patient_evaluations,
                     outputs=[export_file_output, evaluation_stats_display]
                 )
 

evaluation_module_readme.md

@@ -1,97 +1,114 @@
-# Chatbot Evaluation Module 🔬
+# Patient Sample Evaluation Module 🏥
 
 ## 概述 (Overview)
 
-为您的医疗聊天机器人界面添加了一个专业的人类专家评估模块，允许医学专家对AI回复进行评分和反馈。
+为您的医疗AI界面添加了一个专业的患者样本评估模块，允许医学专家对AI生成的患者总结进行评分和反馈，支持按句评论功能。
 
 ## 功能特性 (Features)
 
-### 1. 多维度评估系统
-- **整体评分**: 1-5分制度评估
+### 1. 患者样本评估系统
+- **整体质量评分**: 1-5分制度评估AI总结质量
 - **医学准确性** (Medical Accuracy): 评估医学信息的准确性
-- **临床相关性** (Clinical Relevance): 评估回复的临床价值
-- **沟通清晰度** (Communication Clarity): 评估表达的清晰程度
-- **安全考虑** (Safety Considerations): 评估安全性和风险
-
-### 2. 详细反馈系统
-- 文本框提供详细反馈意见
-- 专家姓名记录
-- 时间戳自动记录
-- 对话ID追踪
-
-### 3. 数据管理
+- **临床相关性** (Clinical Relevance): 评估总结的临床价值
+- **完整性** (Completeness): 评估总结的信息完整度
+- **清晰度与组织** (Clarity & Organization): 评估表达的清晰程度和逻辑结构
+
+### 2. 按句评论系统
+- 针对AI总结的每个句子提供具体评论
+- 支持句子编号格式：`句号: 评论内容`
+- 追踪具体问题和改进建议
+- 详细的逐句分析能力
+
+### 3. 患者数据管理
+- 基于真实患者样本进行评估
+- 显示原始患者数据和AI生成总结
 - 自动保存为JSON和CSV格式
-- 实时统计分析
-- 数据导出功能
-- 评估历史查看
+- 患者ID和评估数据关联
 
 ## 使用方法 (Usage)
 
 ### 对于医学专家 (For Medical Experts)
 
-1. **进行对话**
-   - 与chatbot进行正常对话
-   - 每次回复后，评估模块会自动显示当前对话
+1. **选择患者样本**
+   - 从患者样本列表中选择要评估的病例
+   - 系统会自动显示原始患者数据和AI生成的总结
 
-2. **填写评估**
+2. **进行评估**
    - 输入您的姓名
-   - 使用滑块评分 (1-5分)
-   - 提供详细文字反馈
+   - 对比原始数据和AI总结
+   - 使用滑块进行多维度评分 (1-5分)
+   - 提供整体反馈意见
 
-3. **提交评估**
-   - 点击"Submit Evaluation"按钮
-   - 系统会确认保存成功
+3. **按句评论** (可选)
+   - 在"Sentence-by-Sentence Comments"部分
+   - 对特定句子提供详细评论
+   - 格式：`1: 第一句的评论`
+
+4. **提交评估**
+   - 点击"Submit Patient Evaluation"按钮
+   - 系统会确认保存成功并重置表单
 
 ### 对于管理员 (For Administrators)
 
 1. **查看统计**
-   - 点击"Refresh Statistics"查看评估数据
-   - 包括平均评分、专家数量等
+   - 点击"Refresh Statistics"查看患者评估数据
+   - 包括平均评分、专家数量、患者数量、按句评论数等
 
 2. **导出数据**
    - 点击"Export Data"下载CSV文件
-   - 用于进一步分析
+   - 用于进一步分析和研究
 
 ## 数据存储结构 (Data Structure)
 
-### JSON格式 (Individual Evaluations)
+### JSON格式 (Individual Patient Evaluations)
 ```json
 {
   "timestamp": "2024-01-01T12:00:00",
-  "conversation_id": "user123_20240101_120000",
+  "patient_id": "12345",
   "expert_name": "Dr. Smith",
-  "user_input": "用户输入...",
-  "bot_response": "机器人回复...",
+  "patient_input": "原始患者数据...",
+  "ai_summary": "AI生成的患者总结...",
   "overall_rating": 4,
-  "feedback": "详细反馈...",
+  "feedback": "整体反馈...",
   "categories": {
     "medical_accuracy": 5,
     "clinical_relevance": 4,
-    "communication_clarity": 4,
-    "safety_considerations": 5
-  }
+    "completeness": 4,
+    "clarity": 5
+  },
+  "sentence_comments": [
+    {
+      "sentence_number": "1",
+      "comment": "第一句评论"
+    },
+    {
+      "sentence_number": "3", 
+      "comment": "第三句评论"
+    }
+  ]
 }
 ```
 
 ### CSV格式 (Master File)
 - timestamp: 时间戳
-- conversation_id: 对话ID
+- patient_id: 患者ID
 - expert_name: 专家姓名
 - overall_rating: 整体评分
 - medical_accuracy: 医学准确性
 - clinical_relevance: 临床相关性
-- communication_clarity: 沟通清晰度
-- safety_considerations: 安全考虑
+- completeness: 完整性
+- clarity: 清晰度
 - feedback: 详细反馈
+- sentence_comments_count: 按句评论数量
 
 ## 文件结构 (File Structure)
 
 ```
-/evaluations/
-├── evaluation_YYYY-MM-DDTHH-mm-ss.json  # 单个评估记录
-├── evaluation_YYYY-MM-DDTHH-mm-ss.json
+/patient_evaluations/
+├── patient_eval_12345_YYYY-MM-DDTHH-mm-ss.json  # 单个患者评估记录
+├── patient_eval_67890_YYYY-MM-DDTHH-mm-ss.json
 ├── ...
-└── evaluations_master.csv               # 汇总CSV文件
+└── patient_evaluations_master.csv               # 汇总CSV文件
 ```
 
 ## 技术要求 (Requirements)
@@ -120,36 +137,63 @@ pip install pandas
 - **2分 (Poor)**: 明显问题，需要改进
 - **1分 (Very Poor)**: 严重错误，不可接受
 
-### 医学准确性评估要点
-- 医学事实是否正确
-- 诊断建议是否合理
-- 治疗方案是否适当
-- 药物信息是否准确
-
-### 安全考虑评估要点
-- 是否避免危险建议
-- 是否提醒就医
-- 是否注明AI限制
-- 风险评估是否合理
+### 患者总结评估要点
+
+#### 医学准确性
+- 医学术语使用是否正确
+- 诊断信息是否准确
+- 病史描述是否符合原始数据
+- 检查结果解读是否合理
+
+#### 临床相关性
+- 总结是否抓住关键临床信息
+- 重要症状是否被突出
+- 风险因素是否被识别
+- 治疗相关信息是否完整
+
+#### 完整性
+- 是否遗漏重要信息
+- 患者主要问题是否都涵盖
+- 时间线是否清晰
+- 关键数据是否包含
+
+#### 清晰度与组织
+- 逻辑结构是否清晰
+- 语言表达是否简洁
+- 信息层次是否分明
+- 专业术语使用是否恰当
+
+### 按句评论指南
+- 针对具体句子的准确性、相关性问题
+- 指出遗漏或错误的医学信息
+- 建议改进的表达方式
+- 标注优秀的总结部分
 
 ## 故障排除 (Troubleshooting)
 
 ### 常见问题
-1. **评估未保存**: 检查是否填写了专家姓名和评分
-2. **统计不显示**: 确保有评估数据存在
+1. **评估未保存**: 检查是否选择了患者样本、填写了专家姓名和评分
+2. **统计不显示**: 确保有患者评估数据存在
 3. **导出失败**: 检查文件权限和磁盘空间
+4. **患者数据未显示**: 确保选择了正确的患者样本
 
 ### 数据恢复
-所有评估数据都保存在`/evaluations/`目录下，可以手动备份或恢复。
+所有患者评估数据都保存在`/patient_evaluations/`目录下，可以手动备份或恢复。
 
 ## 更新日志 (Changelog)
 
-### v1.0 (Current)
-- 基础评估功能
+### v2.0 (Current)
+- 患者样本评估功能
+- 按句评论系统
+- 多维度评分系统（针对患者总结）
+- 患者数据管理
+- 评估统计分析面板
+
+### v1.0 (Previous)
+- 基础对话评估功能
 - 多维度评分系统
 - 数据导出功能
-- 统计分析面板
 
 ---
 
-**注意**: 此评估模块专为医学专家设计，用于提升AI医疗助手的质量和安全性。所有评估数据应严格按照医疗数据隐私法规处理。
+**注意**: 此患者评估模块专为医学专家设计，用于评估AI生成的患者总结质量。所有评估数据应严格按照医疗数据隐私法规处理。请确保患者数据的匿名化和隐私保护。

patient_evaluations/patient_eval_15110470_2025-09-03T01-08-09.956832.json

@@ -0,0 +1,16 @@
+{
+  "timestamp": "2025-09-03T01:08:09.956832",
+  "patient_id": "15110470",
+  "expert_name": "Jesse",
+  "patient_input": "PATIENT DATA FOR PRE-OPERATIVE EVALUATION:\n\nDEMOGRAPHICS:\n- Age: 70 years\n- Gender: M\n\nADMISSION INFORMATION:\n- Race: WHITE - RUSSIAN\n- Admission Type: EW EMER.\n- Insurance: Other\n\nPLANNED PROCEDURES (6 total):\n  1. ICD-9: 8659\n  2. ICD-9: 3614\n  3. ICD-9: 3722\n  4. ICD-9: 3615\n  5. ICD-9: 3961\n  6. ICD-9: 8856\n\nDIAGNOSES/COMORBIDITIES (83 total):\n  1. ICD-9: 8730\n  2. ICD-9: 85222\n  3. ICD-9: E8842\n  4. ICD-9: E8490\n  5. ICD-9: 4019\n  6. ICD-9: 2724\n  7. ICD-9: 2749\n  8. ICD-9: 41400\n  9. ICD-9: V4581\n  10. ICD-9: V5866\n  11. ICD-9: V1582\n  12. ICD-9: V061\n  13. ICD-9: 78650\n  14. ICD-10: R079\n  15. ICD-10: I2510\n  16. ICD-10: I10\n  17. ICD-10: Z951\n  18. ICD-10: Z87891\n  19. ICD-10: R51\n  20. ICD-10: Z006\n  21. ICD-10: Z7982\n  22. ICD-9: 41401\n  23. ICD-9: 42822\n  24. ICD-9: 4280\n  25. ICD-9: 42731\n  26. ICD-9: 78057\n  27. ICD-9: 4019\n  28. ICD-9: 2724\n  29. ICD-9: 2749\n  30. ICD-9: 4589\n  31. ICD-9: 78650\n  32. ICD-9: 78609\n  33. ICD-10: I5023\n  34. ICD-10: J189\n  35. ICD-10: C4022\n  36. ICD-10: C7951\n  37. ICD-10: C7802\n  38. ICD-10: C7801\n  39. ICD-10: C785\n  40. ICD-10: K922\n  41. ICD-10: R042\n  42. ICD-10: E222\n  43. ICD-10: I427\n  44. ICD-10: F05\n  45. ICD-10: I513\n  46. ICD-10: I739\n  47. ICD-10: Z951\n  48. ICD-10: Z7901\n  49. ICD-10: E8339\n  50. ICD-10: D649\n  51. ICD-10: Z515\n  52. ICD-10: I2510\n  53. ICD-10: I10\n  54. ICD-10: E785\n  55. ICD-10: I6521\n  56. ICD-10: R7303\n  57. ICD-10: D72828\n  58. ICD-10: Z66\n  59. ICD-10: M898X9\n  60. ICD-10: K5900\n  61. ICD-10: R000\n  62. ICD-10: R339\n  63. ICD-10: Z89431\n  64. ICD-10: Z87891\n  65. ICD-10: T451X5A\n  66. ICD-10: I447\n  67. ICD-10: D72829\n  68. ICD-10: R159\n  69. ICD-10: R0789\n  70. ICD-10: M79672\n  71. ICD-10: M79671\n  72. ICD-9: 4280\n  73. ICD-9: 7823\n  74. ICD-9: E9426\n  75. ICD-9: 5849\n  76. ICD-9: 42789\n  77. ICD-9: 56400\n  78. ICD-9: 40390\n  79. ICD-9: 5859\n  80. ICD-9: V4581\n  81. ICD-9: V1254\n  82. ICD-9: 2724\n  83. ICD-9: V5866\n\nLABORATORY RESULTS:\nTotal laboratory events: 1064\nMost frequent lab tests:\n  - Item ID 51221: 38 measurements\n  - Item ID 51222: 34 measurements\n  - Item ID 51248: 34 measurements\n  - Item ID 51249: 34 measurements\n  - Item ID 51250: 34 measurements\n\nCLINICAL NOTES:\n[DISCHARGE]  \nName:  ___              Unit No:   ___\n \nAdmission Date:  ___              Discharge Date:   ___\n \nDate of Birth:  ___             Sex:   M\n \nService: CARDIOTHORACIC\n \nAllergies: \nLidocaine\n \nAttending: ___.\n \nChief Complaint:\nExtertional chest pain\n \nMajor Surgical or Invasive Procedure:\n___ Cardiac cath\n___ 1. Urgent coronary artery bypass grafting times 5 with \nleft internal mammary artery to left anterior descending \ncoronary; reverse saphenous vein single graft from aorta the \nfirst diagonal coronary artery; reverse saphenous vein graft \nfrom the aorta to the first obtuse marginal coronary; reverse \nsaphenous vein single graft from the aorta to the distal right \ncoronary artery; as well as reverse saphenous vein single graft \nfrom the aorta to the posterior descending coronary artery.\n2. Procedures endoscopic left and right greater saphenous vein \nharvesting.\n\n \nHistory of Present Illness:\n___ year old male reports a longstanding history of intermittent \nchest pain occurring primarily related to stress and not related \nto activity. He reports having this on a weekly basis for years \nand states that over the last month, it has been occurring on a \ndaily basis, which he relates to increased stress in his life. \nHe denies any chest pain occurring with activity but does not \nexercise on a regular basis. He reports having stress tests \nevery ___ years for many years and they have always been normal up \nuntil this one. Due to the abnormalities on the stress test, the \npatient has now been referred for cardiac catheterization. He is \nnow being referred to cardiac surgery for revascularization \nafter finding coronary artery disease upon cardiac \ncatheterization.\n \nPast Medical History:\nDiphtheria as a child; gravely ill \nHypertension\nHyperlipidemia\nGout \nSleep study-does not use CPAP\nTIA- pt states doctor told him he did but he has no recollection \nof any history of this.\ns/p Appendectomy\ns/p left cataract surgery and retinal surgery\n \nSocial History:\n___\nFamily History:\nPremature coronary artery disease- father had heart disease that \nbegan at age ___. Died at age ___.\n \nPhysical Exam:\nPulse:68 Resp:20  O2 sat: 100/RA\nB/P  Right:149/74    Left: 148/81\nHeight:5'5\"     Weight:160 lbs\n\nGeneral: AAOx 3 in NAD, pleasant\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI [x]\nNeck:  Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [x]  Irregular []  Murmur [] grade ______ \nAbdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds\n+ [x]\nExtremities: Warm [x], well-perfused [x]  Edema [] _____\nVaricosities: None [x]\nNeuro: Grossly intact [x]\nPulses:\nFemoral      Right:2+   Left:2+\nDP           Right:2+  Left:2+\n___           Right:2+   Left:2+\nRadial       Right:band in place   Left:2+\n\nCarotid Bruit        Right:none    Left:none\n \nPertinent Results:\n___ Cardiac cath: 1. Selective coronary angiography of this \nright dominant system \ndemonstrated three vessel coronary artery disease.  The LMCA had \nsome \nminimal disease.  The LAD was notable for 90% stenosis of the \nmid-LAD, \nand 90% of the distal LAD.  The mid-LCx had a 90% stenosis.  The \nRCA had \na 40% lesion proximally, and a 90% stenosis in the proximal PDA. \n\n2. Limited resting hemodynamics revealed a moderately elevated \nsystolic \narterial pressure, with a central aortic pressure of 154/80, \nmean 89 \nmmHg. \n\n___ Carotid U/S: Minimal bilateral ICA plaque, no \nappreciable associated stenosis, however (graded as less than \n40% bilaterally). \n\n___ Echo: Pre-CPB: No spontaneous echo contrast is seen in \nthe left atrial appendage. Overall left ventricular systolic \nfunction is mildly depressed (LVEF= 40 - 45 %). There is \nhypokinesis of the basal infero- and anterior septum. There is \nakinesis of the apex. Right ventricular chamber size and free \nwall motion are normal. The descending thoracic aorta is mildly \ndilated. There are simple atheroma in the descending thoracic \naorta. The aortic valve leaflets (3) appear structurally normal \nwith good leaflet excursion and no aortic stenosis or aortic \nregurgitation. The mitral valve leaflets are mildly thickened. \nMild (1+) mitral regurgitation is seen. There is no pericardial \neffusion.\nPost-CPB: The patient is in SR, on no inotropes. Preserved \nbiventricular systolic fxn, with EF now 45 - 50%. 1+ MR, no AI. \nAorta intact.\n \nBrief Hospital Course:\nBriefly, this is a ___ yo male with hypertension and dyslipidemia \ncomplaining of chronic chest pain and s/p abnormal stress test. \nCardiac catheterization showed multivessel disease. He was  \nbrought to the operating room on ___ where the patient \nunderwent  Urgent coronary artery bypass grafting times 5 with \nleft    internal mammary artery to left anterior descending \ncoronary; reverse saphenous vein single graft from aorta the \nfirst diagonal coronary artery; reverse saphenous vein graft \nfrom the aorta to the first obtuse marginal coronary; reverse \nsaphenous vein single graft from the aorta to the distal right \ncoronary artery; as well as reverse saphenous vein single graft \nfrom the aorta to the posterior descending coronary artery,and \nendoscopic left and right greater saphenousvein harvesting.\n\nOverall the patient tolerated the procedure well and \npost-operatively was transferred to the CVICU in stable \ncondition for recovery and invasive monitoring.   POD #1 found \nthe patient extubated, alert and oriented and breathing \ncomfortably.  The patient was neurologically intact and \nhemodynamically stable on no inotropic or vasopressor support.  \nBeta blocker was initiated and the patient was gently diuresed \ntoward the preoperative weight.  The patient was transferred to \nthe telemetry floor for further recovery.  Chest tubes and \npacing wires were discontinued without complication.  The \npatient was evaluated by the physical therapy service for \nassistance with strength and mobility.  By the time of discharge \non POD #4 the patient was ambulating freely, the wound was \nhealing and pain was controlled with oral analgesics.  The \npatient was discharged home in good condition with appropriate \nfollow up instructions.\n\n \nMedications on Admission:\nAMLODIPINE  2.5 mg Tablet - 1 Tablet by mouth daily\nSTUGEROM  Dosage uncertain\nASPIRIN  81 mg Tablet, Chewable - 1 Tablet by mouth daily\nBEE POLLEN Dosage uncertain\nGARLIC [GARLIC-X]  Dosage uncertain\nMV-FA-CA-FE-MIN-LYCOPEN-LUTEIN [CENTRUM] 400 mcg-162 mg-18 \nmg-300\nmcg-250 mcg Tablet - 1 Tablet by mouth once a day\nOMEGA 3-DHA-EPA-FISH OIL [FISH OIL] 900 mg (253 mg-647 mg)-1,400\nmg Capsule, Delayed Release(E.C.) - 1 Capsule by mouth three\ntimes a day\n \nDischarge Medications:\n1. DME\nStandard Wheelchair\nDx: Coronary Artery Disease\ns/p CABG x 5 on ___\nchronic systolic heart failure\n2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 \ntimes a day).  \n3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) \nTablet, Delayed Release (E.C.) PO DAILY (Daily).\nDisp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*\n4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 \ntimes a day) for 2 weeks.\nDisp:*28 Tablet(s)* Refills:*0*\n5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: \ntake 400mg daily until ___ then 200mg daily ongoing.\nDisp:*60 Tablet(s)* Refills:*2*\n6. omega-3 fatty acids     Capsule Sig: One (1) Capsule PO BID \n(2 times a day).  \n7. furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for \n7 days.\nDisp:*14 Tablet(s)* Refills:*0*\n8. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY \n(Daily).\nDisp:*30 Tablet(s)* Refills:*2*\n9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every \n4 hours) as needed for pain/fever.  \n10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO \nthree times a day.\nDisp:*90 Tablet(s)* Refills:*2*\n11. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every \n4 hours) as needed for pain.\nDisp:*65 Tablet(s)* Refills:*0*\n12. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H \n(every 12 hours) for 7 days.\nDisp:*14 Packet(s)* Refills:*0*\n13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) \nML PO HS (at bedtime) as needed for constipation.  \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary artery disease s/p Coronary artery bypass graft x 5\nPast medical history:\nDiphtheria as a child; gravely ill \nHypertension\nHyperlipidemia\nGout \nSleep study-does not use CPAP\nTIA- pt states doctor told him he did but he has no recollection \nof any history of this.\ns/p Appendectomy\ns/p left cataract surgery and retinal surgery\n \nDischarge Condition:\nAlert and oriented x3 nonfocal \nAmbulating with steady gait\nIncisional pain managed with oral analgesics\nIncisions: \nSternal - healing well, no erythema or drainage \nLeg Right and Left - healing well, no erythema or drainage.\nEdema trace to 1+\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming until cleared by surgeon. Look at \nyour incisions daily for redness or drainage\nPlease NO lotions, cream, powder, or ointments to incisions \nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart \n\nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive \nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns ___\n\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n\n\n[DISCHARGE]  \nName:  ___              Unit No:   ___\n \nAdmission Date:  ___              Discharge Date:   ___\n \nDate of Birth:  ___             Sex:   M\n \nService: MEDICINE\n \nAllergies: \nLidocaine\n \nAttending: ___.\n \nChief Complaint:\nDyspnea, leg edema  \n\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nThis is a ___ gentleman with a history of 5 vessel CABG \nin ___ and hypertension presenting with one week of of \nworsening shortness of breath and lower extremity swelling.  \nPatient and his wife state that he began to notice facial and \nhand swelling upon returning from a trip to ___ one week \nago. He took his BP on a home cuff, was systolic 160s. He called \nhis PCP, who phoned in a prescription for amlodipine.  Since \nstarting the amlodipine, he has noticed increasing lower \nextremity swelling, mild improvement in the facial and hand \nswelling. Since ___ he has also had both orthopnea (new per \nwife's report) and more SOB with walking. He denies any \nfevers/chills, cough, chest pain. He also has not had a bowel \nmovement since ___, and has noted diffuse abdominal \ndiscomfort.  \nOf note, patient had been prescribed metoprolol, lisinopril, and \natorvastatin after his CABG. He has not taken any of these \nmedications in the last several months.  \n \nIn the ED, initial vitals were 98.7 104 147/77 24 100%. Labs \nwere notable for a BNP of 262, Cr 1.6 (last 1.5 in ___, \ntroponin < .01, negative D dimer. CXR was unremarkable. ECG \nunchanged from prior. The patient received aspirin and was sent \nto the floor. Vitals on transfer were 98.5, 151/77, 100, 18, \n96%ra.\n \nPast Medical History:\nMEDICAL & SURGICAL HISTORY: (per OMR)  \nCARDIAC HISTORY:  \n___ Cardiac cath  \n___ s/p urgent CABG x5  \n- LIMA to LAD; reverse saphenous vein from aorta to first diag; \nreverse SVG from aorta to first obtuse marginal; reverse; SVG \nfrom aorta to distal RCA; reverse SVG from aorta to PDA  \n \nOTHER PMH:  \nDiphtheria as a child; gravely ill  \nHypertension  \nHyperlipidemia  \nGout  \nSleep study-does not use CPAP  \nTIA- pt states doctor told him he did but he has no recollection \n \nof any history of this.  \ns/p Appendectomy  \ns/p left cataract surgery and retinal surgery\n \nSocial History:\n___\nFamily History:\nPremature coronary artery disease- father had heart disease that \nbegan at age ___. Died at age ___.\n \nPhysical Exam:\nAdmission Exam:\nVitals - 98.4 146/60 102 20 95% RA  \nGENERAL: Pleasant, well appearing in NAD  \nHEENT: Normocephalic, atraumatic. No conjunctival pallor. No \nscleral icterus. MMM. OP clear. Neck Supple, No LAD, No \nthyromegaly.  \nCARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, \nrubs or ___. JVP= just at clavicle at 90 degrees  \nLUNGS: CTAB, good air movement biaterally.  \nABDOMEN: NABS. Soft, mildly tender diffusely, mildly distended. \nNo HSM  \nEXTREMITIES: 1+ pitting edema bilaterally  \nSKIN: No rashes/lesions, ecchymoses.  \nPSYCH: Listens and responds to questions appropriately, pleasant\n \nPertinent Results:\n___ 11:48PM   GLUCOSE-122* UREA N-31* CREAT-1.6* SODIUM-138 \nPOTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16\n___ 11:54PM   LACTATE-1.7\n___ 11:48PM   WBC-7.6 RBC-4.30* HGB-12.0* HCT-36.1* MCV-84 \nMCH-28.0 MCHC-33.3 RDW-14.2\n___ 11:48PM   PLT COUNT-233\n___ 11:48PM   NEUTS-62.0 ___ MONOS-9.0 EOS-2.3 \nBASOS-1.2\n___ 11:48PM   D-DIMER-335\n___ 11:48PM   proBNP-262*\n___ 11:48PM   cTropnT-<0.01\n___ 11:48PM   ALT(SGPT)-28 AST(SGOT)-27 ALK PHOS-47 TOT \nBILI-0.3\n___ 11:48PM   LIPASE-32\n___ 06:19AM   GLUCOSE-99 UREA N-26* CREAT-1.2 SODIUM-138 \nPOTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14\n___ 06:19AM   WBC-6.6 RBC-4.17* HGB-11.6* HCT-35.1* MCV-84 \nMCH-27.7 MCHC-33.0 RDW-13.9\n___ 06:19AM   TSH-3.9\n___ 06:19AM   CALCIUM-8.8 PHOSPHATE-2.9 MAGNESIUM-2.0\n___ 06:19AM   CK-MB-2 cTropnT-<0.01\n___ 06:43AM URINE  HOURS-RANDOM UREA N-566 CREAT-62 \nSODIUM-121 POTASSIUM-38 CHLORIDE-105 TOT PROT-8 PROT/CREA-0.1\n___ 06:43AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n.\n___\nCHEST, PA AND LATERAL:  The lungs are clear.  Changes of median \nsternotomy, with mediastinal clips and coronary artery bypass \ngrafting.  Heart size is top normal.  There are no pleural \neffusions or pneumothorax.  IMPRESSION:  No acute \ncardiopulmonary process.  CABG changes.  The study and the \nreport were reviewed by the staff radiologist.\n.\n___\nThe left atrium is mildly dilated. Left ventricular wall \nthicknesses and cavity size are normal. There is mild regional \nleft ventricular systolic dysfunction with mid- and distal \nseptal hypokinesis. The remaining segments contract normally \n(LVEF = 45%). Right ventricular chamber size and free wall \nmotion are normal. The diameters of aorta at the sinus, \nascending and arch levels are normal. There is no aortic valve \nstenosis. No aortic regurgitation is seen. The mitral valve \nleaflets are mildly thickened. Mild (1+) mitral regurgitation is \nseen. The estimated pulmonary artery systolic pressure is \nnormal. There is no pericardial effusion. \n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, \nc/w CAD. Mild mitral regurgitation.\n\nCompared with the prior study (images reviewed) of ___, \nthe findings are similar.\n \nBrief Hospital Course:\nMr. ___ is a ___ year old male with a history of 5 vessel \nCABG and hypertension presenting with mild increased lower \nextremity and hand swelling and shortness of breath for the last \nweek.  \n.\n#  SWELLING AND SHORTNESS OF BREATH:  Shortness of breath is \nmost likely due to a mild CHF exacerbation, and the swelling is \neither from CHF or amlodipine.  Patient's EKG showed LBBB and \nwas unchanged from prior.  ECHO did not show significant change \nfrom prior in ___ (EF = 45%).  Patient continued to have 1+ \npitting edema on legs and mild edema on hands but clear lungs \nthroughout his hospital stay. His shortness of breath and \northopnea resolved on HD1. CXR clear. BNP = 262 on admission. \nLFTs, TSH, UA and Ulytes are wnl. His amlodopine was held and \nhis was placed on a low salt diet and restarted on his home \nmetoprolol and lisinopril when creatinine improved from 1.6 on \nadmission to 1.2 on HD1. He received 20 mg furosemide IV 2x and \ndiuresed appropriately. He was discharged on lasix 20mg PO and \nwill get his electrolytes checked in Dr. ___ office on \n___.  Both Dr. ___ his nurse ___ \n___ were made aware of patient's admission.\n.\n#  RENAL FAILURE:  Last Cr of 1.5 in ___, 1.6 on \nadmission but improving to 1.2.  Patient without any electrolyte \nabnormalities. ___ have element of CKD from hypertension, may \nalso be acute on chronic secondary to volume overload.   \n.\n#  SINUS TACHYCARDIA:  Patient with mild sinus tachycardia. EKG \nunchanged from baseline. This was thought to be due to secondary \nto volume overload and subsequent compensatory mechanism.  \nAlternatively this could have been due to beta blocker withdrawl \nsince he has not been taking his metoprolol.  A Ddmier was sent \nin the ED, which was negative. Metoprolol was restarted on HD1 \nwith resolution of tachycardia.\n.\n#  CAD s/p CABG:  Worsening shortness of breath may represent \nworsening CAD; however, given subacute duration of symptoms, \nunlikely to be an acute coronary syndrome.  EKG unchanged from \nprior without new signs of ischemia.  Troponins negative.  \n.\n#  HYPERTENSION: He was initially mildly hypertensive. This \nresolved with restart of metoprol and lisinopril.\n.\n#  ABDOMINAL DISCOMFORT: Likely secondary to constipation. This \nresolved with BMs in HD1. LFts WNL. Exam benign.\n.\nTransitional issues:\n.\n--Please follow up electrolytes ___\n \nMedications on Admission:\n1) lisinopril 20 mg 1 Tablet(s) by mouth daily - NOT TAKING  \n2) metoprolol succinate 25 mg Tablet Extended Release 24 hr 1 \nTablet(s) by mouth once a day - NOT TAKING  \n3) aspirin 81 mg Tablet, Chewable 1 Tablet(s) by mouth daily  \n4) garlic [Garlic-X]  \n5) Centrum 400 mcg-162 mg-18 mg-300 mcg-250 mcg Tablet 1 \nTablet(s) by mouth once a day (Prescribed by Other Provider) \n6) omega 3-dha-epa-fish oil [Fish Oil] 900 mg (253 mg-647 \nmg)-1,400 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by \nmouth three times a day  \n7) Amlodpine 5 mg once a day  \n\n \nDischarge Medications:\n1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\nDisp:*30 Tablet(s)* Refills:*2*\n2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at \nbedtime).\nDisp:*30 Tablet(s)* Refills:*2*\n3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable \nPO DAILY (Daily).\nDisp:*30 Tablet, Chewable(s)* Refills:*2*\n4. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1) \nTablet Extended Release 24 hr PO once a day.\nDisp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*\n5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.\nDisp:*30 Tablet(s)* Refills:*2*\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis: Possible CHF exacerbation, peripheral edema \nsecondary to amlodipine\n\n \nDischarge Condition:\nMental Status: clear and coherent.\nLevel of Conciousness: Alert and interactive.\nActivity Level: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you during your \nhospitalization. You were admitted with shortness of breath and \nswelling in your legs and hands.  Likely, this was due to \nrestarting your Amlodipine as these symptoms are side effects.  \nWe did blood tests and an EKG of your heart, which were normal \ncompaired to your prior tests.  We did an echocardiogram of your \nheart which was similar to a few years ago. \n\nPlease stop taking your home Amlodipine and continue eating a \nlow sodium diet as this will minimize your symptoms.  It is also \nimportant that you take your metoprolol, lisinopril, and \natorvastatin.  Please also take furosemide 20mg by mouth every \nday until your appointment with your primary care doctor, ___. \n___.\n\nPlease follow up with Dr. ___ in the next week. You will be \ncalled at home with the appointment. If you have not heard from \nher office by the end of the week or have questions, please call \n___.\n.\nThe following changes were made to your medications:\n--START taking metoprolol succinate (toprol XL) 25mg every day\n--START taking lisinopril 5mg every day\n--START taking atorvastatin 10mg every day\n--START taking furosemide 10mg every day\n.\nThese medications are VERY important for your heart.  You should \ntake all of your medications as directed.\n.\nReturn to the emergency room if you develop chest pain, \nshortness of breath, worsening swelling, nausea, vomiting, \ndiarrhea, or other concerning signs or symptoms.\n \nFollowup Instructions:\n___\n\n\n[DISCHARGE]  \nName:  ___              Unit No:   ___\n \nAdmission Date:  ___              Discharge Date:   ___\n \nDate of Birth:  ___             Sex:   M\n \nService: NEUROSURGERY\n \nAllergies: \nLidocaine / nitroglycerin\n \nAttending: ___\n \nChief Complaint:\nstatus post fall\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ y/o M on aspirin 81mg presents s/p fall. Patient states\nthat he was trying to reach something when he was trying to\nbalance on a chair. The chair started to rock and he fell\nbackwards striking his head. He reports positive loss of\nconsciousness, but reports only for a short period of time. He\nawoke with pain in the back of his head and then noticed blood.\nHe called his sister who then encouraged him to come to the ED.\nUpon arrival to the ED, a head CT was performed and showed a\nsmall R SDH along the tentorium. \n\nPatient reports pain in the back of his head that radiates up to\nthe top of his head and behind his R eye, ___, but denies any\nn/v, dizziness, changes in vision, dysarthria or weakness. \n\n \nPast Medical History:\nHTN, HLD, gout, CAD, remote history of 5 vessel cabbage,\ndiphtheria, TIA, appendectomy, cataract\n\n \nSocial History:\n___\nFamily History:\nPremature coronary artery disease- father had heart disease that \nbegan at age ___. Died at age ___.\n \nPhysical Exam:\nOn the day of admission ___:\nPHYSICAL EXAM:\nO: T: 99.2 BP: 164/91  HR: 76    R: 16   O2Sats: 100%RA\nGen: WD/WN, comfortable, NAD.\nHEENT: small head lac at occiput, repaired in emergency room \nwith\nstaples\nPupils: 3-2mm bilaterally        EOMs: intact\nNeuro:\nMental status: Awake and alert, cooperative with exam, normal\naffect.\nOrientation: Oriented to person, place, and date.\nRecall: ___ objects at 5 minutes.\nLanguage: Speech fluent with good comprehension and repetition.\nNaming intact. No dysarthria or paraphasic errors.\n\nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, 3 to 2\nmm bilaterally. Visual fields are full to confrontation.\nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Hearing intact to voice.\nIX, X: Palatal elevation symmetrical.\nXI: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\ntremors. Strength full power ___ throughout. No pronator drift\n\nSensation: Intact to light touch\nHandedness Left or Right\n\nOn the day of discharge:\nAwake, alert, oriented x3, MAE full. \n \nPertinent Results:\nRadiology Report CT HEAD W/O CONTRAST Study Date of ___ \n4:23 ___ \nIMPRESSION: \n  \n  \n  \n1. 3 mm acute subdural hematoma layering along the right \ntentorium. \n2. Atrophy and chronic small vessel ischemic disease \n\nRadiology Report CT C-SPINE W/O CONTRAST Study Date of \n___ 4:24 ___\n\n IMPRESSION:  \n  \n1.  No acute fracture. \n2.  Mild multilevel degenerative changes \n\nRadiology Report ELBOW (AP, LAT & OBLIQUE) LEFT Study Date of \n___ 4:49 ___ \n\nIMPRESSION:  \n  \nNo acute fracture or dislocation. \n\nRadiology Report CT HEAD W/O CONTRAST Study Date of ___ \n11:08 AM \n\nIMPRESSION:  \n  \nPreliminary Report1. No significant interval change in right \nsubdural hematoma along tentorium. 2. Enlarged cisterna magna as \nbefore \n\n \nBrief Hospital Course:\nThis is a ___ year old man who was status post mechanical fall on \n___ patient presented to the ED and had a small occipital \nscalp laceration that was repaired with staples.  A NCHCT was \nperformed which revealeda small R SDH along the tentorium. The \npatient was evaluated by neurosurgery and was admitted to there \nservice. The patient was assessed every 4 hours with a \nneurological exam.  The patient was consistently neurologically \nintact.  \n\nOn ___, The patient continued with mild headache .  The patient \nwas neurlogically intact on exam.  The patient stated that he \ndid not feel comfortable going home today given that he lives \nalone.  The patient was evaluated by occupational therapy to \nassess for home safety.  The patient was cleared for home, \nhowever then patient was found to be hypertensive in the evening \nto the 170s with activity.  The patient stated that he takes  \nnorvasc at home and this was restarted.  The patient remained in \nthe hospital for hypertension.  Once started on his home meds, \nhis BP was WNL. He was discharged home on ___.\n\n \nMedications on Admission:\nAmlodipine 5mg QD\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN pain \n2. Amlodipine 5 mg PO DAILY \n3. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*20 Tablet Refills:*0\n4. Docusate Sodium 100 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSubdural Hematoma\nScalp laceration\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDischarge Instructions\nBrain Hemorrhage without Surgery\n\nActivity\n·    There are staples at back of head from a head laceration \nthat were placed in Emergency Department on day of admission \n___. Staples should be removed at the primary care office or \nNeurosurgery Office in 7 days.\n\n·    We recommend that you avoid heavy lifting, running, \nclimbing, or other strenuous exercise until your follow-up \nappointment.\n\n·     You make take leisurely walks and slowly increase your \nactivity at your own pace once you are symptom free at rest. \n___ try to do too much all at once.\n\n·     No driving while taking any narcotic or sedating \nmedication. \n\n·     If you experienced a seizure while admitted, you are NOT \nallowed to drive by law. \n\n·     No contact sports until cleared by your neurosurgeon. You \nshould avoid contact sports for 6 months. \n\nMedications\n·     You may resume taking Aspirin 81 mg on ___. Avoid \ntaking any other blood thinning medications (Plavix, Coumadin, \nibuprofen) until after follow-up with your Neurosurgeon.  \n\n·     You may use Acetaminophen (Tylenol) for minor discomfort \nif you are not otherwise restricted from taking this medication.\n\n \n\n \n\nWhat You ___ Experience:\n\n·     You may have difficulty paying attention, concentrating, \nand remembering new information.\n\n·     Emotional and/or behavioral difficulties are common. \n\n·     Feeling more tired, restlessness, irritability, and mood \nswings are also common.\n\n·     Constipation is common. Be sure to drink plenty of fluids \nand eat a high-fiber diet. If you are taking narcotics \n(prescription pain medications), try an over-the-counter stool \nsoftener.\n\n \n\nHeadaches:\n\n·     Headache is one of the most common symptom after a brain \nbleed. \n\n·     Most headaches are not dangerous but you should call your \ndoctor if the headache gets worse, develop arm or leg weakness, \nincreased sleepiness, and/or have nausea or vomiting with a \nheadache. \n\n·     Mild pain medications may be helpful with these headaches \nbut avoid taking pain medications on a daily basis unless \nprescribed by your doctor. \n\n·     There are other things that can be done to help with your \nheadaches: avoid caffeine, get enough sleep, daily exercise, \nrelaxation/ meditation, massage, acupuncture, heat or ice packs. \n\n\n \nWhen to Call Your Doctor at ___ for:\n\n·     Severe pain, swelling, redness or drainage from the \nincision site. \n\n·     Fever greater than 101.5 degrees Fahrenheit\n\n·     Nausea and/or vomiting\n\n·     Extreme sleepiness and not being able to stay awake\n\n·     Severe headaches not relieved by pain relievers\n\n·     Seizures\n\n·     Any new problems with your vision or ability to speak\n\n·     Weakness or changes in sensation in your face, arms, or \nleg\n\n \n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n\n·     Sudden numbness or weakness in the face, arm, or leg\n\n·     Sudden confusion or trouble speaking or understanding\n\n·     Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n\n·     Sudden severe headaches with no known reason\n\n \nFollowup Instructions:\n___\n\n\n[DISCHARGE]  \nName:  ___              Unit No:   ___\n \nAdmission Date:  ___              Discharge Date:   ___\n \nDate of Birth:  ___             Sex:   M\n \nService: MEDICINE\n \nAllergies: \nLidocaine / nitroglycerin\n \nAttending: ___\n \nChief Complaint:\nchest pain\n \nMajor Surgical or Invasive Procedure:\nNone this hospitalization.\n\n \nHistory of Present Illness:\nThis is a ___ with a history of CAD s/p CABG ___ \n(___-LAD,SVG-D1, SVG -OM1, SVG-distal RCA, SVG-PDA), post-op \nAF, HTN, HLD, CVA, who presented with chest pain.  \n\nPer report, the patient awoke with chest pain around 3am. It was \nsharp, left sided, constant, pleuritic and non-radiating. \nAssociated with nausea and vomiting x1 and a headache but no \nshortness of breath. The pain resolved while he was in the ___ \nwaiting room. He also reportedly had RUQ pain that also \nself-resolved.  \n\n- In the ED initial vitals were: pain 8 97.6 70 ___ \nRA.\n- EKG: SR LBBB  \nLabs/studies notable for: Troponin x2 negative, lactate 3.7 --> \n1.5 after 500cc NS, D-dimer 337, WBC 10.3, Hgb 12.8, Hct 38.7, \nPlt 237, Na 136, K 4.3, Cl 99, HCO3 26, BUN 16, Cr 1.0.\n- Imaging showed: CT head with no acute intracranial process and \nCXR with no acute cardiopulmonary process.\n- Stress test: Reversible, small, mild perfusion defect \ninvolving the LCx territory, new since ___. Normal left \nventricular cavity size and systolic function.  \n- Patient was given: Aspirn 324mg, Tylenol ___, Aspirin 81mg, \nTylenol 1g, and 500cc NS.\n- Vitals on transfer: 97.6 65 126/82 19 98% RA.\n  \nOn the floor, patient reports feeling well. He has no complaints \nand denies chest pain or headache. \n \n \nPast Medical History:\n- CAD, s/p CABG ___ (___, SVG-D1, SVG -OM1, \nSVG-distal RCA, SVG-PDA).  \n- HTN  \n- HLD  \n- gout  \n- post op AFib  \n- diphtheria  \n- TIA  \n- appendectomy  \n- cataract  \n \nSocial History:\n___\nFamily History:\nPremature coronary artery disease- father had heart disease that \nbegan at age ___. Died at age ___.\n \nPhysical Exam:\nADMISSIOn PHYSICAL EXAM:  \nVS: T97,.8 BP140/89 HR68 RR18 95%RA 73.6kg  \nGENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.  \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa.  \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, \nlifts. Midline ternal scar well healed  \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi.  \nABDOMEN: Soft, NTND. No HSM or tenderness.  \nEXTREMITIES: No c/c/e. No femoral bruits.  \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.  \nPULSES: Distal pulses palpable and symmetric \n\nDISCHARGE PHYSICAL EXAM:  \nVS: 97.9 ___ 18 95-98%RA \nGENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.  \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa.\nNECK: Supple JVP 7\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, \nlifts. Midline sternal scar. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi.  \nABDOMEN: Soft, NTND. No HSM or tenderness.  \nEXTREMITIES: No c/c/e. No femoral bruits.  \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.  \nPULSES: Distal pulses palpable and symmetric \n \nPertinent Results:\nADMISSION LABS\n___ 06:40AM BLOOD WBC-5.6 RBC-4.23* Hgb-11.9* Hct-36.4* \nMCV-86 MCH-28.1 MCHC-32.7 RDW-14.9 RDWSD-46.7* Plt ___\n___ 06:40AM BLOOD Glucose-103* UreaN-19 Creat-1.1 Na-139 \nK-4.4 Cl-103 HCO3-26 AnGap-14\n___ 06:40AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.0\n\nPERTINENT LABS\n___ 08:35PM BLOOD Lactate-3.7*\n___ 06:16AM BLOOD Lactate-1.5\n___ 01:55PM BLOOD D-Dimer-334\n___ 01:55PM BLOOD cTropnT-<0.01\n___ 08:17PM BLOOD cTropnT-<0.01\n\nDISCHARGE LABS\nDischarged day of admission\n\nSTUDIES\nCXR ___\nNo acute cardiopulmonary process.\n\nCT head ___\nNo acute intracranial abnormality.\n\nCardiac perfusion study ___\nThe image quality is adequate but limited due to soft tissue \nattenuation.  \nLeft ventricular cavity size is normal.   \nRest and stress perfusion images reveal a reversible, mild \nreduction in photon counts involving the basal anterolateral \nwall. \nGated images reveal septal akinesis with normal thickening, \nconsistent with prior cardiac surgery.  \nThe calculated left ventricular ejection fraction is 52% with an \nEDV of 92 ml.\nIMPRESSION:\n1. Reversible, small, mild perfusion defect involving the LCx \nterritory.\n2. Normal left ventricular cavity size and systolic function. \nCompared to the prior study of ___, the perfusion defect \nis new. \n\n \nBrief Hospital Course:\nThis is a ___ with a history of CAD s/p CABG ___ \n(LIMA-LAD,SVG-D1, SVG -OM1, SVG-distal RCA, SVG-PDA), post-op \nAF, HTN, HLD, CVA, who presented with chest pain.\n\n# Chest pain/Coronary artery disease: Patient initially came in \nfor headache but reported sharp stabbing left sided chest pain \nlasting about 8 hours (0400-1200 on ___. Felt similar to \nprior angina except did not resolve. CP resolved spontaneously \nwithout intervention. In ED ECG unchanged, troponin negative x2. \nHe underwent nuclear stress test which showed new small \nreversible defect in LCx territory not seen in ___ study. \nAdmitted for consideration for cath. Cath was deferred as \ninpatient and medical management was optimized. Of note patient \nwas taking only ASA ___ x/week and amlodipine prn SBP > 160. \nAfter extensive discussion he was started on metoprolol XL 25 mg \ndaily, pravastatin 40 mg daily, and encouraged to take \namlodipine and ASA daily. He will follow up with PCP and \noutpatient cardiologist.\n\n# Headache: Mild right sided headache. Similar to previous \npresentation with ___ s/p fall in ___. CT head unremarkable \nand headache responsive to Tylenol. No further intervention \nhere.\n\n# Hypertension: Continued home amlodipine and started metoprolol \nas above.\n\n# Code: FULL\n# CONTACT: ___, sister ___\n\n# TRANSITIONAL ISSUES:\n[]Patient not taking many medications; please enforce importance \nof them given extensive CAD.\n[]Started amlodipine 5 mg, pravastatin 20 mg, metoprolol XL 25 \nmg daily.\n[]Please follow-up pending blood culture from ___.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. coenzyme Q10 30 mg oral DAILY \n3. bee pollen 550 mg oral DAILY \n4. garlic 1 mg oral DAILY \n5. Multivitamins 1 TAB PO DAILY \n6. Niacin 500 mg PO DAILY \n7. Amlodipine 5 mg PO DAILY \n8. Fish Oil (Omega 3) 1000 mg PO DAILY \n9. Fenofibrate 145 mg PO DAILY \n\n \nDischarge Medications:\n1. Amlodipine 5 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Metoprolol Succinate XL 25 mg PO DAILY \nRX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0\n4. Pravastatin 40 mg PO QPM \nRX *pravastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n5. bee pollen 550 mg oral DAILY \n6. coenzyme Q10 30 mg oral DAILY \n7. Fenofibrate 145 mg PO DAILY \n8. Fish Oil (Omega 3) 1000 mg PO DAILY \n9. garlic 1 mg oral DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Niacin 500 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary\nChest pain\n\nSecondary \nCoronary artery disease s/p CABG\nHeadache\nHypertension\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to the hospital because in addition to your \nheadache you also had chest pain. Your chest pain resolved on \nits own. A cardiac stress test showed a small area concerning \nfor worsening of your coronary artery disease. You were \nconsidered for repeat catheterization of your blood vessels; \nhowever ultimately it was decided not to do this.\n\nAs discussed with you we would strongly recommend taking your \nheart medications. Please take your amlodipine every single day. \nWe are also giving you a medication called metoprolol and \npravastatin, which are very important medications for people \nwith coronary artery disease.\n\nWe are setting up an appointment for you with your PCP and with \nyour cardiologist. \n\nIt was a pleasure taking care of you during your stay in the \nhospital.\n\n- Your ___ Team\n \nFollowup Instructions:\n___\n\n\n[DISCHARGE]  \nName:  ___              Unit No:   ___\n \nAdmission Date:  ___              Discharge Date:   ___\n \nDate of Birth:  ___             Sex:   M\n \nService: MEDICINE\n \nAllergies: \nLidocaine / nitroglycerin\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nNone\n\nattach\n \nPertinent Results:\nLABS:\n==============\n___ 06:10AM BLOOD WBC-34.8* RBC-2.36* Hgb-6.7* Hct-21.5* \nMCV-91 MCH-28.4 MCHC-31.2* RDW-18.2* RDWSD-59.7* Plt ___\n___ 09:00AM BLOOD WBC-31.3* RBC-2.57* Hgb-7.2* Hct-23.1* \nMCV-90 MCH-28.0 MCHC-31.2* RDW-18.2* RDWSD-59.3* Plt ___\n___ 08:45PM BLOOD WBC-19.8* RBC-2.67* Hgb-7.4* Hct-23.9* \nMCV-90 MCH-27.7 MCHC-31.0* RDW-19.4* RDWSD-63.6* Plt ___\n___ 07:52AM BLOOD ___ PTT-31.8 ___\n___ 06:10AM BLOOD Glucose-137* UreaN-18 Creat-0.8 Na-129* \nK-5.7* Cl-92* HCO3-20* AnGap-17\n* UreaN-17 Creat-0.8 Na-136 K-5.2 Cl-98 HCO3-23 AnGap-15\n___ 08:45PM BLOOD Glucose-110* UreaN-19 Creat-0.8 Na-134* \nK-4.7 Cl-98 HCO3-23 AnGap-13\n___ 09:00AM BLOOD ALT-9 AST-12 LD(LDH)-197 AlkPhos-64 \nTotBili-0.6\n___ 03:00PM BLOOD ALT-12 AST-16 LD(LDH)-245 AlkPhos-80 \nTotBili-0.5\n___ 10:50AM BLOOD cTropnT-<0.01\n___ 03:00PM BLOOD cTropnT-0.01\n___ 06:40AM BLOOD CK-MB-1 cTropnT-0.02*\n___ 08:45PM BLOOD cTropnT-0.01 proBNP-2742*\n___ 06:10AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9\n___ 09:00AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.7\n___ 06:10AM BLOOD TotProt-6.7 Albumin-3.3* Globuln-3.4 \nCalcium-8.3* Phos-2.8 Mg-1.9\n___ 03:00PM BLOOD Iron-44*\n___ 08:45PM BLOOD Cholest-98\n___ 03:00PM BLOOD calTIBC-259* VitB12-665 Ferritn-870* \nTRF-199*\n___ 03:02AM BLOOD %HbA1c-5.7 eAG-117\n___ 08:45PM BLOOD Triglyc-64 HDL-30* CHOL/HD-3.3 LDLcalc-55\n___ 05:53PM BLOOD Osmolal-273*\n___ 11:07AM BLOOD ___ pO2-53* pCO2-36 pH-7.40 \ncalTCO2-23 Base XS--1 Comment-GREEN TOP\n___ 09:24AM BLOOD ___ pO2-49* pCO2-36 pH-7.41 \ncalTCO2-24 Base XS-0 Comment-GREEN TOP \n___ 11:21PM URINE Color-Straw Appear-CLEAR Sp ___\n___ 11:21PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG\n___ 12:45PM URINE Hours-RANDOM Na-48\n___ 12:45PM URINE Osmolal-586\n\nMICRO:\n==================\n________________________________________________________\n___ 9:44 am MRSA SCREEN      Source: Nasal swab. \n\n                            **FINAL REPORT ___\n\n   MRSA SCREEN (Final ___:    No MRSA isolated. \n__________________________________________________________\n___ 6:40 pm BLOOD CULTURE\n\n                            **FINAL REPORT ___\n\n   Blood Culture, Routine (Final ___:    NO GROWTH. \n__________________________________________________________\nTime Taken Not Noted     Log-In Date/Time: ___ 7:03 pm\n      BLOOD CULTURE      Source: Venipuncture. \n\n                            **FINAL REPORT ___\n\n   Blood Culture, Routine (Final ___:    NO GROWTH. \n\nTime Taken Not Noted     Log-In Date/Time: ___ 7:03 pm\n      BLOOD CULTURE      Source: Venipuncture. \n\n                            **FINAL REPORT ___\n\n   Blood Culture, Routine (Final ___:    NO GROWTH. \n\n___ 3:05 pm BLOOD CULTURE      2 OF 2. \n\n                            **FINAL REPORT ___\n\n   Blood Culture, Routine (Final ___:    NO GROWTH.\n\n___ 3:00 pm BLOOD CULTURE\n\n                            **FINAL REPORT ___\n\n   Blood Culture, Routine (Final ___:    NO GROWTH. \n\n___ 11:21 pm URINE\n\n                            **FINAL REPORT ___\n\n   URINE CULTURE (Final ___:    < 10,000 CFU/mL. \n\nRADIOLOGY:\n================\nCXR (___):\n\nMild pulmonary edema.  Although there is no definite focal \nconsolidation, \nsuperimposed infection cannot be excluded. \n\nBilat Femur X-ray (___):\n\nMultiple lytic lesions are seen involving both femurs left \ngreater than right \nconsistent with known metastasis.  There is permeative  lesion \ninvolving the \nleft proximal fibula.  Which represents patient's known \nangiosarcoma.  Bone \nmineralization is preserved.  Mild degenerative changes \ninvolving both hip \njoints.  Multiple lytic lesions involving the pelvic bones. \n\nCXR (___):\n\nConsolidative opacity in the left upper lobe has worsened and \nmost likely \nrepresents an evolving pneumonia.  Patchy opacity in the right \nmidlung has \nimproved.  Cardiomediastinal silhouette is stable.  No pleural \neffusions.  No \npneumothorax \n\nCTA Chest (___):\n\n1. No evidence of pulmonary embolism or aortic abnormality. \n2. Numerous new solid pulmonary nodules with surrounding \nground-glass halo \nranging up to 2.9 cm are concerning for diffuse pulmonary \nmetastasis \n(hemorrhagic metastasis).  In the differential diagnosis \nconsider angio \ninvasive fungal infection. \n3. Suspected multilobar pneumonia. \n4. Interstitial edema, small left and trace right pleural \neffusion. \n5.  Reference is made to CT abdomen report of study done on the \nsame day for \nabdominal findings. \n\nCT Abdomen/Pelvis (___):\n\n1. Evaluation for GI bleed is limited in the setting of oral \ncontrast \nadministration and with a single phase study.  Within this \nlimitation no \ndefinite GI bleed. If there is persistent concern/high pretest \nprobability for \nactive gastrointestinal bleeding recommend multiphase CT abdomen \nand pelvis \nfollowing passage of oral contrast. \n2. No acute intra-abdominal abnormality.  No free \nintra-abdominal air. \n3. Cholelithiasis without evidence of acute cholecystitis. \n4. 2 new enhancing soft tissue lesions in the right gluteus \nmaximus highly \nsuggestive of metastatic disease and new compared to prior \nstudies. \n5. Numerous aggressive osseous lytic lesions, similar to prior, \nwith mild \nprogressive height loss of the mid L4 vertebral body. \n6.  For chest findings reference is made to CT chest report of \nthe same day \n\nSTUDIES\n================\nEKG: ___: Sinus tachycardia with occasional PVCs and QTc of 518\n \nBrief Hospital Course:\nSUMMARY:\n \n========\n \n___ with PMH metastatic angiosarcoma on paclitaxel and formerly \non TKI, CAD s/p CABG (5v, ___, severe PAD c/b non-occlusive \naortic thrombus (___) on apixaban, EVAR (___), and \nmultiple vascular interventions ___, who p/w subacutely \nprogressive CP iso recent EF drop, also with slightly worsened \nanemia. He was initially treated with IV diuresis, stopped due \nto worsening hyponatremia. His DOAC was held in the setting of \nhis lower GIB. A CXR was read as consistent with pneumonia, and \nhe was started on broad spectrum antibiotics for a HAP. \nUltimately, a CT torso was obtained that showed markedly \nworsening metastatic disease -- including the lungs (more likely \nthan PNA), and in the colon, the likely cause of his bleed. \nNumerous family meetings were had, with patient, sister, PCP, \n___. The patient will discharge to rehabilitation; if \nhe is able to regain any functional ability, may be a candidate \nfor further palliative chemotherapy. His DOAC was held on \ndischarge after discussion with his oncologist. \n \nACUTE ISSUES:\n \n=============\n \n#Goals of Care\n \n#Worsening metastatic cancer\n \nFamily meeting on ___. Goals of care include getting as much \nphysical therapy as possible and following up with Dr. ___ \nat ___ to decide if further chemotherapy is a possibility. His \ncancer has advanced significantly since ___ and he has not \nbeen well enough to receive treatment. We have noted to his \nfamily that because of his poor functional status that it is \nvery possible that he will not be a candidate for chemotherapy, \nand that his poor functional status indicates a poor prognosis \ngoing forward. In addition, we are concerned that his bony pain, \nhemoptysis, tachycardia, and GI bleeding are all related to his \ncancer. He is not interested in increasing pain medications at \nthis time. Of note, the patient declined multiple interventions \n(such as colonoscopy) and imaging studies (such as an MRI of his \nspine), and was intermittently declining care in the hospital. \n \n\n#METASTATIC ANGIOSARCOMA\n \nDx ___, followed at ___ with Dr. ___. Was on TKI \n(pazopanib) but progressed with known pulm and bone mets, so \nswitched to paclitaxel ___ (last ___, planned for q1wk but \non hold given active medical issues as above). E-mailed \noncologist Dr. ___ admission, discussed plan for \nfollow-up. Pall care consulted for recs for GOC and pain, \nalthough patient was reluctant to discuss with pall care. His \ndisease has advanced significantly. He has follow up on ___. \n\n#Constipation\n \nNo BM in 4 days. Previously on Miralax and Senna. Doubled senna \ndosage and gave milk of magnesia on ___. Please ensure he has \na bowel movement. \n \n#Tachycardia\n \nTachycardia to 110's and low 120's. DDx: Anemia vs. worsening \nmalignancy. EKG with sinus tachycardia and no other acute \nchanges or signs of MI. Not hypoxemic. CTA negative for PE on \n___. Improvement possible with transfusion on morning of ___. \nFurther evaluation would also not be within goals of care as \npatient would like to be discharged as soon as possible. \n\n \n#CONCERN FOR DECOMPENSATED HEART FAILURE\n \n#CARDIOMYOPATHY\n \n#CAD s/p CABG (___)\n \nP/w chest pain, has extensive CAD history, initially c/f \nunstable angina in ED. Recent MIBI at ___ (___) without e/o \nischemia, however formal ___ TTE did show EF40% from 50% in \n___. Currently CP free, ECG without changes, and trop 0.01 \nx2. However, BNP elevated at 2,742 - review of OSH records shows \nBNP 169 (___) -> 861 (___) -> 2,859 (___). Last value \nappears to be iso syncopal episode for which he presented to ___ \nED but left AMA with resolution of sx thereafter. Did not f/u \nwith cardiologist afterwards as directed. Constellation of sx \nmost c/f chemotherapy induced cardiomyopathy especially given \nchange in EF after initiation of paclitaxel in ___, though \ncould consider remote effect of TKI pazopanib as well. DDx also \nstill includes CAD, especially considering quite severe \nprogressive PAD. Had chest pain with EKG stable and trops \nnegative on ___. Cardiology consulted for recs.  He initially \nreceived IV furosemide, though this was held on ___ when he \ndeveloped his GIB, and he remained euvoelmic throughout his \nhospitalization on exam. He is not being discharged on any \ndiuretics.\n \n#Hyponatremia\n \n#Concern for SIADH\n \nHyponatremia noted on BMP, serum/urine osmolality consistent \nwith SIADH, likely ___ extensive metastatic lung involvement. \nManaged with 1.5L fluid restriction, will re-check sodium labs \nafter discharge, and provided plan on whether sodium tabs should \nbe started.\n \n#GI Bleed\n \nPer guaiac positive maroon colored stools. Held \nanti-hypertensives and Apixiban. 2 Large bore IV's placed. GI \nconsulted and held off on endoscopy as not within patient's \ngoals of care. Tranfused 1u PRBC for hgb 6.6 on ___ with \nimprovement to 8.0 on ___. CT torso on ___ did show possible \nfocus of bleeding in colon. On oral PPI. Transfused 1 uPRBC for \nhgb on 6.7 on morning of discharge, as it had been slowly \ndowntrending. He refused colonoscopy and ___ \nembolization.\n \n\n#Urinary Retention\n \nNoted throughout admission. Previously started Tamsulosin BID. \nStill required straight catheterization for all urination. \nExtensive metastatic involvement of L4 vertebrae on ___ CT.  \nLikely etastatic involvement of spinal cord or impingement on \nspinal cord. The patient declined MRI of his spine and \ninvolvement of neurosurgery. I discussed with his oncologist Dr. \n___ felt that spinal involvement was likely, and \nrecommended against starting empiric steroids as there was no \npossible surgical decompression. \n\n \n#Possible HAP \n \nNoted on CXR from ___ for chest pain. Patient has persistent \nleukocytosis. No fevers or hypoxemia. Sputum culture \ncontaminated. Discontinued vancomycin ___ - ___ per negative \nMRSA swab. Treated with cefepime (___) and transitioned to \naugmentin and finished course of antibiotics in the hospital for \n7 days. Blood cultures NGTD at time of discharge. Ultimately, in \nthe absence of infective symptoms, his consolidation most likely \nrepresents metastatic spread of his angiosarcoma. \n \n\n \n#Chest Pain\n \nCXR with possible left sided PNA. Patient had some hemoptysis on \n___ which increased concern for PE. EKG unchanged and troponins \nnegative throughout admission. CTA on ___ showed numerous right \nand left sided metastases that could explain pain in chest. Also \ndid not show PE. Treated PNA as above. Treated pain with APAP \nand lidocaine patches. Patient offered oxycodone but declined \ndue to concern for constipation. \n \n\n \n#SEVERE PAD\n \n#HISTORY OF AORTIC THROMBUS\n \n#S/P RESECTIONS OF RLE\n \ns/p EVAR, multiple surgical interventions as noted above, most \nrecently seen at ___ for RLE surgeries and ___ toe, MT head \nresections. Complaining of bilateral pain in thigh. Femoral \nfilms: Multiple lytic lesions are seen involving both femurs \nleft greater than right consistent with known metastasis. \nMultiple lytic lesions involving the pelvic bones. Patient \nrefused ABI/PVR. Continued home ASA81 given PAD benefits \noutweighed risks. Held DOAC i/s/o GI bleed. Previously on \namox-clav to suggested 875mg q12 (from 500mg q12) for 10d course \n(___). Discontinued per initiation of broad spectrum abx for \npossible PNA (above). Pain control with gabapentin and APAP, but \ndecreased dose of gabapentin given delirium and he refused \nhigher doses. Also using lidocaine patch. D/Ced tramadol \npreviously due to severe nightmares. Held home NSAID given c/f \nexacerbating bleed. Pall care consulted for recs for GOC and \npain, although patient was reluctant to discuss with pall care.\n \n\n \n#HYPOPHOSPHATEMIA\n \nContinued home KPhos QID (as neutraphos here given formulary). \nRepleted. \n \n\n \n#PREDIABETES\n \nA1c 5.7 on ___. Utilized HISS while inpt.\n \n\n \n#HOME MEDICATIONS\n \nContinued home vit D supp, articial tears, magic mouthwash. Home \nomeprazole switched to IV BID Protonix per GI Bleed. \nTransitioned patient back to oral PPI.\n \n\n \n#PERSISTENT LEUKOCYTOSIS\n \nPer review of ___ records, has been ongoing issue for at least \nseveral months; worked up by ID, Oncology and felt likely \nreactive iso chronic leg wounds. We feel this was likely \nsecondary to extensive metastatic cancer. \n \n\n \nLANGUAGE: ___ \n \nCODE: DNR/DNI \n \nCONTACT: Name of health care proxy: ___ \n \nRelationship: Sister \n \nPhone number: ___ \n \nDate on form: ___ \n \nProxy form in chart: ___ \n \nComments: Son, ___ ___ is alternative HCP \n \n\n \nTRANSITIONAL ISSUES\n \n=====================\n \n[] Re-check BMP on ___. If sodium <128, add 1 gm sodium \nchloride tabs TID. Re-check BMP on ___.\n \n[] CBC on ___\n \n[] Continue to discuss goals of care and possible transition to \ncomfort measures if he is not a candidate for chemotherapy\n \n\n \nDischarge weight: 119\n \nDischarge Na: 129\n \nDischarge Hgb: 6.7 (received 1 unit pRBCs after this)\n \nDischarge Cr: 0.8 \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Apixaban 5 mg PO BID \n2. Atorvastatin 40 mg PO QPM \n3. Artificial Tears GEL 1% ___ DROP BOTH EYES TID \n4. Vitamin D ___ UNIT PO DAILY \n5. Gabapentin 300 mg PO TID \n6. Ibuprofen 400 mg PO Q6H:PRN Pain - Mild \n7. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN irritation \n8. Omeprazole 20 mg PO DAILY \n9. K-Phos-NeutraL (sod phos di, mono-K phos mono) ___ mg oral \nQID \n10. Acetaminophen 650 mg PO Q6H \n11. Amoxicillin-Clavulanic Acid ___ mg PO BID \n12. Aspirin 81 mg PO DAILY \n13. Lisinopril 5 mg PO DAILY \n14. TraMADol ___ mg PO Q6H:PRN Pain - Moderate \n15. Senna 8.6 mg PO QHS:PRN Constipation - First Line \n16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n\n \nDischarge Medications:\n1.  Ferrous Sulfate 325 mg PO EVERY OTHER DAY  \n2.  Lidocaine 5% Patch 1 PTCH TD QAM  \n3.  Tamsulosin 0.4 mg PO BID  \n4.  Acetaminophen 1000 mg PO Q8H  \n5.  Gabapentin 300 mg PO BID  \n6.  Omeprazole 40 mg PO DAILY  \n7.  Senna 17.2 mg PO BID  \n8.  Artificial Tears GEL 1% ___ DROP BOTH EYES TID  \n9.  Aspirin 81 mg PO DAILY  \n10.  Atorvastatin 40 mg PO QPM  \n11.  K-Phos-NeutraL (sod phos di, mono-K phos mono) ___ mg oral \nQID  \n12.  Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN \nirritation  \n13.  Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain  \n14.  Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine  \n15.  Vitamin D ___ UNIT PO DAILY  \n16. HELD- Apixaban 5 mg PO BID  This medication was held. Do not \nrestart Apixaban until discussion with PCP regarding risks of GI \nbleeding\n17. HELD- Lisinopril 5 mg PO DAILY  This medication was held. Do \nnot restart Lisinopril until discussion with PCP regards risks \nof hypotension with GI bleeding\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n=======================\n#ACUTE SYSTOLIC HEART FAILURE\n#CARDIOMYOPATHY\n#CAD s/p CABG (___)\n#SINUS TACHYCARDIA\n#GI Bleed\n#Urinary Retention\n#Possible HCAP/HAP\n#Chest Pain\n#ACUTE ON CHRONIC ANEMIA\n#SEVERE PAD\n#HISTORY OF AORTIC THROMBUS\n#S/P RESECTIONS OF RLE\n#HYPOPHOSPHATEMIA\n\nSECONDARY DIAGNOSES\n=======================\n#PREDIABETES\n#PERSISTENT LEUKOCYTOSIS\n#METASTATIC ANGIOSARCOMA\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear ___,  \n\nIt was a pleasure taking care of you at the ___ \n___!  \n\nWHY WAS I IN THE HOSPITAL?  \n==========================  \n- You came to the hospital because you were having chest pain.\n- Additionally, you were found to have worsening anemia in the \nemergency room\n\nWHAT HAPPENED IN THE HOSPITAL?  \n==============================  \n- You received a transfusion which normalized you blood count\n- We determined with labwork and ECG that you were not having a \nheart attack\n- The pumping function of your heart was weaker and your \nmedications were adjusted\n- A CT scan showed progression of your cancer which could have \nbeen causing your chest pain and also caused bleeding from your \ncolon. You received a blood transfusion for this bleeding\n- You were treated with antibiotics for possible pneumonia\n- We started you on a new medicine to help you urinate\n\nWHAT SHOULD I DO WHEN I GO HOME?  \n================================  \n- Please continue to take all of your medications as directed\n- Please follow up with all the appointments scheduled with your \ndoctor\n\n___ you for allowing us to be involved in your care, we wish \nyou all the best!  \n\nYour ___ Healthcare Team  \n\n \nFollowup Instructions:\n___\n\n\n[RADIOLOGY] HISTORY:  Pre-assessment for cardiac bypass.\n\nFINDINGS:  Minimal calcific plaque at the origin of both internal carotid\narteries.  The peak systolic velocities bilaterally are normal as are the\nICA/CCA ratios.  There is normal antegrade flow involving both vertebral\narteries.\n\nIMPRESSION:  Minimal bilateral ICA plaque, no appreciable associated stenosis,\nhowever (graded as less than 40% bilaterally).\n\n\n[RADIOLOGY] REASON FOR EXAMINATION:  Evaluation of the patient after CABG, cardiac surgery\nand extubation.\n\nAP radiograph of the chest was reviewed with no prior studies available for\ncomparison.\n\nThe ET tube tip is 4.4 cm above the carina.  The NG tube tip is in the\nstomach.  The left chest tube and mediastinal drains are in place.  The right\ninternal jugular line tip is at the level of cavoatrial junction.\n\nHeart size is mildly enlarged.  Mediastinal contours show relatively large\naortic arch.\n\nMild pulmonary edema is present.  No pneumothorax or pleural effusion noted.\n\n\n[RADIOLOGY] REASON FOR EXAMINATION:  Dropping hematocrit.\n\nPortable AP radiograph of the chest was reviewed with comparison to ___.\n\nThere is no change in mediastinal widening, but still mediastinal hematoma\ncannot be excluded.  The patient was extubated.  The internal jugular line,\nchest tube and mediastinal drains are in place.  No pneumothorax.  Basal\natelectasis on the left has slightly increased which might be related to\ntermination of mechanical ventilation.  Post-sternotomy wires are\nunremarkable.\n\n\n[RADIOLOGY] ___ CHEST X-RAY \n\nCOMPARISON:  Chest x-rays dating between ___ and ___.\n\nFINDINGS:  Following removal of mediastinal drains and left-sided chest tubes,\nthere is no visible pneumothorax.  Cardiomediastinal contours are unchanged in\nposition.  Improving atelectasis at both bases with minor residual atelectasis\nremaining.\n\n\n[RADIOLOGY] REASON FOR EXAMINATION:  Evaluation of the patient after CABG.\n\nPA and lateral upright chest radiographs were reviewed in comparison to\n___.\n\nThe right internal jugular line tip is at the cavoatrial junction. \nPost-sternotomy wires are unremarkable.  The cardiomediastinal silhouette is\nstable, including cardiomegaly.  Small amount of right pleural effusion is\nunchanged.  Small amount of right apical pneumothorax is noted, unchanged.  No\nappreciable left pneumothorax is seen.  Minimal amount of left pleural\neffusion is better appreciated on the lateral view.\n\n\n[RADIOLOGY] INDICATION:  ___ male with chest pain after CABG on ___.\n\n___.\n\nCHEST, PA AND LATERAL:  CABG changes are seen, with median sternotomy wires\nand mediastinal clips.  Pulmonary aeration has improved, with residual left\nlower lobe atelectasis, but no focal consolidation.  Tiny right apical\npneumothorax and small left pleural effusion have resolved.  Mild cardiomegaly\nis stable.  \n\nIMPRESSION:  CABG changes, without acute findings.\n\n\n[RADIOLOGY] INDICATION:  Preop for CABG.\n\nPA AND LATERAL CHEST RADIOGRAPH.\n\nCOMPARISON:  Chest radiograph from ___.\n\nFINDINGS:  The lungs are clear.  No pneumothorax or pleural effusion is\npresent.  The cardiac silhouette, hilar, and mediastinal contours appear\nnormal, although the heart may be top normal in size.  Sternal cerclage wires\nare intact, and there is evidence for prior CABG.  No pneumothorax or pleural\neffusion is present.\n\nIMPRESSION:  Prior CABG but no acute cardiopulmonary findings.\n\n\n[RADIOLOGY] INDICATION:  ___ male with dyspnea and lower extremity edema, evaluate\nfor pulmonary edema.\n\n___.\n\nCHEST, PA AND LATERAL:  The lungs are clear.  Changes of median sternotomy,\nwith mediastinal clips and coronary artery bypass grafting.  Heart size is top\nnormal.  There are no pleural effusions or pneumothorax.\n\nIMPRESSION:  No acute cardiopulmonary process.  CABG changes.\n\n\n[RADIOLOGY] HISTORY:  Chest pain radiating to the left scapula.\n\nCOMPARISON:  Multiple prior chest radiographs from ___ to ___.\n\nFINDINGS:  Median sternotomy wires are again noted.  Mild cardiomegaly is\nstable.  There is no focal consolidation, pleural effusion, pneumothorax, or\npulmonary vascular engorgement.  Widening of the acromioclaviular joints\nbilateraly is unchanged.\n\nIMPRESSION:   No acute cardiopulmonary process.\n\n\n\n[RADIOLOGY] HISTORY:  Chest pain, dyspnea and lightheadedness.\n\nTECHNIQUE:  CT images were obtained through the lungs in an arterial phase\nafter the uneventful intravenous administration of 100 mL Omnipaque contrast\nmedium.  Multiplanar reformations were prepared.\n\nCOMPARISON:  Chest radiograph from earlier the same date.\n\nFINDINGS: The thyroid gland is normal with symmetric enhancement.  The aorta\nand major branches are patent and normal in caliber without evidence of acute\naortic pathology.  The pulmonary arterial tree is well opacified without\nfilling defect to suggest pulmonary embolus. The patient is status post\ncoronary artery bypass grafting with mild cardiomegaly but no pericardial\neffusion.  The esophagus is normal. There is no mediastinal, hilar or axillary\nlymph node enlargement.  The trachea and central airways appear patent to the\nsegmental level with mild bilateral atelectasis likely relating to the shallow\ninspiratory phase of imaging.  \n\nBilateral lower lobe bronchial wall thickening could relate to aspiration. \nSub 4 mm pulmonary nodules are seen in the right upper (2:21) and lower lobe\n(2:59).  There is no pleural effusion.\n\nAlthough this exam is not tailored for subdiaphragmatic evaluation, the imaged\nupper abdomen demonstrates a punctate gallstone without findings of\ncholecystitis.\n\nOSSEOUS STRUCTURES:  There is no lytic or sclerotic bony lesion to suggest\nosseous malignancy or to explain the patient's clinical symptoms with changes\nfrom prior sternotomy noted.\n\nIMPRESSION:\n1.  No acute aortic pathology or pulmonary embolus.  Bilateral lower lobe\nbronchial wall thickening could reflect sequela of aspiration.  \n\n2.  Sub 4 mm pulmonary nodules in the right upper and lower lobe for which ___\nyear follow up can be obtained if patient is high risk for malignancy per\n___ society guidelines.\n\n3.  Cholelithiasis without findings of cholecystitis.\n\n\n\n[RADIOLOGY] CHEST RADIOGRAPH PERFORMED ON ___.\n\nCOMPARISON:  CTA chest and chest radiographs, both dated ___.\n\nCLINICAL HISTORY:  Prior CABG with chest pain and shortness of breath,\nquestion pneumonia or CHF.\n\nFINDINGS:  PA and lateral views of the chest were provided.  Midline\nsternotomy wires and mediastinal clips are again seen.  The heart is stable\nand mildly enlarged.  There is no focal consolidation, effusion, or\npneumothorax.  No signs of CHF/pulmonary edema.  The mediastinal contour is\nstable and normal.  Bony structures are intact.  No free air below the right\nhemidiaphragm.\n\nIMPRESSION:  No acute findings in the chest.  Stable mild cardiomegaly.  No\nsigns of CHF or pulmonary edema.\n\n\n[RADIOLOGY] HISTORY:  Right sided pain. \n\nCOMPARISON:  CTA Chest from ___. \n\nFINDINGS:\n\nThe liver is diffusely increased echogenicity consistent with fatty deposition\nwithin the liver.  No focal liver lesions are identified.  The main portal\nvein is patent with hepatopetal flow.  There is no intra or extrahepatic\nductal dilatation with the common bile duct measuring 3 mm.  \nThe gallbladder is limited in visualization. There is a nonmobile echogenic\nstructure within the gallbladder body measuring 0.3 cm and most likely\nrepresentative of a cholesterol polyp, less likely adherent stone.\nAdditionally, there is a 0.5 cm echogenic structure in the region of the\ngallbladder neck, likely representing a second polyp versus adherent stone.\nOtherwise, the gallbladder is decompressed and within normal limits.  \n\nThe pancreas is limited in visualization due to overlying bowel gas. \nBilateral kidneys are normal with no evidence of hydronephrosis or stone with\nthe right kidney measures 10.1 cm and left kidney measuring 9.9 cm.  The\nspleen is normal measuring 9.2 cm.  \n\nIMPRESSION:\n\n1.  The gallbladder is limited in visualization but there is a 5 mm echogenic\nfocus in the region of the gallbladder neck suggestive of a polyp along with a\n3 mm echogenic focus at the gallbladder body suggestive of either a\ncholesterol polyp versus adherent stone. A gallstone seen previously at CT is\nnot clearly identified, though could be obscured by poor distention.\n\n2.  Echognic liver consistent with fatty deposition.  More significant hepatic\ndisease including significant hepatic fibrosis/cirrhosis cannot be excluded on\nthe basis of this study.  \n\n\n\n[RADIOLOGY] EXAMINATION:  CT HEAD W/O CONTRAST\n\nINDICATION:  History: ___ with brief loss of consciousness, neck pain after\ninjury\n\nTECHNIQUE:  Contiguous axial images images of the brain were obtained without\ncontrast. Coronal and sagittal as well as thin bone-algorithm reconstructed\nimages were obtained.\n\nDOSE:  DLP:  891.9 mGy-cm\nCTDI:  54.9 mGy\n\nCOMPARISON:  None.\n\nFINDINGS: \n\nThere is a small 3 mm subdural hematoma layering along the right tentorium.\nThere is no significant mass effect. No other intracranial hemorrhage, edema\nor acute territorial infarction is identified. Ventricles and sulci are\nprominent consistent with atrophy. There is mild periventricular white matter\nhypodensity consistent with chronic small vessel ischemic disease. Note is\nmade of a probable ___ cisterna magna. There is mucosal thickening of the\nmaxillary sinuses bilaterally. The remainder of the paranasal sinuses, mastoid\nair cells and middle ear cavities are clear. There are no fractures. The\norbits are unremarkable.\n\nIMPRESSION:\n\n\n\n1. 3 mm acute subdural hematoma layering along the right tentorium.\n2. Atrophy and chronic small vessel ischemic disease.\n\n\n[RADIOLOGY] EXAMINATION:  CT C-SPINE W/O CONTRAST\n\nINDICATION:  History: ___ with brief loss of consciousness, neck pain after\ninjury\n\nTECHNIQUE:  Contiguous axial images were obtained.  Sagittal and coronal\nreformatted images were generated.  No contrast was administered.\n\nCTDIvol:  897 mGy\nDLP:  67 mGy-cm\n\nCOMPARISON:  None\n\nFINDINGS: \n\nThere is no acute fracture or prevertebral soft tissue swelling. There is mild\nretrolisthesis of C3 on C4, likely degenerative in etiology. The vertebral\nbody heights are maintained. There is mild multilevel degenerate changes with\ndisc space narrowing. Disc bulges at C3-C4, C5-C6 and C6-C7 cause mild canal\nnarrowing.\n\nThe thyroid gland is unremarkable. There are vascular calcifications of the\ncarotid bifurcations bilaterally. The remainder of the soft tissues are\nunremarkable. Lung apices are clear.\n\nIMPRESSION: \n\n1.  No acute fracture.\n2.  Mild multilevel degenerative changes.\n\n\n[RADIOLOGY] EXAMINATION:  ELBOW (AP, LAT AND OBLIQUE) LEFT\n\nINDICATION:  History: ___ with left elbow pain after fall\n\nTECHNIQUE:  Left elbow, 3 views.\n\nCOMPARISON:  None\n\nFINDINGS: \n\nNo acute fracture or dislocation is detected. No suspicious lytic or sclerotic\nosseous abnormality is identified.  No joint effusion is seen.  No soft tissue\ncalcification or radiopaque foreign body is detected.  Minimal degenerative\nspurring is seen involving the radiohumeral joint.\n\nIMPRESSION: \n\nNo acute fracture or dislocation.\n\n\n[RADIOLOGY] EXAMINATION:  CT HEAD W/O CONTRAST\n\nINDICATION:  ___ year old man with right SDH along tentorium, please evaluate\nfor interval changes.\n\nTECHNIQUE:  Contiguous axial images of the brain were obtained without\ncontrast.  Thin bone-algorithm reconstructed images were obtained.\n\nDOSE:  DLP: 897 mGy-cm\nCTDI: 53 mGy\n\nCOMPARISON:  Non-contrast head CT dated ___.\n\nFINDINGS: \n\nNo significant interval change. The right extra-axial hematoma tracking along\nthe tentorium is overall unchanged. There is no evidence of new hemorrhage.\nThere is no midline shift or herniation. The cisterna magna appears enlarged,\nbut is unchanged. The basal cisterns are patent. There is no evidence of acute\ninfarct. The ventricles and sulci are prominent bilaterally, suggesting\ncortical atrophy and are age-appropriate. The configuration of ventricles and\nsulci are unchanged.  Grey-white matter differentiation is preserved.\n\nThere is no fracture. The right frontal sinus appears hypoplastic.  The\nremaining partially visualized paranasal sinuses, mastoid air cells, and\nmiddle ear cavities are clear. The orbits are unremarkable.\n\nIMPRESSION: \n\n1. No significant interval change in right subdural hematoma along tentorium.\n\n2. Enlarged cisterna magna as before.\n\n\n[RADIOLOGY] EXAMINATION:  CT HEAD W/O CONTRAST\n\nINDICATION:  ___ year old man s/p mechanical fall on ___  // ct of head\nwithout contrast\n\nTECHNIQUE:  Contiguous axial images from skullbase to vertex were obtained\nwithout intravenous contrast.\n\nDOSE:  DLP:  936 mGy-cm\nCTDI:  53 mGy\n\nCOMPARISON:  None.\n\nFINDINGS: \n\nThere is no intra-axial or extra-axial hemorrhage, mass, midline shift, or\nacute vascular territorial infarct.  Previously seen subdural hematoma along\nthe right aspect of the tentorium is no longer seen. Gray-white matter\ndifferentiation is preserved. Ventricles are symmetric and unremarkable.  ___\ncisterna magna is again noted.\n\nIncluded paranasal sinuses and mastoids are clear besides partially visualized\nmucosal thickening in the maxillary sinuses. Skull and extracranial soft\ntissues are unremarkable.\n\nIMPRESSION: \n\nPreviously seen subdural hematoma along the right aspect of the tentorium is\nno longer seen. No acute intracranial process.\n\n\n[RADIOLOGY] EXAMINATION:\nChest:  Frontal and lateral views\n\nINDICATION:  History: ___ with chest pain  // eval heart and lungs\n\nTECHNIQUE:  Chest:  Frontal and Lateral\n\nCOMPARISON:  ___\n\nFINDINGS: \n\nPatient is status post median sternotomy.  No pleural effusion or pneumothorax\nis seen. The cardiac and mediastinal silhouettes are stable.\n\nIMPRESSION: \n\nNo acute cardiopulmonary process.\n\n\n[RADIOLOGY] EXAMINATION:  CT HEAD W/O CONTRAST\n\nINDICATION:  Evaluate for hemorrhage in a patient with significant headache.\n\nTECHNIQUE:  Contiguous axial images from skullbase to vertex were obtained\nwithout intravenous contrast.  Coronal and sagittal reformations and bone\nalgorithms reconstructions were also performed.\n\nDOSE:  Acquisition sequence:\n   1) CT Localizer Radiograph\n   2) CT Localizer Radiograph\n   3) Sequenced Acquisition 18.0 s, 18.7 cm; CTDIvol = 48.4 mGy (Head) DLP =\n903.1 mGy-cm.\n Total DLP (Head) = 903 mGy-cm.\n\nCOMPARISON:  Noncontrast CT head from ___.\n\nFINDINGS: \n\nThere is no evidence of acute infarct, hemorrhage, edema, or mass effect.  A\nhypodensity in the right frontal lobe (02:21) is suggestive of a prior lacunar\ninfarct, and was likely present in ___.  Prominent ventricles and sulci\nare suggestive of age-related involutional change.  Mild periventricular white\nmatter hypodensities are consistent with chronic small vessel ischemic\ndisease.\n\nNo acute fracture is seen. The paranasal sinuses, mastoid air cells, and\nmiddle ear cavities are clear.  The orbits are unremarkable.\n\nIMPRESSION: \n\nNo acute intracranial abnormality.\n\n\n[RADIOLOGY] EXAMINATION:  CTA ABD AND PELVIS\n\nINDICATION:  ___ year old man with AAA// Eval AAA\n\nTECHNIQUE:  Abdomen and pelvis CTA: Non-contrast and postcontrast images were\nacquired through the abdomen and pelvis in the arterial phase.\nOral contrast was not administered.\nMIP reconstructions were performed on independent workstation and reviewed on\nPACS.\n\nDOSE:  Acquisition sequence:\n   1) Spiral Acquisition 7.2 s, 46.9 cm; CTDIvol = 5.7 mGy (Body) DLP = 262.0\nmGy-cm.\n   2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 3.0 mGy (Body) DLP = 0.6\nmGy-cm.\n   3) Stationary Acquisition 6.8 s, 0.2 cm; CTDIvol = 73.8 mGy (Body) DLP =\n14.8 mGy-cm.\n   4) Spiral Acquisition 7.1 s, 46.0 cm; CTDIvol = 6.4 mGy (Body) DLP = 288.0\nmGy-cm.\n Total DLP (Body) = 565 mGy-cm.\n\nCOMPARISON:  Outside facility CT abdomen and pelvis ___\n\nFINDINGS: \n\nThe study is mildly degraded by motion.\n\nVASCULAR:\nThere is severe atherosclerosis/thrombus throughout the infrarenal abdominal\naorta, with areas of severe luminal narrowing by noncalcified plaque.  For\ninstance, a region of focal stenosis results in likely up to 90% luminal\nnarrowing just below the left renal artery (06:53).  Wall calcification is\nminimal. Celiac artery, superior mesenteric artery, and bilateral renal\narteries are patent.  The bilateral iliac arteries are patent, with mild\natherosclerotic narrowing of the common iliac arteries.  Mild to moderate\natherosclerosis of the bilateral common femoral arteries.\n\nLOWER CHEST: No pleural or pericardial effusion.\n\nABDOMEN:\n\nHEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There\nis no evidence of focal lesions. There is no evidence of intrahepatic or\nextrahepatic biliary dilatation.  The gallbladder is within normal limits,\nwithout stones or gallbladder wall thickening.\n\nPANCREAS: The pancreas has normal attenuation throughout, without evidence of\nfocal lesions or pancreatic ductal dilatation. There is no peripancreatic\nstranding.\n\nSPLEEN: The spleen shows normal size and attenuation throughout, without\nevidence of focal lesions.\n\nADRENALS: The right and left adrenal glands are normal in size and shape.\n\nURINARY: The kidneys are of normal and symmetric size with normal nephrogram.\nThere is no evidence of stones, focal renal lesions, or hydronephrosis.  There\nis no perinephric abnormality.\n\nGASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness\nand enhancement throughout. Colon and rectum are within normal limits.\n\nLYMPH NODES: There is no abdominal or pelvic lymphadenopathy by size criteria.\n\nPELVIS: Apparent bladder wall thickening is likely due to luminal\nunderdistension.  There is no free fluid in the pelvis.\n\nREPRODUCTIVE ORGANS: Prostate gland appears enlarged.\n\nBONES: There are several lytic/destructive osseous lesions seen throughout the\nlower lumbar spine and bilateral pelvic bones.  There is also involvement of\nthe left proximal femur.  There is worsening destruction of L4 vertebral body,\nresulting in mild height loss.\n\nSOFT TISSUES: The abdominal and pelvic wall is within normal limits.\n\nIMPRESSION:\n\n\n1. Severe atherosclerosis/luminal thrombus predominantly affecting the\ninfrarenal abdominal aorta, with some areas demonstrating focal high-grade (up\nto 90%) stenosis.\n2. Mild/moderate atherosclerotic narrowing of the common iliac and common\nfemoral arteries bilaterally.\n3. Multiple suspicious lytic/destructive osseous lesions throughout the lower\nlumbar spine and bilateral pelvic bones, suspicious for lytic metastases and\nlikely related to known metastatic angiosarcoma.  Worsening osseous\ndestruction and height loss at L4 vertebral body compared to ___.\n\n\n[RADIOLOGY] EXAMINATION:  CHEST (PA AND LAT)\n\nINDICATION:  History: ___ with chest pain, leukocytosis  // eval pna\n\nTECHNIQUE:  Chest AP upright and lateral\n\nCOMPARISON:  Multiple prior chest radiographs dating back to ___,\nmost recently ___.\nChest CT dated ___.\n\nFINDINGS: \n\nMedian sternotomy wires are intact and aligned.  Mediastinal clips are again\nseen.\n\nThere is mild pulmonary edema, new compared to prior.  There is no pleural\neffusion or pneumothorax.  The cardiomediastinal silhouette remains mildly\nenlarged, similar to prior.\n\nIMPRESSION: \n\nMild pulmonary edema.  Although there is no definite focal consolidation,\nsuperimposed infection cannot be excluded.\n\n\n[RADIOLOGY] EXAMINATION:  FEMUR (AP AND LAT) BILATERAL\n\nINDICATION:  ___ with PMH metastatic angiosarcoma of L fibula (dx ___ on\nC3 of palliative q1wk paclitaxel (DFCI, last ___, CAD s/p CABG (5v,\n___ and severe PAD c/b non-occlusive aortic thrombus (___) on apixaban,\nEVAR (___), multiple vascular surgical interventions ___, and recent\nhospitalization ___ at ___ for R foot amputations who presents from\nrehab with chest pain, admitted for anemia. Has pain on palpation on bilateral\nfemurs.  // Fx vs. mets?\n\nTECHNIQUE:  FEMUR (AP AND LAT) BILATERAL\n\nCOMPARISON:\n___\n\nIMPRESSION: \n\nMultiple lytic lesions are seen involving both femurs left greater than right\nconsistent with known metastasis.  There is permeative  lesion involving the\nleft proximal fibula.  Which represents patient's known angiosarcoma.  Bone\nmineralization is preserved.  Mild degenerative changes involving both hip\njoints.  Multiple lytic lesions involving the pelvic bones.\n\n\n[RADIOLOGY] EXAMINATION:  CHEST (PORTABLE AP)\n\nINDICATION:  ___ year old man with chest pain  // Evaluate for interval changes\n\nTECHNIQUE:  Chest AP\n\nCOMPARISON:  ___\n\nIMPRESSION: \n\nConsolidative opacity in the left upper lobe has worsened and most likely\nrepresents an evolving pneumonia.  Patchy opacity in the right midlung has\nimproved.  Cardiomediastinal silhouette is stable.  No pleural effusions.  No\npneumothorax\n\n\n[RADIOLOGY] EXAMINATION:  CT ABD AND PELVIS WITH CONTRAST\n\nINDICATION:  ___ year old man with metastatic angiosarcoma of the bone to the\nlungs, new HFreF presenting with new hemoptysis and ?HAP with lower gI\nbleeding, refusing colonoscopy  // evaluate for PE, abdominal perforation,\nmalignancy of lung and abdomen, cause for GI bleeding\n\nTECHNIQUE:  Single phase contrast: MDCT axial images were acquired through the\nabdomen and pelvis following intravenous contrast administration.\nOral contrast was administered.\nCoronal and sagittal reformations were performed and reviewed on PACS.\n\nDOSE:  Acquisition sequence:\n   1) Spiral Acquisition 2.5 s, 32.7 cm; CTDIvol = 11.3 mGy (Body) DLP = 370.2\nmGy-cm.\n   2) Spiral Acquisition 3.9 s, 51.7 cm; CTDIvol = 8.0 mGy (Body) DLP = 415.6\nmGy-cm.\n   3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7\nmGy-cm.\n   4) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.6 mGy (Body) DLP =\n8.3 mGy-cm.\n Total DLP (Body) = 796 mGy-cm.\n\nCOMPARISON:  CT from ___\n\nFINDINGS: \n\nLOWER CHEST: For chest findings reference is made to CT chest report of the\nsame day\n\nABDOMEN:\n\nHEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. \nThere is no evidence of focal lesions. There is no evidence of intrahepatic or\nextrahepatic biliary dilatation.  The gallbladder contains gallstones without\nwall thickening or surrounding inflammation.\n\nPANCREAS: The pancreas has normal attenuation throughout, without evidence of\nfocal lesions or pancreatic ductal dilatation.  There is no peripancreatic\nstranding.\n\nSPLEEN: The spleen shows normal size and attenuation throughout, without\nevidence of focal lesions.\n\nADRENALS: The right and left adrenal glands are normal in size and shape.\n\nURINARY: The kidneys are of normal and symmetric size with normal nephrogram. \nThere is no evidence of solid renal lesions or hydronephrosis.  There is no\nperinephric abnormality.\n\nGASTROINTESTINAL: Moderate gastric distention small bowel loops demonstrate\nnormal caliber, wall thickness, and enhancement throughout. High-density\nmaterial is noted in the cecum, likely represents ingested oral contrast\n(304:51).    A calcified peritoneal bodies seen adjacent to the descending\ncolon, likely representing a torsed appendage.\n\nPELVIS: The urinary bladder and distal ureters are unremarkable.  There is no\nfree fluid in the pelvis.\n\nREPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly\nunremarkable.  Bilateral hydroceles are noted.\n\nLYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy.  There\nis no pelvic or inguinal lymphadenopathy.\n\nVASCULAR: Patient is status post placement of an a aortobi-iliac stent graft. \nThe stent appears4 patent.  Mild atherosclerotic disease is noted.\n\nBONES: Again noted are diffuse lytic/destructive metastatic disease involving\nthe lumbar spine pelvis and femurs.  Compared to the prior study there has\nbeen mild interval progression height loss of the mid aspect of the L4\nvertebral body.\n\nSOFT TISSUES: New compared to the prior study are 2.1 cm and 1.4 cm enhancing\nlesions are seen in the right gluteus maximus (304:69, 62).  Adjacent isodense\nnodule in the subcutaneous tissues overlying the gluteus maximus (series 304,\nimage 63) is nonspecific.\n\nIMPRESSION:\n\n\n1. Evaluation for GI bleed is limited in the setting of oral contrast\nadministration and with a single phase study.  Within this limitation no\ndefinite GI bleed. If there is persistent concern/high pretest probability for\nactive gastrointestinal bleeding recommend multiphase CT abdomen and pelvis\nfollowing passage of oral contrast.\n2. No acute intra-abdominal abnormality.  No free intra-abdominal air.\n3. Cholelithiasis without evidence of acute cholecystitis.\n4. 2 new enhancing soft tissue lesions in the right gluteus maximus highly\nsuggestive of metastatic disease and new compared to prior studies.\n5. Numerous aggressive osseous lytic lesions, similar to prior, with mild\nprogressive height loss of the mid L4 vertebral body.\n6.  For chest findings reference is made to CT chest report of the same day\n\n\n[RADIOLOGY] EXAMINATION:  CTA CHEST WITH CONTRAST\n\nINDICATION:  ___ year old man with metastatic angiosarcoma of the bone to the\nlungs, new HFreF presenting with new hemoptysis and ?HAP with lower gI\nbleeding, refusing colonoscopy  // evaluate for PE, abdominal perforation,\nmalignancy of lung and abdomen, cause for GI bleeding\n\nTECHNIQUE:  Axial multidetector CT images were obtained through the thorax\nafter the uneventful administration of intravenous contrast.  Reformatted\ncoronal, sagittal, thin slice axial images, and oblique maximal intensity\nprojection images were submitted to PACS and reviewed.\n\nDOSE:  Acquisition sequence:\n   1) Spiral Acquisition 2.5 s, 32.7 cm; CTDIvol = 11.3 mGy (Body) DLP = 370.2\nmGy-cm.\n   2) Spiral Acquisition 3.9 s, 51.7 cm; CTDIvol = 8.0 mGy (Body) DLP = 415.6\nmGy-cm.\n   3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.32 mGy (Body) DLP =\n1.7 mGy-cm.\n   4) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.6 mGy (Body) DLP =\n8.3 mGy-cm.\n Total DLP (Body) = 796 mGy-cm.\n** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND\nPELVIS WITH CONTRAST)\n\nCOMPARISON:  CT chest from ___\n\nFINDINGS: \n\nHEART AND VASCULATURE: Pulmonary vasculature is well opacified to the\nsubsegmental level without filling defect to indicate a pulmonary embolus. The\nthoracic aorta is normal in caliber without evidence of dissection or\nintramural hematoma.  The heart, pericardium, and great vessels are within\nnormal limits.  Status post CABG.  No pericardial effusion is seen.\n\nAXILLA, HILA, AND MEDIASTINUM: No axillary, or mediastinal adenopathy.  Mildly\nenlarged lymph nodes indeterminate.  There is retention of contrast in the\nesophagus which places the patient at risk for aspiration.\n\nPLEURAL SPACES: There is a small left pleural effusion and a trace right\npleural effusion.  No pneumothorax.\n\nLUNGS/AIRWAYS:\n\nNew compared to prior study there are numerous bilateral solid nodules (in all\nlung lobes) with surrounding ground-glass halos, ranging up to 2.9 cm nodule\nin the right lower lobe (series 302, image 136).  Some areas of ground-glass\nairspace opacification in bilateral upper lobes and being more confluent in\nother areas for example in the left upper lobe (series 302, image 78) favors\ninfection over malignancy.  Interstitial thickening suggest an element of\ninterstitial edema.  There is mild bilateral lower lobe atelectasis.  Airspace\nopacification in the medial basal segment of the left lower lobe is more\nheterogenous suggesting an element of pneumonia.  The airways are patent to\nthe level of the segmental bronchi bilaterally.\n\nBASE OF NECK: Mucosal thickening involving the paranasal sinuses bilateral. \nVisualized portions of the base of the neck show no abnormality.\n\nABDOMEN: Please see the separate report for the same day CT abdomen and pelvis\nfor subdiaphragmatic findings.\n\nBONES: No suspicious osseous abnormality is seen.? There is no acute fracture.\nThe patient is status post median sternotomy.\n\n\nIMPRESSION:\n\n\n1. No evidence of pulmonary embolism or aortic abnormality.\n2. Numerous new solid pulmonary nodules with surrounding ground-glass halo\nranging up to 2.9 cm are concerning for diffuse pulmonary metastasis\n(hemorrhagic metastasis).  In the differential diagnosis consider angio\ninvasive fungal infection.\n3. Suspected multilobar pneumonia.\n4. Interstitial edema, small left and trace right pleural effusion.\n5.  Reference is made to CT abdomen report of study done on the same day for\nabdominal findings.",
+  "ai_summary": "**Patient Summary:**\n\nThe patient is a 70-year-old male with a history of coronary artery disease, hypertension, hyperlipidemia, and gout. He has undergone five coronary artery bypass grafting (CABG) procedures and has a history of metastatic angiosarcoma of the bone. He presents with chest pain, shortness of breath, and lower extremity swelling, which are likely related to worsening metastatic cancer.\n\n**Preoperative Evaluation:**\n\nThe patient's preoperative evaluation includes:\n\n* Demographics: Age 70, male, white, Russian descent\n* Admission information: Emergency department admission, other insurance\n* Planned procedures: Six procedures, including cardiac catheterization, coronary artery bypass grafting, and endoscopic left and right greater saphenous vein harvesting\n* Comorbidities: Hypertension, hyperlipidemia, gout, sleep apnea, TIA, appendectomy, cataract surgery, and diphtheria\n* Medications: Amlodipine, aspirin, metoprolol, lisinopril, and atorvastatin\n* Laboratory results: Elevated BNP, creatinine, and troponin levels\n* Imaging studies: Cardiac catheterization, coronary angiography, echocardiogram, and CT scans of the chest, abdomen, and pelvis\n\n**Risk Factors for Postoperative Complications:**\n\n1. Age: 70 years\n2. Comorbidities: Hypertension, hyperlipidemia, gout, sleep apnea, and TIA\n3. Medications: Amlodipine, aspirin, metoprolol, and atorvastatin\n4. Laboratory results: Elevated BNP, creatinine, and troponin levels\n5. Imaging studies: Cardiac catheterization, coronary angiography, echocardiogram, and CT scans of the chest, abdomen, and pelvis\n\n**Modifiable Risks:**\n\n1. Hypertension: Uncontrolled blood pressure can increase the risk of cardiovascular complications\n2. Hyperlipidemia: Uncontrolled cholesterol levels can increase the risk of cardiovascular complications\n3. Gout: Uncontrolled gout can increase the risk of cardiovascular complications\n4. Sleep apnea: Uncontrolled sleep apnea can increase the risk of cardiovascular complications\n5. TIA: Uncontrolled TIA can increase the risk of stroke and cardiovascular complications\n\n**Surgical Risks:**\n\n1. Cardiac surgery: The patient has a history of coronary artery bypass grafting and has undergone multiple CABG procedures\n2. Pulmonary embolism: The patient has a history of deep vein thrombosis and pulmonary embolism\n3. Bleeding: The patient has a history of bleeding disorders and is taking anticoagulant medications\n4. Infection: The patient has a history of infections and is taking antibiotics\n5. Respiratory complications: The patient has a history of respiratory problems and is taking oxygen therapy\n\n**Postoperative Instructions:**\n\n1. Follow-up appointments with the primary care physician and cardiologist\n2. Medications: Continue taking all medications as directed\n3. Diet: Follow a low-sodium diet\n4. Activity level: Avoid heavy lifting, bending, and strenuous exercise for 10 weeks\n5. Driving: Avoid driving for one month\n6. Follow-up: Follow up with the surgeon and cardiologist for further evaluation and management.",
+  "overall_rating": 2,
+  "feedback": "Good",
+  "categories": {
+    "medical_accuracy": 2,
+    "clinical_relevance": 2,
+    "completeness": 4,
+    "clarity": 2
+  },
+  "sentence_comments": []
+}

patient_evaluations/patient_evaluations_master.csv

@@ -0,0 +1,2 @@
+timestamp,patient_id,expert_name,overall_rating,medical_accuracy,clinical_relevance,completeness,clarity,feedback,sentence_comments_count
+2025-09-03T01:08:09.956832,15110470,Jesse,2,2,2,4,2,Good,0