[
  {
    "title": "Note 1 — Chest Pain / Coronary Artery Disease",
    "label": "I2510",
    "text": "Admission Date: [**2024-01-15**]\nDischarge Date: [**2024-01-19**]\n\nService: CARDIOLOGY\n\nChief Complaint:\nChest pain and shortness of breath.\n\nHistory of Present Illness:\nMr. [**Patient**] is a 68-year-old male with a known history of hypertension, hyperlipidemia, and type 2 diabetes mellitus who presented to the emergency department with a 3-hour history of substernal chest pain rated 8 out of 10 in severity, radiating to the left arm and jaw, associated with diaphoresis and mild shortness of breath. The patient denied nausea or vomiting. He has a history of similar episodes in the past, with cardiac catheterization performed two years ago demonstrating moderate coronary artery disease with 60% stenosis of the left anterior descending artery.\n\nPast Medical History:\n1. Hypertension\n2. Hyperlipidemia\n3. Type 2 Diabetes Mellitus\n4. Coronary artery disease, native vessel\n5. Former smoker, 30 pack-year history\n\nMedications on Admission:\n1. Aspirin 81 mg daily\n2. Metoprolol succinate 50 mg daily\n3. Atorvastatin 40 mg nightly\n4. Lisinopril 10 mg daily\n5. Metformin 1000 mg twice daily\n\nPhysical Examination on Admission:\nVital Signs: Temperature 98.4F, Blood Pressure 158/92 mmHg, Heart Rate 88 bpm, Respiratory Rate 18, O2 Saturation 96% on room air.\nGeneral: Alert and oriented, mild distress secondary to chest pain.\nCardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.\nRespiratory: Clear to auscultation bilaterally.\nAbdomen: Soft, non-tender, non-distended.\nExtremities: No lower extremity edema.\n\nPertinent Laboratory Results:\nTroponin I: 0.04 ng/mL (elevated)\nBNP: 145 pg/mL\nCreatinine: 1.1 mg/dL\nGlucose: 187 mg/dL\nHemoglobin A1c: 7.8%\n\nEKG: Normal sinus rhythm with no acute ST changes. Old T-wave inversions in V4-V6 unchanged from prior.\n\nEchocardiogram: Left ventricular ejection fraction of 50-55%. Mild concentric left ventricular hypertrophy. No wall motion abnormalities at rest.\n\nCardiac Catheterization: Performed on hospital day 2. Demonstrated 70% stenosis of the proximal left anterior descending artery. No intervention was performed given stable presentation. Medical management optimized.\n\nHospital Course:\nThe patient was admitted to the cardiac care unit and placed on telemetry monitoring. Serial troponins showed a mild rise and fall pattern consistent with demand ischemia in the setting of elevated blood pressure. He was started on intravenous heparin, and his antihypertensive regimen was optimized. Cardiology was consulted and recommended medical management. The patient remained hemodynamically stable throughout his admission, with resolution of chest pain by hospital day 2. Cardiac catheterization confirmed known coronary artery disease without critical stenosis requiring intervention.\n\nDischarge Condition: Stable. Ambulating without difficulty. Pain free.\n\nDischarge Medications:\n1. Aspirin 81 mg daily\n2. Metoprolol succinate 100 mg daily (dose increased)\n3. Atorvastatin 80 mg nightly (dose increased)\n4. Lisinopril 20 mg daily (dose increased)\n5. Metformin 1000 mg twice daily\n6. Nitroglycerin 0.4 mg sublingual as needed for chest pain\n\nDischarge Instructions:\nPatient was instructed to follow up with cardiology within one week. He was advised to call 911 immediately if chest pain recurs or worsens. Lifestyle modifications including low-fat diet, regular exercise, and smoking cessation reinforced.\n\nDischarge Diagnosis:\n1. Coronary artery disease, native vessel (I25.10)\n2. Hypertension\n3. Type 2 Diabetes Mellitus\n4. Hyperlipidemia"
  },
  {
    "title": "Note 2 — Sepsis / Pneumonia",
    "label": "J189",
    "text": "Admission Date: [**2024-02-08**]\nDischarge Date: [**2024-02-14**]\n\nService: MEDICINE\n\nChief Complaint:\nFever, productive cough, and confusion.\n\nHistory of Present Illness:\nMrs. [**Patient**] is a 74-year-old female with a past medical history of chronic obstructive pulmonary disease, congestive heart failure with preserved ejection fraction, and atrial fibrillation on anticoagulation who presented from a nursing facility with a 3-day history of fever up to 39.2 degrees Celsius, productive cough with yellowish sputum, progressive shortness of breath, and acute onset confusion. Family members noted she was more lethargic than usual and had decreased oral intake for two days prior to admission. She was brought to the emergency department by ambulance.\n\nPast Medical History:\n1. Chronic obstructive pulmonary disease, moderate severity\n2. Congestive heart failure with preserved ejection fraction\n3. Atrial fibrillation, on anticoagulation\n4. Hypertension\n5. Osteoporosis\n6. Hypothyroidism\n\nMedications on Admission:\n1. Rivaroxaban 20 mg daily with evening meal\n2. Metoprolol tartrate 25 mg twice daily\n3. Furosemide 40 mg daily\n4. Tiotropium inhaler once daily\n5. Albuterol inhaler as needed\n6. Levothyroxine 75 mcg daily\n7. Alendronate 70 mg weekly\n\nPhysical Examination on Admission:\nVital Signs: Temperature 39.1C, Blood Pressure 96/62 mmHg, Heart Rate 112 bpm and irregular, Respiratory Rate 24, O2 Saturation 88% on room air, improved to 94% on 4 liters nasal cannula.\nGeneral: Elderly female, acutely ill appearing, mild confusion, oriented to person only.\nCardiovascular: Irregularly irregular rhythm, no murmurs appreciated.\nRespiratory: Decreased breath sounds at the right base with dullness to percussion. Diffuse expiratory wheezes bilaterally.\nAbdomen: Soft, mildly distended, non-tender.\nExtremities: Trace bilateral lower extremity edema.\nNeurological: Confusion, following simple commands.\n\nPertinent Laboratory Results:\nWhite Blood Cell Count: 18.4 K/uL with 85% neutrophils\nHemoglobin: 10.2 g/dL\nPlatelet Count: 224 K/uL\nSodium: 131 mEq/L\nCreatinine: 1.8 mg/dL (baseline 1.0)\nLactate: 3.2 mmol/L\nProCalcitonin: 8.4 ng/mL\nBlood Cultures: Pending on admission, subsequently grew Streptococcus pneumoniae in 2 of 2 bottles.\n\nChest X-Ray: Right lower lobe consolidation consistent with pneumonia. Mild vascular congestion.\nCT Chest without Contrast: Confirmed right lower lobe consolidation with small right-sided parapneumonic effusion. No pulmonary embolism.\n\nHospital Course:\nThe patient met criteria for sepsis secondary to community-acquired pneumonia and was admitted to the medical intensive care unit. She was started on broad-spectrum intravenous antibiotics including ceftriaxone and azithromycin. Intravenous fluid resuscitation was carefully administered given her underlying heart failure. Blood cultures finalized positive for Streptococcus pneumoniae, and antibiotics were narrowed to ceftriaxone alone. She was weaned off supplemental oxygen over the course of her admission and her confusion resolved by hospital day 3. Repeat chest X-ray on discharge showed improvement in the right lower lobe consolidation.\n\nDischarge Condition: Improved. Alert and oriented to person, place, and time. Ambulating with assistance. O2 saturation 94% on room air.\n\nDischarge Medications:\n1. Amoxicillin-clavulanate 875 mg twice daily for 5 additional days to complete antibiotic course\n2. Rivaroxaban 20 mg daily with evening meal\n3. Metoprolol tartrate 25 mg twice daily\n4. Furosemide 40 mg daily\n5. Tiotropium inhaler once daily\n6. Albuterol inhaler as needed\n7. Levothyroxine 75 mcg daily\n\nDischarge Diagnosis:\n1. Pneumonia, unspecified organism (J18.9)\n2. Sepsis secondary to pneumonia\n3. Acute kidney injury, resolved\n4. Hyponatremia, resolved\n5. COPD exacerbation"
  },
  {
    "title": "Note 3 — Acute Kidney Injury / Diabetes",
    "label": "E119",
    "text": "Admission Date: [**2024-03-22**]\nDischarge Date: [**2024-03-27**]\n\nService: NEPHROLOGY\n\nChief Complaint:\nDecreased urine output, leg swelling, and fatigue.\n\nHistory of Present Illness:\nMr. [**Patient**] is a 55-year-old male with a 20-year history of type 2 diabetes mellitus with known diabetic nephropathy, hypertension, and obesity who presented with a one-week history of progressive lower extremity edema, decreased urine output, fatigue, and nausea. He reports poor compliance with his diabetic regimen over the past two months due to financial difficulties. He ran out of insulin three weeks ago and has been managing his diet alone. He denies fevers, chest pain, or shortness of breath.\n\nPast Medical History:\n1. Type 2 Diabetes Mellitus with diabetic nephropathy\n2. Hypertension\n3. Obesity, BMI 38\n4. Hyperlipidemia\n5. Peripheral neuropathy\n6. Chronic kidney disease, stage 3 (baseline creatinine 2.2 mg/dL)\n\nMedications on Admission:\n1. Insulin glargine 30 units nightly (not taking for 3 weeks)\n2. Insulin lispro sliding scale with meals (not taking for 3 weeks)\n3. Lisinopril 40 mg daily\n4. Amlodipine 10 mg daily\n5. Atorvastatin 40 mg nightly\n6. Gabapentin 300 mg three times daily\n\nPhysical Examination on Admission:\nVital Signs: Temperature 98.6F, Blood Pressure 178/104 mmHg, Heart Rate 94 bpm, Respiratory Rate 18, O2 Saturation 97% on room air. Weight 118 kg (baseline 112 kg).\nGeneral: Obese male, tired appearing but in no acute distress.\nCardiovascular: Regular rate and rhythm. No murmurs.\nRespiratory: Clear to auscultation bilaterally.\nAbdomen: Obese, soft, non-tender. No organomegaly.\nExtremities: 3+ pitting edema bilateral lower extremities to the knees.\nSkin: Intact. No diabetic ulcers. Decreased sensation to light touch bilateral feet.\n\nPertinent Laboratory Results:\nGlucose: 468 mg/dL\nHemoglobin A1c: 11.2%\nCreatinine: 4.1 mg/dL (baseline 2.2)\nBUN: 78 mg/dL\nPotassium: 5.8 mEq/L\nBicarbonate: 18 mEq/L\nUrinalysis: 4+ protein, glucosuria, no infection\nSpot urine protein to creatinine ratio: 4800 mg/g\nRenal Ultrasound: Bilateral echogenic kidneys consistent with chronic kidney disease. No hydronephrosis.\n\nHospital Course:\nThe patient was admitted for acute on chronic kidney injury in the setting of uncontrolled type 2 diabetes mellitus and medication non-compliance. Nephrology was consulted. Intravenous insulin drip was initiated to control hyperglycemia, and the patient was transitioned to subcutaneous insulin regimen once glucose stabilized below 250 mg/dL. Hyperkalemia was managed with sodium polystyrene sulfonate and dietary potassium restriction. Antihypertensive regimen was optimized. Creatinine trended down from 4.1 to 2.8 mg/dL by discharge. Dialysis was deferred given improvement with conservative management. Social work was consulted to assist with insulin access and medication affordability programs.\n\nDischarge Condition: Improved. Ambulatory. Blood pressure better controlled. Glucose in acceptable range.\n\nDischarge Medications:\n1. Insulin glargine 35 units nightly\n2. Insulin lispro 8 units with each meal\n3. Lisinopril 40 mg daily\n4. Amlodipine 10 mg daily\n5. Atorvastatin 40 mg nightly\n6. Gabapentin 300 mg three times daily\n7. Furosemide 80 mg twice daily (new)\n\nDischarge Diagnosis:\n1. Type 2 diabetes mellitus without complications (E11.9)\n2. Acute on chronic kidney injury\n3. Diabetic nephropathy\n4. Hyperkalemia, resolved\n5. Hypertension"
  },
  {
    "title": "Note 4 — Heart Failure / Atrial Fibrillation",
    "label": "I5022",
    "text": "Admission Date: [**2024-04-10**]\nDischarge Date: [**2024-04-16**]\n\nService: CARDIOLOGY\n\nChief Complaint:\nProgressive shortness of breath and inability to lie flat.\n\nHistory of Present Illness:\nMrs. [**Patient**] is a 79-year-old female with a history of chronic systolic heart failure with reduced ejection fraction last measured at 30%, permanent atrial fibrillation, hypertension, and chronic kidney disease stage 3 who presented with a 5-day history of worsening shortness of breath, orthopnea requiring 3 pillows to sleep, paroxysmal nocturnal dyspnea, and bilateral lower extremity swelling. She reports gaining 8 pounds over the past week. She denies chest pain or fever. She admits to dietary indiscretion over the past 2 weeks including increased sodium intake at a family gathering.\n\nPast Medical History:\n1. Systolic congestive heart failure, EF 30%\n2. Permanent atrial fibrillation\n3. Hypertension\n4. Chronic kidney disease, stage 3\n5. Hypothyroidism\n6. Osteoarthritis\n\nMedications on Admission:\n1. Carvedilol 25 mg twice daily\n2. Lisinopril 5 mg daily\n3. Furosemide 80 mg daily\n4. Spironolactone 25 mg daily\n5. Digoxin 0.125 mg daily\n6. Warfarin 5 mg daily (INR 2.4 on admission)\n7. Levothyroxine 50 mcg daily\n\nPhysical Examination on Admission:\nVital Signs: Temperature 98.2F, Blood Pressure 148/88 mmHg, Heart Rate 94 bpm and irregular, Respiratory Rate 22, O2 Saturation 90% on room air, improved to 95% on 2 liters nasal cannula. Weight 72 kg (dry weight 64 kg).\nGeneral: Elderly female in moderate respiratory distress.\nCardiovascular: Irregularly irregular rhythm. S3 gallop present. Jugular venous distension to 12 cm.\nRespiratory: Bilateral basilar crackles halfway up lung fields.\nAbdomen: Mildly distended. Hepatomegaly appreciated.\nExtremities: 3+ pitting edema to bilateral knees.\n\nPertinent Laboratory Results:\nBNP: 2840 pg/mL (baseline 450)\nTroponin I: 0.02 ng/mL (negative)\nCreatinine: 1.9 mg/dL (baseline 1.5)\nSodium: 134 mEq/L\nPotassium: 4.2 mEq/L\nINR: 2.4\n\nChest X-Ray: Cardiomegaly. Bilateral pleural effusions. Pulmonary vascular congestion consistent with pulmonary edema.\nEchocardiogram: Left ventricular ejection fraction 28-30%, unchanged. Moderate mitral regurgitation. Dilated left atrium. Bilateral pleural effusions.\n\nHospital Course:\nThe patient was admitted for acute on chronic systolic heart failure exacerbation secondary to dietary sodium indiscretion. She was started on intravenous furosemide with careful monitoring of renal function and electrolytes. Over the course of her admission she diuresed approximately 9 liters with significant improvement in her respiratory status and peripheral edema. BNP trended down to 890 pg/mL at discharge. Renal function remained stable. She was transitioned to oral furosemide at an increased dose. Cardiology optimized her heart failure regimen and initiated sacubitril-valsartan replacing lisinopril as guideline-directed therapy. She received extensive dietary counseling regarding sodium restriction.\n\nDischarge Condition: Improved. Breathing comfortably on room air. O2 saturation 96% on room air. Minimal residual bilateral lower extremity edema.\n\nDischarge Medications:\n1. Carvedilol 25 mg twice daily\n2. Sacubitril-valsartan 24/26 mg twice daily (new, replacing lisinopril)\n3. Furosemide 120 mg daily (dose increased)\n4. Spironolactone 25 mg daily\n5. Digoxin 0.125 mg daily\n6. Warfarin 5 mg daily\n7. Levothyroxine 50 mcg daily\n\nDischarge Diagnosis:\n1. Acute on chronic systolic heart failure, systolic (I50.22)\n2. Permanent atrial fibrillation\n3. Acute kidney injury, resolved\n4. Hyponatremia, resolved\n5. Hypertension"
  },
  {
    "title": "Note 5 — Stroke / Hypertension",
    "label": "I639",
    "text": "Admission Date: [**2024-05-03**]\nDischarge Date: [**2024-05-10**]\n\nService: NEUROLOGY\n\nChief Complaint:\nSudden onset left-sided weakness and speech difficulty.\n\nHistory of Present Illness:\nMr. [**Patient**] is a 62-year-old right-handed male with a history of hypertension, hyperlipidemia, and former tobacco use who presented to the emergency department via ambulance with sudden onset of left arm and leg weakness and expressive aphasia that began approximately 90 minutes prior to arrival while he was watching television at home. His wife witnessed the event and called 911 immediately. He denied headache, vision changes, or loss of consciousness. He had no prior history of stroke or transient ischemic attack.\n\nPast Medical History:\n1. Hypertension, poorly controlled\n2. Hyperlipidemia\n3. Former tobacco use, quit 5 years ago\n4. Obstructive sleep apnea on CPAP\n5. Obesity, BMI 32\n\nMedications on Admission:\n1. Amlodipine 10 mg daily\n2. Hydrochlorothiazide 25 mg daily\n3. Atorvastatin 20 mg nightly\n\nPhysical Examination on Admission:\nVital Signs: Temperature 98.6F, Blood Pressure 196/112 mmHg, Heart Rate 82 bpm and regular, Respiratory Rate 16, O2 Saturation 97% on room air.\nGeneral: Alert male in no acute distress.\nNeurological: NIHSS score 12. Expressive aphasia with intact comprehension. Left facial droop. Left arm with 2/5 strength. Left leg with 3/5 strength. Left-sided sensory deficit. Gait not tested.\nCardiovascular: Regular rate and rhythm. No carotid bruits.\nRespiratory: Clear to auscultation bilaterally.\nAbdomen: Soft, obese, non-tender.\nExtremities: No edema.\n\nPertinent Laboratory Results:\nGlucose: 134 mg/dL\nHemoglobin A1c: 6.1%\nLDL Cholesterol: 118 mg/dL\nCreatinine: 1.0 mg/dL\nPT/INR: 1.1\naPTT: 28 seconds\nPlatelet Count: 234 K/uL\n\nCT Head without Contrast: No acute intracranial hemorrhage. No obvious early infarct changes.\nCT Angiography Head and Neck: Occlusion of the right middle cerebral artery M2 segment. No significant carotid stenosis.\nMRI Brain with DWI: Acute right MCA territory infarct involving the right frontal and temporal lobes.\nEchocardiogram: Normal left ventricular function. No thrombus identified. Patent foramen ovale with small right-to-left shunt demonstrated on bubble study.\nCardiac Monitor: Normal sinus rhythm throughout. No atrial fibrillation detected.\n\nHospital Course:\nThe patient arrived within the thrombolysis window and received intravenous tPA at 2 hours 15 minutes from symptom onset after CT head confirmed no hemorrhage. Following tPA administration he demonstrated partial improvement in left arm strength and aphasia. He was admitted to the neurology stroke unit for continuous monitoring. MRI brain confirmed right MCA territory infarct. Cardiology was consulted regarding patent foramen ovale as a potential stroke etiology. Antiplatelet therapy with aspirin and clopidogrel was initiated 24 hours after tPA. Antihypertensive regimen was optimized. Physical therapy, occupational therapy, and speech language pathology were involved in his care throughout admission. He made significant functional gains by discharge.\n\nDischarge Condition: Improved. Left arm strength improved to 4/5. Left leg strength 4+/5. Aphasia significantly improved. Ambulatory with minimal assistance.\n\nDischarge Medications:\n1. Aspirin 81 mg daily\n2. Clopidogrel 75 mg daily\n3. Amlodipine 10 mg daily\n4. Lisinopril 10 mg daily (new)\n5. Hydrochlorothiazide 25 mg daily\n6. Atorvastatin 80 mg nightly (dose increased)\n\nDischarge Diagnosis:\n1. Cerebral infarction, unspecified (I63.9)\n2. Hypertension\n3. Hyperlipidemia\n4. Patent foramen ovale\n5. Expressive aphasia secondary to stroke"
  }
]