rsAnnotations-1-120-random.txt

line number	Condition	sentence	negation_status (negated, affirmed, possible)	temporality (historical, recent, hypothetical)	experiencer (patient, other)
1	edema	Extremities reveal no peripheral cyanosis or EDEMA.	Negated	Recent	Patient
2	CHEST:     1. SURGICAL CHANGES RELATED TO THYMOMA RESECTION INCLUDING  ELEVATION OF THE RIGHT HEMIDIAPHRAGM	CHEST:     1.	Affirmed	Recent	Patient
3	Hypertension	HYPERTENSION.	Affirmed	Historical	Patient
4	Osteochondral irregularity is identified within the 45  degree flexion zone of the lateral femoral condyles	FINDINGS:     LEFT KNEE: OSTEOCHONDRAL IRREGULARITY IS IDENTIFIED WITHIN THE 45  DEGREE FLEXION ZONE OF THE LATERAL FEMORAL CONDYLES.	Affirmed	Recent	Patient
5	rales	The lungs are clear to auscultation bilaterally, no wheezes or   RALES.	Negated	Recent	Patient
6	MVP with regurg	Gentamycin 80 mg IVover 30 minutes & Vancomycin 1  gm IV over 60 minutes for MVP WITH REGURG.	Affirmed	Historical	Patient
7	PERRLA	Eyes PERRLA, EOMI.	Affirmed	Recent	Patient
8	Left renal calculi	PRE-OP DIAGNOSIS:     LEFT RENAL CALCULI.	Affirmed	Recent	Patient
9	meningitis	I was also concerned about the   possibility of him having MENINGITIS.	Affirmed	Recent	Patient
10	pulmonary artery size is normal	The PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
11	Head is atraumatic	HEENT:  HEAD IS ATRAUMATIC.	Affirmed	Recent	Patient
12	urinary tract infection	REASON FOR HOSPITAL ADMISSION:    This was a **AGE[in 70s]-year-old demented woman who presented from a nursing home with   an acute complaint of elevated INR and URINARY TRACT INFECTION.	Affirmed	Recent	Patient
13	tobacco use	Given his risk factors   including TOBACCO USE, as well as age for coronary disease, we did perform an   EKG.	Affirmed	Historical	Patient
14	chest pain	She   will call Dr. **NAME[ZZZ] at that same number if there is any newer increased   shortness of breath, new onset of CHEST PAIN, lightheadedness, dizziness,   fainting, ankle swelling, abdominal bloating/weight gain of 2 pounds in 24   hours or 4 pounds in a week or less.	Affirmed	Not particular	Patient
15	fever	My primary concern regarding this gentleman was the possibility of infection   given the FEVER and altered mental status.	Affirmed	Recent	Patient
16	MYOCARDIAL INFARCTION	CHEST PAIN, RULE OUT MYOCARDIAL INFARCTION.	Affirmed	Recent	Patient
17	paranasal sinuses are normal	The visualized  PARANASAL SINUSES ARE NORMAL.	Affirmed	Recent	Patient
18	Chest wall nontender	CHEST WALL NONTENDER.	Affirmed	Recent	Patient
19	Incisions are dry and   intact	INCISIONS ARE DRY AND   INTACT.	Affirmed	Recent	Patient
20	Hypertension	HYPERTENSION.	Affirmed	Historical	Patient
21	Neck:  Supple.  No lymphadenopathy	Neck:  Supple.	Affirmed	Recent	Patient
22	oriented times three	Neurologic - Alert,   ORIENTED TIMES THREE.	Affirmed	Recent	Patient
23	celiac sprue	Four biopsies were obtained and sent for pathology to R/O CELIAC SPRUE.	Affirmed	Recent	Patient
24	myalgia	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no MYALGIA or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
25	Small pericardial effusion	08) SMALL PERICARDIAL EFFUSION seen.	Affirmed	Recent	Patient
26	Cranial nerves II   through XII were within normal limits	CRANIAL NERVES II   THROUGH XII WERE WITHIN NORMAL LIMITS.	Affirmed	Recent	Patient
27	chest is nontender	The CHEST IS NONTENDER.	Affirmed	Recent	Patient
28	murmurs	Heart - Regular rate and rhythm, no   MURMURS, gallops, or rubs.	Negated	Recent	Patient
29	NEUROLOGICAL:  Nonfocal	NEUROLOGICAL:  NONFOCAL.	Affirmed	Recent	Patient
30	NECK:  Supple.  No lymphadenopathy	NECK:  Supple.	Affirmed	Recent	Patient
31	Mild to moderate mitral regurgitation	03) MILD TO MODERATE MITRAL REGURGITATION.	Affirmed	Recent	Patient
32	pain	ED COURSE:    Because of the chronicity of the patient's PAIN and the fact that it is   crampy in nature and an unremarkable abdominal examination, the patient was   reassured.	Affirmed	Recent	Patient
33	left acetabular fracture	The patient sustained a LEFT ACETABULAR FRACTURE.	Affirmed	Recent	Patient
34	PROGRESSION OF ENHANCEMENT IN THE PONTINE MEDULLARY JUNCTION	PROGRESSION OF ENHANCEMENT IN THE PONTINE MEDULLARY JUNCTION,  AND A NEW, MORE CONSPICUOUS AREA OF ENHANCEMENT ALONG THE MEDIAL  ASPECT OF THE LEFT UNCUS ALL OF WHICH IS SUSPICIOUS FOR METASTATIC  DISEASE.	Affirmed	Recent	Patient
35	diaphoresis	She denies   any DIAPHORESIS.	Negated	Recent	Patient
36	Alert	NEURO: ALERT and oriented.	Affirmed	Recent	Patient
37	pulmonary artery   size is normal	The PULMONARY ARTERY   SIZE IS NORMAL.	Affirmed	Recent	Patient
38	mild tricuspid   regurgitation	There is MILD TRICUSPID   REGURGITATION.	Affirmed	Recent	Patient
39	atrial fibrillation	She had a recent admission to the CCU and Cardiac   Pavilion for a new left bundle-branch block and ATRIAL FIBRILLATION.	Affirmed	Recent	Patient
40	pleurisy	The patient admitted with   __________ increased dyspnea in 24 hours, fever, and PLEURISY.	Affirmed	Recent	Patient
41	HYPERTENSION	HYPERTENSION.	Affirmed	Historical	Patient
42	Nondilated right ventricle with hypertrophy and grossly normal function	02) NONDILATED RIGHT VENTRICLE WITH HYPERTROPHY AND GROSSLY NORMAL FUNCTION.	Affirmed	Recent	Patient
43	trace mitral regurgitation	SPECTRAL DOPPLER:   There is TRACE MITRAL REGURGITATION.	Affirmed	Recent	Patient
44	Gastroesophageal reflux disease	GASTROESOPHAGEAL REFLUX DISEASE.	Affirmed	Historical	Patient
45	mild bibasilar atelectasis	Chest radiograph:  Frontal view obtained **DATE[Mar 24 2008], which revealed likely   MILD BIBASILAR ATELECTASIS, less likely pneumonia (cannot be excluded).	Affirmed	Recent	Patient
46	smokes   cigarettes	The patient SMOKES   CIGARETTES.	Affirmed	Historical	Patient
47	CATASTROPHIC ANTIPHOSPOLIPID SYNDROME	CATASTROPHIC ANTIPHOSPOLIPID SYNDROME.	Affirmed	Recent	Patient
48	Nondilated left ventricle with severe hypertrophy and overall preserved  systolic function	FINAL IMPRESSIONS:   01) NONDILATED LEFT VENTRICLE WITH SEVERE HYPERTROPHY AND OVERALL PRESERVED  SYSTOLIC FUNCTION.	Affirmed	Recent	Patient
49	knee pain	No current KNEE PAIN.	Negated	Recent	Patient
50	Left ventricular size is moderately dilated	Wall Thickness:  1.1 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Transient Ischemic Attack  TWO DIMENSIONAL ECHOCARDIOLOGY:   LEFT VENTRICULAR SIZE IS MODERATELY DILATED.	Affirmed	Recent	Patient
51	main portal vein  is patent	The MAIN PORTAL VEIN  IS PATENT.	Affirmed	Recent	Patient
52	Paralysis times four	PARALYSIS TIMES FOUR.	Affirmed	Recent	Patient
53	Conjunctivae are   pink	CONJUNCTIVAE ARE   PINK.	Affirmed	Recent	Patient
54	chest pain	No CHEST PAIN.	Negated	Recent	Patient
55	difficulty   concentrating	The patient does have poor energy and frustration and inability to do   activities she enjoys due to her pain and medical conditions, DIFFICULTY   CONCENTRATING.	Affirmed	Recent	Patient
56	trace tricuspid   regurgitation	There is TRACE TRICUSPID   REGURGITATION.	Affirmed	Recent	Patient
57	TINY RIGHT PLEURAL EFFUSION	IMPRESSION:       TINY RIGHT PLEURAL EFFUSION, OTHERWISE THE LUNGS ARE CLEAR.	Affirmed	Recent	Patient
58	pseudoaneurysms	The patient's bilateral upper extremity duplex   scan revealed no PSEUDOANEURYSMS, no AVM, or no organized hematoma.	Negated	Recent	Patient
59	septated cystic lesions   within the pancreatic body suggestive of IT MN versus mucinous cystic   neoplasm	Right upper quadrant ultrasound obtained **DATE[Mar 26 2008], which revealed the   biliary system decompressed by a new common bile duct stent, the distal   aspect of which is obscured by overlying bowel gas, SEPTATED CYSTIC LESIONS   WITHIN THE PANCREATIC BODY SUGGESTIVE OF IT MN VERSUS MUCINOUS CYSTIC   NEOPLASM, as previously noted on CT.	Affirmed	Recent	Patient
60	Bilateral  transplanted lungs appears clear	BILATERAL  TRANSPLANTED LUNGS APPEARS CLEAR.	Affirmed	Recent	Patient
61	Clear to auscultation	CHEST:  CLEAR TO AUSCULTATION.	Affirmed	Recent	Patient
62	vomiting 	No abdominal pain, nausea, VOMITING or diarrhea.	Negated	Recent	Patient
63	Left ventricular wall thickness is normal	LEFT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
64	Right ventricular wall thickness is normal	RIGHT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
65	normal appearance   of the right foot	X-rays of both feet obtained **DATE[Mar 26 2008], which revealed NORMAL APPEARANCE   OF THE RIGHT FOOT and minor soft-tissue swelling around the midfoot and ankle   on the left.	Affirmed	Recent	Patient
66	polyuria	ENDOCRINE:  Denies any POLYURIA or polyphagia.	Negated	Recent	Patient
67	Segmental left ventricular function is normal	SEGMENTAL LEFT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
68	vague left upper lobe pulmonary nodule	There   was a VAGUE LEFT UPPER LOBE PULMONARY NODULE that was depicted on a chest CT   in 2005.	Affirmed	Recent	Patient
69	moderate mitral regurgitation	There is MODERATE MITRAL REGURGITATION.	Affirmed	Recent	Patient
70	Internal and external hemorrhoids	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) INTERNAL AND EXTERNAL HEMORRHOIDS  2) Normal terminal ileum    3) Normal colonoscopy  4) No additional lesions  5) Normal colonoscopy otherwise    PLAN:  1) Continue surveillance  2) Yearly hemoccult  3) Yearly rectal exams    REPEAT EXAM:  Colonoscopy in 5 year(s).	Affirmed	Recent	Patient
71	urinary tract infection	In terms of her URINARY TRACT INFECTION, the patient had an indwelling Foley   catheter.	Affirmed	Recent	Patient
72	ENCEPHALOPATHY	ENCEPHALOPATHY.	Affirmed	Recent	Patient
73	There are small,  gastrohepatic and porta hepatis lymph nodes	THERE ARE SMALL,  GASTROHEPATIC AND PORTA HEPATIS LYMPH NODES, the sequelae of  chronicrenal disease.	Affirmed	Recent	Patient
74	pneumonia	S_O_H  Counters Report Type Record Type Subgroup Classifier  169,5z75KK5MMhLO RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  XRAY CHEST FRONTAL AND LATERAL VIEWS   **DATE[Aug 06 07]     0111 HOURS    CLINICAL HISTORY:     Rule out PNEUMONIA.	Affirmed	Recent	Patient
75	Moderate left atrial enlargement	05) MODERATE LEFT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
76	incisional pain	On postoperative day #1, she complained of a great deal of   INCISIONAL PAIN for which she was switched from Vicodin to Percocet.	Affirmed	Recent	Patient
77	vitiligo	PAST MEDICAL HISTORY:     Her past medical history is significant for multiple sclerosis, pneumonia,   DVT of the lower extremity, hypothyroidism, hard of hearing, VITILIGO, and   her paralysis from her multiple sclerosis.	Affirmed	Historical	Patient
78	malignancy at the level of the gastric   pylorus and the antrum	The patient's known MALIGNANCY AT THE LEVEL OF THE GASTRIC   PYLORUS AND THE ANTRUM is again shown with marked distal gastric wall   thickening.	Affirmed	Recent	Patient
79	restrictive pulmonary function tests	S_O_H  Counters Report Type Record Type Subgroup Classifier  174,WnIafZDwlSYJ RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  CT THORAX  WITH CONTRAST   **DATE[Mar 16 08]     1406 HOURS    CLINICAL HISTORY:     Dyspnea, RESTRICTIVE PULMONARY FUNCTION TESTS.	Affirmed	Recent	Patient
80	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
81	Left ventricular size is normal	Wall Thickness:  1.3 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Chronic Airway Obstruction 496; Systolic Heart Failure;  Obesity 278.0; Hypertension 401.9  TWO DIMENSIONAL ECHOCARDIOLOGY:   LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
82	Pedunculated polyp in the mid transverse colon  	COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) PEDUNCULATED POLYP IN THE MID TRANSVERSE COLON    2) Diverticuli, scattered in the left colon    3)E xternal  Hemorrhoids      PLAN:  1) Follow-up: as scheduled referring MD  2) Await biopsy results    REPEAT EXAM:  Colonoscopy in 5 - 10 year(s).	Affirmed	Recent	Patient
83	EOMI	Eyes PERRLA, EOMI.	Affirmed	Recent	Patient
84	Lungs clear to auscultation bilaterally	LUNGS CLEAR TO AUSCULTATION BILATERALLY.	Affirmed	Recent	Patient
85	Trace varices were found in the distal esophagus	FINDINGS:  TRACE VARICES WERE FOUND IN THE DISTAL ESOPHAGUS.	Affirmed	Recent	Patient
86	pericardial effusion	02) No PERICARDIAL EFFUSION.	Negated	Recent	Patient
87	PERRLA	Eyes   - PERRLA, EOMI.	Affirmed	Recent	Patient
88	Aortic Valve Disease	Wall Thickness:  1.4 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: AORTIC VALVE DISEASE; Hypertension 401.9  TWO DIMENSIONAL ECHOCARDIOLOGY:   Left ventricular size is normal.	Affirmed	Recent	Patient
89	acute   ischemic changes	EKG Interpretation - A 12-lead EKG shows normal sinus rhythm with no ACUTE   ISCHEMIC CHANGES.	Negated	Recent	Patient
90	trace mitral regurgitation	There is TRACE MITRAL REGURGITATION.	Affirmed	Recent	Patient
91	hepatosplenomegaly	Abdomen: Soft, nontender,   nondistended with positive bowel sounds and no HEPATOSPLENOMEGALY.	Negated	Recent	Patient
92	increased lipase	S_O_H  Counters Report Type Record Type Subgroup Classifier  209,vxfUaUrbUzEw SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PATIENT HISTORY:  Simultaneous pancreas kidney **DATE[Jan 2005], INCREASED LIPASE.	Affirmed	Recent	Patient
93	Angiodysplasia (spider angioma) in the bulb of duodenum	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) Trace varices in the distal esophagus    2) Portal hypertensive gastropathy throughout the stomach    3) Angiodysplasia (spider angioma) in the bulb of duodenum  4) Normal D1/D2    PLAN:  1) **INSTITUTION for Liver Disease with Dr. **NAME[UUU]  2) Protonix 40 mg po qd    REPEAT EXAM:  EGD in 1 - 2 year(s);    __________________________________  **NAME[YYY ZZZ], M.D.  I was present during the entire procedure.	Affirmed	Recent	Patient
94	aortic root size is mildly   dilated	The AORTIC ROOT SIZE IS MILDLY   DILATED.	Affirmed	Recent	Patient
95	CVA	Treatments that were attempted included IVIG for possible ITP with the   complication of an additional CVA.	Affirmed	Recent	Patient
96	multiple back surgeries	S_O_H  Counters Report Type Record Type Subgroup Classifier  211,zW1QfzcDk6fp SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PATIENT HISTORY:  Redo post lumbar, status post MULTIPLE BACK SURGERIES, broken right iliac  bolt.	Affirmed	Historical	Patient
97	Neck is supple	Neck:  NECK IS SUPPLE.	Affirmed	Recent	Patient
98	small bowel obstruction	Also, on the CT scan, there is   dilated proximal small bowel with transition in the right lower quadrant   compatible with a SMALL BOWEL OBSTRUCTION.	Affirmed	Recent	Patient
99	aortic root size is   normal	The AORTIC ROOT SIZE IS   NORMAL.	Affirmed	Recent	Patient
100	burning on urination	Call also for any weight gain   greater than three pounds per day or five pounds per week, any unusual   rashes, nausea, vomiting, fever associated with chill, temperature elevation   greater than 101 degrees Fahrenheit, sustained or low-grade temperature   greater than 100 degrees Fahrenheit, new onset of chest pain,   light-headedness, or dizziness, new or increased shortness of breath, severe   calf pain, BURNING ON URINATION or severe depression.	Affirmed	Not particular	Patient
101	Right ventricular wall thickness is normal	RIGHT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
102	anemia	HISTORY OF PRESENT ILLNESS:    This is a **AGE[in 60s]-year-old male with a past history of diabetes, dementia,   hypertension, hypercholesterolemia, ANEMIA, anxiety, and depression who   presents with a chief complaint of having fallen.	Affirmed	Historical	Patient
103	Gunshot to small bowel	S_O_H  Counters Report Type Record Type Subgroup Classifier  206,itb/3Uy6YB1f SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PATIENT HISTORY:  GUNSHOT TO SMALL BOWEL.	Affirmed	Recent	Patient
104	Candida in her urine	She was also found to   have CANDIDA IN HER URINE and started on fluconazole.	Affirmed	Recent	Patient
105	incontinence	She denies any   INCONTINENCE.	Negated	Recent	Patient
106	Neck - Supple, no lymphadenopathy	NECK - SUPPLE, NO LYMPHADENOPATHY, thyromegaly, or JVD.	Affirmed	Recent	Patient
107	lower extremity swelling, left greater than   right	She did have LOWER EXTREMITY SWELLING, LEFT GREATER THAN   RIGHT, and therefore, we did lower extremity Dopplers to evaluate for DVT.	Affirmed	Recent	Patient
108	low-back pain	HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 40s]-year-old female with a past medical   history significant for chronic LOW-BACK PAIN as well as per her report three   bulging disks.	Affirmed	Historical	Patient
109	HELICOBACTER PYLORI GASTRITIS	olr  _______________________________________________________________  FINAL DIAGNOSIS:  STOMACH, BIOPSY   HELICOBACTER PYLORI GASTRITIS.	Affirmed	Recent	Patient
110	dysuria	Denies any DYSURIA or frequency.	Negated	Recent	Patient
111	expansile destructive lesion of the left ischium with  an associated soft tissue mass	FINDINGS:     There is an EXPANSILE DESTRUCTIVE LESION OF THE LEFT ISCHIUM WITH  AN ASSOCIATED SOFT TISSUE MASS.	Affirmed	Recent	Patient
112	BRONCHIOLITIS OBLITERANS	NO SMALL AIRWAYS PRESENT  TO EVALUATION BRONCHIOLITIS OBLITERANS.	Affirmed	Not particular	Patient
113	paresthesias	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no PARESTHESIAS or paralysis, no rash.	Negated	Recent	Patient
114	PE	;    HISTORY:  The patient is a **AGE[in 60s]-year-old gentleman with a past medical history  significant for ESRD, HIV, chronic thoracic aortic aneurysm, chronic SVC  occlusion, and recent diagnosis of PE who was discharged on **DATE[Jul 2 2007]  after right groin AV fistula placement.	Affirmed	Recent	Patient
115	dizzy	She had come to work, was doing well, was   standing when she felt lightheaded and DIZZY as if she was going to pass out.	Affirmed	Recent	Patient
116	Mild to moderate mitral regurgitation	05) MILD TO MODERATE MITRAL REGURGITATION.	Affirmed	Recent	Patient
117	chills	REVIEW OF SYSTEMS:  Constitutional - No fevers, CHILLS, or sweats.	Negated	Recent	Patient
118	Corrected Transposition Of Great  Vessels  	Wall Thickness:  0.8 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Systolic Heart Failure; CORRECTED TRANSPOSITION OF GREAT  VESSELS    TWO DIMENSIONAL ECHOCARDIOLOGY:   This was a technically difficult study.	Affirmed	Historical	Patient
119	Mild tricuspid regurgitation	05) MILD TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
120	cerebrovascular accident	History of CEREBROVASCULAR ACCIDENT.	Affirmed	Historical	Patient
121	Pupils are equal, round and reactive   to light	PUPILS ARE EQUAL, ROUND AND REACTIVE   TO LIGHT.	Affirmed	Recent	Patient
122	frequency	Denies any dysuria or FREQUENCY.	Negated	Recent	Patient
123	Lung sounds are clear and equal bilaterally	LUNG SOUNDS ARE CLEAR AND EQUAL BILATERALLY.	Affirmed	Recent	Patient
124	Mucous membranes moist	MUCOUS MEMBRANES MOIST.	Affirmed	Recent	Patient
125	BK virus	S_O_H  Counters Report Type Record Type Subgroup Classifier  208,IChweBxS3Zjh SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PROCEDURES  BK Virus Urine (PH)  Interpretation  Urine: Quantitative PCR testing for BK VIRUS is NEGATIVE.	Negated	Recent	Patient
126	aortic root size is   normal	The AORTIC ROOT SIZE IS   NORMAL.	Affirmed	Recent	Patient
127	At L5-S1 diffuse disc bulge is seen without significant canal  compromise or neural foraminal narrowing	AT L5-S1 DIFFUSE DISC BULGE IS SEEN WITHOUT SIGNIFICANT CANAL  COMPROMISE OR NEURAL FORAMINAL NARROWING.	Affirmed	Recent	Patient
128	tachycardic	Her digoxin level is 0.6, which appears   to be subtherapeutic; however, she was not TACHYCARDIC, nor was she was in   atrial fibrillation.	Negated	Recent	Patient
129	rib fracture	There is a 1cm area  of linear fibrosis in the left lower lobe on image 45 of series 4  which may be related to an adjacent old RIB FRACTURE.	Affirmed	Historical	Patient
130	hypothyroidism	PAST MEDICAL HISTORY:     Her past medical history is significant for multiple sclerosis, pneumonia,   DVT of the lower extremity, HYPOTHYROIDISM, hard of hearing, vitiligo, and   her paralysis from her multiple sclerosis.	Affirmed	Historical	Patient
131	rhonchi	No wheezes, rales, or   RHONCHI.	Negated	Recent	Patient
132	good air entry to the bases	He does   have GOOD AIR ENTRY TO THE BASES.	Affirmed	Recent	Patient
133	dementia	HISTORY OF PRESENT ILLNESS:    This is a **AGE[in 60s]-year-old male with a past history of diabetes, DEMENTIA,   hypertension, hypercholesterolemia, anemia, anxiety, and depression who   presents with a chief complaint of having fallen.	Affirmed	Historical	Patient
134	sinus bradycardia	The patient was in SINUS BRADYCARDIA, but blood pressure was elevated.	Affirmed	Recent	Patient
135	chest pain	She denies any CHEST PAIN and denies difficulty breathing.	Negated	Recent	Patient
136	sweats	REVIEW OF SYSTEMS:  Constitutional - No fevers, chills, or SWEATS.	Negated	Recent	Patient
137	bleeding	Follow up ____________ and   the patient is advised to call the PCP if there are any symptoms of chest   pain of shortness of breath or any signs of BLEEDING.	Affirmed	Not particular	Patient
138	PE's	He does have a history of PE'S in the past, but his   signs and symptoms were not consistent with aortic dissection, PE, or   infectious etiologies.	Affirmed	Historical	Patient
139	fainting	She   will call Dr. **NAME[ZZZ] at that same number if there is any newer increased   shortness of breath, new onset of chest pain, lightheadedness, dizziness,   FAINTING, ankle swelling, abdominal bloating/weight gain of 2 pounds in 24   hours or 4 pounds in a week or less.	Affirmed	Not particular	Patient
140	ATRIAL FIBRILLATION	ATRIAL FIBRILLATION.	Affirmed	Historical	Patient
141	tricuspid regurgitation	There is trace TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
142	gout	Also a hip   fracture and GOUT.	Affirmed	Historical	Patient
143	MULTIPLE GUN SHOT WOUNDS TO HIS RIGHT-HAND AND FRACTURES TO HIS DISTAL   PHALANX OF HIS THIRD AND FOURTH DIGITS	ED DISCHARGE DIAGNOSIS(ES):      MULTIPLE GUN SHOT WOUNDS TO HIS RIGHT-HAND AND FRACTURES TO HIS DISTAL   PHALANX OF HIS THIRD AND FOURTH DIGITS.	Affirmed	Recent	Patient
144	shortness of breath	Pulmonary - No SHORTNESS OF BREATH or pleuritic chest pain.	Negated	Recent	Patient
145	Left leg pain	S_O_H  Counters Report Type Record Type Subgroup Classifier  90,nUthm0pbxjh7 ER ER 1001  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   EMERGENCY DEPARTMENT  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  DATE OF SERVICE:  **DATE[Oct 06 07]  PRIMARY CARE PHYSICIAN: A  N  CHIEF COMPLAINT: LEFT LEG PAIN.	Affirmed	Recent	Patient
146	aortic root size is normal	The AORTIC ROOT SIZE IS NORMAL.	Affirmed	Recent	Patient
147	alert	His coworkers saw him on the floor and when they arrived he was   awake and ALERT.	Affirmed	Recent	Patient
148	nausea	No abdominal pain, NAUSEA, vomiting or diarrhea.	Negated	Recent	Patient
149	Thickened aortic valve with mild to moderate regurgitation	03) THICKENED AORTIC VALVE WITH MILD TO MODERATE REGURGITATION.	Affirmed	Recent	Patient
150	alert	General - ALERT and oriented times three, in no acute distress.	Affirmed	Recent	Patient
151	afebrile	PHYSICAL EXAMINATION:    The patient is AFEBRILE.	Affirmed	Recent	Patient
152	cough	she is afebrile but   persistent COUGH.	Affirmed	Recent	Patient
153	shortness of breath	This is a **AGE[in 60s]-year-old female who presents to the Emergency Department   complaining of SHORTNESS OF BREATH and chest pain since yesterday.	Affirmed	Recent	Patient
154	peripancreatic stranding	There was no   PERIPANCREATIC STRANDING and no discrete mass.	Negated	Recent	Patient
155	severe aortic stenosis	There is SEVERE AORTIC STENOSIS.	Affirmed	Recent	Patient
156	difficulty with ambulation	REASON FOR ADMISSION:    Past medical history is positive for hyperlipidemia, hypothyroidism, weakness   and DIFFICULTY WITH AMBULATION, aortic/mitral disease, spinal stenosis,   cataracts, measles, mumps, and varicella in the past.	Affirmed	Historical	Patient
157	tricuspid valve is normal	The   TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
158	Regular   rate and rhythm	Heart: REGULAR   RATE AND RHYTHM.	Affirmed	Recent	Patient
159	Shortness Of Breath  	8  cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: SHORTNESS OF BREATH    TWO DIMENSIONAL ECHOCARDIOLOGY:   This was a technically difficult study.	Affirmed	Recent	Patient
160	dyspnea on exertion	She says she has had intermittent lower back   pain, intermittent chest pain, and DYSPNEA ON EXERTION.	Affirmed	Recent	Patient
161	aortic valve is thickened	The AORTIC VALVE IS THICKENED.	Affirmed	Recent	Patient
162	Oropharynx is clear	OROPHARYNX IS CLEAR.	Affirmed	Recent	Patient
163	cellulitis	PAST MEDICAL HISTORY:  Significant for Alzheimer disease, hypertension,   atrial fibrillation, history of DVTs, anticoagulation, coronary artery   disease, COPD, history of anemia, history of pulmonary nodules, and history   of CELLULITIS.	Affirmed	Historical	Patient
164	pericardial effusion	No PERICARDIAL EFFUSION is seen.	Negated	Recent	Patient
165	murmurs	No MURMURS.	Negated	Recent	Patient
166	LEFT POSTERIOR INTERNAL   CAROTID ARTERY ANEURYSM	TRANSFER DIAGNOSIS(ES):  STATUS POST COILING FOR LEFT POSTERIOR INTERNAL   CAROTID ARTERY ANEURYSM AND SUBARACHNOID HEMORRHAGE.	Affirmed	Recent	Patient
167	hiatal hernia	A  HIATAL HERNIA was found.	Affirmed	Recent	Patient
168	ulcers	There was no  evidence of ULCERS.	Negated	Recent	Patient
169	vomiting	His pain is associated with nausea, no   VOMITING.	Negated	Recent	Patient
170	tenderness on flexion/extension of both her index   and middle finger	She has TENDERNESS ON FLEXION/EXTENSION OF BOTH HER INDEX   AND MIDDLE FINGER.	Affirmed	Recent	Patient
171	acute radiographic abnormalities in the left  shoulder	FINDINGS:     There are no ACUTE RADIOGRAPHIC ABNORMALITIES IN THE LEFT  SHOULDER.	Negated	Recent	Patient
172	right to left intracardiac shunt	Normal saline contrast   injection without evidence of RIGHT TO LEFT INTRACARDIAC SHUNT.	Negated	Recent	Patient
173	NECK:  Supple	NECK:  SUPPLE.	Affirmed	Recent	Patient
174	rubs	The heart was in a regular rate and rhythm with no murmurs or   RUBS.	Negated	Recent	Patient
175	clubbing	No CLUBBING or cyanosis.	Negated	Recent	Patient
176	lightheaded	She was not LIGHTHEADED at all.	Negated	Recent	Patient
177	5/5 motor strength in all   extremities	Sensation is intact to light touch with 5/5 MOTOR STRENGTH IN ALL   EXTREMITIES.	Affirmed	Recent	Patient
178	Right ventricular function is normal	RIGHT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
179	Chronic obstructive pulmonary disease	CHRONIC OBSTRUCTIVE PULMONARY DISEASE.	Affirmed	Recent	Patient
180	minimal subchondral cystic change of  the acromioclavicular joint without significant osteophytosis  	There may be MINIMAL SUBCHONDRAL CYSTIC CHANGE OF  THE ACROMIOCLAVICULAR JOINT WITHOUT SIGNIFICANT OSTEOPHYTOSIS  present.	Affirmed	Recent	Patient
181	right pleural  effusion	Targeted sonography of the right posterior chest  wall was performed demonstrating a moderate RIGHT PLEURAL  EFFUSION.	Affirmed	Recent	Patient
182	severe left hip degenerative joint disease/vascular   necrosis	Chronic pain with SEVERE LEFT HIP DEGENERATIVE JOINT DISEASE/VASCULAR   NECROSIS, phantom limb pain at the left upper extremity.	Affirmed	Recent	Patient
183	ACUTE CARDIOPULMONARY DISEASE	IMPRESSION:       NO EVIDENCE OF ACUTE CARDIOPULMONARY DISEASE.	Negated	Recent	Patient
184	shortness of breath	Denies SHORTNESS OF BREATH, stridor, or air hunger.	Negated	Recent	Patient
185	ALLERGIES:     TO PENICILLIN	ALLERGIES:     TO PENICILLIN.	Affirmed	Historical	Patient
186	headache	The patient   denied any HEADACHE.	Negated	Recent	Patient
187	infection	She had no overt   signs or symptoms of INFECTION.	Negated	Recent	Patient
188	abdominal pain	S_O_H  Counters Report Type Record Type Subgroup Classifier  13,MFZKSI+l8xGn DS DS 5004  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   GENERAL MEDICINE  DISCHARGE SUMMARY     PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  **ROOM  ATTENDING PHYSICIAN:  **NAME[ZZZ M YYY]  ADMISSION DATE:  **DATE[Sep 19 2007]  DISCHARGE DATE:  **DATE[Sep 27 2007]     The patient is a **AGE[in 40s]-year-old with past medical history of partial small bowel   obstruction, who is admitted quite frequently for ABDOMINAL PAIN, bowel   distention, and partial small bowel obstructions.	Affirmed	Historical	Patient
189	bowel   distention	S_O_H  Counters Report Type Record Type Subgroup Classifier  13,MFZKSI+l8xGn DS DS 5004  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   GENERAL MEDICINE  DISCHARGE SUMMARY     PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  **ROOM  ATTENDING PHYSICIAN:  **NAME[ZZZ M YYY]  ADMISSION DATE:  **DATE[Sep 19 2007]  DISCHARGE DATE:  **DATE[Sep 27 2007]     The patient is a **AGE[in 40s]-year-old with past medical history of partial small bowel   obstruction, who is admitted quite frequently for abdominal pain, BOWEL   DISTENTION, and partial small bowel obstructions.	Affirmed	Historical	Patient
190	Sinus bradycardia	CARDIOVASCULAR: SINUS BRADYCARDIA.	Affirmed	Recent	Patient
191	B-CELL LYMPHOPROLIFERATIVE DISORDER, FAVOR MARGINAL  CELL LYMPHOMA	PARTS 2  AND 3:  BONE MARROW, BIOPSY, AND ASPIRATE -  A.          INVOLVED BY B-CELL LYMPHOPROLIFERATIVE DISORDER, FAVOR MARGINAL  CELL LYMPHOMA (see comment).	Affirmed	Recent	Patient
192	medical noncompliance	History of MEDICAL NONCOMPLIANCE.	Affirmed	Historical	Patient
193	Nondilated left ventricle with mildly hypokinetic anterior wall,  anterior septum and inferior septum and overall preserved systolic   function	FINAL IMPRESSIONS:   01) NONDILATED LEFT VENTRICLE WITH MILDLY HYPOKINETIC ANTERIOR WALL,  ANTERIOR SEPTUM AND INFERIOR SEPTUM AND OVERALL PRESERVED SYSTOLIC   FUNCTION.	Affirmed	Recent	Patient
194	Heart size and pulmonary vascularity are normal	HEART SIZE AND PULMONARY VASCULARITY ARE NORMAL.	Affirmed	Recent	Patient
195	EOMI	Eyes PERRLA, EOMI.	Affirmed	Recent	Patient
196	VIRAL SYNDROME	VIRAL SYNDROME.	Affirmed	Recent	Patient
197	alcohol	HIS SOCIAL HISTORY:  He denies any tobacco, ALCOHOL, or drug abuse although   he occasionally drinks beer.	Negated	Historical	Patient
198	left ventricular hypertrophy	Left ventricular wall thickness is   increased, consistent with LEFT VENTRICULAR HYPERTROPHY.	Affirmed	Recent	Patient
199	Systolic Heart Failure	Wall Thickness:  0.8 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: SYSTOLIC HEART FAILURE; Corrected Transposition Of Great  Vessels    TWO DIMENSIONAL ECHOCARDIOLOGY:   This was a technically difficult study.	Affirmed	Recent	Patient
200	constipation	He has   some nausea, vomiting, diarrhea alternated with CONSTIPATION.	Affirmed	Recent	Patient
201	dizziness	Call also for any weight gain   greater than three pounds per day or five pounds per week, any unusual   rashes, nausea, vomiting, fever associated with chill, temperature elevation   greater than 101 degrees Fahrenheit, sustained or low-grade temperature   greater than 100 degrees Fahrenheit, new onset of chest pain,   light-headedness, or DIZZINESS, new or increased shortness of breath, severe   calf pain, burning on urination or severe depression.	Affirmed	Not particular	Patient
202	fever	He denies any FEVER.	Negated	Recent	Patient
203	CVAs	Unfortunately, the patient's mental status has continued to   deteriorate with her multiple CVAS and/or cerebral hemorrhages during this   hospitalization.	Affirmed	Recent	Patient
204	perianal  skin tags	Digital rectal exam was performed and showed PERIANAL  SKIN TAGS.	Affirmed	Recent	Patient
205	pulmonary edema	A chest x-ray does reveal PULMONARY EDEMA.	Affirmed	Recent	Patient
206	fevers	REVIEW OF SYSTEMS:    Review of systems was negative and the patient has denied any FEVERS or   chills.	Negated	Recent	Patient
207	paralysis	No paresthesia or PARALYSIS.	Negated	Recent	Patient
208	mitral valve is normal	The MITRAL VALVE IS NORMAL.	Affirmed	Recent	Patient
209	angina	It is unclear whether this is secondary to his   respiratory disease or whether this is ANGINA.	Affirmed	Recent	Patient
210	PE	Questionable PE with IVC filter.	Affirmed	Historical	Patient
211	Post-menopausal  	S_O_H  Counters Report Type Record Type Subgroup Classifier  210,2O7O4UtVzA6N SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      CLINICAL HISTORY:  Date of last Menstrual Period:  {Not Entered}  Menstrual History:  POST-MENOPAUSAL    Other Clinical Conditions:  Routine Exam  HPV testing requested, if ASCUS  SOURCE OF SPECIMEN/SLIDES REVIEWED:  ENDOCERVIX, PAP TEST, THINPREP  Received:  **DATE[Feb 5 2008], Taken:  **DATE[Feb 3 2008] 00:00  PAP x 1       _______________________________________________________________  FINAL SCREENING TEST RESULT:   ENDOCERVIX, PAP TEST, THINPREP:  ADEQUACY:  SATISFACTORY FOR EVALUATION  ENDOCERVICAL/TRANSFORMATION ZONE COMPONENT IS ABSENT.	Affirmed	Historical	Patient
212	adenocarcinoma of   lung	HISTORY OF PRESENT ILLNESS:  As per attending notes, **DATE[Mar 13 2008], a   **AGE[in 70s]-year-old female well known to us for many years, who has multiple medical   problems including status post right pneumonectomy for ADENOCARCINOMA OF   LUNG, COPD, and remaining lung renal cell cancer, status post nephrectomy,   carcinoma of thyroid status post thyroidectomy.	Affirmed	Historical	Patient
213	injured   her back	REASON FOR ADMISSION:  The patient is a very pleasant **AGE[in 50s]-year-old Caucasian   female who fell approximately 4 feet in **DATE[Sep 2006] at which time she INJURED   HER BACK as well as sustained a fracture in her left hip.	Affirmed	Recent	Patient
214	Normal left ventricular size and function	02) NORMAL LEFT VENTRICULAR SIZE AND FUNCTION.	Affirmed	Recent	Patient
215	aortic root   size is normal	The AORTIC ROOT   SIZE IS NORMAL.	Affirmed	Recent	Patient
216	poor energy	The patient does have POOR ENERGY and frustration and inability to do   activities she enjoys due to her pain and medical conditions, difficulty   concentrating.	Affirmed	Recent	Patient
217	rales	Lungs   - CTP, no RALES, rhonchi, or wheezes.	Negated	Recent	Patient
218	ACUTE EXACERBATION OF CHRONIC LOW-BACK PAIN	ACUTE EXACERBATION OF CHRONIC LOW-BACK PAIN.	Affirmed	Recent	Patient
219	mild   left ventricular hypertrophy	Left ventricular wall thickness is increased, consistent with MILD   LEFT VENTRICULAR HYPERTROPHY.	Affirmed	Recent	Patient
220	nausea	She denies any NAUSEA.	Negated	Recent	Patient
221	Alert	Neurologic:  ALERT and oriented times three.	Affirmed	Recent	Patient
222	obstructive jaundice	She was admitted for OBSTRUCTIVE JAUNDICE and for a   palliative PTC drain.	Affirmed	Recent	Patient
223	Mallory-Weiss tear	There was no evidence of gastric varices, ulcers, or  MALLORY-WEISS TEAR.	Negated	Recent	Patient
224	diarrhea	His   DIARRHEA had been improving.	Affirmed	Recent	Patient
225	cough	She admits to mild nausea   during this episode while she was at the **INSTITUTION and denies any back   pain, denies fevers, denies COUGH, or cold symptoms.	Negated	Recent	Patient
226	focal sensory or motor deficits	No FOCAL SENSORY OR MOTOR DEFICITS on history.	Negated	Recent	Patient
227	palpitations	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no PALPITATIONS, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
228	Right ventricular function is normal	RIGHT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
229	lungs are  otherwise clear	The LUNGS ARE  OTHERWISE CLEAR.	Affirmed	Recent	Patient
230	Right ventricular size is normal	RIGHT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
231	Right ventricular function is normal	RIGHT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
232	SUBARACHNOID HEMORRHAGE	S_O_H  Counters Report Type Record Type Subgroup Classifier  6,LfVHkBQJkc9L DS DS 5105  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION  NEUROSURGERY  TRANSFER SUMMARY  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  **ROOM  ATTENDING PHYSICIAN:  **NAME[YYY M ZZZ]  TRANSFERRED DATE:  **DATE[Aug 09 07]  TRANSFERRED TO:    TRANSFERRED TO CARE OF:    ADMITTING DIAGNOSIS(ES):   LEFT POSTERIOR INTERNAL CAROTID ARTERY ANEURYSM   AND SUBARACHNOID HEMORRHAGE.	Affirmed	Recent	Patient
233	oriented	GENERAL: The patient was in some distress, holding her right wrist, but,   otherwise, she was alert, ORIENTED, and pleasant.	Affirmed	Recent	Patient
234	Nondilated left ventricle with hypertrophy and overall preserved  systolic function	FINAL IMPRESSIONS:   01) NONDILATED LEFT VENTRICLE WITH HYPERTROPHY AND OVERALL PRESERVED  SYSTOLIC FUNCTION.	Affirmed	Recent	Patient
235	anxiety	The patient's past medical history is significant for ANXIETY and depression.	Affirmed	Historical	Patient
236	LEFT LOWER EXTREMITY CALCANEAL STRESS FRACTURE	LEFT LOWER EXTREMITY CALCANEAL STRESS FRACTURE.	Affirmed	Recent	Patient
237	ELEVATED RIGHT HEMIDIAPHRAGM	UNCHANGED ELEVATED RIGHT HEMIDIAPHRAGM.	Affirmed	Historical	Patient
238	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
239	Extraocular muscles are intact	HEENT:    EXTRAOCULAR MUSCLES ARE INTACT.	Affirmed	Recent	Patient
240	dysuria	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   DYSURIA, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
241	Depression 	DEPRESSION and anxiety.	Affirmed	Recent	Patient
242	Trace edema on the left lower extremity	EXTREMITIES:  TRACE EDEMA ON THE LEFT LOWER EXTREMITY.	Affirmed	Recent	Patient
243	moderate to severe   mitral regurgitation	There is MODERATE TO SEVERE   MITRAL REGURGITATION.	Affirmed	Recent	Patient
244	stabbing chest   pain that radiating to both shoulders	REASON FOR ADMISSION:  This is an **AGE[in 80s]-year-old female with a history of   coronary artery disease who presented on **DATE[Dec 9 2007], with STABBING CHEST   PAIN THAT RADIATING TO BOTH SHOULDERS.	Affirmed	Recent	Patient
245	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
246	Gastritis was  found in the antrum	GASTRITIS WAS  FOUND IN THE ANTRUM.	Affirmed	Recent	Patient
247	lower   abdominal pain	She also complains of LOWER   ABDOMINAL PAIN, for which she had been evaluated by her primary care   physician, and there is the thought that CT of the abdomen and pelvis should   be obtained should she have no symptomatic improvement.	Affirmed	Recent	Patient
248	AVF	The patient   underwent bilateral upper extremity duplex scan on **DATE[Nov 16 2007], which   revealed no evidence of active pseudoaneurysm, AVF, or hematoma in the right   neck and shoulder region.	Negated	Recent	Patient
249	headache	No HEADACHE or dizziness.	Negated	Recent	Patient
250	meningitis	She appeared well and had   unremarkable vital signs, no signs of MENINGITIS, otitis, pharyngitis, or   pneumonia.	Negated	Recent	Patient
251	Brain parenchyma is   relatively normal	BRAIN PARENCHYMA IS   RELATIVELY NORMAL in appearance.	Affirmed	Recent	Patient
252	mitral valve is normal	The MITRAL VALVE IS NORMAL.	Affirmed	Recent	Patient
253	DIZZINESS	ADMISSION DIAGNOSIS(ES):    DIZZINESS AND WEAKNESS OF UNCLEAR ETIOLOGY.	Affirmed	Recent	Patient
254	OBSTRUCTIVE JAUNDICE	OBSTRUCTIVE JAUNDICE.	Affirmed	Historical	Patient
255	coronary artery disease	PAST MEDICAL HISTORY:  Past medical history of CORONARY ARTERY DISEASE, status post CABG,   hypertension, and peripheral vascular disease.	Affirmed	Historical	Patient
256	mild tricuspid regurgitation	There   is MILD TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
257	murmurs	No MURMURS, gallops, or rubs.	Negated	Recent	Patient
258	gallops	No murmurs, GALLOPS, rubs.	Negated	Recent	Patient
259	mild to moderate mitral regurgitation	SPECTRAL DOPPLER:   There is MILD TO MODERATE MITRAL REGURGITATION.	Affirmed	Recent	Patient
260	abdominal wall abscess	HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 40s]-year-old gentleman with a history of HIV/AIDS who is status post   recent ABDOMINAL WALL ABSCESS and status post surgical evacuation in **DATE[Dec] of   2007, presents with increasing left lower extremity swelling and pain over   the last 2 weeks.	Affirmed	Historical	Patient
261	oriented times three	NEUROLOGIC:  Alert and ORIENTED TIMES THREE.	Affirmed	Recent	Patient
262	pleuritic chest pain	Pulmonary - No shortness of breath or PLEURITIC CHEST PAIN.	Negated	Recent	Patient
263	Right atrial size   is normal	RIGHT ATRIAL SIZE   IS NORMAL.	Affirmed	Recent	Patient
264	GI bleed	The Coumadin was discontinued at the time of admission   secondary to the GI BLEED.	Affirmed	Recent	Patient
265	DVTs	PAST MEDICAL HISTORY:  Significant for Alzheimer disease, hypertension,   atrial fibrillation, history of DVTS, anticoagulation, coronary artery   disease, COPD, history of anemia, history of pulmonary nodules, and history   of cellulitis.	Affirmed	Historical	Patient
266	chest   pain	In general, my primary concern regarding this patient was regarding her CHEST   PAIN.	Affirmed	Recent	Patient
267	soft abdomen	Examination of his abdomen revealed a SOFT ABDOMEN with mild tenderness in   the periumbilical area.	Affirmed	Recent	Patient
268	orthopnea	He denies any ORTHOPNEA, lower extremity edema, or calf pain.	Negated	Recent	Patient
269	Left ventricular wall thickness is increased	LEFT VENTRICULAR WALL THICKNESS IS INCREASED, consistent with mild   left ventricular hypertrophy.	Affirmed	Recent	Patient
270	carotid bruits	No CAROTID BRUITS.	Negated	Recent	Patient
271	polyps	There was no evidence of POLYPS, mass or diverticula.	Negated	Recent	Patient
272	BK virus	S_O_H  Counters Report Type Record Type Subgroup Classifier  207,ky8CWB3WWPyP SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PROCEDURES  BK Virus Plasma (PH)  Interpretation  Plasma:  Quantitative PCR testing for BK VIRUS is NEGATIVE.	Negated	Recent	Patient
273	orthotopic heart transplantation	05) Findings consistent with ORTHOTOPIC HEART TRANSPLANTATION.	Affirmed	Recent	Patient
274	diaphoresis	Denies any shortness of breath or   DIAPHORESIS.	Negated	Recent	Patient
275	rales	No wheezes, RALES, or   rhonchi.	Negated	Recent	Patient
276	Overall left ventricular function is normal	OVERALL LEFT VENTRICULAR FUNCTION IS NORMAL, with an estimated ejection   fraction of 60-65 %.	Affirmed	Recent	Patient
277	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
278	30-pound weight loss	The   patient has decreased appetite with 30-POUND WEIGHT LOSS and some diarrhea   from C. diff.	Affirmed	Recent	Patient
279	Alert	Neurologic - ALERT,   oriented times three.	Affirmed	Recent	Patient
280	rhinorrhea   	She also   states that she has had URI symptoms over the last week, including RHINORRHEA     and mild sore throat.	Affirmed	Recent	Patient
281	mild mitral regurgitation	There is MILD MITRAL REGURGITATION.	Affirmed	Recent	Patient
282	Endocarditis	Wall Thickness:  1.5 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: ENDOCARDITIS  TWO DIMENSIONAL ECHOCARDIOLOGY:   Left ventricular size is normal.	Affirmed	Recent	Patient
283	epigastric pain	He was also   given Protonix for his EPIGASTRIC PAIN and nitroglycerine for his chest pain.	Affirmed	Recent	Patient
284	E xternal  Hemorrhoids  	COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) Pedunculated polyp in the mid transverse colon    2) Diverticuli, scattered in the left colon    3)E XTERNAL  HEMORRHOIDS      PLAN:  1) Follow-up: as scheduled referring MD  2) Await biopsy results    REPEAT EXAM:  Colonoscopy in 5 - 10 year(s).	Affirmed	Recent	Patient
285	antiphospholipid antibody syndrome	Most recently, the patient has been   maintained on high dose steroids for her ANTIPHOSPHOLIPID ANTIBODY SYNDROME   given anticoagulation was not an option secondary to her known cerebral   hemorrhage.	Affirmed	Recent	Patient
286	malnutrition	The indication for this procedure is history  of Billroth II for perforated ulcer, with MALNUTRITION, nausea and vomiting.	Affirmed	Recent	Patient
287	ABDOMEN:  Soft, nontender, nondistended	ABDOMEN:  SOFT, NONTENDER, NONDISTENDED.	Affirmed	Recent	Patient
288	weakness	If she has any new tingling, any   WEAKNESS, increasing pain, or change in color of her finger, she should   immediately return to the department, otherwise, I feel she is safe for   discharge at this time.	Affirmed	Not particular	Patient
289	chest pain	He denies any   antecedent palpitations, shortness of breath, CHEST PAIN, headache, or   lightheadedness.	Negated	Recent	Patient
290	Herniated disks at L4 and L5	HERNIATED DISKS AT L4 AND L5.	Affirmed	Historical	Patient
291	rubs	No murmurs, gallops, or RUBS.	Negated	Recent	Patient
292	hiatal hernia	A HIATAL HERNIA was found.	Affirmed	Recent	Patient
293	peripheral vascular disease	PAST MEDICAL HISTORY:  Past medical history of coronary artery disease, status post CABG,   hypertension, and PERIPHERAL VASCULAR DISEASE.	Affirmed	Historical	Patient
294	left lower extremity is   more mottled	Most recently, on the day of discharge, the patient's LEFT LOWER EXTREMITY IS   MORE MOTTLED than it previously had been.	Affirmed	Recent	Patient
295	pulmonary embolic	Questionable history of PULMONARY EMBOLIC/inferior vena cava filter.	Affirmed	Historical	Patient
296	hemoccult  positive stool	The indication for this procedure is HEMOCCULT  POSITIVE STOOL.	Affirmed	Recent	Patient
297	central calcifications and mild thickening of the bladder wall	There is  CENTRAL CALCIFICATIONS AND MILD THICKENING OF THE BLADDER WALL.	Affirmed	Recent	Patient
298	Shortness of breath	HISTORY OF PRESENT ILLNESS:    CHIEF COMPLAINT:   SHORTNESS OF BREATH.	Affirmed	Recent	Patient
299	Hairy cell leukemia	LB/acs  PRE-OP DIAGNOSIS:     HAIRY CELL LEUKEMIA.	Affirmed	Recent	Patient
300	cancer of the left eyelid	MEDICAL HISTORY:   Atrial fibrillation, hypertension, arthritis, coronary artery disease, GERD,   cataracts, and CANCER OF THE LEFT EYELID.	Affirmed	Historical	Patient
301	trace tricuspid regurgitation	SPECTRAL DOPPLER:   There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
302	PERINEURAL EXTENSION OF  DISEASE	NEW, SUBTLE ENHANCEMENT ALONG THE RIGHT AND LEFT 7TH AND 8TH  CRANIAL NERVES MAY SUGGEST UNDERLYING PERINEURAL EXTENSION OF  DISEASE.	Affirmed	Recent	Patient
303	Borderline personality disorder	BORDERLINE PERSONALITY DISORDER.	Affirmed	Recent	Patient
304	hypertension	LABORATORY, RADIOGRAPHIC, AND OTHER DIAGNOSTIC STUDY FINDINGS:    HPI AND HOSPITAL COURSE:    Ms. **NAME[AAA] is a very pleasant **AGE[in 80s]-year-old female with a history of HYPERTENSION   who was transferred to **INSTITUTION from an outside hospital because of necrotizing   pancreatitis.	Affirmed	Historical	Patient
305	CHRONIC LYMPHOCYTIC THYROIDITIS, MILD TO MODERATE	B.     CHRONIC LYMPHOCYTIC THYROIDITIS, MILD TO MODERATE.	Affirmed	Recent	Patient
306	nausea	HISTORY OF PRESENT ILLNESS:  Ms. **NAME[AAA] is a **AGE[in 40s]-year-old, African-American   female with a two-day history of fever, body aches, and NAUSEA, vomiting, and   diarrhea.	Affirmed	Recent	Patient
307	pulmonary artery size is   normal	The PULMONARY ARTERY SIZE IS   NORMAL.	Affirmed	Recent	Patient
308	remainder of the brain  parenchyma is unremarkable	The REMAINDER OF THE BRAIN  PARENCHYMA IS UNREMARKABLE.	Affirmed	Recent	Patient
309	right to left intracardiac shunt	Normal saline contrast injection without   evidence of RIGHT TO LEFT INTRACARDIAC SHUNT.	Negated	Recent	Patient
310	aortic root size is normal	The AORTIC ROOT SIZE IS NORMAL.	Affirmed	Recent	Patient
311	mild mitral stenosis	There is MILD MITRAL STENOSIS.	Affirmed	Recent	Patient
312	sessile polyp in the transverse colon  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) 5mm SESSILE POLYP IN THE TRANSVERSE COLON    2) 5mm Sessile polyp in the descending colon  3) 6mm Sessile polyp in the rectum  4) Hemorrhoids  5) Otherwise normal exam    PLAN:  1) Await biopsy results    REPEAT EXAM:  Colonoscopy with internval depending on biopsy results    ______________________________  **NAME[YYY ZZZ], M.D.  I was present during the entire procedure.	Affirmed	Recent	Patient
313	pulmonary hypertension	Congenital heart disease/aortic and mitral valvular disease/nonischemic   cardiomyopathy/PULMONARY HYPERTENSION.	Affirmed	Recent	Patient
314	aortic root   size is borderline dilated	The AORTIC ROOT   SIZE IS BORDERLINE DILATED.	Affirmed	Recent	Patient
315	Right atrial size is normal	RIGHT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
316	use of antibiotics	He does occasionally have loose stools, no fevers or chills, no   sick contacts, no recent USE OF ANTIBIOTICS.	Negated	Recent	Patient
317	some nausea	He has   SOME NAUSEA, vomiting, diarrhea alternated with constipation.	Affirmed	Recent	Patient
318	worsening pain	She will return if she experiences any WORSENING PAIN or   any other new or concerning symptoms.	Affirmed	Not particular	Patient
319	Neck supple	NECK SUPPLE.	Affirmed	Recent	Patient
320	Normal esophagus  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) NORMAL ESOPHAGUS    2) Retained food in thegastric remnant  3) Patent Billroth II anastomosis  4) s/p 10 French NJ tube placement in efferent limb    PLAN:  1) Follow NJ tube order set for feeding  2) No meds through J port    REPEAT EXAM:  No    __________________________________  **NAME[YYY M. ZZZ], M.D.  I was present during the entire procedure.	Affirmed	Recent	Patient
321	esophageal strictures	The patient is a **AGE[in 60s]-year-old woman with ESOPHAGEAL STRICTURES who presents   with two days of a foreign body sensation.	Affirmed	Historical	Patient
322	diarrhea	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or DIARRHEA, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
323	Heart size is normal	FINDINGS:     HEART SIZE IS NORMAL.	Affirmed	Recent	Patient
324	Skin is warm and dry	SKIN IS WARM AND DRY.	Affirmed	Recent	Patient
325	substernal chest pressure 	Cardiovascular - No SUBSTERNAL CHEST PRESSURE or dyspnea on exertion.	Negated	Recent	Patient
326	B12 deficiency	She does have B12 DEFICIENCY and she is getting   vitamin B12 shots every month.	Affirmed	Recent	Patient
327	Left ventricular size is normal	Wall Thickness:  1.5 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Endocarditis  TWO DIMENSIONAL ECHOCARDIOLOGY:   LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
328	Stage I sacral decubitus	STAGE I SACRAL DECUBITUS.	Affirmed	Recent	Patient
329	Segmental left ventricular function is normal	SEGMENTAL LEFT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
330	vomiting	Does not   give a history of deafness and denies any recent nausea, VOMITING and   diarrhea.	Negated	Recent	Patient
331	C. diff colitis	The patient   also developed C. DIFF COLITIS and started on Flagyl.	Affirmed	Recent	Patient
332	esophagus and esophagogastric-junction were normal	FINDINGS:  The ESOPHAGUS AND ESOPHAGOGASTRIC-JUNCTION WERE NORMAL in appearance.	Affirmed	Recent	Patient
333	pulmonary artery size is normal	The PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
334	HYPERLIPIDEMIA	HYPERLIPIDEMIA.	Affirmed	Historical	Patient
335	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
336	trace tricuspid regurgitation	COLOR FLOW DOPPLER:   There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
337	focal neurologic deficits	No FOCAL NEUROLOGIC DEFICITS.	Negated	Recent	Patient
338	Left ventricular wall thickness   is normal	LEFT VENTRICULAR WALL THICKNESS   IS NORMAL.	Affirmed	Recent	Patient
339	Right atrial size is normal	RIGHT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
340	angiodysplasia was noted in the cecum	FINDINGS:  An ANGIODYSPLASIA WAS NOTED IN THE CECUM.	Affirmed	Recent	Patient
341	renal cell cancer	HISTORY OF PRESENT ILLNESS:  As per attending notes, **DATE[Mar 13 2008], a   **AGE[in 70s]-year-old female well known to us for many years, who has multiple medical   problems including status post right pneumonectomy for adenocarcinoma of   lung, COPD, and remaining lung RENAL CELL CANCER, status post nephrectomy,   carcinoma of thyroid status post thyroidectomy.	Affirmed	Historical	Patient
342	alcohol	Denies ALCOHOL or other drug use.	Negated	Historical	Patient
343	pneumothorax	There is no pleural effusion or PNEUMOTHORAX.	Negated	Recent	Patient
344	Thickened mitral valve with  moderate regurgitation	03) THICKENED MITRAL VALVE WITH  MODERATE REGURGITATION.	Affirmed	Recent	Patient
345	vomiting	Call also for any weight gain   greater than three pounds per day or five pounds per week, any unusual   rashes, nausea, VOMITING, fever associated with chill, temperature elevation   greater than 101 degrees Fahrenheit, sustained or low-grade temperature   greater than 100 degrees Fahrenheit, new onset of chest pain,   light-headedness, or dizziness, new or increased shortness of breath, severe   calf pain, burning on urination or severe depression.	Affirmed	Not particular	Patient
346	mild to moderate aortic regurgitation	COLOR FLOW DOPPLER:   There is MILD TO MODERATE AORTIC REGURGITATION.	Affirmed	Recent	Patient
347	foreign body in throat	S_O_H  Counters Report Type Record Type Subgroup Classifier  81,LG2nw5XqlWuD ER ER 1001  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   EMERGENCY DEPARTMENT  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  DATE OF SERVICE:  **DATE[Mar 06 08]  PRIMARY CARE PHYSICIAN: WISHWA N KAPOOR  HISTORY OF PRESENT ILLNESS:    Chief complaint - FOREIGN BODY IN THROAT.	Affirmed	Recent	Patient
348	mild tricuspid regurgitation	There is MILD TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
349	Left ventricular wall thickness is normal	LEFT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
350	pulmonic regurgitation	There is trace PULMONIC REGURGITATION.	Affirmed	Recent	Patient
351	severe epigastric pain	On **DATE[Jul 04 2007], she states that she had SEVERE EPIGASTRIC PAIN   when eating food and therefore went to the Emergency Department.	Affirmed	Recent	Patient
352	pulmonary   artery size is normal	The PULMONARY   ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
353	dehydration	Following his   evaluation, we admitted him to a general floor, primarily for DEHYDRATION.	Affirmed	Recent	Patient
354	CHEST PAIN	ADMISSION DIAGNOSIS(ES):    CHEST PAIN.	Affirmed	Recent	Patient
355	unusual   rashes	Call also for any weight gain   greater than three pounds per day or five pounds per week, any UNUSUAL   RASHES, nausea, vomiting, fever associated with chill, temperature elevation   greater than 101 degrees Fahrenheit, sustained or low-grade temperature   greater than 100 degrees Fahrenheit, new onset of chest pain,   light-headedness, or dizziness, new or increased shortness of breath, severe   calf pain, burning on urination or severe depression.	Affirmed	Not particular	Patient
356	depression	It was felt that her   delusion was due to her medical decondition with some component of   dissociative disorder and borderline personality disorder as well as   DEPRESSION and anxiety.	Affirmed	Recent	Patient
357	cold symptoms	She admits to mild nausea   during this episode while she was at the **INSTITUTION and denies any back   pain, denies fevers, denies cough, or COLD SYMPTOMS.	Negated	Recent	Patient
358	blood pressure was elevated	The patient was in sinus bradycardia, but BLOOD PRESSURE WAS ELEVATED.	Affirmed	Recent	Patient
359	pericardial effusion	No PERICARDIAL EFFUSION is seen.	Negated	Recent	Patient
360	Cranial nerves II to XII intact	CRANIAL NERVES II TO XII INTACT.	Affirmed	Recent	Patient
361	trace mitral regurgitation	COLOR FLOW DOPPLER:   There is TRACE MITRAL REGURGITATION.	Affirmed	Recent	Patient
362	carcinoma of thyroid	HISTORY OF PRESENT ILLNESS:  As per attending notes, **DATE[Mar 13 2008], a   **AGE[in 70s]-year-old female well known to us for many years, who has multiple medical   problems including status post right pneumonectomy for adenocarcinoma of   lung, COPD, and remaining lung renal cell cancer, status post nephrectomy,   CARCINOMA OF THYROID status post thyroidectomy.	Affirmed	Historical	Patient
363	right  hemidiaphragm is elevated	The RIGHT  HEMIDIAPHRAGM IS ELEVATED but unchanged.	Affirmed	Recent	Patient
364	metastatic disease of the lung	Evaluate for restaging  for METASTATIC DISEASE OF THE LUNG.	Affirmed	Recent	Patient
365	awake	GENERAL:  He is AWAKE, alert, in no acute distress.	Affirmed	Recent	Patient
366	Right   atrial size is normal	RIGHT   ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
367	Left ventricular size is normal	Wall Thickness:  0.9 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Respiratory System Disease  TWO DIMENSIONAL ECHOCARDIOLOGY:   LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
368	vegetations	04) No VEGETATIONS seen by this technique.	Negated	Recent	Patient
369	Mild rales at the bases bilaterally	PULMONARY:  MILD RALES AT THE BASES BILATERALLY.	Affirmed	Recent	Patient
370	weakness	Neurologic - No numbness, tingling, or WEAKNESS.	Negated	Recent	Patient
371	neck pain	No NECK PAIN or meningismus.	Negated	Recent	Patient
372	sick contacts	He does occasionally have loose stools, no fevers or chills, no   SICK CONTACTS, no recent use of antibiotics.	Negated	Recent	Patient
373	left lower   extremity is mottled	The patient does have lower extremity edema and her LEFT LOWER   EXTREMITY IS MOTTLED as previously noted.	Affirmed	Recent	Patient
374	atrial flutter with 2:1 conduction	ED COURSE:   EKG INTERPRETATION: EKG reveals ATRIAL FLUTTER WITH 2:1 CONDUCTION and ST   elevations in leads V2, V3, and V4, as well as T-wave inversions in I and   AVL.	Affirmed	Recent	Patient
375	Motor is 5/5 in all extremities	MOTOR IS 5/5 IN ALL EXTREMITIES.	Affirmed	Recent	Patient
376	multiple sclerosis	Assessment of this Patient:  She is a **AGE[in 70s]-year-old female with a history of   MULTIPLE SCLEROSIS, and paralysis with a history of urinary tract infections   and urinary incontinence with chronic Foley, who had been reported to have   vaginal bleeding, however, was found to have blood at the urethral meatus,   consistent with urethral trauma.	Affirmed	Historical	Patient
377	Increased cholesterol	INCREASED CHOLESTEROL.	Affirmed	Historical	Patient
378	pneumonia	Chest x-ray upon admission revealed a small to moderate left   basilar atelectasis/effusion and there were no findings of PNEUMONIA.	Negated	Recent	Patient
379	diarrhea	Denied any constipation or DIARRHEA.	Negated	Recent	Patient
380	acute distress	PHYSICAL EXAMINATION:  General - In no ACUTE DISTRESS.	Negated	Recent	Patient
381	gallops	No murmurs, GALLOPS, or rubs.	Negated	Recent	Patient
382	illicit drug use	SOCIAL HISTORY:     Denies any alcohol, tobacco or ILLICIT DRUG USE.	Negated	Historical	Patient
383	mild enhancement along the expected  course of the right and left 7th and 8th cranial nerves	There is also new, subtle MILD ENHANCEMENT ALONG THE EXPECTED  COURSE OF THE RIGHT AND LEFT 7TH AND 8TH CRANIAL NERVES (series 3,  image 24).	Affirmed	Recent	Patient
384	shortness of breath	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no SHORTNESS OF BREATH, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
385	anterior wall, anterior septum and   inferior septum are mildly hypokinetic	The ANTERIOR WALL, ANTERIOR SEPTUM AND   INFERIOR SEPTUM ARE MILDLY HYPOKINETIC.	Affirmed	Recent	Patient
386	body aches	HISTORY OF PRESENT ILLNESS:  Ms. **NAME[AAA] is a **AGE[in 40s]-year-old, African-American   female with a two-day history of fever, BODY ACHES, and nausea, vomiting, and   diarrhea.	Affirmed	Recent	Patient
387	Hypothyroid	HYPOTHYROID.	Affirmed	Historical	Patient
388	staph   bacteremia	S_O_H  Counters Report Type Record Type Subgroup Classifier  1,01TdvtyYejbW DS DS 1504  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   CARDIOLOGY   DISCHARGE SUMMARY  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM   **ROOM   ATTENDING PHYSICIAN:  **NAME[YYY M ZZZ]  ADMISSION DATE:  **DATE[Sep 27 2007]  DISCHARGE DATE: **DATE[Oct 07 2007]  The patient is a **AGE[in 60s]-year-old gentleman who presented to **INSTITUTION   with complaints of shortness of breath and was found to have STAPH   BACTEREMIA.	Affirmed	Recent	Patient
389	Overall left ventricular function is normal	OVERALL LEFT VENTRICULAR FUNCTION IS NORMAL, with an   estimated ejection fraction of 55-60 %.	Affirmed	Recent	Patient
390	hypertension	PAST MEDICAL HISTORY:  Past medical history of coronary artery disease, status post CABG,   HYPERTENSION, and peripheral vascular disease.	Affirmed	Historical	Patient
391	change in  bowel habits	The indication for this procedure is CHANGE IN  BOWEL HABITS.	Affirmed	Recent	Patient
392	CEREBROVASCULAR ACCIDENT	CEREBROVASCULAR ACCIDENT.	Affirmed	Recent	Patient
393	abdomen is soft, nontender, nondistended	The ABDOMEN IS SOFT, NONTENDER, NONDISTENDED.	Affirmed	Recent	Patient
394	severe left   ventricular hypertrophy	Left   ventricular wall thickness is increased, consistent with SEVERE LEFT   VENTRICULAR HYPERTROPHY.	Affirmed	Recent	Patient
395	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
396	skin is warm and dry 	The SKIN IS WARM AND DRY with no rash.	Affirmed	Recent	Patient
397	Syncope	S_O_H  Counters Report Type Record Type Subgroup Classifier  83,mMAoV8fUczuV ER ER 1005  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   EMERGENCY DEPARTMENT  PATIENT NAME:  **NAME[AAA] JR, **NAME[BBB M]  ACCOUNT #:  **ID-NUM   DATE OF SERVICE:  **DATE[Jun 02 07]   PRIMARY CARE PHYSICIAN: **NAME[VVV M. UUU], M.D.  CHIEF COMPLAINT:  SYNCOPE.	Affirmed	Recent	Patient
398	abdomen is soft	The ABDOMEN IS SOFT.	Affirmed	Recent	Patient
399	hematoma in the right   neck and shoulder region	The patient   underwent bilateral upper extremity duplex scan on **DATE[Nov 16 2007], which   revealed no evidence of active pseudoaneurysm, AVF, or HEMATOMA IN THE RIGHT   NECK AND SHOULDER REGION.	Negated	Recent	Patient
400	Sensation is intact to light touch	SENSATION IS INTACT TO LIGHT TOUCH with 5/5 motor strength in all   extremities.	Affirmed	Recent	Patient
401	aortic/mitral disease	REASON FOR ADMISSION:    Past medical history is positive for hyperlipidemia, hypothyroidism, weakness   and difficulty with ambulation, AORTIC/MITRAL DISEASE, spinal stenosis,   cataracts, measles, mumps, and varicella in the past.	Affirmed	Historical	Patient
402	nausea	She had very low   residuals, as well as no NAUSEA or vomiting.	Negated	Recent	Patient
403	left lower extremity DVT	Of note, the patient also had a recent lower   extremity x-ray which revealed a calcaneal stress _____________ foot fracture     and the Dopplers revealed that he had a new LEFT LOWER EXTREMITY DVT.	Affirmed	Recent	Patient
404	confusion	S_O_H  Counters Report Type Record Type Subgroup Classifier  84,6TRhtqjX2qLX ER ER 1005  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   EMERGENCY DEPARTMENT  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM   DATE OF SERVICE:  **DATE[Dec 31 07]   PRIMARY CARE PHYSICIAN: **NAME[CCC DDD ZZZ]  ATTENDING PHYSICIAN ADDENDUM:  Chief complaint is left-sided weakness and CONFUSION.	Affirmed	Recent	Patient
405	OSSEOUS EROSION INVOLVING THE POSTERIOR ELEMENTS ON THE LEFT AT   C7 AND T1	CT EXAMINATION OF THE NECK   SHOWS OSSEOUS EROSION INVOLVING THE POSTERIOR ELEMENTS ON THE LEFT AT   C7 AND T1 WHICH HAVE PROGRESSED SINCE THE PRIOR CT EXAMINATION OF   **DATE[Jul 14 2004].	Affirmed	Recent	Patient
406	ABDOMEN:  Soft, nontender, nondistended	ABDOMEN:  SOFT, NONTENDER, NONDISTENDED.	Affirmed	Recent	Patient
407	mild to moderate aortic regurgitation	COLOR FLOW DOPPLER:   There is MILD TO MODERATE AORTIC REGURGITATION.	Affirmed	Recent	Patient
408	difficulty voiding	The patient denied   any DIFFICULTY VOIDING.	Negated	Recent	Patient
409	hemodynamically stable	Within 24 hours, the patient was successfully extubated from   mechanical intubation, was found to be neurologically intact and   HEMODYNAMICALLY STABLE.	Affirmed	Recent	Patient
410	Trace varices in the distal esophagus  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) TRACE VARICES IN THE DISTAL ESOPHAGUS    2) Portal hypertensive gastropathy throughout the stomach    3) Angiodysplasia (spider angioma) in the bulb of duodenum  4) Normal D1/D2    PLAN:  1) **INSTITUTION for Liver Disease with Dr. **NAME[UUU]  2) Protonix 40 mg po qd    REPEAT EXAM:  EGD in 1 - 2 year(s);    __________________________________  **NAME[YYY ZZZ], M.D.  I was present during the entire procedure.	Affirmed	Recent	Patient
411	tricuspid valve is normal	The   TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
412	low-grade temperature	While   in the ICU, she had episodes of LOW-GRADE TEMPERATURE but no leukocytosis.	Affirmed	Recent	Patient
413	aortic root   size is normal	The AORTIC ROOT   SIZE IS NORMAL.	Affirmed	Recent	Patient
414	ADRENAL INSUFFICIENCY	ADRENAL INSUFFICIENCY.	Affirmed	Historical	Patient
415	Yeast infection	YEAST INFECTION.	Affirmed	Historical	Patient
416	heart size is normal	FINDINGS:     The HEART SIZE IS NORMAL.	Affirmed	Recent	Patient
417	lower extremity edema	EXTREMITIES:  2+ LOWER EXTREMITY EDEMA.	Affirmed	Recent	Patient
418	moderate mitral   regurgitation	There is MODERATE MITRAL   REGURGITATION.	Affirmed	Recent	Patient
419	At L4-L5, there is moderate canal compromise with diffuse disc  bulge, loss of disc height as well as moderate right neural  foraminal narrowing and mild left neural foraminal narrowing	AT L4-L5, THERE IS MODERATE CANAL COMPROMISE WITH DIFFUSE DISC  BULGE, LOSS OF DISC HEIGHT AS WELL AS MODERATE RIGHT NEURAL  FORAMINAL NARROWING AND MILD LEFT NEURAL FORAMINAL NARROWING.	Affirmed	Recent	Patient
420	delusions	No DELUSIONS, lethargy, or   hallucinations.	Negated	Recent	Patient
421	Diverticula in the left colon  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) DIVERTICULA IN THE LEFT COLON    2) Otherwise normal exam    PLAN:  1) Follow-up: as scheduled referring MD  2) Fiber rich diet    REPEAT EXAM:  Colonoscopy in 5 year(s).	Affirmed	Recent	Patient
422	Portal hypertensive gastropathy throughout the stomach  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) Trace varices in the distal esophagus    2) PORTAL HYPERTENSIVE GASTROPATHY THROUGHOUT THE STOMACH    3) Angiodysplasia (spider angioma) in the bulb of duodenum  4) Normal D1/D2    PLAN:  1) **INSTITUTION for Liver Disease with Dr. **NAME[UUU]  2) Protonix 40 mg po qd    REPEAT EXAM:  EGD in 1 - 2 year(s);    __________________________________  **NAME[YYY ZZZ], M.D.  I was present during the entire procedure.	Affirmed	Recent	Patient
423	Segmental left ventricular function is normal	SEGMENTAL LEFT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
424	Segmental left ventricular function is   abnormal	SEGMENTAL LEFT VENTRICULAR FUNCTION IS   ABNORMAL.	Affirmed	Recent	Patient
425	ALLERGIES - PHENOBARBITAL AND TRILEPTAL	ALLERGIES - PHENOBARBITAL AND TRILEPTAL.	Affirmed	Recent	Patient
426	Left ventricular size is normal	Wall Thickness:  1.1 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Coronary Artery Disease, Native Coronary Arte  TWO DIMENSIONAL ECHOCARDIOLOGY:   LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
427	malignant thymoma	CHEST:  The patient has undergone a median sternotomy and  resection of a MALIGNANT THYMOMA.	Affirmed	Recent	Patient
428	clubbing	Extremities:  No cyanosis or CLUBBING, there is +2 pitting edema.	Negated	Recent	Patient
429	MINIMAL SUBCHONDRAL CYSTIC CHANGE WITHOUT  HYPERTROPHIC OSTEOPHYTOSIS OF THE ACROMIOCLAVICULAR JOINT	IMPRESSION:       NO SIGNIFICANT RADIOGRAPHIC ABNORMALITIES IN THE LEFT SHOULDER  REGION, EXCEPT FOR MINIMAL SUBCHONDRAL CYSTIC CHANGE WITHOUT  HYPERTROPHIC OSTEOPHYTOSIS OF THE ACROMIOCLAVICULAR JOINT.	Affirmed	Recent	Patient
430	awake	General:  The patient is AWAKE, alert, lucid, appears to be in mild amount of   pain, in no acute distress.	Affirmed	Recent	Patient
431	Right ventricular size is normal	RIGHT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
432	aortic root   size is normal	The AORTIC ROOT   SIZE IS NORMAL.	Affirmed	Recent	Patient
433	Right ventricular size is normal	RIGHT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
434	pulmonary artery size is normal	The PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
435	paralysis	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or PARALYSIS, no rash.	Negated	Recent	Patient
436	Motor and   sensation intact distally in all four extremities	MOTOR AND   SENSATION INTACT DISTALLY IN ALL FOUR EXTREMITIES.	Affirmed	Recent	Patient
437	respiratory insufficiency	The patient was treated for RESPIRATORY INSUFFICIENCY and hemodynamic   instability.	Affirmed	Recent	Patient
438	Neck:  Supple and nontender	NECK:  SUPPLE AND NONTENDER.	Affirmed	Recent	Patient
439	necrotizing   pancreatitis	A repeat CT done at the outside hospital showed NECROTIZING   PANCREATITIS and therefore, she was transferred to **INSTITUTION for further   management.	Affirmed	Recent	Patient
440	heart rate was fast	It   did say that she noted that her HEART RATE WAS FAST, but she does not feel   like that any more.	Affirmed	Recent	Patient
441	mild aortic regurgitation	SPECTRAL DOPPLER:   There is MILD AORTIC REGURGITATION.	Affirmed	Recent	Patient
442	pain	The   patient states that her PAIN was 1-2/10 in intensity in her chest.	Affirmed	Recent	Patient
443	abdominal hysterectomy with bilateral   salpingooophorectomy 	Status post total ABDOMINAL HYSTERECTOMY WITH BILATERAL   SALPINGOOOPHORECTOMY in 1996.	Affirmed	Historical	Patient
444	Mild aortic root dilation	05) MILD AORTIC ROOT DILATION.	Affirmed	Recent	Patient
445	foreign body sensa-tion	She still continues to have   throat discomfort and complains of a FOREIGN BODY SENSA-TION in the same   area.	Affirmed	Recent	Patient
446	Left ventricular wall thickness is normal	LEFT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
447	Extraocular muscles are intact	HEENT:  EXTRAOCULAR MUSCLES ARE INTACT.	Affirmed	Recent	Patient
448	mitral   valve is normal	The MITRAL   VALVE IS NORMAL.	Affirmed	Recent	Patient
449	changes in hearing	In general, he denies any   changes in vision or diplopia, no CHANGES IN HEARING, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
450	Nondilated left ventricle with mild hypertrophy and overall preserved  systolic function	02) NONDILATED LEFT VENTRICLE WITH MILD HYPERTROPHY AND OVERALL PRESERVED  SYSTOLIC FUNCTION.	Affirmed	Recent	Patient
451	Right ventricular wall thickness is   normal	RIGHT VENTRICULAR WALL THICKNESS IS   NORMAL.	Affirmed	Recent	Patient
452	right   ventricular hypertrophy	Right ventricular wall thickness is increased, consistent with RIGHT   VENTRICULAR HYPERTROPHY.	Affirmed	Recent	Patient
453	advanced degenerative joint disease of the right  knee joint and ossification present just above the patella  probably in the distal quadriceps tendon region	There is ADVANCED DEGENERATIVE JOINT DISEASE OF THE RIGHT  KNEE JOINT AND OSSIFICATION PRESENT JUST ABOVE THE PATELLA  PROBABLY IN THE DISTAL QUADRICEPS TENDON REGION.	Affirmed	Recent	Patient
454	Right   ventricular size is normal	RIGHT   VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
455	cough	He is developing some   URI symptoms including COUGH and rhinorrhea.	Affirmed	Recent	Patient
456	Normal esophagus  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) NORMAL ESOPHAGUS    2) Normal stomach    3) Duodenitis in the bulb of duodenum      PLAN:  1) **INSTITUTION for Liver Disease  2) await biopsy results    REPEAT EXAM:  No    __________________________________  **NAME[YYY ZZZ]  I was present during the entire procedure.	Affirmed	Recent	Patient
457	oral mucosa is moist with no erythema or exudates	The ORAL MUCOSA IS MOIST WITH NO ERYTHEMA OR EXUDATES.	Affirmed	Recent	Patient
458	trace mitral regurgitation	There is TRACE MITRAL REGURGITATION.	Affirmed	Recent	Patient
459	wide mediastinum	Chest x-ray with demonstrate   no WIDE MEDIASTINUM.	Negated	Recent	Patient
460	significant coronary artery disease	This is a negative   stress EKG/echocardiographic test for ischemia, therefore, there is a   low suspicion for SIGNIFICANT CORONARY ARTERY DISEASE.	Negated	Recent	Patient
461	new or increased shortness of breath	Call also for any weight gain   greater than three pounds per day or five pounds per week, any unusual   rashes, nausea, vomiting, fever associated with chill, temperature elevation   greater than 101 degrees Fahrenheit, sustained or low-grade temperature   greater than 100 degrees Fahrenheit, new onset of chest pain,   light-headedness, or dizziness, NEW OR INCREASED SHORTNESS OF BREATH, severe   calf pain, burning on urination or severe depression.	Affirmed	Not particular	Patient
462	Positive S1 and S2	Heart:  POSITIVE S1 AND S2.	Affirmed	Recent	Patient
463	aortic valve is normal	The AORTIC VALVE IS NORMAL.	Affirmed	Recent	Patient
464	emesis	It is   reported that the patient here had multiple episodes of food contents as well   as clear EMESIS.	Affirmed	Recent	Patient
465	gastric  varices	There was no evidence of esophageal varices or GASTRIC  VARICES.	Negated	Recent	Patient
466	rhabdomyolysis	History of RHABDOMYOLYSIS.	Affirmed	Historical	Patient
467	gastropathy	POST-OP DIAGNOSIS:  Rule out H. pylori, gastritis and GASTROPATHY.	Affirmed	Recent	Patient
468	hallucinations	No delusions, lethargy, or   HALLUCINATIONS.	Negated	Recent	Patient
469	dizziness	She   will call Dr. **NAME[ZZZ] at that same number if there is any newer increased   shortness of breath, new onset of chest pain, lightheadedness, DIZZINESS,   fainting, ankle swelling, abdominal bloating/weight gain of 2 pounds in 24   hours or 4 pounds in a week or less.	Affirmed	Not particular	Patient
470	colitis	pre-SBTx work up, r/o polyps cancer, COLITIS    DESCRIPTION OF OPERATION:  After explaining the risks of, the benefits of, and alternatives to ileoscopy,  informed consent was obtained from the informed patient.	Affirmed	Recent	Patient
471	headache	She also complains of HEADACHE.	Affirmed	Recent	Patient
472	trace pulmonic regurgitation	There is TRACE PULMONIC REGURGITATION.	Affirmed	Recent	Patient
473	Mild to moderate aortic regurgitation	02) MILD TO MODERATE AORTIC REGURGITATION.	Affirmed	Recent	Patient
474	ACUTE FRACTURES DETECTED IN THE PELVIS OR RIGHT HIP REGION	IMPRESSION:       NO ACUTE FRACTURES DETECTED IN THE PELVIS OR RIGHT HIP REGION.	Negated	Recent	Patient
475	gout	Rheumatologic - The patient has a history of GOUT, and we continued her on   her home dose of allopurinol.	Affirmed	Historical	Patient
476	trace pulmonic regurgitation	There is TRACE PULMONIC REGURGITATION.	Affirmed	Recent	Patient
477	Right   ventricular size is normal	RIGHT   VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
478	apical lateral wall and   apical septum are severely hypokinetic	The APICAL LATERAL WALL AND   APICAL SEPTUM ARE SEVERELY HYPOKINETIC.	Affirmed	Recent	Patient
479	glenohumeral  joint is normal	The GLENOHUMERAL  JOINT IS NORMAL.	Affirmed	Recent	Patient
480	neck pain	In general, he denies any   changes in vision or diplopia, no changes in hearing, no NECK PAIN, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
481	vomiting	Return to the Emergency Department or PCP if he develops nausea, VOMITING,   fevers or chills.	Affirmed	Not particular	Patient
482	hypertension	MEDICAL HISTORY:   Atrial fibrillation, HYPERTENSION, arthritis, coronary artery disease, GERD,   cataracts, and cancer of the left eyelid.	Affirmed	Historical	Patient
483	organomegaly	Abdomen - Soft, nontender, nondistended, positive   bowel sounds, no mass or ORGANOMEGALY.	Negated	Recent	Patient
484	thrombocytopenia	Also throughout this hospital course, the patient had the following   complications:  sepsis, respiratory failure with trach placement,   THROMBOCYTOPENIA, rectal sheath hematoma with intraabdominal bleed status   post iliac and epigastric embolization of arteries, renal failure secondary   to ureteral obstruction with bilateral nephrostomy tube placement, right MCA   CVA, rectal ischemia and further complications related to her underlying   hypercoagulable state.	Affirmed	Recent	Patient
485	wheezes	No WHEEZES, rales, or   rhonchi.	Negated	Recent	Patient
486	pulmonary artery size is normal	The PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
487	alert	GENERAL:  He is awake, ALERT, in no acute distress.	Affirmed	Recent	Patient
488	intrahepatic biliary   ductile dilation	Progression of metastatic   disease involving retroperitoneal, and peripancreatic, and porta lymph nodes   which may be causing some component of the patient's INTRAHEPATIC BILIARY   DUCTILE DILATION, post-surgical changes from gastric jejunostomy and   gastrostomy tube.	Affirmed	Recent	Patient
489	shortness of breath 	The patient states that the SHORTNESS OF BREATH has   been ongoing for approximately the two to three days.	Affirmed	Recent	Patient
490	fevers	Return to the Emergency Department or PCP if he develops nausea, vomiting,   FEVERS or chills.	Affirmed	Not particular	Patient
491	diffuse crampy   abdominal pain	Mr. **NAME[AAA] is a **AGE[in 30s]-year-old, White male who complains of DIFFUSE CRAMPY   ABDOMINAL PAIN over the last two months.	Affirmed	Recent	Patient
492	Overall left ventricular function is   normal	OVERALL LEFT VENTRICULAR FUNCTION IS   NORMAL, with an estimated ejection fraction of 55-60 %.	Affirmed	Recent	Patient
493	temperature elevation   greater than 101 degrees Fahrenheit	Call also for any weight gain   greater than three pounds per day or five pounds per week, any unusual   rashes, nausea, vomiting, fever associated with chill, TEMPERATURE ELEVATION   GREATER THAN 101 DEGREES FAHRENHEIT, sustained or low-grade temperature   greater than 100 degrees Fahrenheit, new onset of chest pain,   light-headedness, or dizziness, new or increased shortness of breath, severe   calf pain, burning on urination or severe depression.	Affirmed	Not particular	Patient
494	Positive bowel sounds	POSITIVE BOWEL SOUNDS.	Affirmed	Recent	Patient
495	Pneumonia	PNEUMONIA.	Affirmed	Historical	Patient
496	numbness	Neurologic - No NUMBNESS, tingling, or weakness.	Negated	Recent	Patient
497	Small left (venous) ventricular cavity size with overall preserved  systolic function	03) Small left (venous) ventricular cavity size with overall preserved  systolic function.	Affirmed	Recent	Patient
498	remainder of the lungs are  clear	The REMAINDER OF THE LUNGS ARE  CLEAR.	Affirmed	Recent	Patient
499	ESOPHAGEAL FOOD IMPACTION	She is discharged with the diagnosis of ESOPHAGEAL FOOD IMPACTION.	Affirmed	Recent	Patient
500	Right ventricular function is   normal	RIGHT VENTRICULAR FUNCTION IS   NORMAL.	Affirmed	Recent	Patient
501	Left atrial size is small	LEFT ATRIAL SIZE IS SMALL.	Affirmed	Recent	Patient
502	atrial fibrillation	She does have a history of ATRIAL FIBRILLATION and is on   Lopressor p.o.	Affirmed	Historical	Patient
503	mitral valve is normal	The MITRAL VALVE IS NORMAL.	Affirmed	Recent	Patient
504	DRUG ALLERGIES	ALLERGIES:   NO KNOWN DRUG ALLERGIES.	Negated	Historical	Patient
505	Segmental left   ventricular function is normal	SEGMENTAL LEFT   VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
506	wound	The WOUND was dressed with Bacitracin and Band Aid.	Affirmed	Recent	Patient
507	ST   elevations in leads V2, V3, and V4	ED COURSE:   EKG INTERPRETATION: EKG reveals atrial flutter with 2:1 conduction and ST   ELEVATIONS IN LEADS V2, V3, AND V4, as well as T-wave inversions in I and   AVL.	Affirmed	Recent	Patient
508	rhonchi	There are no rales or RHONCHI noted on   examination.	Negated	Recent	Patient
509	increased   temperature	Her postoperative course was remarkable for an INCREASED   TEMPERATURE and leukocytosis.	Affirmed	Recent	Patient
510	pain	The   patient described the PAIN as sharp and burning.	Affirmed	Recent	Patient
511	FOCALLY ACTIVE ILEITIS WITH ULCERATION	PART 2:  NEOTERMINAL ILEUM, BIOPSY   A.          FOCALLY ACTIVE ILEITIS WITH ULCERATION  B.     NO EVIDENCE OF DYSPLASIA.	Affirmed	Recent	Patient
512	polyps 	There was no evidence of POLYPS or  ulceration.	Negated	Recent	Patient
513	Borderline pulmonary hypertension	03) BORDERLINE PULMONARY HYPERTENSION.	Affirmed	Recent	Patient
514	pneumonia	HOSPITAL COURSE:  A **AGE[in 70s]-year-old female admitted with PNEUMONIA.	Affirmed	Recent	Patient
515	Chest Pain	S_O_H  Counters Report Type Record Type Subgroup Classifier  59,daDE/5sV6EoL ECHO ECHO   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      **INSTITUTION - **INSTITUTION Echocardiography Lab            Echocardiographic Report                            An Intersocietal Commission for the Accreditation of               Echocardiography Laboratories Certified Laboratory                       Name: **NAME[AAA, BBB]  Date/Time of Procedure: **DATE[Jun 11 2007] 10:32 AM  Institution: **INSTITUTION  Sex: M  Date of Birth: **DATE[May 15 1927]  Echo Number: 181260  Account: **ID-NUM  Type: Echo      Transthoracic Echocardiogram                          ECHOCARDIOGRAPHIC MEASUREMENTS:    *** Measurements Not Obtainable ***                           REFERRING DIAGNOSIS: CHEST PAIN, Other  TWO DIMENSIONAL ECHOCARDIOLOGY:   This was a technically difficult study.	Affirmed	Recent	Patient
516	pulmonic regurgitation	There is trace PULMONIC REGURGITATION.	Affirmed	Recent	Patient
517	focal numbness	No FOCAL NUMBNESS or weakness, though she does have pain on movement of   her index and middle fingers.	Negated	Recent	Patient
518	Right atrial size   is mildly enlarged	RIGHT ATRIAL SIZE   IS MILDLY ENLARGED.	Affirmed	Recent	Patient
519	coronary artery disease	ED COURSE:  Because of the patient's CORONARY ARTERY DISEASE history and his symptoms, it   was thought that his symptoms were most likely secondary to coronary   ischemia.	Affirmed	Historical	Patient
520	left acetabular fracture	ED COURSE:    RADIOGRAPHS:    X-rays do confirm a LEFT ACETABULAR FRACTURE.	Affirmed	Recent	Patient
521	pneumonia	She showed no clinical signs or symptoms of PNEUMONIA.	Negated	Recent	Patient
522	Migraine	MIGRAINE.	Affirmed	Recent	Patient
523	spleen is normal in size	The exam is not tailored for  evaluation for primary hepatic lesions given the underlying  diagnosis of hepatitis-C. The SPLEEN IS NORMAL IN SIZE.	Affirmed	Recent	Patient
524	back pain	The patient denies   any BACK PAIN.	Negated	Recent	Patient
525	mitral valve is   normal	The MITRAL VALVE IS   NORMAL.	Affirmed	Recent	Patient
526	wound	The WOUND was irrigated   with a copious amount of normal saline, scrubbed with Betadine and three   simple interrupted 4-0 nylon sutures were placed with good WOUND   approximation.	Affirmed	Recent	Patient
527	Right atrial size is mildly   enlarged	RIGHT ATRIAL SIZE IS MILDLY   ENLARGED.	Affirmed	Recent	Patient
528	spinal stenosis	REASON FOR ADMISSION:    Past medical history is positive for hyperlipidemia, hypothyroidism, weakness   and difficulty with ambulation, aortic/mitral disease, SPINAL STENOSIS,   cataracts, measles, mumps, and varicella in the past.	Affirmed	Historical	Patient
529	leg cramp	S_O_H  Counters Report Type Record Type Subgroup Classifier  16,OQsVgUtX4Kw6 DS DS 5004  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   GENERAL MEDICINE  DISCHARGE SUMMARY  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  **ROOM  ATTENDING PHYSICIAN:  **NAME[YYY M ZZZ]  ADMISSION DATE:  **DATE[Nov 03 2007]  DISCHARGE DATE:  **DATE[Nov 03 2007]  The patient was admitted to the floor just a few hours ago from the ED as he   came in with a complaint of LEG CRAMP.	Affirmed	Recent	Patient
530	positive peripheral pulses	He had POSITIVE PERIPHERAL PULSES, lower extremity   edema with 1+ bilaterally.	Affirmed	Recent	Patient
531	polyps	There was no evidence of POLYPS, although the examination  was limited by the quality of the prep.	Negated	Recent	Patient
532	colon problem	The patient had history of   COLON PROBLEM and diverticulitis in the past.	Affirmed	Historical	Patient
533	pericardial   effusion	No PERICARDIAL   EFFUSION is seen.	Negated	Recent	Patient
534	cancer	pre-SBTx work up, r/o polyps CANCER, colitis    DESCRIPTION OF OPERATION:  After explaining the risks of, the benefits of, and alternatives to ileoscopy,  informed consent was obtained from the informed patient.	Affirmed	Recent	Patient
535	Extraocular   movements intact	EXTRAOCULAR   MOVEMENTS INTACT.	Affirmed	Recent	Patient
536	Bladder cancer	S_O_H  Counters Report Type Record Type Subgroup Classifier  204,BMebu46WkGKy SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      CLINICAL HISTORY:  BLADDER CANCER.	Affirmed	Recent	Patient
537	dextroscoliosis of the lumbar  spine related to loss of heightdue to degenerative change	There is mild DEXTROSCOLIOSIS OF THE LUMBAR  SPINE RELATED TO LOSS OF HEIGHTDUE TO DEGENERATIVE CHANGE.	Affirmed	Recent	Patient
538	posterior neck pain	Denies POSTERIOR NECK PAIN.	Negated	Recent	Patient
539	drug abuse	SOCIAL HISTORY:   She denies any tobacco, alcohol or DRUG ABUSE.	Negated	Historical	Patient
540	strong   pulses, including strong distal pedal pulses in the affected extremity	He has STRONG   PULSES, INCLUDING STRONG DISTAL PEDAL PULSES IN THE AFFECTED EXTREMITY.	Affirmed	Recent	Patient
541	Moderate left atrial enlargement	03) MODERATE LEFT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
542	pericardial   effusion	No PERICARDIAL   EFFUSION is seen.	Negated	Recent	Patient
543	chest pain	Positive for CHEST PAIN, no palpitations.	Affirmed	Recent	Patient
544	mumps	REASON FOR ADMISSION:    Past medical history is positive for hyperlipidemia, hypothyroidism, weakness   and difficulty with ambulation, aortic/mitral disease, spinal stenosis,   cataracts, measles, MUMPS, and varicella in the past.	Affirmed	Historical	Patient
545	diarrhea	He has   some nausea, vomiting, DIARRHEA alternated with constipation.	Affirmed	Recent	Patient
546	Heart rate greater   than 110 beats or less than 50 beats/minute	Call the physician if any of the following are noted:  HEART RATE GREATER   THAN 110 BEATS OR LESS THAN 50 BEATS/MINUTE, increased redness, swelling, or   drainage at or around the incision site.	Affirmed	Not particular	Patient
547	hypertension	PAST MEDICAL HISTORY:     The patient has HYPERTENSION, type 2 diabetes, Obstructive Sleep Apnea, and   wears oxygen at night.	Affirmed	Historical	Patient
548	Conjunctivae are mildly   pale	CONJUNCTIVAE ARE MILDLY   PALE.	Affirmed	Recent	Patient
549	Mild left atrial enlargement	02) MILD LEFT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
550	chest pain	Pain: The patient continues to have CHEST PAIN that is consistent with the  CHEST PAIN he felt on his previous admission.	Affirmed	Recent	Patient
551	BACK EXAMINATION:  Reveals no stepoff or tenderness	BACK EXAMINATION:  REVEALS NO STEPOFF OR TENDERNESS.	Affirmed	Recent	Patient
552	necrotizing pancreatitis	We do not know the exact etiology of her   NECROTIZING PANCREATITIS, although she does need a cholecystectomy in the   near future.	Affirmed	Recent	Patient
553	increased   shortness of breath	She   will call Dr. **NAME[ZZZ] at that same number if there is any newer INCREASED   SHORTNESS OF BREATH, new onset of chest pain, lightheadedness, dizziness,   fainting, ankle swelling, abdominal bloating/weight gain of 2 pounds in 24   hours or 4 pounds in a week or less.	Affirmed	Not particular	Patient
554	Right ventricular wall thickness is normal	RIGHT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
555	minor soft-tissue swelling around the midfoot and ankle   on the left	X-rays of both feet obtained **DATE[Mar 26 2008], which revealed normal appearance   of the right foot and MINOR SOFT-TISSUE SWELLING AROUND THE MIDFOOT AND ANKLE   ON THE LEFT.	Affirmed	Recent	Patient
556	aortic valve is normal	The AORTIC VALVE IS NORMAL.	Affirmed	Recent	Patient
557	left ventricular hypertrophy	Left ventricular wall thickness is   increased, consistent with LEFT VENTRICULAR HYPERTROPHY.	Affirmed	Recent	Patient
558	emesis with mild blood   streaking	The patient does admit to 2 episodes of EMESIS WITH MILD BLOOD   STREAKING, and he also admits to coughing.	Affirmed	Recent	Patient
559	DIABETES	DIABETES.	Affirmed	Historical	Patient
560	Vaginal bleeding	S_O_H  Counters Report Type Record Type Subgroup Classifier  82,KGLB6WjS5Rt6 ER ER 1005  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   EMERGENCY DEPARTMENT  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM   DATE OF SERVICE:  **DATE[Sep 31 07]   PRIMARY CARE PHYSICIAN: **NAME[UUU M VVV]  HISTORY OF PRESENT ILLNESS:    CHIEF COMPLAINT:  VAGINAL BLEEDING.	Affirmed	Recent	Patient
561	Peripheral vascular disease	PERIPHERAL VASCULAR DISEASE.	Affirmed	Recent	Patient
562	Segmental   left ventricular function is normal	SEGMENTAL   LEFT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
563	rales	No wheezes or RALES.	Negated	Recent	Patient
564	Shortness Of Breath	8  cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: SHORTNESS OF BREATH    TWO DIMENSIONAL ECHOCARDIOLOGY:   This was a technically difficult study.	Affirmed	Recent	Patient
565	rales	No wheezes, RALES, or rhonchi.	Negated	Recent	Patient
566	fluctuating white count	Thrombocytosis:  The patient was noted to have a chronically elevated   platelet count as well as a FLUCTUATING WHITE COUNT.	Affirmed	Historical	Patient
567	Left atrial   size is mildly enlarged	LEFT ATRIAL   SIZE IS MILDLY ENLARGED.	Affirmed	Recent	Patient
568	tongue elevation	No TONGUE ELEVATION.	Negated	Recent	Patient
569	fever	He will follow up with his primary care   physician when he gets back for Los Vegas in 7 to 10 days for suture removal   and he was instructed to return to the Emergency Department if there was   redness, FEVER, or pus from the site.	Affirmed	Not particular	Patient
570	cough	She denies a COUGH.	Negated	Recent	Patient
571	acute fractures identified in the remainder of the pelvis	There  are no ACUTE FRACTURES IDENTIFIED IN THE REMAINDER OF THE PELVIS.	Negated	Recent	Patient
572	Right atrial size is normal	RIGHT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
573	Moderately dilated right ventricle with mildly decreased function	02) MODERATELY DILATED RIGHT VENTRICLE WITH MILDLY DECREASED FUNCTION.	Affirmed	Recent	Patient
574	thyromegaly	No lymphadenopathy, THYROMEGALY or JVD.	Negated	Recent	Patient
575	rubs	No murmurs, RUBS, or   gallops.	Negated	Recent	Patient
576	polyps	No evidence of POLYPS.	Negated	Recent	Patient
577	pulmonic regurgitation	There is trace PULMONIC REGURGITATION.	Affirmed	Recent	Patient
578	Left ventricular wall thickness is   increased	LEFT VENTRICULAR WALL THICKNESS IS   INCREASED, consistent with left ventricular hypertrophy.	Affirmed	Recent	Patient
579	blood pressure was found to be elevated	Upon transfer to the   floor, the patient's BLOOD PRESSURE WAS FOUND TO BE ELEVATED.	Affirmed	Recent	Patient
580	ESRD	;    HISTORY:  The patient is a **AGE[in 60s]-year-old gentleman with a past medical history  significant for ESRD, HIV, chronic thoracic aortic aneurysm, chronic SVC  occlusion, and recent diagnosis of PE who was discharged on **DATE[Jul 2 2007]  after right groin AV fistula placement.	Affirmed	Historical	Patient
581	congestive heart   failure	HISTORY OF PRESENT ILLNESS:  Mr. **NAME[AAA] is a **AGE[90+]-year-old gentleman with a past medical history of coronary   artery disease, status post CABG, but no history of known CONGESTIVE HEART   FAILURE, who has not been admitted to the hospital in the last five to six   years, who presents today after a syncopal episode.	Negated	Historical	Patient
582	At L2-L3, there is a diffusedegenerated disc with disc bulge	AT L2-L3, THERE IS A DIFFUSEDEGENERATED DISC WITH DISC BULGE.	Affirmed	Recent	Patient
583	colon polyps	FH is +ve for a  sister with COLON POLYPS at age **AGE[in 60s] who is under colonoscopic surveillance.	Affirmed	Historical	Family member
584	left posterior   basal atelectasis	Chest x-ray showed there is LEFT POSTERIOR   BASAL ATELECTASIS.	Affirmed	Recent	Patient
585	Bilateral shoulder pain	S_O_H  Counters Report Type Record Type Subgroup Classifier  172,zyEn/YZTr0P7 RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  XRAY SHOULDER MINIMUM 2 VIEWS RIGHT   **DATE[Jul 09 07]     1330 HOURS    CLINICAL HISTORY:     BILATERAL SHOULDER PAIN.	Affirmed	Recent	Patient
586	left bundle-branch block	She had a recent admission to the CCU and Cardiac   Pavilion for a new LEFT BUNDLE-BRANCH BLOCK and atrial fibrillation.	Affirmed	Recent	Patient
587	afebrile	The patient was AFEBRILE throughout her hospital   stay.	Affirmed	Recent	Patient
588	moderate coronary   artery disease	At that   time, she was taken to the cath lab and found to have a MODERATE CORONARY   ARTERY DISEASE.	Affirmed	Recent	Patient
589	loss of consciousness	No LOSS OF CONSCIOUSNESS.	Negated	Recent	Patient
590	acute distress	She was afebrile with   stable vitals; awake, alert, and oriented in no ACUTE DISTRESS.	Negated	Recent	Patient
591	tamponade	No echocardiographic signs of TAMPONADE are seen.	Negated	Recent	Patient
592	Overall left ventricular   function is normal	OVERALL LEFT VENTRICULAR   FUNCTION IS NORMAL, with an estimated ejection fraction of 55-60 %.	Affirmed	Recent	Patient
593	right femoral neck fracture	An x-ray of her hip revealed a RIGHT FEMORAL NECK FRACTURE.	Affirmed	Recent	Patient
594	left-sided   substernal chest pressure radiating to his left shoulder	HISTORY OF PRESENT ILLNESS:  Mr. **NAME[AAA] is a **AGE[in 50s]-year-old African-American male with no history of   coronary artery disease who presents with a one-day history of LEFT-SIDED   SUBSTERNAL CHEST PRESSURE RADIATING TO HIS LEFT SHOULDER.	Affirmed	Recent	Patient
595	Sensation is intact bilaterally	SENSATION IS INTACT BILATERALLY.	Affirmed	Recent	Patient
596	anxiety	He has had a previous diagnosis of ANXIETY and depression in the past.	Affirmed	Historical	Patient
597	thoughts were logical	Her THOUGHTS WERE LOGICAL.	Affirmed	Recent	Patient
598	pain  proximal to his hand	No PAIN  PROXIMAL TO HIS HAND and otherwise has  no other injuries.	Negated	Recent	Patient
599	RIGHT UPPER EXTREMITY DEEP VEIN THROMBOSIS	HISTORY OF RIGHT UPPER EXTREMITY DEEP VEIN THROMBOSIS.	Affirmed	Historical	Patient
600	cranial nerves II through XII are intact	Neurologic:  The patient's CRANIAL NERVES II THROUGH XII ARE INTACT.	Affirmed	Recent	Patient
601	heart  size is normal	The HEART  SIZE IS NORMAL without pericardial effusion.	Affirmed	Recent	Patient
602	mid anteroseptum and   apical anterior wall are severely hypokinetic	The MID ANTEROSEPTUM AND   APICAL ANTERIOR WALL ARE SEVERELY HYPOKINETIC.	Affirmed	Recent	Patient
603	JVD	Neck supple, no JVD.	Negated	Recent	Patient
604	abdominal  pain	The indication for this procedure is ABDOMINAL  PAIN and chronic diarrhea.	Affirmed	Recent	Patient
605	hypertension	HISTORY OF PRESENT ILLNESS:  The patient is a **AGE[90+]-year-old female with past   medical history significant for atrial fibrillation, history of DVTs, and   HYPERTENSION who presents to the Emergency Department after 2 episodes of   coffee-ground emesis.	Affirmed	Historical	Patient
606	coronary artery disease	HISTORY OF PRESENT ILLNESS:  Mr. **NAME[AAA] is a **AGE[in 50s]-year-old African-American male with no history of   CORONARY ARTERY DISEASE who presents with a one-day history of left-sided   substernal chest pressure radiating to his left shoulder.	Negated	Historical	Patient
607	abdominal bloating	She   will call Dr. **NAME[ZZZ] at that same number if there is any newer increased   shortness of breath, new onset of chest pain, lightheadedness, dizziness,   fainting, ankle swelling, ABDOMINAL BLOATING/weight gain of 2 pounds in 24   hours or 4 pounds in a week or less.	Affirmed	Not particular	Patient
608	Thrombocytopenia	CBC: THROMBOCYTOPENIA with platelets of 130, otherwise   unremarkable.	Affirmed	Recent	Patient
609	sinus bradycardia	The baseline EKG showed SINUS BRADYCARDIA   with nonspecific STT changes.	Affirmed	Recent	Patient
610	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
611	shortness of breath	Denies any SHORTNESS OF BREATH or   diaphoresis.	Negated	Recent	Patient
612	pedal edema	Towards the   end of her rehab stay, she was noted to have slight increase in PEDAL EDEMA.	Affirmed	Recent	Patient
613	Hypopharynx and larynx were normal	FINDINGS:  HYPOPHARYNX AND LARYNX WERE NORMAL.	Affirmed	Recent	Patient
614	regular rhythm with a tachycardia	Cardiovascular examination reveals a REGULAR RHYTHM WITH A TACHYCARDIA of   approximately 100.	Affirmed	Recent	Patient
615	nausea	His pain is associated with NAUSEA, no   vomiting.	Affirmed	Recent	Patient
616	mild sore throat	She also   states that she has had URI symptoms over the last week, including rhinorrhea     and MILD SORE THROAT.	Affirmed	Recent	Patient
617	status post CABG	HISTORY OF PRESENT ILLNESS:  Mr. **NAME[AAA] is a **AGE[90+]-year-old gentleman with a past medical history of coronary   artery disease, STATUS POST CABG, but no history of known congestive heart   failure, who has not been admitted to the hospital in the last five to six   years, who presents today after a syncopal episode.	Affirmed	Historical	Patient
618	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
619	rash	No RASH.	Negated	Recent	Patient
620	Pharynx good.  Moist   mucous membranes	Pharynx good.	Affirmed	Recent	Patient
621	lower extremity edema	The patient does have LOWER EXTREMITY EDEMA and her left lower   extremity is mottled as previously noted.	Affirmed	Recent	Patient
622	tricuspid regurgitation	There is trace TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
623	interstitial pulmonary edema	Left lung showed remarkable INTERSTITIAL PULMONARY EDEMA.	Affirmed	Recent	Patient
624	pericardial   effusion	No PERICARDIAL   EFFUSION is seen.	Negated	Recent	Patient
625	ileal mucosa was normal	FINDINGS:  The ILEAL MUCOSA WAS NORMAL in appearance.	Affirmed	Recent	Patient
626	fever	The patient admitted with   __________ increased dyspnea in 24 hours, FEVER, and pleurisy.	Affirmed	Recent	Patient
627	drugs	Denies alcohol or DRUGS.	Negated	Historical	Patient
628	colon problems	Also history of diverticulitis and COLON PROBLEMS.	Affirmed	Historical	Patient
629	rubs	No murmurs, RUBS or gallops.	Negated	Recent	Patient
630	Overall left ventricular function is normal	OVERALL LEFT VENTRICULAR FUNCTION IS NORMAL,   with an estimated ejection fraction of 60-65 %.	Affirmed	Recent	Patient
631	Hypertension	HYPERTENSION.	Affirmed	Historical	Patient
632	Right ventricular function is normal	RIGHT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
633	mild to moderate tricuspid regurgitation	SPECTRAL DOPPLER:   There is MILD TO MODERATE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
634	bladder lift x 2	Status post BLADDER LIFT X 2.	Affirmed	Historical	Patient
635	altered   mental status	BRIEF HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 40s]-year-old female with complex   medical history with multiple hospital admissions who was admitted to   **INSTITUTION from **DATE[Feb 13 2008], through **DATE[Feb 20 2008], for ALTERED   MENTAL STATUS and lethargy.	Affirmed	Recent	Patient
636	Left ventricular size is normal	Wall Thickness:  1.0 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Chest Pain, Other  TWO DIMENSIONAL ECHOCARDIOLOGY:   LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
637	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
638	Neck - Supple	NECK - SUPPLE no JVD, lymph node, or cervical lymphadenopathy.	Affirmed	Recent	Patient
639	abdominal bloating	Today, she states that she still has ABDOMINAL BLOATING, which she refers to   as gas pains.	Affirmed	Recent	Patient
640	Neck supple	NECK SUPPLE, no JVD.	Affirmed	Recent	Patient
641	nonsustained supraventricular tachycardia	There was NONSUSTAINED SUPRAVENTRICULAR TACHYCARDIA during stress.	Affirmed	Recent	Patient
642	tolerate some p.o. fluids	The patient states   that she was able to tolerate some p.o.	Affirmed	Recent	Patient
643	myalgias	Denied any MYALGIAS or arthralgias.	Negated	Recent	Patient
644	dissociative disorder	It was felt that her   delusion was due to her medical decondition with some component of   DISSOCIATIVE DISORDER and borderline personality disorder as well as   depression and anxiety.	Affirmed	Recent	Patient
645	abdominal  pain	The indication for this procedure is ABDOMINAL  PAIN despite treatment and heartburn.	Affirmed	Recent	Patient
646	Both kidneys are otherwisenormal	BOTH KIDNEYS ARE OTHERWISENORMAL.	Affirmed	Recent	Patient
647	Left ventricular size is normal	LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
648	2+ radial pulses and good capillary refill	The forearm compartments are   soft, 2+ radial pulses and good capillary refill.	Affirmed	Recent	Patient
649	chronically elevated   platelet count	Thrombocytosis:  The patient was noted to have a CHRONICALLY ELEVATED   PLATELET COUNT as well as a fluctuating white count.	Affirmed	Historical	Patient
650	wheezing 	The patient is a **AGE[in 40s]-year-old male with a history of COPD, tobacco use,   presents to the Emergency Department with complaint of chest tightness,   pressure, as well as complaint of shortness of breath and WHEEZING at home.	Affirmed	Recent	Patient
651	trace mitral regurgitation	There is TRACE MITRAL REGURGITATION.	Affirmed	Recent	Patient
652	hallucinations	No evidence of delusions or HALLUCINATIONS but   had bizarre behavior that therapist felt to be her associated state.	Negated	Recent	Patient
653	Mild left atrial enlargement	02) MILD LEFT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
654	Right ventricular wall thickness is normal	RIGHT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
655	dilated proximal small bowel	Also, on the CT scan, there is   DILATED PROXIMAL SMALL BOWEL with transition in the right lower quadrant   compatible with a small bowel obstruction.	Affirmed	Recent	Patient
656	esophagus and esophagogastric-junction were normal	FINDINGS:  The ESOPHAGUS AND ESOPHAGOGASTRIC-JUNCTION WERE NORMAL in appearance.	Affirmed	Recent	Patient
657	marginal  cell lymphoma	Given the few atypical circulating cells (some with monocytoid  appearance) seen on peripheral blood and the above marrow findings, a MARGINAL  CELL LYMPHOMA is favored.	Affirmed	Recent	Patient
658	marginal cell lymphoma	The most likely  possibilities include MARGINAL CELL LYMPHOMA vs. an atypical follicular  lymphoma.	Affirmed	Recent	Patient
659	gallops	No murmurs, rubs or GALLOPS.	Negated	Recent	Patient
660	pleural effusion	There is no PLEURAL EFFUSION or  pneumothorax.	Negated	Recent	Patient
661	Mucous membranes are dry	MUCOUS MEMBRANES ARE DRY.	Affirmed	Recent	Patient
662	awake	He was AWAKE, alert, and oriented.	Affirmed	Recent	Patient
663	Pulmonary hypertension	PULMONARY HYPERTENSION.	Affirmed	Historical	Patient
664	Chronic Airway Obstruction	Wall Thickness:  1.3 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: CHRONIC AIRWAY OBSTRUCTION 496; Systolic Heart Failure;  Obesity 278.0; Hypertension 401.9  TWO DIMENSIONAL ECHOCARDIOLOGY:   Left ventricular size is normal.	Affirmed	Historical	Patient
665	alert	Neurologic - The patient is ALERT and oriented times three.	Affirmed	Recent	Patient
666	T-wave inversions in I and   AVL	ED COURSE:   EKG INTERPRETATION: EKG reveals atrial flutter with 2:1 conduction and ST   elevations in leads V2, V3, and V4, as well as T-WAVE INVERSIONS IN I AND   AVL.	Affirmed	Recent	Patient
667	sclerae is anicteric	His SCLERAE IS ANICTERIC.	Affirmed	Recent	Patient
668	Severe Esophagitis	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) SEVERE ESOPHAGITIS s/p biopsy  2) Large Hiatal hernia  3) Gastritis in the antrum s/p biopsy  4) Normal duodenum      PLAN:  1) Follow-up: as scheduled referring MD  2) Await biopsy results  3) Follow-up of helicobacter pylori  status, treat if indicated  4) Protonix 40mg qd    REPEAT EXAM:  EGD in ; As needed    __________________________________  **NAME[YYY ZZZ], MD  I was present during the entire procedure.	Affirmed	Recent	Patient
669	fevers	REVIEW OF SYSTEMS:  Constitutional - No FEVERS, chills, or sweats.	Negated	Recent	Patient
670	alcohol	SOCIAL HISTORY:     Denies any ALCOHOL, tobacco or illicit drug use.	Negated	Historical	Patient
671	healed fractures	No residua of HEALED FRACTURES can be seen  otherwise.	Affirmed	Recent	Patient
672	Right epicardial fat pad	RIGHT EPICARDIAL FAT PAD.	Affirmed	Recent	Patient
673	pulmonic   valve is normal	The PULMONIC   VALVE IS NORMAL.	Affirmed	Recent	Patient
674	bone marrow signal is normal	The BONE MARROW SIGNAL IS NORMAL.	Affirmed	Recent	Patient
675	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
676	amputation of left upper extremity above elbow	Coronary artery disease status post coronary artery bypass graft in **DATE[Apr   2007] with complication of mediastinitis and embolization resulting in   AMPUTATION OF LEFT UPPER EXTREMITY ABOVE ELBOW.	Affirmed	Historical	Patient
677	Congenital Heart Disease  	Wall Thickness:  1.2 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: CONGENITAL HEART DISEASE    TWO DIMENSIONAL ECHOCARDIOLOGY:   Left ventricular size is normal.	Affirmed	Recent	Patient
678	ischemic EKG changes	There were no ISCHEMIC EKG CHANGES during   stress.	Negated	Recent	Patient
679	nauseated	ED COURSE:    The patient was offered glucagon which she declined as she states this made   her severely NAUSEATED the last time she had it.	Affirmed	Historical	Patient
680	Coronary artery disease	CORONARY ARTERY DISEASE.	Affirmed	Recent	Patient
681	mitral valve is normal	The MITRAL VALVE IS NORMAL.	Affirmed	Recent	Patient
682	Systolic Heart Failure	Wall Thickness:  1.3 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Chronic Airway Obstruction 496; SYSTOLIC HEART FAILURE;  Obesity 278.0; Hypertension 401.9  TWO DIMENSIONAL ECHOCARDIOLOGY:   Left ventricular size is normal.	Affirmed	Recent	Patient
683	mitral valve is   thickened	The MITRAL VALVE IS   THICKENED.	Affirmed	Recent	Patient
684	pulmonic valve is normal	The   PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
685	GOUT	GOUT.	Affirmed	Historical	Patient
686	diarrhea	She did have DIARRHEA   during her stay and her C. diff toxin was positive.	Affirmed	Recent	Patient
687	chills	REVIEW OF SYSTEMS:  CONSTITUTIONAL:  He has some CHILLS, but no fever.	Affirmed	Recent	Patient
688	Abdominal pain	FINAL DIAGNOSIS:  ABDOMINAL PAIN, uncertain etiology.	Affirmed	Recent	Patient
689	Mitral annular calcification	04) MITRAL ANNULAR CALCIFICATION.	Affirmed	Recent	Patient
690	tamponade	09) No echocardiographic signs of TAMPONADE are seen.	Negated	Recent	Patient
691	URINARY TRACT INFECTION	URINARY TRACT INFECTION.	Affirmed	Recent	Patient
692	ruptured chordae	08) There is mobile filamentous mass attached to the left ventricular apical  endocardium most likely a RUPTURED CHORDAE, however, other pathology can   not be excluded.	Affirmed	Recent	Patient
693	mild tricuspid   regurgitation	There is MILD TRICUSPID   REGURGITATION.	Affirmed	Recent	Patient
694	duodenum was normal	The DUODENUM WAS NORMAL.	Affirmed	Recent	Patient
695	diarrhea	We sent   stool studies because of his DIARRHEA.	Affirmed	Recent	Patient
696	pericardium is thickened consistent with fat pad	The PERICARDIUM IS THICKENED CONSISTENT WITH FAT PAD.	Affirmed	Recent	Patient
697	sessile polyp was found in the transverse colon	FINDINGS:  A 5mm SESSILE POLYP WAS FOUND IN THE TRANSVERSE COLON and removed with snare  polypectomy.	Affirmed	Recent	Patient
698	colon cancer	The indication for this procedure is family  history of COLON CANCER (father in his early 70's) and a personal history of  adenomatous polyps (***PATH-NUMBER[1]).	Affirmed	Historical	Family member
699	Oropharynx is clear	OROPHARYNX IS CLEAR.	Affirmed	Recent	Patient
700	Normal duodenum  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) Normal esophagus  2) Hiatal hernia    3) Erosions, multiple in the antrum  4) NORMAL DUODENUM    5) No additional lesions    PLAN:  1) Await biopsy results  2) **INSTITUTION as scheduled    REPEAT EXAM:  No    __________________________________  **NAME[YYY ZZZ]  I was present during the entire procedure.	Affirmed	Recent	Patient
701	mitral valve is thickened	The MITRAL VALVE IS THICKENED.	Affirmed	Recent	Patient
702	shortness of breath	S_O_H  Counters Report Type Record Type Subgroup Classifier  1,01TdvtyYejbW DS DS 1504  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   CARDIOLOGY   DISCHARGE SUMMARY  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM   **ROOM   ATTENDING PHYSICIAN:  **NAME[YYY M ZZZ]  ADMISSION DATE:  **DATE[Sep 27 2007]  DISCHARGE DATE: **DATE[Oct 07 2007]  The patient is a **AGE[in 60s]-year-old gentleman who presented to **INSTITUTION   with complaints of SHORTNESS OF BREATH and was found to have staph   bacteremia.	Affirmed	Recent	Patient
703	right humeral hemiarthroplasty is unchanged in position without  periprosthetic lucency	FINDINGS:     A RIGHT HUMERAL HEMIARTHROPLASTY IS UNCHANGED IN POSITION WITHOUT  PERIPROSTHETIC LUCENCY.	Affirmed	Recent	Patient
704	clot at   the urethra	GENITOURINARY:  Genitourinary exam performed by attending physician, Dr.   **NAME[ZZZ] had shown a Foley with 20 mL of fluid in the balloon, a CLOT AT   THE URETHRA consistent with Foley trauma.	Affirmed	Recent	Patient
705	loose stools	He does occasionally have LOOSE STOOLS, no fevers or chills, no   sick contacts, no recent use of antibiotics.	Affirmed	Recent	Patient
706	Down's syndrome	REASON FOR ADMISSION:  Mr. **NAME[AAA] is a **AGE[in 40s]-year-old gentleman who has a history of DOWN'S SYNDROME.	Affirmed	Historical	Patient
707	oriented	He was awake, alert, and ORIENTED.	Affirmed	Recent	Patient
708	changes in vision	In general, he denies any   CHANGES IN VISION or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
709	lightheadedness	He denies any   antecedent palpitations, shortness of breath, chest pain, headache, or   LIGHTHEADEDNESS.	Negated	Recent	Patient
710	Right ventricular size is   normal	RIGHT VENTRICULAR SIZE IS   NORMAL.	Affirmed	Recent	Patient
711	Systolic Heart Failure  	Wall Thickness:  1.3 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: SYSTOLIC HEART FAILURE    TWO DIMENSIONAL ECHOCARDIOLOGY:   This was a technically difficult study.	Affirmed	Recent	Patient
712	Left ventricular wall thickness is normal	LEFT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
713	moderate arthrosis of the right hip joint	There  is MODERATE ARTHROSIS OF THE RIGHT HIP JOINT and  advancedenthesopathic change with some heterotopic ossification  adjacent to the greater trochanter.	Affirmed	Recent	Patient
714	demented	REASON FOR HOSPITAL ADMISSION:    This was a **AGE[in 70s]-year-old DEMENTED woman who presented from a nursing home with   an acute complaint of elevated INR and urinary tract infection.	Affirmed	Recent	Patient
715	acute coronary   ischemia	The patient will get admitted to the Cardiac Pavilion for his ACUTE CORONARY   ISCHEMIA.	Affirmed	Recent	Patient
716	Abdomen is soft, nontender, and mildly distended	ABDOMEN: ABDOMEN IS SOFT, NONTENDER, AND MILDLY DISTENDED.	Affirmed	Recent	Patient
717	advanced facet   arthrosis	Degenerative disc disease is present and there is ADVANCED FACET   ARTHROSIS, which appears to be most pronounced on the left at C7-T1   with evidence of erosions.	Affirmed	Recent	Patient
718	normal   sinus rhythm	The EKG demonstrated a NORMAL   SINUS RHYTHM at a rate of 63 with a P-R of 160, QRS of 100, Q-Tc of 464 and   axis of -42.	Affirmed	Recent	Patient
719	aortic root size is normal	The AORTIC ROOT SIZE IS NORMAL.	Affirmed	Recent	Patient
720	peripheral cyanosis	Extremities reveal no PERIPHERAL CYANOSIS or edema.	Negated	Recent	Patient
721	paraesthesias	The patient denied any headache,   neck pain, weakness, numbness or PARAESTHESIAS.	Negated	Recent	Patient
722	bleeding	GI  ROS is -ve for change in bowel habit, BLEEDING (occult nor overt), change in  weight, anemia or any "alarm" symptom or sign.	Negated	Recent	Patient
723	gallops	No murmurs, rubs, or GALLOPS.	Negated	Recent	Patient
724	vomiting	His nausea and VOMITING resolved.	Negated	Recent	Patient
725	aortic valve is thickened	The AORTIC VALVE IS THICKENED.	Affirmed	Recent	Patient
726	CTAP	Lungs:  CTAP.	Affirmed	Recent	Patient
727	wheezes	No rales, rhonchi or WHEEZES.	Negated	Recent	Patient
728	Mild left atrial enlargement	06) MILD LEFT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
729	coarse breath sounds   bilaterally	Her lungs have COARSE BREATH SOUNDS   BILATERALLY.	Affirmed	Recent	Patient
730	dyspneic	The patient   became DYSPNEIC and had nonsustained arrhythmias at peak stress.	Affirmed	Recent	Patient
731	mild left   ventricular hypertrophy	Left ventricular wall thickness is increased, consistent with MILD LEFT   VENTRICULAR HYPERTROPHY.	Affirmed	Recent	Patient
732	Pneumonia	DISCHARGE INSTRUCTIONS:  **DATE[Mar 22 2008]:  DISCHARGE DIAGNOSIS:  PNEUMONIA.	Affirmed	Recent	Patient
733	change in   bowel or bladder habits	She denies CHANGE IN   BOWEL OR BLADDER HABITS.	Negated	Recent	Patient
734	OTHERWISE,  UNREMARKABLE RADIOGRAPHS OF THE RIGHT KNEE	OTHERWISE,  UNREMARKABLE RADIOGRAPHS OF THE RIGHT KNEE.	Affirmed	Recent	Patient
735	anemia	HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 50s]-year-old female with a history of sickle cell disease, ANEMIA,   who presents with one-week history of intermittent pain typical of her sickle   cell crisis pain, she says.	Affirmed	Historical	Patient
736	Overall left ventricular function is severely decreased	OVERALL LEFT VENTRICULAR FUNCTION IS SEVERELY DECREASED, with an estimated   ejection fraction of 15-20 %.	Affirmed	Recent	Patient
737	Hemorrhoids	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) 5mm sessile polyp in the transverse colon    2) 5mm Sessile polyp in the descending colon  3) 6mm Sessile polyp in the rectum  4) HEMORRHOIDS  5) Otherwise normal exam    PLAN:  1) Await biopsy results    REPEAT EXAM:  Colonoscopy with internval depending on biopsy results    ______________________________  **NAME[YYY ZZZ], M.D.  I was present during the entire procedure.	Affirmed	Recent	Patient
738	pink, red, or tea-colored urine	She will alert the physician if any of the following are   noted:  Nosebleeds, excessive bruising, PINK, RED, OR TEA-COLORED URINE,   bright red or tarry black stools, unusual headaches, or stomach pain.	Affirmed	Not particular	Patient
739	peptic ulcer disease	This   was found to be consistent with an upper GI bleed secondary to esophagitis   versus gastritis versus PEPTIC ULCER DISEASE versus **NAME[UUU] wise tear.	Affirmed	Recent	Patient
740	neck   is supple and nontender	The NECK   IS SUPPLE AND NONTENDER.	Affirmed	Recent	Patient
741	Diverticulosis in the sigmoid colon	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) DIVERTICULOSIS IN THE SIGMOID COLON  2) Normal colonoscopy    PLAN:  1) Fiber rich diet  2) Follow-up: as scheduled referring MD    REPEAT EXAM:  Colonoscopy in 10 year(s).	Affirmed	Recent	Patient
742	occulded graft	He was readmitteed on **DATE[Jul 3 07] with  right leg pain and swelling and was found to have an OCCULDED GRAFT.	Affirmed	Recent	Patient
743	pharyngitis	She appeared well and had   unremarkable vital signs, no signs of meningitis, otitis, PHARYNGITIS, or   pneumonia.	Negated	Recent	Patient
744	diarrhea	The indication for this procedure is abdominal  pain and chronic DIARRHEA.	Affirmed	Recent	Patient
745	neck is supple.  No adenopathy present	No adenopathy present.	Affirmed	Recent	Patient
746	The neck without any tenderness	NECK:  THE NECK WITHOUT ANY TENDERNESS.	Affirmed	Recent	Patient
747	obese	Abdomen:  Soft, nontender and nondistended, mildly OBESE.	Affirmed	Recent	Patient
748	Left ventricular size is normal	LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
749	pericardial   effusion	No PERICARDIAL   EFFUSION is seen.	Negated	Recent	Patient
750	mild flattening of the lateral femoral  condyle	RIGHT KNEE: There is MILD FLATTENING OF THE LATERAL FEMORAL  CONDYLE.	Affirmed	Recent	Patient
751	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
752	cooperative	The   patient was not COOPERATIVE.	Negated	Recent	Patient
753	aortic root size is normal	The AORTIC ROOT SIZE IS NORMAL.	Affirmed	Recent	Patient
754	oriented times three	General - alert and ORIENTED TIMES THREE, in no acute distress.	Affirmed	Recent	Patient
755	Normocephalic	Head - NORMOCEPHALIC, atraumatic.	Affirmed	Recent	Patient
756	UTI	UTI:  The patient was noted to have a UTI, which grew out E. coli.	Affirmed	Recent	Patient
757	diverticuli were found in the sigmoid colon	FINDINGS:  Scattered DIVERTICULI WERE FOUND IN THE SIGMOID COLON.	Affirmed	Recent	Patient
758	uterine CA	The  appearance was most consistent with radiation changes s/p XRT for UTERINE CA.	Affirmed	Historical	Patient
759	frustration 	The patient does have poor energy and FRUSTRATION and inability to do   activities she enjoys due to her pain and medical conditions, difficulty   concentrating.	Affirmed	Recent	Patient
760	Foley trauma	GENITOURINARY:  Genitourinary exam performed by attending physician, Dr.   **NAME[ZZZ] had shown a Foley with 20 mL of fluid in the balloon, a clot at   the urethra consistent with FOLEY TRAUMA.	Affirmed	Recent	Patient
761	increased   blood pressure	The patient was also given a one-time dose of hydralazine for an INCREASED   BLOOD PRESSURE.	Affirmed	Recent	Patient
762	alcohol	She states that she has no history of pancreatitis or ALCOHOL   use.	Negated	Historical	Patient
763	hematoma	The patient's bilateral upper extremity duplex   scan revealed no pseudoaneurysms, no AVM, or no organized HEMATOMA.	Negated	Recent	Patient
764	awake	NEUROLOGICAL:  The patient is AWAKE, alert.	Affirmed	Recent	Patient
765	Right ventricular wall thickness is increased	RIGHT VENTRICULAR WALL THICKNESS IS INCREASED, consistent with right   ventricular hypertrophy.	Affirmed	Recent	Patient
766	Candida urinary tract infection	CANDIDA URINARY TRACT INFECTION.	Affirmed	Recent	Patient
767	Upper GI bleed	DISCHARGE ORDERS:  DISCHARGE DIAGNOSIS:  UPPER GI BLEED.	Affirmed	Recent	Patient
768	chest pain 	The patient also experienced associated CHEST PAIN   with these episodes.	Affirmed	Recent	Patient
769	Gun shot wound to his right-hand	CHIEF COMPLAINT:     GUN SHOT WOUND TO HIS RIGHT-HAND.	Affirmed	Recent	Patient
770	tobacco	SOCIAL HISTORY:   She denies any TOBACCO, alcohol or drug abuse.	Negated	Historical	Patient
771	vomiting	No nausea or VOMITING.	Negated	Recent	Patient
772	moderate to severe tricuspid regurgitation	There is MODERATE TO SEVERE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
773	wound	The WOUND was irrigated   with a copious amount of normal saline, scrubbed with Betadine and three   simple interrupted 4-0 nylon sutures were placed with good WOUND   approximation.	Affirmed	Recent	Patient
774	RIGHT DISTAL RADIAL FRACTURE	DISCHARGE DIAGNOSIS(ES):   RIGHT DISTAL RADIAL FRACTURE, SPLINTED IN THE EMERGENCY DEPARTMENT.	Affirmed	Recent	Patient
775	Segmental left   ventricular function is normal	SEGMENTAL LEFT   VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
776	HYPOXIA	HYPOXIA.	Affirmed	Recent	Patient
777	distal phalanx fractures of   his third and fourth digit	ED COURSE:     X-rays of his hand were obtained demonstrating DISTAL PHALANX FRACTURES OF   HIS THIRD AND FOURTH DIGIT otherwise no other obvious fractures.	Affirmed	Recent	Patient
778	epigastric and chest pain radiating down his left arm	HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE:  Mr. **NAME[BBB AAA] is a **AGE[in 40s]-year-old male with a medical history significant for   bipolar disorder as well as depression who presented with a several day   history of EPIGASTRIC AND CHEST PAIN RADIATING DOWN HIS LEFT ARM.	Affirmed	Recent	Patient
779	Bioprosthesis in the mitral position with normal motion and function	03) BIOPROSTHESIS IN THE MITRAL POSITION WITH NORMAL MOTION AND FUNCTION.	Affirmed	Recent	Patient
780	HIV/AIDS	HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 40s]-year-old gentleman with a history of HIV/AIDS who is status post   recent abdominal wall abscess and status post surgical evacuation in **DATE[Dec] of   2007, presents with increasing left lower extremity swelling and pain over   the last 2 weeks.	Affirmed	Historical	Patient
781	Moderate pulmonary hypertension	08) MODERATE PULMONARY HYPERTENSION.	Affirmed	Recent	Patient
782	forearm compartments are   soft	The FOREARM COMPARTMENTS ARE   SOFT, 2+ radial pulses and good capillary refill.	Affirmed	Recent	Patient
783	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
784	VOMITING	NAUSEA AND VOMITING.	Affirmed	Recent	Patient
785	Right atrial size is normal	RIGHT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
786	cyanosis	EXTREMITIES:  No clubbing or CYANOSIS.	Negated	Recent	Patient
787	viral syndrome	ED COURSE:  The patient likely has a VIRAL SYNDROME.	Affirmed	Recent	Patient
788	nodular enhancement along the pontine medullary  junction	FINDINGS:     Unfortunately, the NODULAR ENHANCEMENT ALONG THE PONTINE MEDULLARY  JUNCTION has increased since **DATE[Aug 2007].	Affirmed	Recent	Patient
789	trace aortic regurgitation	COLOR FLOW DOPPLER:   There is TRACE AORTIC REGURGITATION.	Affirmed	Recent	Patient
790	Chronic pain 	CHRONIC PAIN with severe left hip degenerative joint disease/vascular   necrosis, phantom limb pain at the left upper extremity.	Affirmed	Recent	Patient
791	moderate external hemorrhoids	Digital rectal exam was performed and showed MODERATE EXTERNAL HEMORRHOIDS.	Affirmed	Recent	Patient
792	incontinent	She did not become INCONTINENT.	Negated	Recent	Patient
793	trace aortic regurgitation	SPECTRAL DOPPLER:   There is TRACE AORTIC REGURGITATION.	Affirmed	Recent	Patient
794	gliosis in the  surgical bed and ex vacuo dilatation of the anterior horn of the  right lateral ventricle	There is GLIOSIS IN THE  SURGICAL BED AND EX VACUO DILATATION OF THE ANTERIOR HORN OF THE  RIGHT LATERAL VENTRICLE.	Affirmed	Recent	Patient
795	rhonchi	No rales, RHONCHI or wheezes.	Negated	Recent	Patient
796	depression	HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE:  Mr. **NAME[BBB AAA] is a **AGE[in 40s]-year-old male with a medical history significant for   bipolar disorder as well as DEPRESSION who presented with a several day   history of epigastric and chest pain radiating down his left arm.	Affirmed	Historical	Patient
797	pain	She was getting more pleasant after PAIN was more   controlled and moving around with wheelchair accompanied by her husband.	Affirmed	Recent	Patient
798	Lungs:  Clear	LUNGS:  CLEAR.	Affirmed	Recent	Patient
799	Left ventricular size is moderately   dilated	LEFT VENTRICULAR SIZE IS MODERATELY   DILATED.	Affirmed	Recent	Patient
800	CTP	Lungs: CTP.	Affirmed	Recent	Patient
801	GASTRIC ADENOCARCINOMA	TRANSFER DIAGNOSIS(ES):    GASTRIC ADENOCARCINOMA.	Affirmed	Recent	Patient
802	new tingling	If she has any NEW TINGLING, any   weakness, increasing pain, or change in color of her finger, she should   immediately return to the department, otherwise, I feel she is safe for   discharge at this time.	Affirmed	Not particular	Patient
803	cooperative	Again, his review of systems is limited by the fact that he is not terribly   COOPERATIVE and he is difficult to keep focused.	Negated	Recent	Patient
804	duodenal bulb was otherwise normal in appearance, as was  the postbulbar duodenum	The DUODENAL BULB WAS OTHERWISE NORMAL IN APPEARANCE, AS WAS  THE POSTBULBAR DUODENUM.	Affirmed	Recent	Patient
805	duodenal bulb was normal in appearance, as was the postbulbar duodenum	Two biopsies were obtained and sent for pathology to R/O H pylori  The DUODENAL BULB WAS NORMAL IN APPEARANCE, AS WAS THE POSTBULBAR DUODENUM.	Affirmed	Recent	Patient
806	diabetes	HISTORY OF PRESENT ILLNESS:    This is a **AGE[in 60s]-year-old male with a past history of DIABETES, dementia,   hypertension, hypercholesterolemia, anemia, anxiety, and depression who   presents with a chief complaint of having fallen.	Affirmed	Historical	Patient
807	left-sided weakness	S_O_H  Counters Report Type Record Type Subgroup Classifier  84,6TRhtqjX2qLX ER ER 1005  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   EMERGENCY DEPARTMENT  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM   DATE OF SERVICE:  **DATE[Dec 31 07]   PRIMARY CARE PHYSICIAN: **NAME[CCC DDD ZZZ]  ATTENDING PHYSICIAN ADDENDUM:  Chief complaint is LEFT-SIDED WEAKNESS and confusion.	Affirmed	Recent	Patient
808	nausea	No NAUSEA or vomiting.	Negated	Recent	Patient
809	tricuspid regurgitation	There is trace TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
810	elevated creatinine	Also the patient did have an   ELEVATED CREATININE from his baseline.	Affirmed	Recent	Patient
811	Right ventricular function is grossly normal	RIGHT VENTRICULAR FUNCTION IS GROSSLY NORMAL.	Affirmed	Recent	Patient
812	gallops	No murmurs, rubs or GALLOPS.	Negated	Recent	Patient
813	pulmonary artery size is normal	The   PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
814	mild periumbilical discomfort	He   does complain of some MILD PERIUMBILICAL DISCOMFORT.	Affirmed	Recent	Patient
815	poor mental status	There was a concern for a possible aspiration   pneumonia given the patient's vomiting and POOR MENTAL STATUS.	Affirmed	Recent	Patient
816	pedunculated polyp was found in the mid transverse colon	FINDINGS:  A PEDUNCULATED POLYP WAS FOUND IN THE MID TRANSVERSE COLON.	Affirmed	Recent	Patient
817	urethral trauma	Assessment of this Patient:  She is a **AGE[in 70s]-year-old female with a history of   multiple sclerosis, and paralysis with a history of urinary tract infections   and urinary incontinence with chronic Foley, who had been reported to have   vaginal bleeding, however, was found to have blood at the urethral meatus,   consistent with URETHRAL TRAUMA.	Affirmed	Recent	Patient
818	headache	HISTORY OF PRESENT ILLNESS:  The patient is an **AGE[in 80s]-year-old female presenting with worsening dizziness,   HEADACHE, nausea, as well as leg weakness.	Affirmed	Recent	Patient
819	atypical follicular  lymphoma	The most likely  possibilities include marginal cell lymphoma vs. an ATYPICAL FOLLICULAR  LYMPHOMA.	Affirmed	Recent	Patient
820	pleural effusion	There is no PLEURAL EFFUSION or pneumothorax.	Negated	Recent	Patient
821	cervical lymphadenopathy	Neck - Supple no JVD, lymph node, or CERVICAL LYMPHADENOPATHY.	Negated	Recent	Patient
822	pain	Her PAIN was well controlled with fentanyl 25 mcg patch,   Neurontin 300 mg p.o.	Affirmed	Recent	Patient
823	myeloma	This may  represent metastatic lesion or MYELOMA.	Affirmed	Recent	Patient
824	vomiting	She is currently at   her goal and tolerating these tube feeds well without any nausea, VOMITING,   or residuals.	Negated	Recent	Patient
825	abdominal pain	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no ABDOMINAL PAIN, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
826	Hypertension	HYPERTENSION.	Affirmed	Historical	Patient
827	Paradoxical septal motion	03) PARADOXICAL SEPTAL MOTION consistent with abnormal electrical  activation.	Affirmed	Recent	Patient
828	leg cramp	The patient was admitted   with LEG CRAMP, and in the ED, labs revealed a potassium of 3.	Affirmed	Recent	Patient
829	tricuspid valve is normal	The TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
830	septal infarct	There is evidence of a SEPTAL INFARCT with negative deflections   and Q waves in the septal leads.	Affirmed	Recent	Patient
831	AVM	The patient's bilateral upper extremity duplex   scan revealed no pseudoaneurysms, no AVM, or no organized hematoma.	Negated	Recent	Patient
832	multiple sclerosis	She is a **AGE[in 70s]-year-old female who has a history of MULTIPLE SCLEROSIS   complicated by paralysis and urinary incontinence with chronic Foley, who was   brought in by ambulance today from **INSTITUTION in Mt.	Affirmed	Historical	Patient
833	Anicteric	ANICTERIC.	Affirmed	Recent	Patient
834	pancreatitis	She states that she has no history of PANCREATITIS or alcohol   use.	Negated	Historical	Patient
835	respiratory distress	At the time of discharge, she showed no signs of RESPIRATORY DISTRESS.	Negated	Recent	Patient
836	alert	She was afebrile with   stable vitals; awake, ALERT, and oriented in no acute distress.	Affirmed	Recent	Patient
837	left ventricular hypertrophy	Left ventricular wall thickness is   increased, consistent with LEFT VENTRICULAR HYPERTROPHY.	Affirmed	Recent	Patient
838	flattening   of the interventricular septum	There is FLATTENING   OF THE INTERVENTRICULAR SEPTUM, consistent with right ventricular pressure   or volume overload.	Affirmed	Recent	Patient
839	Flattened interventricular septum	04) FLATTENED INTERVENTRICULAR SEPTUM, consistent with right ventricular  pressure or volume overload.	Affirmed	Recent	Patient
840	pneumonia	She required an EVD placement that was   removed on **DATE[Jul 25 2007], and also required a stay in the ICU while   intubated and was treated for PNEUMONIA with pipera-cillin/tazobactam.	Affirmed	Recent	Patient
841	bilateral areas of lobar consolidation	Slightly improved pulmonary ventilation in a patient with  BILATERAL AREAS OF LOBAR CONSOLIDATION and left-sided pleural  effusion.	Affirmed	Recent	Patient
842	Sessile polyp in the rectum	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) 5mm sessile polyp in the transverse colon    2) 5mm Sessile polyp in the descending colon  3) 6mm SESSILE POLYP IN THE RECTUM  4) Hemorrhoids  5) Otherwise normal exam    PLAN:  1) Await biopsy results    REPEAT EXAM:  Colonoscopy with internval depending on biopsy results    ______________________________  **NAME[YYY ZZZ], M.D.  I was present during the entire procedure.	Affirmed	Recent	Patient
843	infection	No sign of INFECTION.	Negated	Recent	Patient
844	Right ventricular wall thickness is normal	RIGHT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
845	dizziness	He denies any headaches or   DIZZINESS.	Negated	Recent	Patient
846	headache	He denies any   antecedent palpitations, shortness of breath, chest pain, HEADACHE, or   lightheadedness.	Negated	Recent	Patient
847	Left   ventricular wall thickness is increased	LEFT   VENTRICULAR WALL THICKNESS IS INCREASED, consistent with severe left   ventricular hypertrophy.	Affirmed	Recent	Patient
848	allergies	ALLERGIES:  He has no known ALLERGIES.	Negated	Historical	Patient
849	alert	NEUROLOGICAL:  The patient is awake, ALERT.	Affirmed	Recent	Patient
850	Partial small bowel obstruction	PARTIAL SMALL BOWEL OBSTRUCTION, resolved.	Negated	Recent	Patient
851	trace mitral regurgitation	SPECTRAL DOPPLER:   There is TRACE MITRAL REGURGITATION.	Affirmed	Recent	Patient
852	shortness of breath	Positive for SHORTNESS OF BREATH,   no cough.	Affirmed	Recent	Patient
853	febrile	He was noted to be FEBRILE and somewhat   confused.	Affirmed	Recent	Patient
854	Overall left ventricular function is moderate to severely decreased	OVERALL LEFT VENTRICULAR FUNCTION IS MODERATE TO SEVERELY DECREASED, with an   estimated ejection fraction of 25-30 %.	Affirmed	Recent	Patient
855	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
856	advanced glenoid rim  osteoarthritis	There is ADVANCED GLENOID RIM  OSTEOARTHRITIS.	Affirmed	Recent	Patient
857	Strength is good in   all four extremities	STRENGTH IS GOOD IN   ALL FOUR EXTREMITIES.	Affirmed	Recent	Patient
858	nausea	The patient was admitted   on **DATE[Sep 25 2007], complaining of NAUSEA and vomiting.	Affirmed	Recent	Patient
859	nausea	She is currently at   her goal and tolerating these tube feeds well without any NAUSEA, vomiting,   or residuals.	Negated	Recent	Patient
860	Congenital heart disease	CONGENITAL HEART DISEASE/aortic and mitral valvular disease/nonischemic   cardiomyopathy/pulmonary hypertension.	Affirmed	Recent	Patient
861	aortic valve is normal	The AORTIC VALVE IS NORMAL.	Affirmed	Recent	Patient
862	mild to moderate aortic regurgitation	SPECTRAL DOPPLER:   There is MILD TO MODERATE AORTIC REGURGITATION.	Affirmed	Recent	Patient
863	ventriculomegaly	HOSPITAL COURSE:   Ms. **NAME[AAA] is a **AGE[in 30s]-year-old female who was transferred to **INSTITUTION on **DATE[Jul 19   2007], with a subarachnoid hemorrhage and VENTRICULOMEGALY.	Affirmed	Recent	Patient
864	difficulty taking p.o.	She has also developed significant pain in the abdomen and has had   DIFFICULTY TAKING P.O.	Affirmed	Recent	Patient
865	Obstructive Sleep Apnea	PAST MEDICAL HISTORY:     The patient has hypertension, type 2 diabetes, OBSTRUCTIVE SLEEP APNEA, and   wears oxygen at night.	Affirmed	Historical	Patient
866	Mild left atrial enlargement	07) MILD LEFT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
867	diverticula	There was no evidence of polyps, mass or DIVERTICULA.	Negated	Recent	Patient
868	aortic and mitral valvular disease	Congenital heart disease/AORTIC AND MITRAL VALVULAR DISEASE/nonischemic   cardiomyopathy/pulmonary hypertension.	Affirmed	Recent	Patient
869	trace mitral regurgitation	SPECTRAL DOPPLER:   There is TRACE MITRAL REGURGITATION.	Affirmed	Recent	Patient
870	Regular rate and rhythm	Heart:  REGULAR RATE AND RHYTHM.	Affirmed	Recent	Patient
871	increased abdominal pain	She should return to the Emergency Department if she experiences nausea,   vomiting, INCREASED ABDOMINAL PAIN, shortness of breath, or chest pain.	Affirmed	Not particular	Patient
872	ANEMIA	ANEMIA.	Affirmed	Recent	Patient
873	oriented x 1	She was ORIENTED X 1   at that time.	Affirmed	Recent	Patient
874	Type 2 diabetes	TYPE 2 DIABETES.	Affirmed	Historical	Patient
875	anemia	PAST MEDICAL HISTORY:  Significant for Alzheimer disease, hypertension,   atrial fibrillation, history of DVTs, anticoagulation, coronary artery   disease, COPD, history of ANEMIA, history of pulmonary nodules, and history   of cellulitis.	Affirmed	Historical	Patient
876	anxiety	HISTORY OF PRESENT ILLNESS:    This is a **AGE[in 60s]-year-old male with a past history of diabetes, dementia,   hypertension, hypercholesterolemia, anemia, ANXIETY, and depression who   presents with a chief complaint of having fallen.	Affirmed	Historical	Patient
877	dense mitral annular calcification	There is DENSE MITRAL ANNULAR CALCIFICATION.	Affirmed	Recent	Patient
878	progression of  metastatic disease	Evaluate for PROGRESSION OF  METASTATIC DISEASE.	Affirmed	Recent	Patient
879	pericardial effusion	No PERICARDIAL EFFUSION is seen.	Negated	Recent	Patient
880	small bowel obstruction	She was kept on strict NPO and a   Duo-Tube was placed initially to decompress her stomach secondary to the   SMALL BOWEL OBSTRUCTION.	Affirmed	Recent	Patient
881	severe pain to his hand, non-radiating, sharp, and  worse with movement	Complains of SEVERE PAIN TO HIS HAND, NON-RADIATING, SHARP, AND  WORSE WITH MOVEMENT.	Affirmed	Recent	Patient
882	Left ventricular size is normal	BASELINE TWO-DIMENSIONAL ECHOCARDIOGRAPHY:   LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
883	drug use	Denied any DRUG USE.	Negated	Historical	Patient
884	hypothyroidism	REASON FOR ADMISSION:    Past medical history is positive for hyperlipidemia, HYPOTHYROIDISM, weakness   and difficulty with ambulation, aortic/mitral disease, spinal stenosis,   cataracts, measles, mumps, and varicella in the past.	Affirmed	Historical	Patient
885	Left atrial size is moderately   enlarged	LEFT ATRIAL SIZE IS MODERATELY   ENLARGED.	Affirmed	Recent	Patient
886	hemodynamically   stable	Disposition: On **DATE[Jul 19 2007], the patient was afebrile, HEMODYNAMICALLY   STABLE, and is being discharge to **PLACE Transitional Care Unit.	Affirmed	Recent	Patient
887	Normal left ventricular size and function	FINAL IMPRESSIONS:   01) NORMAL LEFT VENTRICULAR SIZE AND FUNCTION.	Affirmed	Recent	Patient
888	atrial fibrillation with   T-wave inversion	A **AGE[90+]-year-old female was transferred from **INSTITUTION after a   condition C was called for an EKG which showed ATRIAL FIBRILLATION WITH   T-WAVE INVERSION.	Affirmed	Recent	Patient
889	acute abdomen	He   had no signs of an ACUTE ABDOMEN; no signs of cholecystitis, pancreatitis or   peptic ulcer disease.	Negated	Recent	Patient
890	lightheadedness	She had definite   presyncope with LIGHTHEADEDNESS and dizziness as if she was going to pass   out.	Affirmed	Recent	Patient
891	biventricular heart failure	Clinically and radiographically, the patient was in   BIVENTRICULAR HEART FAILURE.	Affirmed	Recent	Patient
892	moderate to severe   mitral regurgitation	There is MODERATE TO SEVERE   MITRAL REGURGITATION.	Affirmed	Recent	Patient
893	gallops	Heart - Regular rate and rhythm, no   murmurs, GALLOPS, or rubs.	Negated	Recent	Patient
894	hemodynamic   instability	The patient was treated for respiratory insufficiency and HEMODYNAMIC   INSTABILITY.	Affirmed	Recent	Patient
895	Gastritis in the antrum	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) Severe Esophagitis s/p biopsy  2) Large Hiatal hernia  3) GASTRITIS IN THE ANTRUM s/p biopsy  4) Normal duodenum      PLAN:  1) Follow-up: as scheduled referring MD  2) Await biopsy results  3) Follow-up of helicobacter pylori  status, treat if indicated  4) Protonix 40mg qd    REPEAT EXAM:  EGD in ; As needed    __________________________________  **NAME[YYY ZZZ], MD  I was present during the entire procedure.	Affirmed	Recent	Patient
896	lower extremity swelling	No LOWER EXTREMITY SWELLING.	Negated	Recent	Patient
897	rhonchi	No wheezes, rales, or RHONCHI.	Negated	Recent	Patient
898	left hip fracture	She subsequently   underwent a repair of her LEFT HIP FRACTURE but unfortunately has been left   with intractable radicular pain of the left lower extremity.	Affirmed	Recent	Patient
899	right renal  cyst	There is a RIGHT RENAL  CYST.	Affirmed	Recent	Patient
900	Syncope	S_O_H  Counters Report Type Record Type Subgroup Classifier  47,oTDCcOjI2m16 ECHO ECHO   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      **INSTITUTION - **INSTITUTION Echocardiography Lab            Echocardiographic Report                            An Intersocietal Commission for the Accreditation of               Echocardiography Laboratories Certified Laboratory                       Name: **NAME[AAA, BBB]  Date/Time of Procedure: **DATE[Jun 29 2007] 1:12 PM  Institution: **INSTITUTION  Sex: M  Date of Birth: **DATE[Jun 13 1931]  Echo Number: 183991  Account: **ID-NUM  Type: Echo      Transthoracic Echocardiogram                          ECHOCARDIOGRAPHIC MEASUREMENTS:    *** Measurements Not Obtainable ***                           REFERRING DIAGNOSIS: SYNCOPE And Collapse  TWO DIMENSIONAL ECHOCARDIOLOGY:   This was a technically difficult study.	Affirmed	Recent	Patient
901	pericardial effusion	No   PERICARDIAL EFFUSION is seen.	Negated	Recent	Patient
902	vomiting	The patient was admitted   on **DATE[Sep 25 2007], complaining of nausea and VOMITING.	Affirmed	Recent	Patient
903	good range of motion in all of his digits	He has GOOD RANGE OF MOTION IN ALL OF HIS DIGITS.	Affirmed	Recent	Patient
904	infection	My primary concern regarding this gentleman was the possibility of INFECTION   given the fever and altered mental status.	Affirmed	Recent	Patient
905	osteoporotic	She has had a   DEXAscan in the past, which showed her to be OSTEOPOROTIC.	Affirmed	Historical	Patient
906	Right atrial size   is normal	RIGHT ATRIAL SIZE   IS NORMAL.	Affirmed	Recent	Patient
907	Cranial nerves II   through XII are intact	CRANIAL NERVES II   THROUGH XII ARE INTACT.	Affirmed	Recent	Patient
908	pneumonia	Given his   hypoxia, I was concerned for a possible PNEUMONIA; however, a chest x-ray did   show pulmonary edema which is new for this patient.	Affirmed	Recent	Patient
909	mild to moderate mitral regurgitation	COLOR FLOW DOPPLER:   There is MILD TO MODERATE MITRAL REGURGITATION.	Affirmed	Recent	Patient
910	normal sinus rhythm	Discharge heart rhythm is NORMAL SINUS RHYTHM.	Affirmed	Recent	Patient
911	Abdomen soft, nontender, nondistended	ABDOMEN SOFT, NONTENDER, NONDISTENDED.	Affirmed	Recent	Patient
912	aortic valve is normal	The AORTIC VALVE IS NORMAL.	Affirmed	Recent	Patient
913	esophageal varices	There was no evidence of ESOPHAGEAL VARICES or gastric  varices.	Negated	Recent	Patient
914	tonic/clonic movement	The witnesses did not notice any TONIC/CLONIC MOVEMENT and there was   no history of a seizure.	Negated	Recent	Patient
915	liver  transplant	The patient is status post LIVER  TRANSPLANT.	Affirmed	Historical	Patient
916	advancedenthesopathic change with some heterotopic ossification  adjacent to the greater trochanter	There  is moderate arthrosis of the right hip joint and  ADVANCEDENTHESOPATHIC CHANGE WITH SOME HETEROTOPIC OSSIFICATION  ADJACENT TO THE GREATER TROCHANTER.	Affirmed	Recent	Patient
917	linear  atelectasis or scarring at both lung bases	There is a minimal amount of LINEAR  ATELECTASIS OR SCARRING AT BOTH LUNG BASES.	Affirmed	Recent	Patient
918	increasing ambulation and activity	Physical   therapy, occupational therapy, and cardiopulmonary therapy were consulted for   ways of INCREASING AMBULATION AND ACTIVITY.	Affirmed	Not particular	Patient
919	Right (systemic) ventricular size is severely dilated	Right (systemic) ventricular size is severely dilated.	Affirmed	Recent	Patient
920	right lower extremity arterial clot	Additionally, the   patient has probable RIGHT LOWER EXTREMITY ARTERIAL CLOT that has not been   formally visualized on imaging, but based on the examination is suspected.	Affirmed	Recent	Patient
921	chest tightness,   pressure	The patient is a **AGE[in 40s]-year-old male with a history of COPD, tobacco use,   presents to the Emergency Department with complaint of CHEST TIGHTNESS,   PRESSURE, as well as complaint of shortness of breath and wheezing at home.	Affirmed	Recent	Patient
922	mild pulmonic regurgitation	There is MILD PULMONIC REGURGITATION.	Affirmed	Recent	Patient
923	oriented	NEURO: Alert and ORIENTED.	Affirmed	Recent	Patient
924	afebrile	On the day of   discharge he was AFEBRILE.	Affirmed	Recent	Patient
925	Overall left ventricular   function is normal	OVERALL LEFT VENTRICULAR   FUNCTION IS NORMAL, with an estimated ejection fraction of 55-60 %.	Affirmed	Recent	Patient
926	headaches	She refused nitroglycerin for her   chest pain, as she stated that it worsened her HEADACHES significantly.	Affirmed	Recent	Patient
927	deafness	Does not   give a history of DEAFNESS and denies any recent nausea, vomiting and   diarrhea.	Negated	Historical	Patient
928	Right atrial size is normal	RIGHT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
929	pericardial   effusion	No PERICARDIAL   EFFUSION is seen.	Negated	Recent	Patient
930	Scattered  pulmonary nodules also contain calcification consistent with  granulomas	SCATTERED  PULMONARY NODULES ALSO CONTAIN CALCIFICATION CONSISTENT WITH  GRANULOMAS.	Affirmed	Recent	Patient
931	neck pain	No NECK PAIN.	Negated	Recent	Patient
932	clots in her vagina	Upon discussion with the charge nurse on the third floor at **INSTITUTION, the   patient had some CLOTS IN HER VAGINA, but the urine was clear and the family   had wanted her transferred for evaluation of her vaginal bleeding.	Affirmed	Recent	Patient
933	Right atrial size is normal	RIGHT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
934	biliary system decompressed by a new common bile duct stent	Right upper quadrant ultrasound obtained **DATE[Mar 26 2008], which revealed the   BILIARY SYSTEM DECOMPRESSED BY A NEW COMMON BILE DUCT STENT, the distal   aspect of which is obscured by overlying bowel gas, septated cystic lesions   within the pancreatic body suggestive of IT MN versus mucinous cystic   neoplasm, as previously noted on CT.	Affirmed	Recent	Patient
935	RIGHT SHOULDER HEMIARTHROPLASTY WITHOUT HARDWARE COMPLICATION	RIGHT SHOULDER HEMIARTHROPLASTY WITHOUT HARDWARE COMPLICATION.	Affirmed	Recent	Patient
936	neck discomfort anteriorly	Complains of NECK DISCOMFORT ANTERIORLY.	Affirmed	Recent	Patient
937	rubs	No murmurs, RUBS, or gallops.	Negated	Recent	Patient
938	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
939	Cranial nerves II through XII are intact	Neurologic:  CRANIAL NERVES II THROUGH XII ARE INTACT.	Affirmed	Recent	Patient
940	tobacco	SOCIAL HISTORY:     Denies any alcohol, TOBACCO or illicit drug use.	Negated	Historical	Patient
941	Conjugate gaze	CONJUGATE GAZE.	Affirmed	Recent	Patient
942	Severe left atrial enlargement	08) SEVERE LEFT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
943	vomiting	Chief complaint is nausea, VOMITING, and diarrhea.	Affirmed	Recent	Patient
944	mediastinitis and embolization	Coronary artery disease status post coronary artery bypass graft in **DATE[Apr   2007] with complication of MEDIASTINITIS AND EMBOLIZATION resulting in   amputation of left upper extremity above elbow.	Affirmed	Historical	Patient
945	soft  tissue masses are shown at the margins of the surgical resection	No SOFT  TISSUE MASSES ARE SHOWN AT THE MARGINS OF THE SURGICAL RESECTIONto  suggest recurrent disease.	Negated	Recent	Patient
946	regular S-1 and S-2 without murmurs	Has a REGULAR S-1 AND S-2 WITHOUT MURMURS.	Affirmed	Recent	Patient
947	headache	She states the HEADACHE is at the apex of her skull.	Affirmed	Recent	Patient
948	wheezes 	He does have audible   WHEEZES on initial examination.	Affirmed	Recent	Patient
949	murmurs	No MURMURS, rubs or gallops.	Negated	Recent	Patient
950	throat discomfort	She still continues to have   THROAT DISCOMFORT and complains of a foreign body sensa-tion in the same   area.	Affirmed	Recent	Patient
951	aortic valve is normal	The AORTIC VALVE IS NORMAL.	Affirmed	Recent	Patient
952	change in sleep	The patient denies CHANGE IN SLEEP.	Negated	Recent	Patient
953	sickle cell disease	HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 50s]-year-old female with a history of SICKLE CELL DISEASE, anemia,   who presents with one-week history of intermittent pain typical of her sickle   cell crisis pain, she says.	Affirmed	Recent	Patient
954	Overall left ventricular function is normal	OVERALL LEFT VENTRICULAR FUNCTION IS NORMAL,   with an estimated ejection fraction of 55-60 %.	Affirmed	Recent	Patient
955	Regular rate and rhythm	HEART:  REGULAR RATE AND RHYTHM.	Affirmed	Recent	Patient
956	Pharynx clear   with moist mucous membranes	PHARYNX CLEAR   WITH MOIST MUCOUS MEMBRANES.	Affirmed	Recent	Patient
957	chills	She had no CHILLS.	Negated	Recent	Patient
958	heart size and pulmonary vascularity are normal	FINDINGS:     The HEART SIZE AND PULMONARY VASCULARITY ARE NORMAL.	Affirmed	Recent	Patient
959	Mild tricuspid regurgitation	05) MILD TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
960	mild aortic regurgitation	SPECTRAL DOPPLER:   There is MILD AORTIC REGURGITATION.	Affirmed	Recent	Patient
961	Abdominal pain	HISTORY OF PRESENT ILLNESS:    CHIEF COMPLAINT:  ABDOMINAL PAIN.	Affirmed	Recent	Patient
962	dysphagia	The indication for this procedure is dyspepsia    and DYSPHAGIA.	Affirmed	Recent	Patient
963	trace pulmonic   regurgitation	There is TRACE PULMONIC   REGURGITATION.	Affirmed	Recent	Patient
964	enlarged liver	Important to note, on physical exam, the only interesting finding is that the   patient seemed to have an ENLARGED LIVER.	Affirmed	Recent	Patient
965	pulmonary edema	Ischemic trigger is certainly concerning given the patient's presentation of   sudden syncope and diffuse weakness with new PULMONARY EDEMA which he never   had before.	Affirmed	Recent	Patient
966	Left atrial size is normal	LEFT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
967	head is normocephalic, atraumatic	On HEENT examination, his HEAD IS NORMOCEPHALIC, ATRAUMATIC.	Affirmed	Recent	Patient
968	Portal hypertensive gastropathy	PORTAL HYPERTENSIVE GASTROPATHY was found throughout  the stomach.	Affirmed	Recent	Patient
969	CHF	CHF.	Affirmed	Historical	Patient
970	pain	HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 50s]-year-old female with a history of sickle cell disease, anemia,   who presents with one-week history of intermittent PAIN typical of her sickle   cell crisis PAIN, she says.	Affirmed	Recent	Patient
971	Extraocular movements   intact	EXTRAOCULAR MOVEMENTS   INTACT.	Affirmed	Recent	Patient
972	Right ventricular size is   normal	RIGHT VENTRICULAR SIZE IS   NORMAL.	Affirmed	Recent	Patient
973	moderate aortic regurgitation	SPECTRAL DOPPLER:   There is MODERATE AORTIC REGURGITATION.	Affirmed	Recent	Patient
974	mitral valve is normal	The MITRAL VALVE IS NORMAL.	Affirmed	Recent	Patient
975	Left atrial size is mildly enlarged	LEFT ATRIAL SIZE IS MILDLY ENLARGED.	Affirmed	Recent	Patient
976	bilateral high-grade carotid stenosis	A CT angiogram   showed left MCA CVA, BILATERAL HIGH-GRADE CAROTID STENOSIS.	Affirmed	Recent	Patient
977	vaginal bleeding	Upon discussion with the charge nurse on the third floor at **INSTITUTION, the   patient had some clots in her vagina, but the urine was clear and the family   had wanted her transferred for evaluation of her VAGINAL BLEEDING.	Affirmed	Recent	Patient
978	injury proximal to his wrist	No INJURY PROXIMAL TO HIS WRIST.	Negated	Recent	Patient
979	confusion	HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 50s]-year-old male who presents to the   Emergency Department complaining of left-sided weakness and CONFUSION.	Affirmed	Recent	Patient
980	CORONARY ARTERY BYPASS GRAFT TIMES FOUR	TRANSFER DIAGNOSIS(ES):   STATUS POST CORONARY ARTERY BYPASS GRAFT TIMES FOUR.	Affirmed	Recent	Patient
981	Abdominal pain	CHIEF COMPLAINT:  ABDOMINAL PAIN.	Affirmed	Recent	Patient
982	weakness	No   WEAKNESS.	Negated	Recent	Patient
983	agitated	She saw the patient in hospital on **DATE[Feb 18 2008], and the patient was   AGITATED in a child state.	Affirmed	Recent	Patient
984	lethargy	No delusions, LETHARGY, or   hallucinations.	Negated	Recent	Patient
985	enlarged nodes	No ENLARGED NODES are identified.	Negated	Recent	Patient
986	Mild aortic root dilation	09) MILD AORTIC ROOT DILATION.	Affirmed	Recent	Patient
987	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
988	wheezes	No WHEEZES, rales or rhonchi.	Negated	Recent	Patient
989	rectal sheath hematoma with intraabdominal bleed	Also throughout this hospital course, the patient had the following   complications:  sepsis, respiratory failure with trach placement,   thrombocytopenia, RECTAL SHEATH HEMATOMA WITH INTRAABDOMINAL BLEED status   post iliac and epigastric embolization of arteries, renal failure secondary   to ureteral obstruction with bilateral nephrostomy tube placement, right MCA   CVA, rectal ischemia and further complications related to her underlying   hypercoagulable state.	Affirmed	Recent	Patient
990	shortness of breath	The patient had no chest pain   or SHORTNESS OF BREATH.	Negated	Recent	Patient
991	Colitis in the sigmoid colon  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POST-OPERATIVE DIAGNOSIS(ES):  1) Stenosis in the sigmoid colon  2) COLITIS IN THE SIGMOID COLON      PLAN:  1) Follow-up: today **INSTITUTION  2) Await biopsy results    REPEAT EXAM:  No    ______________________________  **NAME[YYY M. ZZZ], M.D.  I was present during the entire procedure.	Affirmed	Recent	Patient
992	portal hypertension	The indication for this procedure is cirrhosis  and staging of PORTAL HYPERTENSION.	Affirmed	Recent	Patient
993	cholecystectomy	He has also history of CHOLECYSTECTOMY and cataract surgery.	Affirmed	Historical	Patient
994	bipolar disorder	HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE:  Mr. **NAME[BBB AAA] is a **AGE[in 40s]-year-old male with a medical history significant for   BIPOLAR DISORDER as well as depression who presented with a several day   history of epigastric and chest pain radiating down his left arm.	Affirmed	Historical	Patient
995	cirrhosis	The indication for this procedure is CIRRHOSIS  and staging of portal hypertension.	Affirmed	Recent	Patient
996	blood at the urethral meatus	Assessment of this Patient:  She is a **AGE[in 70s]-year-old female with a history of   multiple sclerosis, and paralysis with a history of urinary tract infections   and urinary incontinence with chronic Foley, who had been reported to have   vaginal bleeding, however, was found to have BLOOD AT THE URETHRAL MEATUS,   consistent with urethral trauma.	Affirmed	Recent	Patient
997	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
998	DRUG ALLERGIES	ALLERGIES:  NO KNOWN DRUG ALLERGIES.	Negated	Historical	Patient
999	chest pain	Her last episode of   CHEST PAIN was yesterday.	Affirmed	Recent	Patient
1000	alcohol	SOCIAL HISTORY:   She denies any tobacco, ALCOHOL or drug abuse.	Negated	Historical	Patient
1001	dysuria	She denies any   DYSURIA.	Negated	Recent	Patient
1002	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
1003	nausea	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no NAUSEA, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
1004	necrotizing pancreatitis	Pancreaticobiliary was consulted for further   management of her NECROTIZING PANCREATITIS.	Affirmed	Recent	Patient
1005	pulmonary artery size is normal	The PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
1006	pulmonary artery size is normal	The PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
1007	trace pulmonic regurgitation	There is TRACE PULMONIC REGURGITATION.	Affirmed	Recent	Patient
1008	chest pain	She states that the   pain is actually worse than her CHEST PAIN at this point.	Affirmed	Recent	Patient
1009	fever	She had no FEVER.	Negated	Recent	Patient
1010	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
1011	Left atrial size is normal	LEFT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
1012	abdominal pain	She denies any ABDOMINAL PAIN, no chest pain or shortness of   breath, she has had no particular sick contacts, and she has been using   over-the-counter remedies with no specific relief.	Negated	Recent	Patient
1013	active lung disease	This patient did have a chest x-ray on **DATE[May 22 2008], and the heart was within   normal range with no ACTIVE LUNG DISEASE.	Negated	Recent	Patient
1014	Overall left ventricular   function is normal	OVERALL LEFT VENTRICULAR   FUNCTION IS NORMAL, with an estimated ejection fraction of 55-60 %.	Affirmed	Recent	Patient
1015	change in color of her finger	If she has any new tingling, any   weakness, increasing pain, or CHANGE IN COLOR OF HER FINGER, she should   immediately return to the department, otherwise, I feel she is safe for   discharge at this time.	Affirmed	Not particular	Patient
1016	mild distress	In general, the patient appears to be in MILD DISTRESS.	Affirmed	Recent	Patient
1017	Internal hemorrhoids	FINDINGS:  INTERNAL HEMORRHOIDS were found.	Affirmed	Recent	Patient
1018	Chest:  Nontender	CHEST:  NONTENDER.	Affirmed	Recent	Patient
1019	Neck is supple	NECK: NECK IS SUPPLE.	Affirmed	Recent	Patient
1020	Great toe laceration	GREAT TOE LACERATION.	Affirmed	Recent	Patient
1021	metastatic disease in the pelvis	No findings of METASTATIC DISEASE IN THE PELVIS.	Negated	Recent	Patient
1022	gastrojejunostomy was  patent	The GASTROJEJUNOSTOMY WAS  PATENT.	Affirmed	Recent	Patient
1023	DVTs	This   was most likely predisposed by Coumadin as the patient was on anticoagulation   for history of DVTS and atrial fibrillation.	Affirmed	Historical	Patient
1024	altered mental status	My primary concern regarding this gentleman was the possibility of infection   given the fever and ALTERED MENTAL STATUS.	Affirmed	Recent	Patient
1025	Right ventricular   wall thickness is normal	RIGHT VENTRICULAR   WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
1026	anxieties were mild	On admission, her ANXIETIES WERE MILD.	Affirmed	Recent	Patient
1027	laceration to her   hypothenar eminence	HISTORY OF PRESENT ILLNESS:  Ms. **NAME[AAA] is a **AGE[in 50s]-year-old, white female who sustained a LACERATION TO HER   HYPOTHENAR EMINENCE eight days ago.	Affirmed	Recent	Patient
1028	CHRONIC OBSTRUCTIVE PULMONARY DISEASE EXACERBATION	CHRONIC OBSTRUCTIVE PULMONARY DISEASE EXACERBATION.	Affirmed	Recent	Patient
1029	shortness of   breath	She denies any abdominal pain, no chest pain or SHORTNESS OF   BREATH, she has had no particular sick contacts, and she has been using   over-the-counter remedies with no specific relief.	Negated	Recent	Patient
1030	anterior   cervical lymphadenopathy	No ANTERIOR   CERVICAL LYMPHADENOPATHY.	Negated	Recent	Patient
1031	chronic lymphocytic leukemia	Precise classification of this process cannot be definitively done on the  material available, but these findings would NOT support a diagnosis of  CHRONIC LYMPHOCYTIC LEUKEMIA or hairy cell leukemia.	Negated	Recent	Patient
1032	Duodenitis in the bulb of duodenum  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) Normal esophagus    2) Normal stomach    3) DUODENITIS IN THE BULB OF DUODENUM      PLAN:  1) **INSTITUTION for Liver Disease  2) await biopsy results    REPEAT EXAM:  No    __________________________________  **NAME[YYY ZZZ]  I was present during the entire procedure.	Affirmed	Recent	Patient
1033	Dizziness	S_O_H  Counters Report Type Record Type Subgroup Classifier  162,9VJSVs8NGvo/ RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  XRAY CHEST FRONTAL AND LATERAL VIEWS   **DATE[Aug 03 07]     1440 HOURS    CLINICAL HISTORY:     DIZZINESS and headache.	Affirmed	Recent	Patient
1034	stable	CONDITION ON DISCHARGE:    This patient is STABLE for discharge for discharge, status post CABG times   four.	Affirmed	Recent	Patient
1035	vomiting	GI - No nausea or VOMITING.	Negated	Recent	Patient
1036	Colitis in the sigmoid colon	COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) COLITIS IN THE SIGMOID COLON  2) No additional lesions    PLAN:  1) Await biopsy results    REPEAT EXAM:  Colonoscopy in 10 year(s).	Affirmed	Recent	Patient
1037	more pleasant	She   became MORE PLEASANT.	Affirmed	Recent	Patient
1038	Back and leg pain	S_O_H  Counters Report Type Record Type Subgroup Classifier  168,mwiXu5INSvkz RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  XRAY FEMUR 2 VIEWS RIGHT   **DATE[May 03 07]     1144 HOURS    CLINICAL HISTORY:     BACK AND LEG PAIN.	Affirmed	Recent	Patient
1039	afebrile	Disposition: On **DATE[Jul 19 2007], the patient was AFEBRILE, hemodynamically   stable, and is being discharge to **PLACE Transitional Care Unit.	Affirmed	Recent	Patient
1040	atrial fibrillation	PAST MEDICAL HISTORY:  Significant for Alzheimer disease, hypertension,   ATRIAL FIBRILLATION, history of DVTs, anticoagulation, coronary artery   disease, COPD, history of anemia, history of pulmonary nodules, and history   of cellulitis.	Affirmed	Historical	Patient
1041	Regular rate and rhythm	REGULAR RATE AND RHYTHM.	Affirmed	Recent	Patient
1042	locally extensive gastric adenocarcinoma	REASON FOR HOSPITAL ADMISSION:    Ms. **NAME[AAA] is an **AGE[in 80s]-year-old woman, who was hospitalized in **DATE[Feb 2008] with a   LOCALLY EXTENSIVE GASTRIC ADENOCARCINOMA.	Affirmed	Recent	Patient
1043	ENHANCEMENT ALONG THE RIGHT AND LEFT 7TH AND 8TH  CRANIAL NERVES	NEW, SUBTLE ENHANCEMENT ALONG THE RIGHT AND LEFT 7TH AND 8TH  CRANIAL NERVES MAY SUGGEST UNDERLYING PERINEURAL EXTENSION OF  DISEASE.	Affirmed	Recent	Patient
1044	left-sided pleural  effusion	Slightly improved pulmonary ventilation in a patient with  bilateral areas of lobar consolidation and LEFT-SIDED PLEURAL  EFFUSION.	Affirmed	Recent	Patient
1045	left lower extremity DVT	Throughout the course of this hospitalization, the patient was   found to have LEFT LOWER EXTREMITY DVT, status post IVC placement, and upon   attempted anticoagulation had a catastrophic rebleed.	Affirmed	Recent	Patient
1046	gas pains	Today, she states that she still has abdominal bloating, which she refers to   as GAS PAINS.	Affirmed	Recent	Patient
1047	Left lower lobe pneumonia	LEFT LOWER LOBE PNEUMONIA.	Affirmed	Recent	Patient
1048	bright red or tarry black stools	She will alert the physician if any of the following are   noted:  Nosebleeds, excessive bruising, pink, red, or tea-colored urine,   BRIGHT RED OR TARRY BLACK STOOLS, unusual headaches, or stomach pain.	Affirmed	Not particular	Patient
1049	pulmonary artery and aorta are normal in caliber	FINDINGS:     The PULMONARY ARTERY AND AORTA ARE NORMAL IN CALIBER.	Affirmed	Recent	Patient
1050	unknown coagulation disorder	He  has an UNKNOWN COAGULATION DISORDER including a +LAC, so he intermittenly  bleeds/oozes or clots, so his anticoagulation remains a challenge.	Affirmed	Historical	Patient
1051	JVD	Neck - Supple, no lymphadenopathy, thyromegaly, or JVD.	Negated	Recent	Patient
1052	severe depression	Call also for any weight gain   greater than three pounds per day or five pounds per week, any unusual   rashes, nausea, vomiting, fever associated with chill, temperature elevation   greater than 101 degrees Fahrenheit, sustained or low-grade temperature   greater than 100 degrees Fahrenheit, new onset of chest pain,   light-headedness, or dizziness, new or increased shortness of breath, severe   calf pain, burning on urination or SEVERE DEPRESSION.	Affirmed	Not particular	Patient
1053	cerebral hemorrhages	Unfortunately, the patient's mental status has continued to   deteriorate with her multiple CVAs and/or CEREBRAL HEMORRHAGES during this   hospitalization.	Affirmed	Recent	Patient
1054	shortness of breath	COMMENTS:   The patient developed SHORTNESS OF BREATH during the test.	Affirmed	Recent	Patient
1055	stress fracture on the left calcaneum	The patient also had a STRESS FRACTURE ON THE LEFT CALCANEUM, for which   Orthopedics was involved.	Affirmed	Recent	Patient
1056	Sickle cell disease	SICKLE CELL DISEASE.	Affirmed	Recent	Patient
1057	weakness	REASON FOR ADMISSION:    Past medical history is positive for hyperlipidemia, hypothyroidism, WEAKNESS   and difficulty with ambulation, aortic/mitral disease, spinal stenosis,   cataracts, measles, mumps, and varicella in the past.	Affirmed	Historical	Patient
1058	paradoxical septal motion	There is   post-operative PARADOXICAL SEPTAL MOTION.	Affirmed	Recent	Patient
1059	JVD	No JVD or lymphadenopathy.	Negated	Recent	Patient
1060	stable condition	She was admitted in STABLE CONDITION to a monitored   bed.	Affirmed	Recent	Patient
1061	perforated ulcer	The indication for this procedure is history  of Billroth II for PERFORATED ULCER, with malnutrition, nausea and vomiting.	Affirmed	Historical	Patient
1062	mild UTI	She does have the MILD UTI.	Affirmed	Recent	Patient
1063	Regular rate and rhythm	CARDIOVASCULAR:  REGULAR RATE AND RHYTHM.	Affirmed	Recent	Patient
1064	chronic pain syndrome	Altered mental status was likely secondary to high dose of   opioids at home for CHRONIC PAIN SYNDROME.	Affirmed	Recent	Patient
1065	pulmonary infiltrate or edema	The chest x-ray does not demonstrate any   evidence of PULMONARY INFILTRATE OR EDEMA.	Negated	Recent	Patient
1066	pericardial effusion	No   PERICARDIAL EFFUSION is seen.	Negated	Recent	Patient
1067	drug use	Denies alcohol or other DRUG USE.	Negated	Historical	Patient
1068	left renal calculi	_______________________________________________________________  GROSS DESCRIPTION:  The specimen is received unfixed labeled with the patient's name, initials LC  and "LEFT RENAL CALCULI, for chemical analysis".	Affirmed	Recent	Patient
1069	Bowel sounds are present	ABDOMEN:  BOWEL SOUNDS ARE PRESENT, nontender.	Affirmed	Recent	Patient
1070	Segmental left ventricular function is normal	SEGMENTAL LEFT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
1071	Diverticuli, scattered in the left colon  	COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) Pedunculated polyp in the mid transverse colon    2) DIVERTICULI, SCATTERED IN THE LEFT COLON    3)E xternal  Hemorrhoids      PLAN:  1) Follow-up: as scheduled referring MD  2) Await biopsy results    REPEAT EXAM:  Colonoscopy in 5 - 10 year(s).	Affirmed	Recent	Patient
1072	polyps	There was no evidence of POLYPS or mass.	Negated	Recent	Patient
1073	Hiatal hernia  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) Normal esophagus  2) HIATAL HERNIA    3) Erosions, multiple in the antrum  4) Normal duodenum    5) No additional lesions    PLAN:  1) Await biopsy results  2) **INSTITUTION as scheduled    REPEAT EXAM:  No    __________________________________  **NAME[YYY ZZZ]  I was present during the entire procedure.	Affirmed	Recent	Patient
1074	Clear to auscultation bilaterally	Lungs:  CLEAR TO AUSCULTATION BILATERALLY.	Affirmed	Recent	Patient
1075	fevers	He does occasionally have loose stools, no FEVERS or chills, no   sick contacts, no recent use of antibiotics.	Negated	Recent	Patient
1076	some lumbar spinal tenderness	Musculoskeletal:  The patient has mild amount of left lumbar paraspinal   tenderness as well as SOME LUMBAR SPINAL TENDERNESS.	Affirmed	Recent	Patient
1077	Smoker	Social history:  SMOKER.	Affirmed	Historical	Patient
1078	HUMAN IMMUNODEFICIENCY VIRUS/ACQUIRED IMMUNODEFICIENCY SYNDROME	HUMAN IMMUNODEFICIENCY VIRUS/ACQUIRED IMMUNODEFICIENCY SYNDROME.	Affirmed	Recent	Patient
1079	Diverticulosis/sigmoid colon	COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) Normal colonoscopy  2) DIVERTICULOSIS/SIGMOID COLON    PLAN:  1) Follow-up: as scheduled referring MD  2) High fiber diet    REPEAT EXAM:  Colonoscopy in 10 year(s).	Affirmed	Recent	Patient
1080	tricuspid valve is normal	The TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
1081	Lumbar disk ruptures	S_O_H  Counters Report Type Record Type Subgroup Classifier  12,4NSg7tOMI2JM DS DS 5104  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION  NEUROSURGERY  DISCHARGE SUMMARY  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #  **ID-NUM  **ROOM  ATTENDING PHYSICIAN:  **NAME[YYY M ZZZ]  ADMISSION DATE:  **DATE[Aug 14 2007]  DISCHARGE DATE:  **DATE[Aug 16 2007]  PRINCIPLE DIAGNOSES:  LUMBAR DISK RUPTURES.	Affirmed	Recent	Patient
1082	pulmonary artery size is normal	The PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
1083	stable	On the day of discharge, which was **DATE[May 21 2008], this patient was STABLE for   her discharge to home.	Affirmed	Recent	Patient
1084	thyromegaly	No lymphadenopathy, THYROMEGALY or JVD.	Negated	Recent	Patient
1085	left-sided weakness	He did have some LEFT-SIDED WEAKNESS although that   seemed to have resolved by the time he had reached the Emergency Department.	Negated	Recent	Patient
1086	density occupying the posterior half of the left globe	The DENSITY OCCUPYING THE POSTERIOR HALF OF THE LEFT GLOBE is   redemonstrated with no change.	Affirmed	Historical	Patient
1087	mild nausea	She admits to MILD NAUSEA   during this episode while she was at the **INSTITUTION and denies any back   pain, denies fevers, denies cough, or cold symptoms.	Affirmed	Recent	Patient
1088	Revision of right iliac bolt	PROCEDURE:  REVISION OF RIGHT ILIAC BOLT.	Affirmed	Recent	Patient
1089	COPD	S_O_H  Counters Report Type Record Type Subgroup Classifier  202,JHBTO8+z8pgj SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PATIENT HISTORY:  Status post double lung transplant for COPD.	Affirmed	Historical	Patient
1090	angiodysplasia (spider angiomata) was found in the bulb of  the duodenum	An angiodysplasia (spider angiomata) was found in the bulb of  the duodenum.	Affirmed	Recent	Patient
1091	Normal biventricular size and systolic function	FINAL IMPRESSIONS:   01) NORMAL BIVENTRICULAR SIZE AND SYSTOLIC FUNCTION.	Affirmed	Recent	Patient
1092	pain in the abdomen	She has also developed significant PAIN IN THE ABDOMEN and has had   difficulty taking p.o.	Affirmed	Recent	Patient
1093	Tobacco	SOCIAL HISTORY:   TOBACCO: Quit smoking in 1958.	Negated	Historical	Patient
1094	mild nausea	Currently, the   patient has some MILD NAUSEA and his abdominal cramping is much improved at   this time.	Affirmed	Recent	Patient
1095	There is mitral annular calcification	THERE IS MITRAL ANNULAR CALCIFICATION.	Affirmed	Recent	Patient
1096	Erosions, multiple in the antrum	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) Normal esophagus  2) Hiatal hernia    3) EROSIONS, MULTIPLE IN THE ANTRUM  4) Normal duodenum    5) No additional lesions    PLAN:  1) Await biopsy results  2) **INSTITUTION as scheduled    REPEAT EXAM:  No    __________________________________  **NAME[YYY ZZZ]  I was present during the entire procedure.	Affirmed	Recent	Patient
1097	Measles	MEASLES.	Affirmed	Historical	Patient
1098	seizure	The witnesses did not notice any tonic/clonic movement and there was   no history of a SEIZURE.	Negated	Historical	Patient
1099	Duodenitis	DUODENITIS.	Affirmed	Recent	Patient
1100	fever associated with chill	Call also for any weight gain   greater than three pounds per day or five pounds per week, any unusual   rashes, nausea, vomiting, FEVER ASSOCIATED WITH CHILL, temperature elevation   greater than 101 degrees Fahrenheit, sustained or low-grade temperature   greater than 100 degrees Fahrenheit, new onset of chest pain,   light-headedness, or dizziness, new or increased shortness of breath, severe   calf pain, burning on urination or severe depression.	Affirmed	Not particular	Patient
1101	cyanosis	Extremities: No clubbing, CYANOSIS, or edema.	Negated	Recent	Patient
1102	renal failure secondary   to ureteral obstruction 	Also throughout this hospital course, the patient had the following   complications:  sepsis, respiratory failure with trach placement,   thrombocytopenia, rectal sheath hematoma with intraabdominal bleed status   post iliac and epigastric embolization of arteries, RENAL FAILURE SECONDARY   TO URETERAL OBSTRUCTION with bilateral nephrostomy tube placement, right MCA   CVA, rectal ischemia and further complications related to her underlying   hypercoagulable state.	Affirmed	Recent	Patient
1103	air hunger	Denies shortness of breath, stridor, or AIR HUNGER.	Negated	Recent	Patient
1104	right to left  intracardiac shunt	04) Normal saline contrast injection without evidence of RIGHT TO LEFT  INTRACARDIAC SHUNT.	Negated	Recent	Patient
1105	ALLERGIES INCLUDE PENICILLIN AND OXYCODONE	ALLERGIES:   HER ALLERGIES INCLUDE PENICILLIN AND OXYCODONE.	Affirmed	Historical	Patient
1106	fever	He denied any FEVER.	Negated	Recent	Patient
1107	shortness of breath	Also, the patient later complained of a cough and SHORTNESS OF BREATH so a   chest x-ray was obtained and found to be unremarkable.	Affirmed	Recent	Patient
1108	gastritis	POST-OP DIAGNOSIS:  Rule out H. pylori, GASTRITIS and gastropathy.	Affirmed	Recent	Patient
1109	Mitral annular calcification	04) MITRAL ANNULAR CALCIFICATION.	Affirmed	Recent	Patient
1110	mild tricuspid   regurgitation	There is MILD TRICUSPID   REGURGITATION.	Affirmed	Recent	Patient
1111	2+ edema   bilaterally up to the mid calf level in the lower extremities	There is 2+ edema   bilaterally up to the mid calf level in the lower extremities.	Affirmed	Recent	Patient
1112	palpitations	He denies any   antecedent PALPITATIONS, shortness of breath, chest pain, headache, or   lightheadedness.	Negated	Recent	Patient
1113	Left atrial size is normal	LEFT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
1114	polyps	There was no evidence of POLYPS.	Negated	Recent	Patient
1115	Barrett's esophagus	The esophagus was entirely normal without  signs of inflammation or BARRETT'S ESOPHAGUS.	Negated	Recent	Patient
1116	Diabetes	DIABETES.	Affirmed	Historical	Patient
1117	stomach wall was normally distensable and no pathology was noted	The STOMACH WALL WAS NORMALLY DISTENSABLE AND NO PATHOLOGY WAS NOTED.	Affirmed	Recent	Patient
1118	hairy cell leukemia	Review of the  **INSTITUTION consultation report (slides not submitted for review at  UPMC-Presbyterian) indicates a diagnosis of HAIRY CELL LEUKEMIA rendered at  that time.	Affirmed	Historical	Patient
1119	Patellar reflexes   are 2+ bilaterally	Patellar reflexes   are 2+ bilaterally.	Affirmed	Recent	Patient
1120	wall  motion abnormalities	09) There were no stress induced chest pain, ischemic EKG changes or WALL  MOTION ABNORMALITIES at a relatively low level of stress.	Negated	Recent	Patient
1121	Right ventricular function is normal	RIGHT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
1122	1cm area  of linear fibrosis in the left lower lobe	There is a 1CM AREA  OF LINEAR FIBROSIS IN THE LEFT LOWER LOBE on image 45 of series 4  which may be related to an adjacent old rib fracture.	Affirmed	Recent	Patient
1123	broken right iliac  bolt	S_O_H  Counters Report Type Record Type Subgroup Classifier  211,zW1QfzcDk6fp SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PATIENT HISTORY:  Redo post lumbar, status post multiple back surgeries, BROKEN RIGHT ILIAC  BOLT.	Affirmed	Recent	Patient
1124	Coronary Artery Disease	Wall Thickness:  1.1 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: CORONARY ARTERY DISEASE, Native Coronary Arte  TWO DIMENSIONAL ECHOCARDIOLOGY:   Left ventricular size is normal.	Affirmed	Recent	Patient
1125	SUBACUTE SUBDURAL HEMATOMA WITH REBLEED	SUBACUTE SUBDURAL HEMATOMA WITH REBLEED.	Affirmed	Recent	Patient
1126	abnormal bleeding other than the bleeding from her vagina	Denied any ABNORMAL BLEEDING OTHER THAN THE BLEEDING FROM HER VAGINA.	Negated	Recent	Patient
1127	leg weakness	HISTORY OF PRESENT ILLNESS:  The patient is an **AGE[in 80s]-year-old female presenting with worsening dizziness,   headache, nausea, as well as LEG WEAKNESS.	Affirmed	Recent	Patient
1128	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
1129	right pleural effusion	S_O_H  Counters Report Type Record Type Subgroup Classifier  161,JAlB6a0EJoOb RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  US GUIDED THORACENTESIS PUNCTURE RIGHT   **DATE[Nov 07 07]     1251 HOURS    CLINICAL HISTORY:     Right thoracentesis, RIGHT PLEURAL EFFUSION.	Affirmed	Recent	Patient
1130	myalgias	Musculoskeletal - No arthralgias or MYALGIAS.	Negated	Recent	Patient
1131	Lungs were clear to auscultation	LUNGS: LUNGS WERE CLEAR TO AUSCULTATION.	Affirmed	Recent	Patient
1132	chronic thoracic aortic aneurysm	;    HISTORY:  The patient is a **AGE[in 60s]-year-old gentleman with a past medical history  significant for ESRD, HIV, CHRONIC THORACIC AORTIC ANEURYSM, chronic SVC  occlusion, and recent diagnosis of PE who was discharged on **DATE[Jul 2 2007]  after right groin AV fistula placement.	Affirmed	Historical	Patient
1133	Obesity	Wall Thickness:  1.3 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Chronic Airway Obstruction 496; Systolic Heart Failure;  OBESITY 278.0; Hypertension 401.9  TWO DIMENSIONAL ECHOCARDIOLOGY:   Left ventricular size is normal.	Affirmed	Historical	Patient
1134	frequency	GU - No FREQUENCY, urgency, or dysuria.	Negated	Recent	Patient
1135	rupture   of a left posterior internal carotid aneurysm	She had RUPTURE   OF A LEFT POSTERIOR INTERNAL CAROTID ANEURYSM and underwent a coiling on   **DATE[Jul 20 2007], by Dr. **NAME[ZZZ].	Affirmed	Recent	Patient
1136	ambulating 150 feet with a wheeled walker	She was able to go up and down 12 stairs using a hand rail, and   she was AMBULATING 150 FEET WITH A WHEELED WALKER.	Affirmed	Recent	Patient
1137	nausea	His NAUSEA and vomiting resolved.	Negated	Recent	Patient
1138	Alert	Neuro: ALERT and oriented times three.	Affirmed	Recent	Patient
1139	breast carcinoma	S_O_H  Counters Report Type Record Type Subgroup Classifier  176,oxqq7HvwF3fi RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  MR BRAIN WITH AND WITHOUT CONTRAST   **DATE[Oct 14 07]     1710 HOURS    CLINICAL HISTORY:     History of BREAST CARCINOMA.	Affirmed	Recent	Patient
1140	edema	The extremities have   no cyanosis, clubbing, or EDEMA.	Negated	Recent	Patient
1141	Right   atrial size is normal	RIGHT   ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
1142	esophageal strictures	PAST MEDICAL HISTORY:     Past medical history is significant for ESOPHAGEAL STRICTURES.	Affirmed	Historical	Patient
1143	ABDOMEN:  Soft.  	ABDOMEN:  Soft.	Affirmed	Recent	Patient
1144	mitral annular calcification	There is MITRAL ANNULAR CALCIFICATION.	Affirmed	Recent	Patient
1145	coughing	The patient does admit to 2 episodes of emesis with mild blood   streaking, and he also admits to COUGHING.	Affirmed	Recent	Patient
1146	GIANT CELL ARTERITIS	HISTORY OF GIANT CELL ARTERITIS.	Affirmed	Historical	Patient
1147	edema	Extremities: No clubbing, cyanosis, or EDEMA.	Negated	Recent	Patient
1148	hematuria	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no HEMATURIA or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
1149	Clear to auscultation bilaterally	LUNGS:  CLEAR TO AUSCULTATION BILATERALLY.	Affirmed	Recent	Patient
1150	partial small bowel obstructions	S_O_H  Counters Report Type Record Type Subgroup Classifier  13,MFZKSI+l8xGn DS DS 5004  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   GENERAL MEDICINE  DISCHARGE SUMMARY     PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  **ROOM  ATTENDING PHYSICIAN:  **NAME[ZZZ M YYY]  ADMISSION DATE:  **DATE[Sep 19 2007]  DISCHARGE DATE:  **DATE[Sep 27 2007]     The patient is a **AGE[in 40s]-year-old with past medical history of partial small bowel   obstruction, who is admitted quite frequently for abdominal pain, bowel   distention, and PARTIAL SMALL BOWEL OBSTRUCTIONS.	Affirmed	Historical	Patient
1151	acute distress	General:  The patient is awake, alert, lucid, appears to be in mild amount of   pain, in no ACUTE DISTRESS.	Negated	Recent	Patient
1152	trace pulmonic   regurgitation	There is TRACE PULMONIC   REGURGITATION.	Affirmed	Recent	Patient
1153	Thickened mitral valve with  moderate to severe regurgitation	04) THICKENED MITRAL VALVE WITH  MODERATE TO SEVERE REGURGITATION.	Affirmed	Recent	Patient
1154	vomiting	The indication for this procedure is history  of Billroth II for perforated ulcer, with malnutrition, nausea and VOMITING.	Affirmed	Recent	Patient
1155	sputum production	He denies any SPUTUM PRODUCTION   or high fever.	Negated	Recent	Patient
1156	Transplanted Heart	Wall Thickness:  1.0 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: TRANSPLANTED HEART  TWO DIMENSIONAL ECHOCARDIOLOGY:   Left ventricular size is normal.	Affirmed	Recent	Patient
1157	weight loss	No   WEIGHT LOSS.	Negated	Recent	Patient
1158	mild tricuspid regurgitation	There is MILD TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
1159	Mild aortic regurgitation	02) MILD AORTIC REGURGITATION.	Affirmed	Recent	Patient
1160	slight confusion	PHYSICAL EXAM:    Blood pressure 156/86, pulse is 75, respiratory rate is 16, O2 saturation   100% room air, Glasgow coma scale of 14 with SLIGHT CONFUSION.	Affirmed	Recent	Patient
1161	nausea	Call also for any weight gain   greater than three pounds per day or five pounds per week, any unusual   rashes, NAUSEA, vomiting, fever associated with chill, temperature elevation   greater than 101 degrees Fahrenheit, sustained or low-grade temperature   greater than 100 degrees Fahrenheit, new onset of chest pain,   light-headedness, or dizziness, new or increased shortness of breath, severe   calf pain, burning on urination or severe depression.	Affirmed	Not particular	Patient
1162	mitral valve is normal	The MITRAL VALVE IS NORMAL.	Affirmed	Recent	Patient
1163	Abdomen:  Soft, nontender and nondistended	ABDOMEN:  SOFT, NONTENDER AND NONDISTENDED.	Affirmed	Recent	Patient
1164	dyspepsia  	The indication for this procedure is DYSPEPSIA    and dysphagia.	Affirmed	Recent	Patient
1165	gastric varices	There was no evidence of GASTRIC VARICES, ulcers, or  Mallory-Weiss tear.	Negated	Recent	Patient
1166	Head normocephalic, atraumatic	HEENT:  HEAD NORMOCEPHALIC, ATRAUMATIC.	Affirmed	Recent	Patient
1167	subacute subdural hematoma	HOSPITAL COURSE:  Ms. **NAME[AAA] is a **AGE[in 60s]-year-old Caucasian woman with a significant history of   antiphospholipid antibody syndrome and lupus anticoagulant who was initially   admitted to an outside hospital on **DATE[Jan 09 2008] with mental status changes   and was found to have a SUBACUTE SUBDURAL HEMATOMA and promptly transferred   to **INSTITUTION.	Affirmed	Recent	Patient
1168	Cranial nerves II through XII   grossly intact	CRANIAL NERVES II THROUGH XII   GROSSLY INTACT.	Affirmed	Recent	Patient
1169	Right ventricular wall thickness is normal	RIGHT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
1170	Segmental left ventricular function is normal	SEGMENTAL LEFT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
1171	lumbar disk ruptures at the L4-L5 and   L5-S1 levels	Neurodiagnostic   imaging was performed and suggested LUMBAR DISK RUPTURES AT THE L4-L5 AND   L5-S1 LEVELS.	Affirmed	Recent	Patient
1172	wheezes	Lungs   - CTP, no rales, rhonchi, or WHEEZES.	Negated	Recent	Patient
1173	drinks alcohol	He DRINKS ALCOHOL.	Affirmed	Recent	Patient
1174	alert	GENERAL: The patient was in some distress, holding her right wrist, but,   otherwise, she was ALERT, oriented, and pleasant.	Affirmed	Recent	Patient
1175	regular rate and rhythm	On the day of transfer, the patient's physical examination is notable for   cardiac with REGULAR RATE AND RHYTHM.	Affirmed	Recent	Patient
1176	meningismus	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   MENINGISMUS, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
1177	stable vital signs	The patient remained afebrile with STABLE VITAL SIGNS   which were a temperature of 36.1, heart rate 75, in normal sinus rhythm,   respirations 60, oxygenation 95% on two liters, blood pressure was 111/52 in   the left arm.	Affirmed	Recent	Patient
1178	Nosebleeds	She will alert the physician if any of the following are   noted:  NOSEBLEEDS, excessive bruising, pink, red, or tea-colored urine,   bright red or tarry black stools, unusual headaches, or stomach pain.	Affirmed	Not particular	Patient
1179	hiatal hernia	He   also states he has history of HIATAL HERNIA in the past.	Affirmed	Historical	Patient
1180	Right   atrial size is normal	RIGHT   ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
1181	acute MI	I do not believe the   patient is having an ACUTE MI at this time.	Negated	Recent	Patient
1182	rubs	No murmurs, gallops, RUBS.	Negated	Recent	Patient
1183	obese	She was OBESE.	Affirmed	Recent	Patient
1184	tricuspid valve is normal	The TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
1185	gallops	No murmurs, rubs, or   GALLOPS.	Negated	Recent	Patient
1186	Left atrial size is normal	LEFT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
1187	Left ventricular size is normal	Wall Thickness:  1.2 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Congenital Heart Disease    TWO DIMENSIONAL ECHOCARDIOLOGY:   LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
1188	incomplete right   bundle	There was a   cardiologist in the Emergency Department at the time of the patient's arrival   and they reviewed the EKG and reviewed the EKG with Dr. **NAME[RRR QQQ] and felt   that these were early repole changes and likely secondary to INCOMPLETE RIGHT   BUNDLE.	Affirmed	Recent	Patient
1189	Right ventricular function is   normal	RIGHT VENTRICULAR FUNCTION IS   NORMAL.	Affirmed	Recent	Patient
1190	pericardial effusion	No PERICARDIAL EFFUSION is   seen.	Negated	Recent	Patient
1191	pain on movement of   her index and middle fingers	No focal numbness or weakness, though she does have PAIN ON MOVEMENT OF   HER INDEX AND MIDDLE FINGERS.	Affirmed	Recent	Patient
1192	colon cancer	The indication for this procedure is family  history of COLON CANCER.	Affirmed	Historical	Family member
1193	splenomegaly	S_O_H  Counters Report Type Record Type Subgroup Classifier  203,nTDzpWJFwMeA SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PATIENT HISTORY:  The patient is a **AGE[in 70s]-year-old male with a history of SPLENOMEGALY status post  splenectomy.	Affirmed	Historical	Patient
1194	well-developed 	PHYSICAL EXAMINATION:  On examination, the patient is a WELL-DEVELOPED white female in no acute   distress.	Affirmed	Recent	Patient
1195	pneumonia	Chest radiograph:  Frontal view obtained **DATE[Mar 24 2008], which revealed likely   mild bibasilar atelectasis, less likely PNEUMONIA (cannot be excluded).	Affirmed	Recent	Patient
1196	edema	Extremities:  No EDEMA or cyanosis.	Negated	Recent	Patient
1197	oriented times three	Neuro: Alert and ORIENTED TIMES THREE.	Affirmed	Recent	Patient
1198	shortness of breath	No chest pain, no SHORTNESS OF BREATH, and no abdominal pain.	Negated	Recent	Patient
1199	joint space narrowing	No JOINT SPACE NARROWING is shown.	Negated	Recent	Patient
1200	status post  splenectomy	S_O_H  Counters Report Type Record Type Subgroup Classifier  203,nTDzpWJFwMeA SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PATIENT HISTORY:  The patient is a **AGE[in 70s]-year-old male with a history of splenomegaly STATUS POST  SPLENECTOMY.	Affirmed	Historical	Patient
1201	abdominal pain	He did not have any ABDOMINAL PAIN.	Negated	Recent	Patient
1202	pericardial effusion	No PERICARDIAL EFFUSION is seen.	Negated	Recent	Patient
1203	shortness of breath	The patient is a **AGE[in 40s]-year-old male with a history of COPD, tobacco use,   presents to the Emergency Department with complaint of chest tightness,   pressure, as well as complaint of SHORTNESS OF BREATH and wheezing at home.	Affirmed	Recent	Patient
1204	change in   vision	In general, no CHANGE IN   VISION, diplopia or change in hearing.	Negated	Recent	Patient
1205	tricuspid valve is normal	The   TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
1206	Right atrial size is mildly enlarged	RIGHT ATRIAL SIZE IS MILDLY ENLARGED.	Affirmed	Recent	Patient
1207	palpitations	Positive for chest pain, no PALPITATIONS.	Negated	Recent	Patient
1208	pericardial   effusion	No PERICARDIAL   EFFUSION is seen.	Negated	Recent	Patient
1209	conus is normal	The  CONUS IS NORMAL in signal and intensity, size and location at L1.	Affirmed	Recent	Patient
1210	numbness	No NUMBNESS or  tingling or other injuries.	Negated	Recent	Patient
1211	minimal energy	Since she has been there, she has had MINIMAL ENERGY and some   abdominal pain.	Affirmed	Recent	Patient
1212	ALLERGIES INCLUDE PENICILLIN AND SULFA DRUGS	ALLERGIES:  THIS PATIENT's ALLERGIES INCLUDE PENICILLIN AND SULFA DRUGS.	Affirmed	Historical	Patient
1213	gastric mucosa was normal	The GASTRIC MUCOSA WAS NORMAL without evidence of inflammation or vascular  abnormalities.	Affirmed	Recent	Patient
1214	Right ventricular wall thickness is normal	RIGHT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
1215	altered mental status	Multiple history of ALTERED MENTAL STATUS secondary to accidental overdose   on opioids.	Affirmed	Historical	Patient
1216	splenectomy	KW/cef  _______________________________________________________________  ADDENDA:  Addendum       Additional telephone conversation with and information provided by Dr. **NAME[WWW  M. XXX] on **DATE[Mar 15 2008] following sign-out of this case indicates that this  patient previously had a SPLENECTOMY on **DATE[May 15 2006], which was reviewed in  consultation at **INSTITUTION **PLACE, MN.	Affirmed	Historical	Patient
1217	CHEST PAIN	DISCHARGE DIAGNOSIS:  CHEST PAIN.	Affirmed	Recent	Patient
1218	mild lower quadrant   tenderness on palpation with no rebound, no guarding, and no masses	There is MILD LOWER QUADRANT   TENDERNESS ON PALPATION WITH NO REBOUND, NO GUARDING, AND NO MASSES palpated.	Affirmed	Recent	Patient
1219	END STAGE GLENOHUMERAL OSTEOARTHRITIS OF THE LEFT SHOULDER	END STAGE GLENOHUMERAL OSTEOARTHRITIS OF THE LEFT SHOULDER.	Affirmed	Recent	Patient
1220	hypertension	HISTORY OF PRESENT ILLNESS:    This is a **AGE[in 60s]-year-old male with a past history of diabetes, dementia,   HYPERTENSION, hypercholesterolemia, anemia, anxiety, and depression who   presents with a chief complaint of having fallen.	Affirmed	Historical	Patient
1221	Segmental left ventricular function is abnormal	SEGMENTAL LEFT VENTRICULAR FUNCTION IS ABNORMAL.	Affirmed	Recent	Patient
1222	positive bowel sounds	Abdomen: Soft, nontender,   nondistended with POSITIVE BOWEL SOUNDS and no hepatosplenomegaly.	Affirmed	Recent	Patient
1223	chest pain 	He still denies any   CHEST PAIN or shortness of breath.	Negated	Recent	Patient
1224	depression	The patient's past medical history is significant for anxiety and DEPRESSION.	Affirmed	Historical	Patient
1225	chest pressure	The patient does report that the CHEST PRESSURE developed   late last night, but he has been feeling "tight" since the onset of his   symptoms.	Affirmed	Recent	Patient
1226	RADIOGRAPHIC ABNORMALITIES IN THE LEFT SHOULDER  REGION	IMPRESSION:       NO SIGNIFICANT RADIOGRAPHIC ABNORMALITIES IN THE LEFT SHOULDER  REGION, EXCEPT FOR MINIMAL SUBCHONDRAL CYSTIC CHANGE WITHOUT  HYPERTROPHIC OSTEOPHYTOSIS OF THE ACROMIOCLAVICULAR JOINT.	Negated	Recent	Patient
1227	PERSISTENT THROMBOCYTOSIS	PERSISTENT THROMBOCYTOSIS.	Affirmed	Historical	Patient
1228	cyanosis	Extremities - No clubbing, CYANOSIS,   or edema.	Negated	Recent	Patient
1229	hyperlipidemia	REASON FOR ADMISSION:    Past medical history is positive for HYPERLIPIDEMIA, hypothyroidism, weakness   and difficulty with ambulation, aortic/mitral disease, spinal stenosis,   cataracts, measles, mumps, and varicella in the past.	Affirmed	Historical	Patient
1230	atrial fibrillation	This   was most likely predisposed by Coumadin as the patient was on anticoagulation   for history of DVTs and ATRIAL FIBRILLATION.	Affirmed	Historical	Patient
1231	volume overloaded	HOSPITAL COURSE:    The patient was started on a dobutamine drip with the goal of diuresing her   with Lasix as she was clinically and radiographically VOLUME OVERLOADED.	Affirmed	Recent	Patient
1232	Segmental left ventricular function is normal	SEGMENTAL LEFT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
1233	Mediastinal contours are normal	MEDIASTINAL CONTOURS ARE NORMAL.	Affirmed	Recent	Patient
1234	double lung transplant	S_O_H  Counters Report Type Record Type Subgroup Classifier  202,JHBTO8+z8pgj SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PATIENT HISTORY:  Status post DOUBLE LUNG TRANSPLANT for COPD.	Affirmed	Historical	Patient
1235	change in  bowel habits	The indication for this procedure is CHANGE IN  BOWEL HABITS.	Affirmed	Recent	Patient
1236	ALLOGRAFT LUNG, RIGHT LOWER LOBE, TRANSBRONCHIAL BIOPSY   A.          NO EVIDENCE OF ACUTE CELLULAR REJECTION	_______________________________________________________________  FINAL DIAGNOSIS:  ALLOGRAFT LUNG, RIGHT LOWER LOBE, TRANSBRONCHIAL BIOPSY   A.          NO EVIDENCE OF ACUTE CELLULAR REJECTION.	Affirmed	Recent	Patient
1237	diarrhea	UUU]'s the night before with vomiting and DIARRHEA.	Affirmed	Recent	Other
1238	Left ventricular wall thickness is normal	LEFT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
1239	mitral valve is normal	The MITRAL VALVE IS NORMAL.	Affirmed	Recent	Patient
1240	Left atrial size is normal	LEFT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
1241	Heart is irregularly irregular	HEART: HEART IS IRREGULARLY IRREGULAR.	Affirmed	Recent	Patient
1242	Arthritis	ARTHRITIS.	Affirmed	Historical	Patient
1243	Left ventricular size is normal	Wall Thickness:  1.4 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Aortic Valve Disease; Hypertension 401.9  TWO DIMENSIONAL ECHOCARDIOLOGY:   LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
1244	vomiting	HISTORY OF PRESENT ILLNESS:  Ms. **NAME[AAA] is a **AGE[in 40s]-year-old, African-American   female with a two-day history of fever, body aches, and nausea, VOMITING, and   diarrhea.	Affirmed	Recent	Patient
1245	shortness of breath	Follow up ____________ and   the patient is advised to call the PCP if there are any symptoms of chest   pain of SHORTNESS OF BREATH or any signs of bleeding.	Affirmed	Not particular	Patient
1246	SIGNIFICANT LUNG DISEASE	IMPRESSION:       NEGATIVE FOR SIGNIFICANT LUNG DISEASE.	Negated	Recent	Patient
1247	chills	REVIEW OF SYSTEMS:    Review of systems was negative and the patient has denied any fevers or   CHILLS.	Negated	Recent	Patient
1248	Mild scoliosis is noted of thoracic spine	MILD SCOLIOSIS IS NOTED OF THORACIC SPINE.	Affirmed	Recent	Patient
1249	neurologically intact	Within 24 hours, the patient was successfully extubated from   mechanical intubation, was found to be NEUROLOGICALLY INTACT and   hemodynamically stable.	Affirmed	Recent	Patient
1250	calcaneal fracture	No CALCANEAL FRACTURE can be seen.	Negated	Recent	Patient
1251	regular rate and rhythm	Cardiovascular - REGULAR RATE AND RHYTHM.	Affirmed	Recent	Patient
1252	ITP	Treatments that were attempted included IVIG for possible ITP with the   complication of an additional CVA.	Affirmed	Recent	Patient
1253	urinary tract infections	Assessment of this Patient:  She is a **AGE[in 70s]-year-old female with a history of   multiple sclerosis, and paralysis with a history of URINARY TRACT INFECTIONS   and urinary incontinence with chronic Foley, who had been reported to have   vaginal bleeding, however, was found to have blood at the urethral meatus,   consistent with urethral trauma.	Affirmed	Historical	Patient
1254	Gait was steady with mild assistance	GAIT WAS STEADY WITH MILD ASSISTANCE.	Affirmed	Recent	Patient
1255	PVC	He has one PVC, otherwise he has   nonspecific ST and T wave changes and left axis deviation.	Affirmed	Recent	Patient
1256	small   pericardial effusion	There is a SMALL   PERICARDIAL EFFUSION.	Affirmed	Recent	Patient
1257	PLEURAL FLUID  	SB/tf  SOURCE OF SPECIMEN:  PLEURAL FLUID    __________________________________________________________________________  FINAL DIAGNOSIS:  PLEURAL FLUID:  SATISFACTORY FOR INTERPRETATION.	Affirmed	Recent	Patient
1258	claudication	She was limited by significant   CLAUDICATION.	Affirmed	Historical	Patient
1259	inferior wall, mid posterior wall and mid inferoseptum are   akinetic	The INFERIOR WALL, MID POSTERIOR WALL AND MID INFEROSEPTUM ARE   AKINETIC.	Affirmed	Recent	Patient
1260	change in hearing	In general, no change in   vision, diplopia or CHANGE IN HEARING.	Negated	Recent	Patient
1261	aortic valve is normal	The AORTIC VALVE IS NORMAL.	Affirmed	Recent	Patient
1262	Right ventricular   function is normal	RIGHT VENTRICULAR   FUNCTION IS NORMAL.	Affirmed	Recent	Patient
1263	afebrile	she is AFEBRILE but   persistent cough.	Affirmed	Recent	Patient
1264	lower extremity edema	He denies any orthopnea, LOWER EXTREMITY EDEMA, or calf pain.	Negated	Recent	Patient
1265	more pleasant 	She was getting MORE PLEASANT after pain was more   controlled and moving around with wheelchair accompanied by her husband.	Affirmed	Recent	Patient
1266	some diarrhea	The   patient has decreased appetite with 30-pound weight loss and SOME DIARRHEA   from C. diff.	Affirmed	Recent	Patient
1267	hemodynamically stable	However, due to no evidence of active bleeding, the   patient remained HEMODYNAMICALLY STABLE.	Affirmed	Recent	Patient
1268	left ventricular hypertrophy	Left ventricular wall thickness is   increased, consistent with LEFT VENTRICULAR HYPERTROPHY.	Affirmed	Recent	Patient
1269	HYPOTHYROIDISM	HYPOTHYROIDISM.	Affirmed	Historical	Patient
1270	Thickened and calcified aortic valve with mild stenosis and mild  regurgitation	02) THICKENED AND CALCIFIED AORTIC VALVE WITH MILD STENOSIS AND MILD  REGURGITATION.	Affirmed	Recent	Patient
1271	headaches	He denies any HEADACHES or   dizziness.	Negated	Recent	Patient
1272	neoplastic process, histologically low-grade, B-cell type	The phenotype of the present marrow evaluation is similar to that reported for  the spleen and most likely represents marrow involvement by the same  NEOPLASTIC PROCESS, HISTOLOGICALLY LOW-GRADE, B-CELL TYPE.	Affirmed	Recent	Patient
1273	abdomen is soft, nontender, and nondistended	Abdomen - The ABDOMEN IS SOFT, NONTENDER, AND NONDISTENDED.	Affirmed	Recent	Patient
1274	paralysis	Assessment of this Patient:  She is a **AGE[in 70s]-year-old female with a history of   multiple sclerosis, and PARALYSIS with a history of urinary tract infections   and urinary incontinence with chronic Foley, who had been reported to have   vaginal bleeding, however, was found to have blood at the urethral meatus,   consistent with urethral trauma.	Affirmed	Historical	Patient
1275	minimal subacromial narrowing	There is MINIMAL SUBACROMIAL NARROWING.	Affirmed	Recent	Patient
1276	mild to moderate mitral regurgitation	SPECTRAL DOPPLER:   There is MILD TO MODERATE MITRAL REGURGITATION.	Affirmed	Recent	Patient
1277	wound has been healing well	Her WOUND HAS BEEN HEALING WELL.	Affirmed	Recent	Patient
1278	B-CELL LYMPHOPROLIFERATIVE PROCESS	B.     SEE ALSO PREVIOUS MARROW REPORT INDICATING PROBABLE SUBTLE INVOLVEMENT  BY A B-CELL LYMPHOPROLIFERATIVE PROCESS (***PATH-NUMBER[1]).	Affirmed	Historical	Patient
1279	awake	His coworkers saw him on the floor and when they arrived he was   AWAKE and alert.	Affirmed	Recent	Patient
1280	interatrial baffle	There is an   echodensity seen in the atria consistent with the patient''s know   INTERATRIAL BAFFLE.	Affirmed	Historical	Patient
1281	small to moderate left   basilar atelectasis/effusion	Chest x-ray upon admission revealed a SMALL TO MODERATE LEFT   BASILAR ATELECTASIS/EFFUSION and there were no findings of pneumonia.	Affirmed	Recent	Patient
1282	Nondilated left ventricle with hypertrophy and overall preserved  systolic function	FINAL IMPRESSIONS:   01) NONDILATED LEFT VENTRICLE WITH HYPERTROPHY AND OVERALL PRESERVED  SYSTOLIC FUNCTION.	Affirmed	Recent	Patient
1283	Shortness of breath	S_O_H  Counters Report Type Record Type Subgroup Classifier  97,fwxvgRdnbcvh ER ER 1005  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   EMERGENCY DEPARTMENT  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM   DATE OF SERVICE:  **DATE[Feb 18 08]   PRIMARY CARE **NAME[UUU: SSS]  WALKER  HISTORY OF PRESENT ILLNESS:    CHIEF COMPLAINT:  SHORTNESS OF BREATH.	Affirmed	Recent	Patient
1284	trace pulmonic   regurgitation	There is TRACE PULMONIC   REGURGITATION.	Affirmed	Recent	Patient
1285	right ventricular hypertrophy	Right ventricular   wall thickness is increased, consistent with RIGHT VENTRICULAR HYPERTROPHY.	Affirmed	Recent	Patient
1286	Hypertension	Wall Thickness:  1.4 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Aortic Valve Disease; HYPERTENSION 401.9  TWO DIMENSIONAL ECHOCARDIOLOGY:   Left ventricular size is normal.	Affirmed	Recent	Patient
1287	chest pain	He was also   given Protonix for his epigastric pain and nitroglycerine for his CHEST PAIN.	Affirmed	Recent	Patient
1288	neck pain	The patient denied any headache,   NECK PAIN, weakness, numbness or paraesthesias.	Negated	Recent	Patient
1289	Colitis was found in the sigmoid colon	FINDINGS:  COLITIS WAS FOUND IN THE SIGMOID COLON.	Affirmed	Recent	Patient
1290	shortness of breath	PULMONARY:  Denies any SHORTNESS OF BREATH.	Negated	Recent	Patient
1291	Segmental left ventricular function is abnormal	SEGMENTAL LEFT VENTRICULAR FUNCTION IS ABNORMAL.	Affirmed	Recent	Patient
1292	trivial   pericardial effusion	There is a TRIVIAL   PERICARDIAL EFFUSION.	Affirmed	Recent	Patient
1293	arthralgia	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or ARTHRALGIA, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
1294	abdominal pain	No ABDOMINAL PAIN, nausea, vomiting or diarrhea.	Negated	Recent	Patient
1295	DIFFUSE CRAMPY ABDOMINAL PAIN	DISCHARGE DIAGNOSIS(ES):    DIFFUSE CRAMPY ABDOMINAL PAIN.	Affirmed	Recent	Patient
1296	Overall left ventricular function is normal	OVERALL LEFT VENTRICULAR FUNCTION IS NORMAL, with an estimated ejection   fraction of 55-60 %.	Affirmed	Recent	Patient
1297	Right ventricular wall thickness is normal	RIGHT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
1298	large and small bowel are normal in caliber	PELVIS:  The LARGE AND SMALL BOWEL ARE NORMAL IN CALIBER.	Affirmed	Recent	Patient
1299	chronic muskuloskeletal pain	We  are treating this as CHRONIC MUSKULOSKELETAL PAIN with oxycodone.	Affirmed	Recent	Patient
1300	tricuspid valve is normal	The   TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
1301	Clear to auscultation bilaterally	Lungs:  CLEAR TO AUSCULTATION BILATERALLY.	Affirmed	Recent	Patient
1302	left-sided   facial pain	She complains only of a mild headache and LEFT-SIDED   FACIAL PAIN.	Affirmed	Recent	Patient
1303	difficulty hearing	HEENT - No headache or DIFFICULTY HEARING.	Negated	Recent	Patient
1304	positive bowel sounds	Abdomen:  Abdomen is soft, nontender, nondistended, POSITIVE BOWEL SOUNDS.	Affirmed	Recent	Patient
1305	Right ventricular size is normal	RIGHT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
1306	Right thyroid nodule	S_O_H  Counters Report Type Record Type Subgroup Classifier  171,6m8BkOIO0pg+ RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  XRAY CHEST FRONTAL AND LATERAL VIEWS   **DATE[Mar 11 08]     1715 HOURS    CLINICAL HISTORY:     RIGHT THYROID NODULE.	Affirmed	Recent	Patient
1307	atrial fibrillation	The patient with history of ATRIAL FIBRILLATION and DVTs;   on anticoagulation.	Affirmed	Historical	Patient
1308	pericardial   effusion	No PERICARDIAL   EFFUSION is seen.	Negated	Recent	Patient
1309	abdominal pain	On **DATE[Sep 26 2007], his nutrition was increased to clear   liquids, then on **DATE[Sep 27 2007], the patient had a turkey sandwich of smashed   potatoes for lunch and states that he did not have ABDOMINAL PAIN, and wished   to go home.	Negated	Recent	Patient
1310	Left atrial size is severely enlarged	LEFT ATRIAL SIZE IS SEVERELY ENLARGED.	Affirmed	Recent	Patient
1311	Congestive heart failure	S_O_H  Counters Report Type Record Type Subgroup Classifier  164,nbRrWS58GCHh RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  XRAY CHEST FRONTAL VIEW   **DATE[Aug 23 07]     0628 HOURS    CLINICAL HISTORY:     CONGESTIVE HEART FAILURE.	Affirmed	Recent	Patient
1312	Type 2 diabetes	TYPE 2 DIABETES.	Affirmed	Recent	Patient
1313	MULTINODULAR GOITER WITH DOMINANT NODULE	**INITIALS  _______________________________________________________________  FINAL DIAGNOSIS:  THYROID, RIGHT LOBE AND ISTHMUS, LOBECTOMY AND ISTHMUSECTOMY (22.7 GRAMS)   A.          MULTINODULAR GOITER WITH DOMINANT NODULE (3.6 CM).	Affirmed	Recent	Patient
1314	hypoxic 	While in the Emergency   Department, the patient was found to be HYPOXIC and a chest x-ray was   obtained.	Affirmed	Recent	Patient
1315	rashes	SKIN:  No RASHES.	Negated	Recent	Patient
1316	Head normocephalic, atraumatic	HEAD NORMOCEPHALIC, ATRAUMATIC.	Affirmed	Recent	Patient
1317	subdural hematoma	On transfer, the patient underwent SUBDURAL HEMATOMA   evacuation.	Affirmed	Recent	Patient
1318	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
1319	cough	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   COUGH, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
1320	lungs were decreased at the   bilateral bases	The LUNGS WERE DECREASED AT THE   BILATERAL BASES.	Affirmed	Recent	Patient
1321	coagulopathy	Vitamin K was given to correct the COAGULOPATHY.	Affirmed	Recent	Patient
1322	pneumothorax	There is no  PNEUMOTHORAX with bilateral chest tubes in place.	Negated	Recent	Patient
1323	HYPERTENSIVE EMERGENCY	HYPERTENSIVE EMERGENCY.	Affirmed	Recent	Patient
1324	Abdomen: Soft, nontender,   nondistended	ABDOMEN: SOFT, NONTENDER,   NONDISTENDED with positive bowel sounds and no hepatosplenomegaly.	Affirmed	Recent	Patient
1325	lucid	General:  The patient is awake, alert, LUCID, appears to be in mild amount of   pain, in no acute distress.	Affirmed	Recent	Patient
1326	syncope	Ischemic trigger is certainly concerning given the patient's presentation of   sudden SYNCOPE and diffuse weakness with new pulmonary edema which he never   had before.	Affirmed	Recent	Patient
1327	pneumothorax	There is no pleural effusion or  PNEUMOTHORAX.	Negated	Recent	Patient
1328	PE	He does have a history of PE's in the past, but his   signs and symptoms were not consistent with aortic dissection, PE, or   infectious etiologies.	Negated	Recent	Patient
1329	hairy cell leukemia	Precise classification of this process cannot be definitively done on the  material available, but these findings would NOT support a diagnosis of  chronic lymphocytic leukemia or HAIRY CELL LEUKEMIA.	Negated	Recent	Patient
1330	NECK:  Supple	NECK:  SUPPLE.	Affirmed	Recent	Patient
1331	small internal hemorrhoids	Retroflexion of the endoscope revealed SMALL INTERNAL HEMORRHOIDS.	Affirmed	Recent	Patient
1332	severe left ventricular hypertrophy	Left ventricular wall thickness is   increased, consistent with SEVERE LEFT VENTRICULAR HYPERTROPHY.	Affirmed	Recent	Patient
1333	re-occluded  the graft	Vascular: Mr. **NAME[AAA] underwent thrombectomy, but subsequently RE-OCCLUDED  THE GRAFT.	Affirmed	Recent	Patient
1334	borderline personality disorder	It was felt that her   delusion was due to her medical decondition with some component of   dissociative disorder and BORDERLINE PERSONALITY DISORDER as well as   depression and anxiety.	Affirmed	Recent	Patient
1335	chills	He does occasionally have loose stools, no fevers or CHILLS, no   sick contacts, no recent use of antibiotics.	Negated	Recent	Patient
1336	Normal left ventricular size and function	FINAL IMPRESSIONS:   01) NORMAL LEFT VENTRICULAR SIZE AND FUNCTION.	Affirmed	Recent	Patient
1337	Borderline aortic root dilation	05) BORDERLINE AORTIC ROOT DILATION.	Affirmed	Recent	Patient
1338	delusions	No evidence of DELUSIONS or hallucinations but   had bizarre behavior that therapist felt to be her associated state.	Negated	Recent	Patient
1339	ischemic EKG changes	09) There were no stress induced chest pain, ISCHEMIC EKG CHANGES or wall  motion abnormalities at a relatively low level of stress.	Negated	Recent	Patient
1340	edema	Extremities:  No clubbing, cyanosis or EDEMA.	Negated	Recent	Patient
1341	sitting comfortably	She is SITTING COMFORTABLY in the   bed.	Affirmed	Recent	Patient
1342	INTRAEPITHELIAL LESION OR MALIGNANCY	INTERPRETATION:  NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY.	Negated	Recent	Patient
1343	GASTROESOPHAGEAL REFLUX DISEASE	GASTROESOPHAGEAL REFLUX DISEASE.	Affirmed	Historical	Patient
1344	Left ventricular wall thickness is   increased	LEFT VENTRICULAR WALL THICKNESS IS   INCREASED, consistent with left ventricular hypertrophy.	Affirmed	Recent	Patient
1345	Moderate to severe tricuspid regurgitation	05) MODERATE TO SEVERE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
1346	transposition of the great vessels	There is a double barrel configuration of the great vessels   consistent with the patient''s know TRANSPOSITION OF THE GREAT VESSELS.	Affirmed	Historical	Patient
1347	sensation intact to   light touch	The   patient's cranial nerves II through XII are intact with SENSATION INTACT TO   LIGHT TOUCH.	Affirmed	Recent	Patient
1348	1cm  nodular opacity over the left lung base may be due to nipple  shadow	The 1CM  NODULAR OPACITY OVER THE LEFT LUNG BASE MAY BE DUE TO NIPPLE  SHADOW.	Affirmed	Recent	Patient
1349	sickle cell disease	MEDICAL DECISION MAKING:  This is a **AGE[in 50s]-year-old female with history of SICKLE CELL DISEASE, coming in   with what she says is her typical sickle cell crisis as well as an outpatient   laboratory showing hemoglobin of 8.	Affirmed	Recent	Patient
1350	LV diastolic dysfunction  	10) 11) Doppler consistent with LV DIASTOLIC DYSFUNCTION      This is an electronically authenticated signature, which is an attestation   that I have personally interpreted this/these examination(s) and agree with   the findings as noted above.	Affirmed	Recent	Patient
1351	dizziness	She had definite   presyncope with lightheadedness and DIZZINESS as if she was going to pass   out.	Affirmed	Recent	Patient
1352	aortic valve is restricted, thickened and calcified	The AORTIC VALVE IS RESTRICTED, THICKENED AND CALCIFIED.	Affirmed	Recent	Patient
1353	gastritis	This   was found to be consistent with an upper GI bleed secondary to esophagitis   versus GASTRITIS versus peptic ulcer disease versus **NAME[UUU] wise tear.	Affirmed	Recent	Patient
1354	nausea	GI - No NAUSEA or vomiting.	Negated	Recent	Patient
1355	Mild left atrial enlargement	04) MILD LEFT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
1356	atrial fibrillation	Her digoxin level is 0.6, which appears   to be subtherapeutic; however, she was not tachycardic, nor was she was in   ATRIAL FIBRILLATION.	Negated	Recent	Patient
1357	Angiodysplasia in the cecum  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) ANGIODYSPLASIA IN THE CECUM    2) Otherwise normal exam    PLAN:  1) Follow-up: primary MD PRN    REPEAT EXAM:  Colonoscopy in 7 - 10 year(s).	Affirmed	Recent	Patient
1358	adrenal insufficiency	Endocrine - The patient has ADRENAL INSUFFICIENCY; therefore, we continued   her on her home dose of Cortef.	Affirmed	Recent	Patient
1359	chest tightness	PLAN/FOLLOW-UP:  The patient will be admitted for both his respiratory care, as well as the   CHEST TIGHTNESS.	Affirmed	Recent	Patient
1360	point tenderness   over the left lateral hip with limited range of motion secondary to pain	He has POINT TENDERNESS   OVER THE LEFT LATERAL HIP WITH LIMITED RANGE OF MOTION SECONDARY TO PAIN.	Affirmed	Recent	Patient
1361	dysuria	GENITOURINARY:  No DYSURIA or frequency.	Negated	Recent	Patient
1362	partial small bowel   obstruction	S_O_H  Counters Report Type Record Type Subgroup Classifier  13,MFZKSI+l8xGn DS DS 5004  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   GENERAL MEDICINE  DISCHARGE SUMMARY     PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  **ROOM  ATTENDING PHYSICIAN:  **NAME[ZZZ M YYY]  ADMISSION DATE:  **DATE[Sep 19 2007]  DISCHARGE DATE:  **DATE[Sep 27 2007]     The patient is a **AGE[in 40s]-year-old with past medical history of PARTIAL SMALL BOWEL   OBSTRUCTION, who is admitted quite frequently for abdominal pain, bowel   distention, and partial small bowel obstructions.	Affirmed	Historical	Patient
1363	Left atrial size is mildly enlarged	LEFT ATRIAL SIZE IS MILDLY ENLARGED.	Affirmed	Recent	Patient
1364	severe chest pain	The patient then presented to the   Emergency Department for this SEVERE CHEST PAIN.	Affirmed	Recent	Patient
1365	tricuspid valve is   normal	The TRICUSPID VALVE IS   NORMAL.	Affirmed	Recent	Patient
1366	Fecal occult blood	FECAL OCCULT BLOOD was negative.	Negated	Recent	Patient
1367	chest pain	He did   not have any complaints of CHEST PAIN of shortness of breath and he was   started on Lovenox and Coumadin and he will be discharged once the INR is   2.0.	Negated	Recent	Patient
1368	smoker 	SOCIAL HISTORY:   She was a SMOKER for approximately 60 years, two packs per day.	Affirmed	Historical	Patient
1369	NECROTIZING PANCREATITIS	NECROTIZING PANCREATITIS.	Affirmed	Recent	Patient
1370	nausea	Chief complaint is NAUSEA, vomiting, and diarrhea.	Affirmed	Recent	Patient
1371	tobacco	HIS SOCIAL HISTORY:  He denies any TOBACCO, alcohol, or drug abuse although   he occasionally drinks beer.	Negated	Historical	Patient
1372	palpitations	No PALPITATIONS while she was here.	Negated	Recent	Patient
1373	stable	Condition on discharge is STABLE.	Affirmed	Recent	Patient
1374	multiple sclerosis	PAST MEDICAL HISTORY:     Her past medical history is significant for MULTIPLE SCLEROSIS, pneumonia,   DVT of the lower extremity, hypothyroidism, hard of hearing, vitiligo, and   her paralysis from her MULTIPLE SCLEROSIS.	Affirmed	Historical	Patient
1375	ambulating 20 feet x1 with minimal assistance	At the time of transfer to the   Rehabilitation Unit she was AMBULATING 20 FEET X1 WITH MINIMAL ASSISTANCE and   a wheeled walker.	Affirmed	Recent	Patient
1376	unremarkable vital signs	She appeared well and had   UNREMARKABLE VITAL SIGNS, no signs of meningitis, otitis, pharyngitis, or   pneumonia.	Affirmed	Recent	Patient
1377	take care of himself	The   patient was brought to **INSTITUTION today by his family as it was felt that he could   no longer TAKE CARE OF HIMSELF.	Negated	Recent	Patient
1378	Gross cardiomegaly	FINDINGS:     GROSS CARDIOMEGALY, severe pulmonary edema, bibasilar atelectasis    and bilateral small pleural effusions are present.	Affirmed	Recent	Patient
1379	chest pain	Pain: The patient continues to have CHEST PAIN that is consistent with the  CHEST PAIN he felt on his previous admission.	Affirmed	Recent	Patient
1380	small gastric remnant (aproximately 13 cm) was normal	There  was a small gastric remnant (aproximately 13 cm) was normal.	Affirmed	Recent	Patient
1381	Left atrial size is mildly enlarged	LEFT ATRIAL SIZE IS MILDLY ENLARGED.	Affirmed	Recent	Patient
1382	osteoporosis most   likely due to past usage of her psychiatric medications	Osteoporosis:  The patient does have a history of OSTEOPOROSIS MOST   LIKELY DUE TO PAST USAGE OF HER PSYCHIATRIC MEDICATIONS.	Affirmed	Historical	Patient
1383	normal sensation in all   his digits	He   has got good capillary refill in all his digits and NORMAL SENSATION IN ALL   HIS DIGITS.	Affirmed	Recent	Patient
1384	myalgia	No MYALGIA or arthralgia.	Negated	Recent	Patient
1385	HYPOTHYROIDISM	HYPOTHYROIDISM.	Affirmed	Historical	Patient
1386	infection	It was complicated by INFECTION and removed.	Affirmed	Historical	Patient
1387	Left ventricular wall thickness is normal	LEFT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
1388	alert	General:  The patient is awake, ALERT, lucid, appears to be in mild amount of   pain, in no acute distress.	Affirmed	Recent	Patient
1389	Colitis was found in the sigmoid colon	COLITIS WAS FOUND IN THE SIGMOID COLON (see image2  and image3).	Affirmed	Recent	Patient
1390	drug abuse	HIS SOCIAL HISTORY:  He denies any tobacco, alcohol, or DRUG ABUSE although   he occasionally drinks beer.	Negated	Historical	Patient
1391	AV fistula occlusion	Admitting diagnosis:  AV FISTULA OCCLUSION.	Affirmed	Recent	Patient
1392	MILD THROMBOCYTOPENIA	MILD THROMBOCYTOPENIA.	Affirmed	Recent	Patient
1393	shortness of breath	He denies any   antecedent palpitations, SHORTNESS OF BREATH, chest pain, headache, or   lightheadedness.	Negated	Recent	Patient
1394	pericardial effusion	No PERICARDIAL EFFUSION is seen.	Negated	Recent	Patient
1395	polyps	There was no evidence of POLYPS or mass.	Negated	Recent	Patient
1396	Segmental   left ventricular function is normal	SEGMENTAL   LEFT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
1397	Cranial nerves II through XII   grossly intact	CRANIAL NERVES II THROUGH XII   GROSSLY INTACT.	Affirmed	Recent	Patient
1398	aspiration pneumonia	The patient   was given Unasyn 3 g IV for possible ASPIRATION PNEUMONIA.	Affirmed	Recent	Patient
1399	weakness	She was left with no residual WEAKNESS.	Negated	Recent	Patient
1400	Dyspnea	S_O_H  Counters Report Type Record Type Subgroup Classifier  174,WnIafZDwlSYJ RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  CT THORAX  WITH CONTRAST   **DATE[Mar 16 08]     1406 HOURS    CLINICAL HISTORY:     DYSPNEA, restrictive pulmonary function tests.	Affirmed	Recent	Patient
1401	depression	HISTORY OF PRESENT ILLNESS:    This is a **AGE[in 60s]-year-old male with a past history of diabetes, dementia,   hypertension, hypercholesterolemia, anemia, anxiety, and DEPRESSION who   presents with a chief complaint of having fallen.	Affirmed	Historical	Patient
1402	mild to moderate mitral regurgitation	COLOR FLOW DOPPLER:   There is MILD TO MODERATE MITRAL REGURGITATION.	Affirmed	Recent	Patient
1403	vomiting	While in the ED, the patient was given Unasyn 3 g IV to cover for a   possible aspiration pneumonia given her decreased mental status and VOMITING.	Affirmed	Recent	Patient
1404	rales	No RALES, rhonchi, or wheeze.	Negated	Recent	Patient
1405	infection	The patient was sent back to **INSTITUTION the   following day for further evaluation and management of his INFECTION.	Affirmed	Recent	Patient
1406	focal neurologic deficit	She   does not have any FOCAL NEUROLOGIC DEFICIT.	Negated	Recent	Patient
1407	Abdominal pain	S_O_H  Counters Report Type Record Type Subgroup Classifier  216,w6a3H4SqN8I8 SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PATIENT HISTORY:  ABDOMINAL PAIN.	Affirmed	Recent	Patient
1408	mitral regurgitation	COLOR FLOW DOPPLER:   There is trace MITRAL REGURGITATION.	Affirmed	Recent	Patient
1409	fever	HISTORY OF PRESENT ILLNESS:  Ms. **NAME[AAA] is a **AGE[in 40s]-year-old, African-American   female with a two-day history of FEVER, body aches, and nausea, vomiting, and   diarrhea.	Affirmed	Recent	Patient
1410	shortness of breath	She should return to the Emergency Department if she experiences nausea,   vomiting, increased abdominal pain, SHORTNESS OF BREATH, or chest pain.	Affirmed	Not particular	Patient
1411	EOMI	Eyes:  PERRLA, EOMI.	Affirmed	Recent	Patient
1412	Dissociative disorder	DISSOCIATIVE DISORDER.	Affirmed	Recent	Patient
1413	coronary   artery disease	HISTORY OF PRESENT ILLNESS:  Mr. **NAME[AAA] is a **AGE[90+]-year-old gentleman with a past medical history of CORONARY   ARTERY DISEASE, status post CABG, but no history of known congestive heart   failure, who has not been admitted to the hospital in the last five to six   years, who presents today after a syncopal episode.	Affirmed	Historical	Patient
1414	rhonchi	No rales, RHONCHI, or wheeze.	Negated	Recent	Patient
1415	MUCOCELE	FINAL DIAGNOSIS:  Mandibular Anterior Vestibule, Biopsy:  MUCOCELE (527.6)  **INITIALS       Pathologist:  **NAME[WWW M. XXX], D.D.S.       ** Report Electronically Signed Out **       By Pathologist:  **NAME[WWW M. XXX], D.D.S.       **DATE[Dec 8 2007] 17:48  My signature is attestation that I have personally reviewed the submitted  material(s) and the final diagnosis reflects that evaluation.	Affirmed	Recent	Patient
1416	Overall left ventricular function is   normal	OVERALL LEFT VENTRICULAR FUNCTION IS   NORMAL, with an estimated ejection fraction of 55-60 %.	Affirmed	Recent	Patient
1417	Collapse	S_O_H  Counters Report Type Record Type Subgroup Classifier  47,oTDCcOjI2m16 ECHO ECHO   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      **INSTITUTION - **INSTITUTION Echocardiography Lab            Echocardiographic Report                            An Intersocietal Commission for the Accreditation of               Echocardiography Laboratories Certified Laboratory                       Name: **NAME[AAA, BBB]  Date/Time of Procedure: **DATE[Jun 29 2007] 1:12 PM  Institution: **INSTITUTION  Sex: M  Date of Birth: **DATE[Jun 13 1931]  Echo Number: 183991  Account: **ID-NUM  Type: Echo      Transthoracic Echocardiogram                          ECHOCARDIOGRAPHIC MEASUREMENTS:    *** Measurements Not Obtainable ***                           REFERRING DIAGNOSIS: Syncope And COLLAPSE  TWO DIMENSIONAL ECHOCARDIOLOGY:   This was a technically difficult study.	Affirmed	Recent	Patient
1418	Head and face are atraumatic	HEAD AND FACE ARE ATRAUMATIC.	Affirmed	Recent	Patient
1419	left   ventricular hypertrophy	Left ventricular wall thickness is increased, consistent with LEFT   VENTRICULAR HYPERTROPHY.	Affirmed	Recent	Patient
1420	oriented times three	Neurologically, she is alert and ORIENTED TIMES THREE.	Affirmed	Recent	Patient
1421	polyps	There was no evidence of POLYPS or mass.	Negated	Recent	Patient
1422	Mild aortic root dilation	08) 9)  MILD AORTIC ROOT DILATION.	Affirmed	Recent	Patient
1423	Right   ventricular size is normal	RIGHT   VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
1424	sensation is intact	The patient's SENSATION IS INTACT.	Affirmed	Recent	Patient
1425	MENINGITIS - LIKELY VIRAL	MENINGITIS - LIKELY VIRAL.	Affirmed	Recent	Patient
1426	Mild tricuspid regurgitation	07) MILD TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
1427	oriented	She was afebrile with   stable vitals; awake, alert, and ORIENTED in no acute distress.	Affirmed	Recent	Patient
1428	Alzheimer disease	PAST MEDICAL HISTORY:  Significant for ALZHEIMER DISEASE, hypertension,   atrial fibrillation, history of DVTs, anticoagulation, coronary artery   disease, COPD, history of anemia, history of pulmonary nodules, and history   of cellulitis.	Affirmed	Historical	Patient
1429	valvular abnormalities	02) No VALVULAR ABNORMALITIES.	Negated	Recent	Patient
1430	MI	Therefore, he was admitted to the Medicine Service to rule   out MI.	Affirmed	Recent	Patient
1431	Small left ventricular cavity size with severe hypertrophy 	02) SMALL LEFT VENTRICULAR CAVITY SIZE WITH SEVERE HYPERTROPHY and overall  preserved systolic function.	Affirmed	Recent	Patient
1432	anxiety	Depression and ANXIETY.	Affirmed	Recent	Patient
1433	pneumonia	The recent chest x-ray on **DATE[Mar 21   2008], showed no evidence of PNEUMONIA or metastatic disease status post right   pneumonectomy, stable appearance of the chest.	Negated	Recent	Patient
1434	pulmonary artery size is normal	The PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
1435	Degenerative disc disease	DEGENERATIVE DISC DISEASE is present and there is advanced facet   arthrosis, which appears to be most pronounced on the left at C7-T1   with evidence of erosions.	Affirmed	Recent	Patient
1436	mitral valve is normal	The MITRAL VALVE IS NORMAL.	Affirmed	Recent	Patient
1437	organomegaly	No   masses or ORGANOMEGALY.	Negated	Recent	Patient
1438	tricuspid valve is normal	The TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
1439	afebrile	The patient was AFEBRILE at the time of transfer.	Affirmed	Recent	Patient
1440	polyps	The indication for this procedure is a personal  history of POLYPS.	Affirmed	Recent	Patient
1441	CT of her   head was done immediately which showed no acute lesion	A CT OF HER   HEAD WAS DONE IMMEDIATELY WHICH SHOWED NO ACUTE LESION.	Affirmed	Recent	Patient
1442	paranasal sinuses are normal	The visualized  PARANASAL SINUSES ARE NORMAL.	Affirmed	Recent	Patient
1443	rashes	SKIN:  No RASHES.	Negated	Recent	Patient
1444	Regular rate and rhythm	Heart:  REGULAR RATE AND RHYTHM.	Affirmed	Recent	Patient
1445	afebrile	She was AFEBRILE with   stable vitals; awake, alert, and oriented in no acute distress.	Affirmed	Recent	Patient
1446	paralysis	She is a **AGE[in 70s]-year-old female who has a history of multiple sclerosis   complicated by PARALYSIS and urinary incontinence with chronic Foley, who was   brought in by ambulance today from **INSTITUTION in Mt.	Affirmed	Historical	Patient
1447	Posttraumatic stress disorder	POSTTRAUMATIC STRESS DISORDER.	Affirmed	Recent	Patient
1448	abdomen was soft, nontender	The   ABDOMEN WAS SOFT, NONTENDER with positive bowel sounds.	Affirmed	Recent	Patient
1449	dementia	REVIEW OF SYSTEMS:      Upon arrival here review of systems on the patient is a bit difficult and   unreliable due to his DEMENTIA.	Affirmed	Recent	Patient
1450	pericardial effusion	The heart  size is normal without PERICARDIAL EFFUSION.	Negated	Recent	Patient
1451	extensive pancreatic necrosis	GI: Repeat abdominal and pelvis CT with contrast was done on **DATE[Jul 12 2007],   which showed findings of EXTENSIVE PANCREATIC NECROSIS with only minimal   residual enhancing pancreatic tissue in the tail and head.	Affirmed	Recent	Patient
1452	vomiting	She had very low   residuals, as well as no nausea or VOMITING.	Negated	Recent	Patient
1453	SEIZURE	SEIZURE.	Affirmed	Recent	Patient
1454	Syncope	9  cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: SYNCOPE And Collapse  TWO DIMENSIONAL ECHOCARDIOLOGY:   Left ventricular size is normal.	Affirmed	Recent	Patient
1455	pneumonia	She appeared well and had   unremarkable vital signs, no signs of meningitis, otitis, pharyngitis, or   PNEUMONIA.	Negated	Recent	Patient
1456	cyanosis	Extremities:  No CYANOSIS or clubbing, there is +2 pitting edema.	Negated	Recent	Patient
1457	light-headedness	Call also for any weight gain   greater than three pounds per day or five pounds per week, any unusual   rashes, nausea, vomiting, fever associated with chill, temperature elevation   greater than 101 degrees Fahrenheit, sustained or low-grade temperature   greater than 100 degrees Fahrenheit, new onset of chest pain,   LIGHT-HEADEDNESS, or dizziness, new or increased shortness of breath, severe   calf pain, burning on urination or severe depression.	Affirmed	Not particular	Patient
1458	weight gain of 2 pounds in 24   hours or 4 pounds in a week or less	She   will call Dr. **NAME[ZZZ] at that same number if there is any newer increased   shortness of breath, new onset of chest pain, lightheadedness, dizziness,   fainting, ankle swelling, abdominal bloating/WEIGHT GAIN OF 2 POUNDS IN 24   HOURS OR 4 POUNDS IN A WEEK OR LESS.	Affirmed	Not particular	Patient
1459	gait is antalgic	Her GAIT IS ANTALGIC but otherwise, normal.	Affirmed	Recent	Patient
1460	murmurs	No MURMURS, gallops, rubs.	Negated	Recent	Patient
1461	murmurs	Cardiovascular - Regular rate and rhythm, no MURMURS, rubs, gallops.	Negated	Recent	Patient
1462	phantom limb pain at the left upper extremity	Chronic pain with severe left hip degenerative joint disease/vascular   necrosis, PHANTOM LIMB PAIN AT THE LEFT UPPER EXTREMITY.	Affirmed	Recent	Patient
1463	pass out	She had come to work, was doing well, was   standing when she felt lightheaded and dizzy as if she was going to PASS OUT.	Affirmed	Not particular	Patient
1464	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
1465	tricuspid regurgitation	There is trace TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
1466	HEENT: Atraumatic	HEENT: ATRAUMATIC.	Affirmed	Recent	Patient
1467	LEFT LOWER EXTREMITY DEEP VEIN THROMBOSIS	LEFT LOWER EXTREMITY DEEP VEIN THROMBOSIS.	Affirmed	Recent	Patient
1468	inability to walk	However because of the   patient's persistent complaints of dizziness and INABILITY TO WALK and fear   of further fall, it may not be appropriate to send her home, especially in   the early hours of Friday night.	Affirmed	Recent	Patient
1469	dysuria	No hematuria or   DYSURIA.	Negated	Recent	Patient
1470	Rapid heart rate	S_O_H  Counters Report Type Record Type Subgroup Classifier  85,TV6NrxQTpYda ER ER 1005  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   EMERGENCY DEPARTMENT  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM   DATE OF SERVICE:  **DATE[Oct 02 07]   PRIMARY CARE PHYSICIAN: **NAME[UUU M VVV]  HISTORY OF PRESENT ILLNESS:   CHIEF COMPLAINT: RAPID HEART RATE.	Affirmed	Recent	Patient
1471	leukocytosis	Her postoperative course was remarkable for an increased   temperature and LEUKOCYTOSIS.	Affirmed	Recent	Patient
1472	Pharynx is pink without exudates	PHARYNX IS PINK WITHOUT EXUDATES.	Affirmed	Recent	Patient
1473	afebrile	The patient remained AFEBRILE with stable vital signs   which were a temperature of 36.1, heart rate 75, in normal sinus rhythm,   respirations 60, oxygenation 95% on two liters, blood pressure was 111/52 in   the left arm.	Affirmed	Recent	Patient
1474	incomplete right bundle with elevation of the ST segments   in V3, V4, and V5	EKG INTERPRETATION:    His EKG reveals an INCOMPLETE RIGHT BUNDLE WITH ELEVATION OF THE ST SEGMENTS   IN V3, V4, AND V5.	Affirmed	Recent	Patient
1475	appears acutely ill	PHYSICAL EXAMINATION:  In general, the patient APPEARS ACUTELY ILL.	Affirmed	Recent	Patient
1476	definite findings  to suggest instability	Although  there is significant irregularity, there are no DEFINITE FINDINGS  TO SUGGEST INSTABILITY.	Negated	Recent	Patient
1477	posterior pharynx is mildly erythematous	His POSTERIOR PHARYNX IS MILDLY ERYTHEMATOUS.	Affirmed	Recent	Patient
1478	Soft, nontender and nondistended	Abdomen:  SOFT, NONTENDER AND NONDISTENDED, mildly obese.	Affirmed	Recent	Patient
1479	mitral valve is thickened	The MITRAL VALVE IS THICKENED.	Affirmed	Recent	Patient
1480	Skin is warm and moist without   lesion	SKIN IS WARM AND MOIST WITHOUT   LESION.	Affirmed	Recent	Patient
1481	diplopia	In general, no change in   vision, DIPLOPIA or change in hearing.	Negated	Recent	Patient
1482	submucosal mass  of the mandibular anterior vestibule	S_O_H  Counters Report Type Record Type Subgroup Classifier  213,3GQ7jJazVbTT SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PATIENT HISTORY:  The patient is a **AGE[in teens]-year-old Caucasian female with a 1 cm soft SUBMUCOSAL MASS  OF THE MANDIBULAR ANTERIOR VESTIBULE.	Affirmed	Recent	Patient
1483	laceration	He has been having oozing from the LACERATION.	Affirmed	Recent	Patient
1484	Abdomen - Soft, nontender, nondistended	ABDOMEN - SOFT, NONTENDER, NONDISTENDED, positive   bowel sounds, no mass or organomegaly.	Affirmed	Recent	Patient
1485	TMs are clear   bilaterally	TMS ARE CLEAR   BILATERALLY.	Affirmed	Recent	Patient
1486	cholecystitis	He   had no signs of an acute abdomen; no signs of CHOLECYSTITIS, pancreatitis or   peptic ulcer disease.	Negated	Recent	Patient
1487	PELVIS:     NO FINDINGS TO SUGGEST FDG AVID MALIGNANCY	PELVIS:     NO FINDINGS TO SUGGEST FDG AVID MALIGNANCY.	Affirmed	Recent	Patient
1488	type 2 diabetes	PAST MEDICAL HISTORY:     The patient has hypertension, TYPE 2 DIABETES, Obstructive Sleep Apnea, and   wears oxygen at night.	Affirmed	Historical	Patient
1489	pain	She has had an intense PAIN since that   time.	Affirmed	Recent	Patient
1490	thoracic aortic aneurysm	Anticoagulation: Given his THORACIC AORTIC ANEURYSM, he has a conservative  goal INR of 2-2.5 for his PE.	Affirmed	Historical	Patient
1491	ATRIAL FIBRILLATION/ATRIAL FLUTTER	ATRIAL FIBRILLATION/ATRIAL FLUTTER.	Affirmed	Recent	Patient
1492	Regular rate and rhythm	Heart - REGULAR RATE AND RHYTHM, no   murmurs, gallops, or rubs.	Affirmed	Recent	Patient
1493	lethargy	BRIEF HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 40s]-year-old female with complex   medical history with multiple hospital admissions who was admitted to   **INSTITUTION from **DATE[Feb 13 2008], through **DATE[Feb 20 2008], for altered   mental status and LETHARGY.	Affirmed	Recent	Patient
1494	renal insufficiency	Given the patient's RENAL INSUFFICIENCY, this   may be artificially elevated, as she is not able to clear a small amount of   troponin possibly from an old infarct.	Affirmed	Recent	Patient
1495	urinary incontinence	Assessment of this Patient:  She is a **AGE[in 70s]-year-old female with a history of   multiple sclerosis, and paralysis with a history of urinary tract infections   and URINARY INCONTINENCE with chronic Foley, who had been reported to have   vaginal bleeding, however, was found to have blood at the urethral meatus,   consistent with urethral trauma.	Affirmed	Historical	Patient
1496	oriented times three	Neurologic - The patient is alert and ORIENTED TIMES THREE.	Affirmed	Recent	Patient
1497	pancreatitis	He   had no signs of an acute abdomen; no signs of cholecystitis, PANCREATITIS or   peptic ulcer disease.	Negated	Recent	Patient
1498	loose bowel movement	The patient did have one LOOSE BOWEL MOVEMENT   accidentally today.	Affirmed	Recent	Patient
1499	Diverticuli, scattered in the sigmoid colon  	COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) DIVERTICULI, SCATTERED IN THE SIGMOID COLON    2) Normal colonoscopy otherwise    PLAN:  1) Follow-up: PRN referring MD  2) Every other year hemoccult testing with 3 HemOccult cards.	Affirmed	Recent	Patient
1500	mild to moderate aortic regurgitation	SPECTRAL DOPPLER:   There is MILD TO MODERATE AORTIC REGURGITATION.	Affirmed	Recent	Patient
1501	headache	The patient denied any HEADACHE,   neck pain, weakness, numbness or paraesthesias.	Negated	Recent	Patient
1502	positive bowel sounds	The   abdomen was soft, nontender with POSITIVE BOWEL SOUNDS.	Affirmed	Recent	Patient
1503	urethral injury	times 10 days for suspected   urinary tract infection, especially given her coexistent hematuria and   URETHRAL INJURY.	Affirmed	Recent	Patient
1504	Diverticula were found in the left colon	FINDINGS:  DIVERTICULA WERE FOUND IN THE LEFT COLON (see image3).	Affirmed	Recent	Patient
1505	Normocephalic	HEENT - NORMOCEPHALIC and atraumatic, mucous membranes moist.	Affirmed	Recent	Patient
1506	change in  weight	GI  ROS is -ve for change in bowel habit, bleeding (occult nor overt), CHANGE IN  WEIGHT, anemia or any "alarm" symptom or sign.	Negated	Recent	Patient
1507	scattered calcification  throughout the spleen	Images through the upper abdomen reveal SCATTERED CALCIFICATION  THROUGHOUT THE SPLEEN.	Affirmed	Recent	Patient
1508	wound is healing well	EXTREMITIES:  The WOUND IS HEALING WELL.	Affirmed	Recent	Patient
1509	CHEST PAIN	CHEST PAIN, RULE OUT MYOCARDIAL INFARCTION.	Affirmed	Recent	Patient
1510	hypercoagulable state	The patient has had multiple arterial and venous   complications related to her underlying HYPERCOAGULABLE STATE as detailed   above.	Affirmed	Recent	Patient
1511	mental status has continued to   deteriorate	Unfortunately, the patient's MENTAL STATUS HAS CONTINUED TO   DETERIORATE with her multiple CVAs and/or cerebral hemorrhages during this   hospitalization.	Affirmed	Recent	Patient
1512	right groin AV fistula	;    HISTORY:  The patient is a **AGE[in 60s]-year-old gentleman with a past medical history  significant for ESRD, HIV, chronic thoracic aortic aneurysm, chronic SVC  occlusion, and recent diagnosis of PE who was discharged on **DATE[Jul 2 2007]  after RIGHT GROIN AV FISTULA placement.	Affirmed	Recent	Patient
1513	Pupils are equal, round, and reactive to light	PUPILS ARE EQUAL, ROUND, AND REACTIVE TO LIGHT.	Affirmed	Recent	Patient
1514	Overall left ventricular function is low normal	OVERALL LEFT VENTRICULAR FUNCTION IS LOW NORMAL, with an estimated   ejection fraction of 50-55 %.	Affirmed	Recent	Patient
1515	cholecystolithiasis	An MRI done on the same day showed no   biliary dilatation and positive for CHOLECYSTOLITHIASIS.	Affirmed	Recent	Patient
1516	LEFT FEMORAL NECK FRACTURE	PRIOR ORIF OF A LEFT FEMORAL NECK FRACTURE.	Affirmed	Historical	Patient
1517	Right groin AV fistula thrombosis	Admitting diagnosis: RIGHT GROIN AV FISTULA THROMBOSIS  Discharge diagnosis: same.	Affirmed	Recent	Patient
1518	shortness of breath	The patient's report shows clinical improvement   with slight SHORTNESS OF BREATH.	Affirmed	Recent	Patient
1519	pain	The patient does have poor energy and frustration and inability to do   activities she enjoys due to her PAIN and medical conditions, difficulty   concentrating.	Affirmed	Recent	Patient
1520	Left ventricular wall thickness is increased	LEFT VENTRICULAR WALL THICKNESS IS INCREASED, consistent with left   ventricular hypertrophy.	Affirmed	Recent	Patient
1521	intractable radicular pain of the left lower extremity	She subsequently   underwent a repair of her left hip fracture but unfortunately has been left   with INTRACTABLE RADICULAR PAIN OF THE LEFT LOWER EXTREMITY.	Affirmed	Recent	Patient
1522	atelectasis	It showed ATELECTASIS versus pneumonia in the left lower lobe   involving pleural effusion.	Affirmed	Recent	Patient
1523	abdomen is soft, nontender, and nondistended	The ABDOMEN IS SOFT, NONTENDER, AND NONDISTENDED.	Affirmed	Recent	Patient
1524	subchondral cysts of the  scaphoid and radius	The fusion wheel and screws are  in position without change and the SUBCHONDRAL CYSTS OF THE  SCAPHOID AND RADIUS have not changed in size.	Affirmed	Historical	Patient
1525	cranial nerves II through XII are intact 	The   patient's CRANIAL NERVES II THROUGH XII ARE INTACT with sensation intact to   light touch.	Affirmed	Recent	Patient
1526	Right ventricular function is normal	RIGHT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
1527	diverticulitis	The patient had history of   colon problem and DIVERTICULITIS in the past.	Affirmed	Historical	Patient
1528	Digital rectal exam was performed and showed no abnormalities	DIGITAL RECTAL EXAM WAS PERFORMED AND SHOWED NO ABNORMALITIES.	Affirmed	Recent	Patient
1529	Decreased air entry	Pulmonary - DECREASED AIR ENTRY with bilateral crackles.	Affirmed	Recent	Patient
1530	focal neurologic deficits	She has no FOCAL NEUROLOGIC DEFICITS.	Negated	Recent	Patient
1531	lymphadenopathy	No LYMPHADENOPATHY,   thyromegaly, or JVD.	Negated	Recent	Patient
1532	sickle   cell crisis pain	HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 50s]-year-old female with a history of sickle cell disease, anemia,   who presents with one-week history of intermittent pain typical of her SICKLE   CELL CRISIS PAIN, she says.	Affirmed	Recent	Patient
1533	mitral valve is normal	The MITRAL VALVE IS NORMAL.	Affirmed	Recent	Patient
1534	sciatic and pain in her left leg	She also has EMGs that show irritation at the L5 nerve root,   resulting in her SCIATIC AND PAIN IN HER LEFT LEG.	Affirmed	Recent	Patient
1535	urgency	GU - No frequency, URGENCY, or dysuria.	Negated	Recent	Patient
1536	2+ pulses in all four extremities	EXTREMITIES: Extremities 2+ pulses in all four extremities.	Affirmed	Recent	Patient
1537	Alert	NEUROLOGIC:  ALERT and oriented times three.	Affirmed	Recent	Patient
1538	sustained or low-grade temperature   greater than 100 degrees Fahrenheit	Call also for any weight gain   greater than three pounds per day or five pounds per week, any unusual   rashes, nausea, vomiting, fever associated with chill, temperature elevation   greater than 101 degrees Fahrenheit, SUSTAINED OR LOW-GRADE TEMPERATURE   GREATER THAN 100 DEGREES FAHRENHEIT, new onset of chest pain,   light-headedness, or dizziness, new or increased shortness of breath, severe   calf pain, burning on urination or severe depression.	Affirmed	Not particular	Patient
1539	aortic valve is thickened	The AORTIC VALVE IS THICKENED.	Affirmed	Recent	Patient
1540	edema	Extremities - No clubbing, cyanosis,   or EDEMA.	Negated	Recent	Patient
1541	Overall left ventricular function is normal	OVERALL LEFT VENTRICULAR FUNCTION IS NORMAL,   with an estimated ejection fraction of 60-65 %.	Affirmed	Recent	Patient
1542	ACUTE CORONARY SYNDROME	ACUTE CORONARY SYNDROME.	Affirmed	Recent	Patient
1543	tolerated minimal p.o.	She has TOLERATED MINIMAL P.O.	Affirmed	Recent	Patient
1544	cough	Positive for shortness of breath,   no COUGH.	Negated	Recent	Patient
1545	headache	S_O_H  Counters Report Type Record Type Subgroup Classifier  92,681OwhV0ZFnK ER ER 1001  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   EMERGENCY DEPARTMENT  PATIENT NAME:  **NAME[AAA, BBB]  ACCOUNT #:  **ID-NUM  DATE OF SERVICE:  **DATE[Aug 13 07]  PRIMARY CARE PHYSICIAN: **NAME[YYY M ZZZ]  ATTENDING PHYSICIAN ADDENDUM:    CHIEF COMPLAINT:  Weakness and HEADACHE.	Affirmed	Recent	Patient
1546	mitral annular calcification	There is MITRAL ANNULAR CALCIFICATION.	Affirmed	Recent	Patient
1547	Overall left ventricular   function is normal	OVERALL LEFT VENTRICULAR   FUNCTION IS NORMAL, with an estimated ejection fraction of 55-60 %.	Affirmed	Recent	Patient
1548	infection	The patient has normal range   of motion in her hand with good capillary refill, and no signs of INFECTION.	Negated	Recent	Patient
1549	lungs are otherwise clear	The LUNGS ARE OTHERWISE CLEAR.	Affirmed	Recent	Patient
1550	tobacco use	The patient is a **AGE[in 40s]-year-old male with a history of COPD, TOBACCO USE,   presents to the Emergency Department with complaint of chest tightness,   pressure, as well as complaint of shortness of breath and wheezing at home.	Affirmed	Historical	Patient
1551	agitation	The patient was started on Geodon for AGITATION.	Affirmed	Recent	Patient
1552	Left atrial   size is normal	LEFT ATRIAL   SIZE IS NORMAL.	Affirmed	Recent	Patient
1553	pulmonary artery size is normal	The PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
1554	Heart is normal in size	HEART IS NORMAL IN SIZE.	Affirmed	Recent	Patient
1555	Patent Billroth II anastomosis	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) Normal esophagus    2) Retained food in thegastric remnant  3) PATENT BILLROTH II ANASTOMOSIS  4) s/p 10 French NJ tube placement in efferent limb    PLAN:  1) Follow NJ tube order set for feeding  2) No meds through J port    REPEAT EXAM:  No    __________________________________  **NAME[YYY M. ZZZ], M.D.  I was present during the entire procedure.	Affirmed	Recent	Patient
1556	chronicrenal disease	There are small,  gastrohepatic and porta hepatis lymph nodes, the sequelae of  CHRONICRENAL DISEASE.	Affirmed	Historical	Patient
1557	measles	REASON FOR ADMISSION:    Past medical history is positive for hyperlipidemia, hypothyroidism, weakness   and difficulty with ambulation, aortic/mitral disease, spinal stenosis,   cataracts, MEASLES, mumps, and varicella in the past.	Affirmed	Historical	Patient
1558	Cataracts	CATARACTS.	Affirmed	Historical	Patient
1559	Right atrial size   is normal	RIGHT ATRIAL SIZE   IS NORMAL.	Affirmed	Recent	Patient
1560	dyspnea on exertion	Cardiovascular - No substernal chest pressure or DYSPNEA ON EXERTION.	Negated	Recent	Patient
1561	portal hypertension	The indication for this procedure is staging  of PORTAL HYPERTENSION.	Affirmed	Recent	Patient
1562	murmur	There is no MURMUR or ectopy noted.	Negated	Recent	Patient
1563	Scattered diverticuli were found in the  left colon	SCATTERED DIVERTICULI WERE FOUND IN THE  LEFT COLON.	Affirmed	Recent	Patient
1564	Chest Pain	Wall Thickness:  1.0 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: CHEST PAIN, Other  TWO DIMENSIONAL ECHOCARDIOLOGY:   Left ventricular size is normal.	Affirmed	Recent	Patient
1565	left leg has some external rotation	The patient's LEFT LEG HAS SOME EXTERNAL ROTATION.	Affirmed	Recent	Patient
1566	pain	Psychiatric Service was consulted, and the patient's   depressive mood was worsening for 2 months in coordination with medical   complications and PAIN.	Affirmed	Recent	Patient
1567	chest pain	The patient had no CHEST PAIN   or shortness of breath.	Negated	Recent	Patient
1568	extremity examination shows +2 pulses	The extremity examination shows +2 pulses and no peripheral edema.	Affirmed	Recent	Patient
1569	bilateral crackles	Pulmonary - Decreased air entry with BILATERAL CRACKLES.	Affirmed	Recent	Patient
1570	lower back pain	S_O_H  Counters Report Type Record Type Subgroup Classifier  177,D62IdM/5h0BX RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  MR SPINE LUMBAR WITHOUT CONTRAST   **DATE[Jul 26 07]     1331 HOURS    CLINICAL HISTORY:     **AGE[in 80s]-year-old female with LOWER BACK PAIN.	Affirmed	Recent	Patient
1571	ear, nose, or throat pain	ENT:  Denies any EAR, NOSE, OR THROAT PAIN.	Negated	Recent	Patient
1572	well hydrated	She appeared WELL HYDRATED.	Affirmed	Recent	Patient
1573	trace aortic regurgitation	COLOR FLOW DOPPLER:   There is TRACE AORTIC REGURGITATION.	Affirmed	Recent	Patient
1574	acute   disk herniation	She had no signs of ACUTE   DISK HERNIATION or weakness.	Negated	Recent	Patient
1575	CHF	The patient with history of CHF and atrial fibrillation.	Affirmed	Historical	Patient
1576	mitral regurgitation	SPECTRAL DOPPLER:   There is trace MITRAL REGURGITATION.	Affirmed	Recent	Patient
1577	mild tricuspid   regurgitation	There is MILD TRICUSPID   REGURGITATION.	Affirmed	Recent	Patient
1578	OTHERWISE THE LUNGS ARE CLEAR	IMPRESSION:       TINY RIGHT PLEURAL EFFUSION, OTHERWISE THE LUNGS ARE CLEAR.	Affirmed	Recent	Patient
1579	right ventricular  pressure or volume overload	04) Flattened interventricular septum, consistent with RIGHT VENTRICULAR  PRESSURE OR VOLUME OVERLOAD.	Affirmed	Recent	Patient
1580	numbness	The patient denied any headache,   neck pain, weakness, NUMBNESS or paraesthesias.	Negated	Recent	Patient
1581	Moderate right atrial enlargement	06) MODERATE RIGHT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
1582	Crohn's disease	POST-OP DIAGNOSIS: Active CROHN'S DISEASE.	Affirmed	Recent	Patient
1583	dehydration	He received IV   fluids in the Emergency Department for his DEHYDRATION.	Affirmed	Recent	Patient
1584	paresthesias	He denies PARESTHESIAS.	Negated	Recent	Patient
1585	constipation	Denied any CONSTIPATION or diarrhea.	Negated	Recent	Patient
1586	nausea	He was given a prescription for Zofran in case his NAUSEA returns, otherwise   will return to the Emergency Department for worsening complaints.	Affirmed	Recent	Patient
1587	chest pain	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no CHEST PAIN, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
1588	pain	He states the   PAIN is on and off and cramping in all regions.	Affirmed	Recent	Patient
1589	EOMI	Eyes   - PERRLA, EOMI.	Affirmed	Recent	Patient
1590	interatrial baffle	07) There is an echodensity seen in the atria consistent with the patient''s  know INTERATRIAL BAFFLE.	Affirmed	Historical	Patient
1591	fevers	She denies any   FEVERS or chills.	Negated	Recent	Patient
1592	chest tightness 	His respiratory complaints   and his CHEST TIGHTNESS did improve with the DuoNebs times two and the   prednisone 60 mg he received orally.	Affirmed	Recent	Patient
1593	Nondilated left ventricle with overall preserved systolic function	02) NONDILATED LEFT VENTRICLE WITH OVERALL PRESERVED SYSTOLIC FUNCTION.	Affirmed	Recent	Patient
1594	nausea	She should return to the Emergency Department if she experiences NAUSEA,   vomiting, increased abdominal pain, shortness of breath, or chest pain.	Affirmed	Not particular	Patient
1595	Right ventricular size is   normal	RIGHT VENTRICULAR SIZE IS   NORMAL.	Affirmed	Recent	Patient
1596	LEFT POSTERIOR INTERNAL CAROTID ARTERY ANEURYSM	S_O_H  Counters Report Type Record Type Subgroup Classifier  6,LfVHkBQJkc9L DS DS 5105  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION  NEUROSURGERY  TRANSFER SUMMARY  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  **ROOM  ATTENDING PHYSICIAN:  **NAME[YYY M ZZZ]  TRANSFERRED DATE:  **DATE[Aug 09 07]  TRANSFERRED TO:    TRANSFERRED TO CARE OF:    ADMITTING DIAGNOSIS(ES):   LEFT POSTERIOR INTERNAL CAROTID ARTERY ANEURYSM   AND SUBARACHNOID HEMORRHAGE.	Affirmed	Recent	Patient
1597	mild headache	She complains only of a MILD HEADACHE and left-sided   facial pain.	Affirmed	Recent	Patient
1598	vomited	She has been extreme-ly nauseated since then and has VOMITED several times.	Affirmed	Recent	Patient
1599	pupils are   equal, round, and reactive	His PUPILS ARE   EQUAL, ROUND, AND REACTIVE.	Affirmed	Recent	Patient
1600	redness, swelling, or   drainage at or around the incision site	Call the physician if any of the following are noted:  Heart rate greater   than 110 beats or less than 50 beats/minute, increased REDNESS, SWELLING, OR   DRAINAGE AT OR AROUND THE INCISION SITE.	Affirmed	Not particular	Patient
1601	orthotopic heart transplantatio	06) Findings consistent with ORTHOTOPIC HEART TRANSPLANTATIOn.	Affirmed	Recent	Patient
1602	decondition	It was recommended to   have Home Care PT and OT to visit 3 times per week for 4 weeks with a   diagnosis of DECONDITION.	Affirmed	Recent	Patient
1603	Moderate left atrial enlargement	06) 7)  MODERATE LEFT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
1604	urinary incontinence	She is a **AGE[in 70s]-year-old female who has a history of multiple sclerosis   complicated by paralysis and URINARY INCONTINENCE with chronic Foley, who was   brought in by ambulance today from **INSTITUTION in Mt.	Affirmed	Historical	Patient
1605	mucocele	Clinical impression: Rule out MUCOCELE.	Affirmed	Recent	Patient
1606	neurologically stable	She remained   NEUROLOGICALLY STABLE with no change in mental status.	Affirmed	Recent	Patient
1607	Duodenitis was  found in the bulb of the duodenum	DUODENITIS WAS  FOUND IN THE BULB OF THE DUODENUM.	Affirmed	Recent	Patient
1608	ankle swelling	She   will call Dr. **NAME[ZZZ] at that same number if there is any newer increased   shortness of breath, new onset of chest pain, lightheadedness, dizziness,   fainting, ANKLE SWELLING, abdominal bloating/weight gain of 2 pounds in 24   hours or 4 pounds in a week or less.	Affirmed	Not particular	Patient
1609	strong radial pulses	Also has   STRONG RADIAL PULSES.	Affirmed	Recent	Patient
1610	Right ventricular   function is normal	RIGHT VENTRICULAR   FUNCTION IS NORMAL.	Affirmed	Recent	Patient
1611	Mitral annular calcification	03) MITRAL ANNULAR CALCIFICATION.	Affirmed	Recent	Patient
1612	Heart   sounds regular	HEART   SOUNDS REGULAR.	Affirmed	Recent	Patient
1613	chest pain	She should return to the Emergency Department if she experiences nausea,   vomiting, increased abdominal pain, shortness of breath, or CHEST PAIN.	Affirmed	Not particular	Patient
1614	right ventricular pressure   or volume overload	There is flattening   of the interventricular septum, consistent with RIGHT VENTRICULAR PRESSURE   OR VOLUME OVERLOAD.	Affirmed	Recent	Patient
1615	sessile polyp was found in the descending colon	A 5mm SESSILE POLYP WAS FOUND IN THE DESCENDING COLON and  removed with snare polypectomy.	Affirmed	Recent	Patient
1616	mobile filamentous mass attached to the left ventricular apical  endocardium	08) There is MOBILE FILAMENTOUS MASS ATTACHED TO THE LEFT VENTRICULAR APICAL  ENDOCARDIUM most likely a ruptured chordae, however, other pathology can   not be excluded.	Affirmed	Recent	Patient
1617	moderate external hemorrhoids	Digital rectal exam was performed and showed MODERATE EXTERNAL HEMORRHOIDS.	Affirmed	Recent	Patient
1618	chest pain	No CHEST PAIN.	Negated	Recent	Patient
1619	sinus rhythm	He did have a SINUS RHYTHM with a rate of approximately 100.	Affirmed	Recent	Patient
1620	HEALED RIGHT CALCANEAL AND LEFT DISTAL TIB FIB FRACTURES	IMPRESSION:       HEALED RIGHT CALCANEAL AND LEFT DISTAL TIB FIB FRACTURES.	Affirmed	Recent	Patient
1621	Moderate left atrial enlargement	06) MODERATE LEFT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
1622	Blood pressure was slightly low	BLOOD PRESSURE WAS SLIGHTLY LOW, it   was 98/60.	Affirmed	Recent	Patient
1623	Collapse	9  cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Syncope And COLLAPSE  TWO DIMENSIONAL ECHOCARDIOLOGY:   Left ventricular size is normal.	Affirmed	Recent	Patient
1624	PTSD	The patient reports PTSD about childhood trauma with occasional flashbacks,   reliving events.	Affirmed	Recent	Patient
1625	acute distress	PAST MEDICAL HISTORY:     PHYSICAL EXAM:    General Appearance:  In no ACUTE DISTRESS.	Negated	Recent	Patient
1626	lower back   pain	She says she has had intermittent LOWER BACK   PAIN, intermittent chest pain, and dyspnea on exertion.	Affirmed	Recent	Patient
1627	tricuspid valve is normal	The   TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
1628	DRUG ALLERGIES	HE HAS NO KNOWN DRUG ALLERGIES.	Negated	Historical	Patient
1629	acute distress	PHYSICAL EXAM:  GENERAL:  In no ACUTE DISTRESS.	Negated	Recent	Patient
1630	ileal mucosa was  normal	The ILEAL MUCOSA WAS  NORMAL in appearance.	Affirmed	Recent	Patient
1631	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
1632	Right ventricular   function is normal	RIGHT VENTRICULAR   FUNCTION IS NORMAL.	Affirmed	Recent	Patient
1633	rales	There are no RALES or rhonchi noted on   examination.	Negated	Recent	Patient
1634	headaches	Denied   any HEADACHES.	Negated	Recent	Patient
1635	Right ventricular size is normal	RIGHT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
1636	Normal stomach  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) Normal esophagus    2) NORMAL STOMACH    3) Duodenitis in the bulb of duodenum      PLAN:  1) **INSTITUTION for Liver Disease  2) await biopsy results    REPEAT EXAM:  No    __________________________________  **NAME[YYY ZZZ]  I was present during the entire procedure.	Affirmed	Recent	Patient
1637	shortness of breath	He still denies any   chest pain or SHORTNESS OF BREATH.	Negated	Recent	Patient
1638	Extraocular motions are intact	EXTRAOCULAR MOTIONS ARE INTACT.	Affirmed	Recent	Patient
1639	Positive bowel sounds	POSITIVE BOWEL SOUNDS.	Affirmed	Recent	Patient
1640	METASTATIC  DISEASE	PROGRESSION OF ENHANCEMENT IN THE PONTINE MEDULLARY JUNCTION,  AND A NEW, MORE CONSPICUOUS AREA OF ENHANCEMENT ALONG THE MEDIAL  ASPECT OF THE LEFT UNCUS ALL OF WHICH IS SUSPICIOUS FOR METASTATIC  DISEASE.	Affirmed	Recent	Patient
1641	respiratory failure	Also throughout this hospital course, the patient had the following   complications:  sepsis, RESPIRATORY FAILURE with trach placement,   thrombocytopenia, rectal sheath hematoma with intraabdominal bleed status   post iliac and epigastric embolization of arteries, renal failure secondary   to ureteral obstruction with bilateral nephrostomy tube placement, right MCA   CVA, rectal ischemia and further complications related to her underlying   hypercoagulable state.	Affirmed	Recent	Patient
1642	some   URI symptoms	He is developing SOME   URI SYMPTOMS including cough and rhinorrhea.	Affirmed	Recent	Patient
1643	trace pulmonic regurgitation	There is TRACE PULMONIC REGURGITATION.	Affirmed	Recent	Patient
1644	tingling	No numbness or  TINGLING or other injuries.	Negated	Recent	Patient
1645	left hip, the right  hemipelvis, the sacrum show no other focal abnormalities	The LEFT HIP, THE RIGHT  HEMIPELVIS, THE SACRUM SHOW NO OTHER FOCAL ABNORMALITIES.	Affirmed	Recent	Patient
1646	hyponatremia	She also   had abdominal pain at that time, as well as HYPONATREMIA.	Affirmed	Recent	Patient
1647	elevation of right hemidiaphragm	No change in  ELEVATION OF RIGHT HEMIDIAPHRAGM.	Affirmed	Recent	Patient
1648	normal sinus rhythm	EKG INTERPRETATION: His EKG was NORMAL SINUS RHYTHM at a rate of 73, QRS of   106 milliseconds, QTc of 467 milliseconds.	Affirmed	Recent	Patient
1649	pain 	She felt her PAIN was much improved.	Affirmed	Recent	Patient
1650	infiltrate	The patient did have a chest x-ray which was noted to be negative for any   INFILTRATE or effusion.	Negated	Recent	Patient
1651	ABDOMEN:     1. NO FINDINGS TO SUGGEST FDG AVID MALIGNANCY	NO FINDINGS TO SUGGEST FDG AVID MALIGNANCY.	Affirmed	Recent	Patient
1652	HIV	;    HISTORY:  The patient is a **AGE[in 60s]-year-old gentleman with a past medical history  significant for ESRD, HIV, chronic thoracic aortic aneurysm, chronic SVC  occlusion, and recent diagnosis of PE who was discharged on **DATE[Jul 2 2007]  after right groin AV fistula placement.	Affirmed	Historical	Patient
1653	Rejection	PRE-OP DIAGNOSIS: REJECTION.	Affirmed	Recent	Patient
1654	pulmonary artery size is normal	The PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
1655	Left ventricular wall thickness is normal	LEFT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
1656	Right ventricular   wall thickness is increased	RIGHT VENTRICULAR   WALL THICKNESS IS INCREASED, consistent with right ventricular hypertrophy.	Affirmed	Recent	Patient
1657	infection	This gradually   cleared, and there were no further signs or symptoms of INFECTION.	Negated	Recent	Patient
1658	Laceration of the toe	S_O_H  Counters Report Type Record Type Subgroup Classifier  93,AXpSCxmBWx2O ER ER 1001  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   EMERGENCY DEPARTMENT  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  DATE OF SERVICE:  **DATE[Dec 21 07]  PRIMARY CARE PHYSICIAN: **NAME[VVV M UUU]  CHIEF COMPLAINT:  LACERATION OF THE TOE.	Affirmed	Recent	Patient
1659	vaginal bleeding	Lebanon, where she was   said to have had VAGINAL BLEEDING for the past two days, as well as to have a   supratherapeutic INR at 4.5 on **DATE[Sep 29], which had been held for the past two   days.	Affirmed	Recent	Patient
1660	GRANULOMATOUS DISEASE	FINDINGS OF PRIOR GRANULOMATOUS DISEASE.	Affirmed	Historical	Patient
1661	Right atrial size is normal	RIGHT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
1662	felt a piece stuck in her throat	She was eating chicken two days   ago when she FELT A PIECE STUCK IN HER THROAT.	Affirmed	Recent	Patient
1663	or calf pain	He denies any orthopnea, lower extremity edema, OR CALF PAIN.	Negated	Recent	Patient
1664	Weakness	S_O_H  Counters Report Type Record Type Subgroup Classifier  92,681OwhV0ZFnK ER ER 1001  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   EMERGENCY DEPARTMENT  PATIENT NAME:  **NAME[AAA, BBB]  ACCOUNT #:  **ID-NUM  DATE OF SERVICE:  **DATE[Aug 13 07]  PRIMARY CARE PHYSICIAN: **NAME[YYY M ZZZ]  ATTENDING PHYSICIAN ADDENDUM:    CHIEF COMPLAINT:  WEAKNESS and headache.	Affirmed	Recent	Patient
1665	Clostridium difficile colitis	CLOSTRIDIUM DIFFICILE COLITIS.	Affirmed	Recent	Patient
1666	upper GI bleed	This   was found to be consistent with an UPPER GI BLEED secondary to esophagitis   versus gastritis versus peptic ulcer disease versus **NAME[UUU] wise tear.	Affirmed	Recent	Patient
1667	ALVEOLAR HEMOSIDEROSIS	C.     ALVEOLAR HEMOSIDEROSIS.	Affirmed	Recent	Patient
1668	headache	Denies HEADACHE.	Negated	Recent	Patient
1669	pulmonary edema	Given his   hypoxia, I was concerned for a possible pneumonia; however, a chest x-ray did   show PULMONARY EDEMA which is new for this patient.	Affirmed	Recent	Patient
1670	Slightly improved pulmonary ventilation	SLIGHTLY IMPROVED PULMONARY VENTILATION in a patient with  bilateral areas of lobar consolidation and left-sided pleural  effusion.	Affirmed	Recent	Patient
1671	murmurs	No MURMURS, rubs or gallops.	Negated	Recent	Patient
1672	prostate gland is enlarged	The PROSTATE GLAND IS ENLARGED.	Affirmed	Recent	Patient
1673	cocaine abuse	The patient has an extensive history   of COCAINE ABUSE.	Affirmed	Historical	Patient
1674	left lower extremity swelling and pain	HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 40s]-year-old gentleman with a history of HIV/AIDS who is status post   recent abdominal wall abscess and status post surgical evacuation in **DATE[Dec] of   2007, presents with increasing LEFT LOWER EXTREMITY SWELLING AND PAIN over   the last 2 weeks.	Affirmed	Recent	Patient
1675	viral gastroenteritis	We felt that the patient had a VIRAL GASTROENTERITIS.	Affirmed	Recent	Patient
1676	Stenosis in the sigmoid colon	FINDINGS:  STENOSIS IN THE SIGMOID COLON (see image1).	Affirmed	Recent	Patient
1677	ST segments did appear concave	The ST SEGMENTS DID APPEAR CONCAVE in nature.	Affirmed	Recent	Patient
1678	Left atrial size is normal	LEFT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
1679	Right ventricular size is normal	RIGHT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
1680	laceration on the dorsal aspect of the   left great toe	EXTREMITIES:  There is a 2 cm diagonal LACERATION ON THE DORSAL ASPECT OF THE   LEFT GREAT TOE.	Affirmed	Recent	Patient
1681	headache	HEENT - No HEADACHE or difficulty hearing.	Negated	Recent	Patient
1682	Right ventricular function is   mildly decreased	RIGHT VENTRICULAR FUNCTION IS   MILDLY DECREASED.	Affirmed	Recent	Patient
1683	Anemia	ANEMIA.	Affirmed	Historical	Patient
1684	cataract surgery	He has also history of cholecystectomy and CATARACT SURGERY.	Affirmed	Historical	Patient
1685	effusion	The patient did have a chest x-ray which was noted to be negative for any   infiltrate or EFFUSION.	Negated	Recent	Patient
1686	vomiting	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, VOMITING, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
1687	hip   fracture	Also a HIP   FRACTURE and gout.	Affirmed	Historical	Patient
1688	abdominal pain	Since she has been there, she has had minimal energy and some   ABDOMINAL PAIN.	Affirmed	Recent	Patient
1689	Left atrial size is moderately enlarged	LEFT ATRIAL SIZE IS MODERATELY ENLARGED.	Affirmed	Recent	Patient
1690	course of the carotid arteries and the jugular veins are  normal	The COURSE OF THE CAROTID ARTERIES AND THE JUGULAR VEINS ARE  NORMAL.	Affirmed	Recent	Patient
1691	positive bowel sounds	He did have POSITIVE BOWEL SOUNDS.	Affirmed	Recent	Patient
1692	DVT	PRINCIPAL PROCEDURES AND TESTS:  Doppler of the lower extremities negative   for DVT.	Negated	Recent	Patient
1693	JVD	No lymphadenopathy,   thyromegaly, or JVD.	Negated	Recent	Patient
1694	aortic dissection	He does have a history of PE's in the past, but his   signs and symptoms were not consistent with AORTIC DISSECTION, PE, or   infectious etiologies.	Negated	Recent	Patient
1695	fever	She denies FEVER, chills, or other constitutional symptoms.	Negated	Recent	Patient
1696	Crohn's	S_O_H  Counters Report Type Record Type Subgroup Classifier  205,N0obGVkbCPHP SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PATIENT HISTORY:  CROHN'S, status post ileocecal resection, on 6MP.  PRE-OP DIAGNOSIS: As above.	Affirmed	Historical	Patient
1697	tolerating p.o. intake	intake and voiding without difficulty and ambulating   independently.	Affirmed	Recent	Patient
1698	WEAKNESS	ADMISSION DIAGNOSIS(ES):    DIZZINESS AND WEAKNESS OF UNCLEAR ETIOLOGY.	Affirmed	Recent	Patient
1699	Mild left atrial enlargement	03) MILD LEFT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
1700	Fever	S_O_H  Counters Report Type Record Type Subgroup Classifier  179,+R8TvtInQNPG RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  XRAY CHEST FRONTAL AND LATERAL VIEWS   **DATE[Aug 27 07]     1013 HOURS    CLINICAL HISTORY:     FEVER.	Affirmed	Recent	Patient
1701	intact extraocular   movements	HEENT examination reveals normocephalic   and atraumatic head, equal and reactive pupils, and INTACT EXTRAOCULAR   MOVEMENTS.	Affirmed	Recent	Patient
1702	JVD	No lymphadenopathy, thyromegaly or JVD.	Negated	Recent	Patient
1703	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
1704	mild amount of left lumbar paraspinal   tenderness	Musculoskeletal:  The patient has MILD AMOUNT OF LEFT LUMBAR PARASPINAL   TENDERNESS as well as some lumbar spinal tenderness.	Affirmed	Recent	Patient
1705	decondition 	It was felt that her   delusion was due to her medical DECONDITION with some component of   dissociative disorder and borderline personality disorder as well as   depression and anxiety.	Affirmed	Recent	Patient
1706	Mild pulmonary hypertension	07) MILD PULMONARY HYPERTENSION.	Affirmed	Recent	Patient
1707	pneumonia	PAST MEDICAL HISTORY:     Her past medical history is significant for multiple sclerosis, PNEUMONIA,   DVT of the lower extremity, hypothyroidism, hard of hearing, vitiligo, and   her paralysis from her multiple sclerosis.	Affirmed	Historical	Patient
1708	GERD	MEDICAL HISTORY:   Atrial fibrillation, hypertension, arthritis, coronary artery disease, GERD,   cataracts, and cancer of the left eyelid.	Affirmed	Historical	Patient
1709	nauseated	She has been extreme-ly NAUSEATED since then and has vomited several times.	Affirmed	Recent	Patient
1710	nonsmoker	Social history:  The patient drinks alcohol occasionally, is a NONSMOKER.	Affirmed	Historical	Patient
1711	left MCA CVA	A CT angiogram   showed LEFT MCA CVA, bilateral high-grade carotid stenosis.	Affirmed	Recent	Patient
1712	mild aortic regurgitation	COLOR FLOW DOPPLER:   There is MILD AORTIC REGURGITATION.	Affirmed	Recent	Patient
1713	some   tingling over the lateral aspect of her fifth finger	She does have SOME   TINGLING OVER THE LATERAL ASPECT OF HER FIFTH FINGER, but motor is intact to   the radial to using the interossei muscles.	Affirmed	Recent	Patient
1714	right to left  intracardiac shunt	04) Normal saline contrast injection without evidence of RIGHT TO LEFT  INTRACARDIAC SHUNT.	Negated	Recent	Patient
1715	Severe pulmonary hypertension	07) SEVERE PULMONARY HYPERTENSION.	Affirmed	Recent	Patient
1716	anemia	The patient's H   and H were at baseline without any evidence of significant ANEMIA.	Negated	Recent	Patient
1717	hypothyroidism	The patient with HYPOTHYROIDISM.	Affirmed	Recent	Patient
1718	weakness	She had no signs of acute   disk herniation or WEAKNESS.	Negated	Recent	Patient
1719	polyps	There was no evidence of POLYPS or mass.	Negated	Recent	Patient
1720	aspiration pneumonia	While in the ED, the patient was given Unasyn 3 g IV to cover for a   possible ASPIRATION PNEUMONIA given her decreased mental status and vomiting.	Affirmed	Recent	Patient
1721	additional abnormal areas of  enhancement within the brain parenchyma	There are no other ADDITIONAL ABNORMAL AREAS OF  ENHANCEMENT WITHIN THE BRAIN PARENCHYMA.	Negated	Recent	Patient
1722	stool-filled colon	Radiographs of the abdomen including erect and decubitus views obtained   **DATE[Mar 24 2008], which revealed nonobstructive scattered bowel gas pattern and a   STOOL-FILLED COLON.	Affirmed	Recent	Patient
1723	nonsustained ventricular tachycardia	There was NONSUSTAINED VENTRICULAR TACHYCARDIA during stress.	Affirmed	Recent	Patient
1724	blood in the vagina	There was no BLOOD IN THE VAGINA.	Negated	Recent	Patient
1725	clubbing	Extremities - No CLUBBING, cyanosis,   or edema.	Negated	Recent	Patient
1726	GASTROENTERITIS	S_O_H  Counters Report Type Record Type Subgroup Classifier  10,Lcu1BWkuMaJU DS DS 5004  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   GENERAL MEDICINE  DISCHARGE SUMMARY  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  **ROOM  ATTENDING PHYSICIAN:  **NAME[YYY M ZZZ]  ADMISSION DATE:  **DATE[Mar 03 2008]  DISCHARGE DATE:  **DATE[Mar 05 2008]  DISCHARGE DIAGNOSIS(ES):  GASTROENTERITIS.	Affirmed	Recent	Patient
1727	Pupils are equal and reactive to light	PUPILS ARE EQUAL AND REACTIVE TO LIGHT.	Affirmed	Recent	Patient
1728	Segmental left   ventricular function is abnormal	SEGMENTAL LEFT   VENTRICULAR FUNCTION IS ABNORMAL.	Affirmed	Recent	Patient
1729	normal sinus rhythm	EKG Interpretation - A 12-lead EKG shows NORMAL SINUS RHYTHM with no acute   ischemic changes.	Affirmed	Recent	Patient
1730	Segmental left   ventricular function is normal	SEGMENTAL LEFT   VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
1731	Right ventricular   function is normal	RIGHT VENTRICULAR   FUNCTION IS NORMAL.	Affirmed	Recent	Patient
1732	dyspnea	The patient admitted with   __________ increased DYSPNEA in 24 hours, fever, and pleurisy.	Affirmed	Recent	Patient
1733	fractures in the right hip	FINDINGS:     RIGHT HIP: There are no detected FRACTURES IN THE RIGHT HIP.	Negated	Recent	Patient
1734	normal sinus rhythm	EKG INTERPRETATION:  EKG done in the emergency room shows her to have a NORMAL SINUS RHYTHM with a   sinus arrhythmia.	Affirmed	Recent	Patient
1735	diarrhea	HISTORY OF PRESENT ILLNESS:  Ms. **NAME[AAA] is a **AGE[in 40s]-year-old, African-American   female with a two-day history of fever, body aches, and nausea, vomiting, and   DIARRHEA.	Affirmed	Recent	Patient
1736	necrotizing   pancreatitis	Her blood sugars are elevated secondary to her NECROTIZING   PANCREATITIS.	Affirmed	Recent	Patient
1737	FACET ARTHROSIS	WHILE THESE APPEAR TO BE DUE TO FACET ARTHROSIS, NO   REFORMATS WERE OBTAINED AND I CANNOT EXCLUDE THAT THESE REPRESENT   NEOPLASM.	Affirmed	Recent	Patient
1738	aortic valve is normal	The AORTIC VALVE IS NORMAL.	Affirmed	Recent	Patient
1739	hemorrhoids	Retroflexion of the endoscope revealed HEMORRHOIDS.	Affirmed	Recent	Patient
1740	adenomatous polyps	The indication for this procedure is family  history of colon cancer (father in his early 70's) and a personal history of  ADENOMATOUS POLYPS (***PATH-NUMBER[1]).	Affirmed	Historical	Patient
1741	pulmonary artery   size is normal	The PULMONARY ARTERY   SIZE IS NORMAL.	Affirmed	Recent	Patient
1742	urinary tract infection	The patient was also found to have urinary   analysis consistent with URINARY TRACT INFECTION and a therapeutic INR.	Affirmed	Recent	Patient
1743	ventricles, sulci and cisterns are  otherwise normal	The VENTRICLES, SULCI AND CISTERNS ARE  OTHERWISE NORMAL.	Affirmed	Recent	Patient
1744	left hip fracture	Status post LEFT HIP FRACTURE repair in 2006.	Affirmed	Historical	Patient
1745	necrotizing   pancreatitis	LABORATORY, RADIOGRAPHIC, AND OTHER DIAGNOSTIC STUDY FINDINGS:    HPI AND HOSPITAL COURSE:    Ms. **NAME[AAA] is a very pleasant **AGE[in 80s]-year-old female with a history of hypertension   who was transferred to **INSTITUTION from an outside hospital because of NECROTIZING   PANCREATITIS.	Affirmed	Recent	Patient
1746	left lower lobe pneumonia	Chest x-ray   showed LEFT LOWER LOBE PNEUMONIA.	Affirmed	Recent	Patient
1747	hyponatremia	On my exam, her HYPONATREMIA from last week appears have   resolved, with a sodium of 134.	Negated	Recent	Patient
1748	metastatic   disease involving retroperitoneal, and peripancreatic, and porta lymph nodes	Progression of METASTATIC   DISEASE INVOLVING RETROPERITONEAL, AND PERIPANCREATIC, AND PORTA LYMPH NODES   which may be causing some component of the patient's intrahepatic biliary   ductile dilation, post-surgical changes from gastric jejunostomy and   gastrostomy tube.	Affirmed	Recent	Patient
1749	Pharynx   clear with moist mucous membranes	PHARYNX   CLEAR WITH MOIST MUCOUS MEMBRANES.	Affirmed	Recent	Patient
1750	lightheaded	She had come to work, was doing well, was   standing when she felt LIGHTHEADED and dizzy as if she was going to pass out.	Affirmed	Recent	Patient
1751	chest pain	This is a **AGE[in 60s]-year-old female who presents to the Emergency Department   complaining of shortness of breath and CHEST PAIN since yesterday.	Affirmed	Recent	Patient
1752	SCHIZOPHRENIA	SCHIZOPHRENIA.	Affirmed	Historical	Patient
1753	delusion	It was felt that her   DELUSION was due to her medical decondition with some component of   dissociative disorder and borderline personality disorder as well as   depression and anxiety.	Affirmed	Recent	Patient
1754	tricuspid valve is normal	The   TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
1755	shortness of breath	He did   not have any complaints of chest pain of SHORTNESS OF BREATH and he was   started on Lovenox and Coumadin and he will be discharged once the INR is   2.0.	Negated	Recent	Patient
1756	Dense mitral annular calcification	05) 6)  DENSE MITRAL ANNULAR CALCIFICATION.	Affirmed	Recent	Patient
1757	lethargic	The patient was not LETHARGIC or agitated during the   hospitalization.	Negated	Recent	Patient
1758	lungs are clear to auscultation bilaterally	The LUNGS ARE CLEAR TO AUSCULTATION BILATERALLY, no wheezes or   rales.	Affirmed	Recent	Patient
1759	ruptured chordae	There is mobile   filamentous mass attached to the left ventricular apical endocardium most   likely a RUPTURED CHORDAE, however, other pathology can not be excluded.	Affirmed	Recent	Patient
1760	Sclerae are anicteric	SCLERAE ARE ANICTERIC.	Affirmed	Recent	Patient
1761	peptic ulcer disease	He   had no signs of an acute abdomen; no signs of cholecystitis, pancreatitis or   PEPTIC ULCER DISEASE.	Negated	Recent	Patient
1762	nonsustained arrhythmias	The patient   became dyspneic and had NONSUSTAINED ARRHYTHMIAS at peak stress.	Affirmed	Recent	Patient
1763	Right ventricular   wall thickness is normal	RIGHT VENTRICULAR   WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
1764	clubbing	Extremities: No CLUBBING, cyanosis, or edema.	Negated	Recent	Patient
1765	pancreas and adrenal glands are normal	The  PANCREAS AND ADRENAL GLANDS ARE NORMAL.	Affirmed	Recent	Patient
1766	Thyroid nodule	S_O_H  Counters Report Type Record Type Subgroup Classifier  217,k488T/Xrr116 SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PATIENT HISTORY:  PRE-OP DIAGNOSIS:       THYROID NODULE.	Affirmed	Recent	Patient
1767	Segmental left ventricular function is normal	SEGMENTAL LEFT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
1768	On his right-hand the patient has open wounds on   the distal most aspect of his third and fourth digits and an open wound on   his thenar eminence	ON HIS RIGHT-HAND THE PATIENT HAS OPEN WOUNDS ON   THE DISTAL MOST ASPECT OF HIS THIRD AND FOURTH DIGITS AND AN OPEN WOUND ON   HIS THENAR EMINENCE.	Affirmed	Recent	Patient
1769	Left ventricular wall thickness is normal	LEFT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
1770	B-cell lymphoproliferative  disorder	Results from a bone marrow biopsy (***PATH-NUMBER[1], **DATE[Apr 07 06]) raised  the possibility of subtle involvement by a B-CELL LYMPHOPROLIFERATIVE  DISORDER.	Affirmed	Historical	Patient
1771	confused	He was noted to be febrile and somewhat   CONFUSED.	Affirmed	Recent	Patient
1772	depressive mood	Psychiatric Service was consulted, and the patient's   DEPRESSIVE MOOD was worsening for 2 months in coordination with medical   complications and pain.	Affirmed	Recent	Patient
1773	diffuse weakness	Ischemic trigger is certainly concerning given the patient's presentation of   sudden syncope and DIFFUSE WEAKNESS with new pulmonary edema which he never   had before.	Affirmed	Recent	Patient
1774	Congenital heart disease	CONGENITAL HEART DISEASE.	Affirmed	Recent	Patient
1775	subarachnoid hemorrhage	HOSPITAL COURSE:   Ms. **NAME[AAA] is a **AGE[in 30s]-year-old female who was transferred to **INSTITUTION on **DATE[Jul 19   2007], with a SUBARACHNOID HEMORRHAGE and ventriculomegaly.	Affirmed	Recent	Patient
1776	fracture of the right distal radius, comminuted, with minimal displacement	Hand x-rays showed a   FRACTURE OF THE RIGHT DISTAL RADIUS, COMMINUTED, WITH MINIMAL DISPLACEMENT.	Affirmed	Recent	Patient
1777	syncopal event	It was reported he had a SYNCOPAL EVENT.	Affirmed	Recent	Patient
1778	redness	He will follow up with his primary care   physician when he gets back for Los Vegas in 7 to 10 days for suture removal   and he was instructed to return to the Emergency Department if there was   REDNESS, fever, or pus from the site.	Affirmed	Not particular	Patient
1779	Mild right atrial enlargement	04) MILD RIGHT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
1780	discrete hepatic lesions	No DISCRETE HEPATIC LESIONS are shown.	Negated	Recent	Patient
1781	drinks alcohol	Social history:  The patient DRINKS ALCOHOL occasionally, is a nonsmoker.	Affirmed	Historical	Patient
1782	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
1783	peripheral edema	The extremity examination shows +2 pulses and no PERIPHERAL EDEMA.	Negated	Recent	Patient
1784	cerebral   hemorrhage	Most recently, the patient has been   maintained on high dose steroids for her antiphospholipid antibody syndrome   given anticoagulation was not an option secondary to her known CEREBRAL   HEMORRHAGE.	Affirmed	Recent	Patient
1785	COPD	PAST MEDICAL HISTORY:  Significant for Alzheimer disease, hypertension,   atrial fibrillation, history of DVTs, anticoagulation, coronary artery   disease, COPD, history of anemia, history of pulmonary nodules, and history   of cellulitis.	Affirmed	Historical	Patient
1786	hemodynamically stable	The patient remained   HEMODYNAMICALLY STABLE with the heart rate in 70s.	Affirmed	Recent	Patient
1787	sickle cell crisis	MEDICAL DECISION MAKING:  This is a **AGE[in 50s]-year-old female with history of sickle cell disease, coming in   with what she says is her typical SICKLE CELL CRISIS as well as an outpatient   laboratory showing hemoglobin of 8.	Affirmed	Recent	Patient
1788	Cranial nerves II through XII - Grossly intact	CRANIAL NERVES II THROUGH XII - GROSSLY INTACT.	Affirmed	Recent	Patient
1789	duodenal bulb was normal	The DUODENAL BULB WAS NORMAL in appearance, as was the  postbulbar duodenum.	Affirmed	Recent	Patient
1790	Overall left ventricular function is normal	OVERALL LEFT VENTRICULAR FUNCTION IS NORMAL, with an estimated ejection   fraction of 55-60 %.	Affirmed	Recent	Patient
1791	mild aortic regurgitation	COLOR FLOW DOPPLER:   There is MILD AORTIC REGURGITATION.	Affirmed	Recent	Patient
1792	Dyspnea	DYSPNEA decreased.	Affirmed	Recent	Patient
1793	severe   calf pain	Call also for any weight gain   greater than three pounds per day or five pounds per week, any unusual   rashes, nausea, vomiting, fever associated with chill, temperature elevation   greater than 101 degrees Fahrenheit, sustained or low-grade temperature   greater than 100 degrees Fahrenheit, new onset of chest pain,   light-headedness, or dizziness, new or increased shortness of breath, SEVERE   CALF PAIN, burning on urination or severe depression.	Affirmed	Not particular	Patient
1794	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
1795	rubs	No murmurs, RUBS or gallops.	Negated	Recent	Patient
1796	osteomyelitis	No findings suggesting OSTEOMYELITIS.	Negated	Recent	Patient
1797	hairy cell leukemia	The current marrow findings, however, would not be typical for a diagnosis of  HAIRY CELL LEUKEMIA.	Negated	Recent	Patient
1798	Left atrial size is moderately enlarged	LEFT ATRIAL SIZE IS MODERATELY ENLARGED.	Affirmed	Recent	Patient
1799	extremities are without edema or tenderness	Extremities - The EXTREMITIES ARE WITHOUT EDEMA OR TENDERNESS.	Affirmed	Recent	Patient
1800	sepsis	Also throughout this hospital course, the patient had the following   complications:  SEPSIS, respiratory failure with trach placement,   thrombocytopenia, rectal sheath hematoma with intraabdominal bleed status   post iliac and epigastric embolization of arteries, renal failure secondary   to ureteral obstruction with bilateral nephrostomy tube placement, right MCA   CVA, rectal ischemia and further complications related to her underlying   hypercoagulable state.	Affirmed	Recent	Patient
1801	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
1802	hypercholesterolemia	HISTORY OF PRESENT ILLNESS:    This is a **AGE[in 60s]-year-old male with a past history of diabetes, dementia,   hypertension, HYPERCHOLESTEROLEMIA, anemia, anxiety, and depression who   presents with a chief complaint of having fallen.	Affirmed	Historical	Patient
1803	weight gain   greater than three pounds per day or five pounds per week	Call also for any WEIGHT GAIN   GREATER THAN THREE POUNDS PER DAY OR FIVE POUNDS PER WEEK, any unusual   rashes, nausea, vomiting, fever associated with chill, temperature elevation   greater than 101 degrees Fahrenheit, sustained or low-grade temperature   greater than 100 degrees Fahrenheit, new onset of chest pain,   light-headedness, or dizziness, new or increased shortness of breath, severe   calf pain, burning on urination or severe depression.	Affirmed	Not particular	Patient
1804	End stage glenohumeralosteoarthritis of the left shoulder	END STAGE GLENOHUMERALOSTEOARTHRITIS OF THE LEFT SHOULDER is  unchanged.	Affirmed	Recent	Patient
1805	chills	Return to the Emergency Department or PCP if he develops nausea, vomiting,   fevers or CHILLS.	Affirmed	Not particular	Patient
1806	Pupils equal, round, and reactive to light	PUPILS EQUAL, ROUND, AND REACTIVE TO LIGHT.	Affirmed	Recent	Patient
1807	mild aortic regurgitation	SPECTRAL DOPPLER:   There is MILD AORTIC REGURGITATION.	Affirmed	Recent	Patient
1808	LEFT ACETABULAR FRACTURE STATUS POST FALL	ADMITTING DIAGNOSIS(ES):    LEFT ACETABULAR FRACTURE STATUS POST FALL.	Affirmed	Recent	Patient
1809	chest tightness, pressure	The patient presents with a complaint of   shortness of breath, likely COPD exacerbation but also complains of some   CHEST TIGHTNESS, PRESSURE.	Affirmed	Recent	Patient
1810	acute distress	GENERAL:  He is awake, alert, in no ACUTE DISTRESS.	Negated	Recent	Patient
1811	Severely dilated right (systemic) ventricle with hypertrophy and  severely decreased function	05) Severely dilated right (systemic) ventricle with hypertrophy and  severely decreased function.	Affirmed	Recent	Patient
1812	good insight and judgment	She had a GOOD INSIGHT AND JUDGMENT.	Affirmed	Recent	Patient
1813	Right ventricular function is   normal	RIGHT VENTRICULAR FUNCTION IS   NORMAL.	Affirmed	Recent	Patient
1814	acute distress	PHYSICAL EXAMINATION:     GENERAL:  In no ACUTE DISTRESS.	Negated	Recent	Patient
1815	coronary artery disease	MEDICAL HISTORY:   Atrial fibrillation, hypertension, arthritis, CORONARY ARTERY DISEASE, GERD,   cataracts, and cancer of the left eyelid.	Affirmed	Historical	Patient
1816	cough	She denies any COUGH or sputum production.	Negated	Recent	Patient
1817	Right   ventricular wall thickness is normal	RIGHT   VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
1818	PROBABLE LEFT NIPPLE PROJECTED OVER THE LEFT LUNG BASE	IMPRESSION:       PROBABLE LEFT NIPPLE PROJECTED OVER THE LEFT LUNG BASE.	Affirmed	Recent	Patient
1819	sigmoid diverticulosis without diverticulitis	Incidentally, on the pelvic CT   scan, there was SIGMOID DIVERTICULOSIS WITHOUT DIVERTICULITIS.	Affirmed	Recent	Patient
1820	normocephalic   and atraumatic head	HEENT examination reveals NORMOCEPHALIC   AND ATRAUMATIC HEAD, equal and reactive pupils, and intact extraocular   movements.	Affirmed	Recent	Patient
1821	tingling	Neurologic - No numbness, TINGLING, or weakness.	Negated	Recent	Patient
1822	scrape up her knees	She did SCRAPE UP HER KNEES, but she was   able to ambulate.	Affirmed	Recent	Patient
1823	free air or obstruction	ED COURSE:  Work up of the patient's complaint included a head CT that was unremarkable   and x-ray of the abdomen with flat and upright views to rule out obstruction   and that also shows no FREE AIR OR OBSTRUCTION.	Negated	Recent	Patient
1824	regular   rhythm	The heart is tachycardic with a REGULAR   RHYTHM.	Affirmed	Recent	Patient
1825	chest pain	No CHEST PAIN, no shortness of breath, and no abdominal pain.	Negated	Recent	Patient
1826	change in bowel habit	GI  ROS is -ve for CHANGE IN BOWEL HABIT, bleeding (occult nor overt), change in  weight, anemia or any "alarm" symptom or sign.	Negated	Recent	Patient
1827	syncopal episode	HISTORY OF PRESENT ILLNESS:  Mr. **NAME[AAA] is a **AGE[90+]-year-old gentleman with a past medical history of coronary   artery disease, status post CABG, but no history of known congestive heart   failure, who has not been admitted to the hospital in the last five to six   years, who presents today after a SYNCOPAL EPISODE.	Affirmed	Recent	Patient
1828	mild aortic regurgitation	COLOR FLOW DOPPLER:   There is MILD AORTIC REGURGITATION.	Affirmed	Recent	Patient
1829	Atrial Fibrillation  	9  cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: ATRIAL FIBRILLATION    TWO DIMENSIONAL ECHOCARDIOLOGY:   This was a technically difficult study.	Affirmed	Recent	Patient
1830	PERRLA	Eyes:  PERRLA, EOMI.	Affirmed	Recent	Patient
1831	rubs	Heart - Regular rate and rhythm, no   murmurs, gallops, or RUBS.	Negated	Recent	Patient
1832	tricuspid valve is   normal	The TRICUSPID VALVE IS   NORMAL.	Affirmed	Recent	Patient
1833	Left ventricular size is normal	LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
1834	Stenosis in the sigmoid colon	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POST-OPERATIVE DIAGNOSIS(ES):  1) STENOSIS IN THE SIGMOID COLON  2) Colitis in the sigmoid colon      PLAN:  1) Follow-up: today **INSTITUTION  2) Await biopsy results    REPEAT EXAM:  No    ______________________________  **NAME[YYY M. ZZZ], M.D.  I was present during the entire procedure.	Affirmed	Recent	Patient
1835	aortic valve is normal	The   AORTIC VALVE IS NORMAL.	Affirmed	Recent	Patient
1836	Left ventricular size is normal	Wall Thickness:  1.0 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Transplanted Heart  TWO DIMENSIONAL ECHOCARDIOLOGY:   LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
1837	aortic root size is normal	The AORTIC ROOT SIZE IS NORMAL.	Affirmed	Recent	Patient
1838	abdominal pain	No   ABDOMINAL PAIN.	Negated	Recent	Patient
1839	pus from the site	He will follow up with his primary care   physician when he gets back for Los Vegas in 7 to 10 days for suture removal   and he was instructed to return to the Emergency Department if there was   redness, fever, or PUS FROM THE SITE.	Affirmed	Not particular	Patient
1840	right upper extremity   DVT	The patient has a history of known RIGHT UPPER EXTREMITY   DVT for which he is on anticoagulation with Coumadin.	Affirmed	Historical	Patient
1841	vomiting	There was a concern for a possible aspiration   pneumonia given the patient's VOMITING and poor mental status.	Affirmed	Recent	Patient
1842	unusual headaches	She will alert the physician if any of the following are   noted:  Nosebleeds, excessive bruising, pink, red, or tea-colored urine,   bright red or tarry black stools, UNUSUAL HEADACHES, or stomach pain.	Affirmed	Not particular	Patient
1843	lungs show no airspace opacities	The LUNGS SHOW NO AIRSPACE OPACITIES,  pneumothorax or effusions.	Affirmed	Recent	Patient
1844	sternum was stable	The STERNUM WAS STABLE.	Affirmed	Recent	Patient
1845	nonischemic   cardiomyopathy	Congenital heart disease/aortic and mitral valvular disease/NONISCHEMIC   CARDIOMYOPATHY/pulmonary hypertension.	Affirmed	Recent	Patient
1846	chills	She denies any   fevers or CHILLS.	Negated	Recent	Patient
1847	At L3-L4, there is moderate canal compromise related to diffuse  disc bulge and ligamentum flavum hypertrophy as well as facet  arthrosis	AT L3-L4, THERE IS MODERATE CANAL COMPROMISE RELATED TO DIFFUSE  DISC BULGE AND LIGAMENTUM FLAVUM HYPERTROPHY AS WELL AS FACET  ARTHROSIS.	Affirmed	Recent	Patient
1848	Left atrial size is mildly enlarged	LEFT ATRIAL SIZE IS MILDLY ENLARGED.	Affirmed	Recent	Patient
1849	mild tricuspid regurgitation	There is MILD TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
1850	rash	SKIN: Skin is otherwise unremarkable, with no RASH or abrasions, as above.	Negated	Recent	Patient
1851	pulmonary artery size is normal	The   PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
1852	coronary artery   disease	PAST MEDICAL HISTORY:  Significant for Alzheimer disease, hypertension,   atrial fibrillation, history of DVTs, anticoagulation, CORONARY ARTERY   DISEASE, COPD, history of anemia, history of pulmonary nodules, and history   of cellulitis.	Affirmed	Historical	Patient
1853	Erosive gastritis	EROSIVE GASTRITIS.	Affirmed	Recent	Patient
1854	depression	He has had a previous diagnosis of anxiety and DEPRESSION in the past.	Affirmed	Historical	Patient
1855	wheeze	No rales, rhonchi, or WHEEZE.	Negated	Recent	Patient
1856	COPD	HISTORY OF PRESENT ILLNESS:  As per attending notes, **DATE[Mar 13 2008], a   **AGE[in 70s]-year-old female well known to us for many years, who has multiple medical   problems including status post right pneumonectomy for adenocarcinoma of   lung, COPD, and remaining lung renal cell cancer, status post nephrectomy,   carcinoma of thyroid status post thyroidectomy.	Affirmed	Historical	Patient
1857	bowel obstruction	There  are no findings to suggest BOWEL OBSTRUCTION.	Negated	Recent	Patient
1858	right knee is otherwise  unremarkable	The appearance of the RIGHT KNEE IS OTHERWISE  UNREMARKABLE.	Affirmed	Recent	Patient
1859	alcohol	Denies ALCOHOL or drugs.	Negated	Historical	Patient
1860	some abrasions over her bilateral knees	Other Extremities: There   are SOME ABRASIONS OVER HER BILATERAL KNEES.	Affirmed	Recent	Patient
1861	acute anterolateral MI	In the ER, an EKG was positive for   ACUTE ANTEROLATERAL MI.	Affirmed	Recent	Patient
1862	fevers	She admits to mild nausea   during this episode while she was at the **INSTITUTION and denies any back   pain, denies FEVERS, denies cough, or cold symptoms.	Negated	Recent	Patient
1863	diarrhea	He also had DIARRHEA.	Affirmed	Recent	Patient
1864	stress induced chest pain	09) There were no STRESS INDUCED CHEST PAIN, ischemic EKG changes or wall  motion abnormalities at a relatively low level of stress.	Negated	Recent	Patient
1865	Right ventricular function is normal	RIGHT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
1866	DRUG ALLERGIES	ALLERGIES:  NO KNOWN DRUG ALLERGIES.	Negated	Historical	Patient
1867	RIGHT-SIDED WEAKNESS	S_O_H  Counters Report Type Record Type Subgroup Classifier  165,QKOEGhJzBXyz RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      CT HEAD:  **DATE[Aug 1 07]  3:45 PM   HISTORY: RIGHT-SIDED WEAKNESS.	Affirmed	Recent	Patient
1868	RIGHT THYROID:  SATISFACTORY FOR INTERPRETATION.  NEGATIVE FOR MALIGNANT CELLS.  COLLOID NODULE	SOURCE OF SPECIMEN:  FNA RIGHT THYROID, RADIOLOGIC  __________________________________________________________________________  FINAL DIAGNOSIS:  FINE NEEDLE ASPIRATION OF RIGHT THYROID:  SATISFACTORY FOR INTERPRETATION.	Affirmed	Recent	Patient
1869	Mild mitral regurgitation	03) MILD MITRAL REGURGITATION.	Affirmed	Recent	Patient
1870	afebrile	She was AFEBRILE and vital signs were within normal limits as   documented in the nursing report.	Affirmed	Recent	Patient
1871	blurred vision	OPHTHALMOLOGIC:  Denies any BLURRED VISION.	Negated	Recent	Patient
1872	Normal esophagus	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) NORMAL ESOPHAGUS  2) Hiatal hernia    3) Erosions, multiple in the antrum  4) Normal duodenum    5) No additional lesions    PLAN:  1) Await biopsy results  2) **INSTITUTION as scheduled    REPEAT EXAM:  No    __________________________________  **NAME[YYY ZZZ]  I was present during the entire procedure.	Affirmed	Recent	Patient
1873	Thickened aortic valve	03) THICKENED AORTIC VALVE.	Affirmed	Recent	Patient
1874	Normal left ventricular size and function	FINAL IMPRESSIONS:   01) NORMAL LEFT VENTRICULAR SIZE AND FUNCTION.	Affirmed	Recent	Patient
1875	trace pulmonic   regurgitation	There is TRACE PULMONIC   REGURGITATION.	Affirmed	Recent	Patient
1876	ulcerative jejunitis	The patient had an EGD on **DATE[Sep 23 2007], by Dr. **NAME[RRR],   showing esophagitis, ULCERATIVE JEJUNITIS, and status post feeding tube   placement.	Affirmed	Recent	Patient
1877	hypertension	PAST MEDICAL HISTORY:  Significant for Alzheimer disease, HYPERTENSION,   atrial fibrillation, history of DVTs, anticoagulation, coronary artery   disease, COPD, history of anemia, history of pulmonary nodules, and history   of cellulitis.	Affirmed	Historical	Patient
1878	rhonchi	Lungs   - CTP, no rales, RHONCHI, or wheezes.	Negated	Recent	Patient
1879	nonobstructive scattered bowel gas pattern	Radiographs of the abdomen including erect and decubitus views obtained   **DATE[Mar 24 2008], which revealed NONOBSTRUCTIVE SCATTERED BOWEL GAS PATTERN and a   stool-filled colon.	Affirmed	Recent	Patient
1880	hard of hearing	PAST MEDICAL HISTORY:     Her past medical history is significant for multiple sclerosis, pneumonia,   DVT of the lower extremity, hypothyroidism, HARD OF HEARING, vitiligo, and   her paralysis from her multiple sclerosis.	Affirmed	Historical	Patient
1881	Normal terminal ileum  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) NORMAL TERMINAL ILEUM    2) Normal colonoscopy, but poor prep.	Affirmed	Recent	Patient
1882	Extremities have 5/5 strength	EXTREMITIES HAVE 5/5 STRENGTH in all extremities.	Affirmed	Recent	Patient
1883	multiple back surgeries	PRE-OP DIAGNOSIS:  Status post MULTIPLE BACK SURGERIES.	Affirmed	Historical	Patient
1884	weakness	The patient denied any headache,   neck pain, WEAKNESS, numbness or paraesthesias.	Negated	Recent	Patient
1885	right MCA   CVA	Also throughout this hospital course, the patient had the following   complications:  sepsis, respiratory failure with trach placement,   thrombocytopenia, rectal sheath hematoma with intraabdominal bleed status   post iliac and epigastric embolization of arteries, renal failure secondary   to ureteral obstruction with bilateral nephrostomy tube placement, RIGHT MCA   CVA, rectal ischemia and further complications related to her underlying   hypercoagulable state.	Affirmed	Recent	Patient
1886	COLONIC MUCOSA WITH FOCAL EROSION AND ARCHITECTURE CHANGES	PART 3:  RECTOSIGMOID COLON, BIOPSY -  A.          COLONIC MUCOSA WITH FOCAL EROSION AND ARCHITECTURE CHANGES.	Affirmed	Recent	Patient
1887	rash	The skin is warm and dry with no RASH.	Negated	Recent	Patient
1888	nausea	The indication for this procedure is history  of Billroth II for perforated ulcer, with malnutrition, NAUSEA and vomiting.	Affirmed	Recent	Patient
1889	transposition of the great vessels	02) There is a double barrel configuration of the great vessels consistent  with the patient''s know TRANSPOSITION OF THE GREAT VESSELS.	Affirmed	Historical	Patient
1890	heartburn	The indication for this procedure is abdominal  pain despite treatment and HEARTBURN.	Affirmed	Recent	Patient
1891	fever	REVIEW OF SYSTEMS:  CONSTITUTIONAL:  He has some chills, but no FEVER.	Negated	Recent	Patient
1892	Migraine	MIGRAINE.	Affirmed	Historical	Patient
1893	Moderate pulmonary hypertension	07) MODERATE PULMONARY HYPERTENSION.	Affirmed	Recent	Patient
1894	Overall left ventricular function is normal	OVERALL LEFT VENTRICULAR FUNCTION IS NORMAL, with an   estimated ejection fraction of 55-60 %.	Affirmed	Recent	Patient
1895	pericardial   effusion	No PERICARDIAL   EFFUSION is seen.	Negated	Recent	Patient
1896	splenomegaly	No masses,   SPLENOMEGALY.	Negated	Recent	Patient
1897	sessile polyp was found in the rectum	A 6mm SESSILE POLYP WAS FOUND IN THE RECTUM  and removed with snare polypectomy.	Affirmed	Recent	Patient
1898	head is atraumatic	HEENT - HEAD IS ATRAUMATIC.	Affirmed	Recent	Patient
1899	mitral   annular calcification	There is MITRAL   ANNULAR CALCIFICATION.	Affirmed	Recent	Patient
1900	Thickened, calcified and restricted aortic valve with severe stenosis  and moderate regurgitation	02) THICKENED, CALCIFIED AND RESTRICTED AORTIC VALVE WITH SEVERE STENOSIS  AND MODERATE REGURGITATION.	Affirmed	Recent	Patient
1901	trace tricuspid regurgitation	There is TRACE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
1902	abdomen was soft.  It was nontender	His   abdomen was soft.	Affirmed	Recent	Patient
1903	CARDIOMYOPATHY	CARDIOMYOPATHY.	Affirmed	Historical	Patient
1904	rectal exam was performed and showed no abnormalities	Digital RECTAL EXAM WAS PERFORMED AND SHOWED NO ABNORMALITIES.	Affirmed	Recent	Patient
1905	MI	MI.	Affirmed	Historical	Patient
1906	Normal bowel   sounds	NORMAL BOWEL   SOUNDS.	Affirmed	Recent	Patient
1907	mitral annular   calcification	There is MITRAL ANNULAR   CALCIFICATION.	Affirmed	Recent	Patient
1908	rubs	Cardiovascular - Regular rate and rhythm, no murmurs, RUBS, gallops.	Negated	Recent	Patient
1909	clubbing	Extremities:  No CLUBBING, cyanosis or edema.	Negated	Recent	Patient
1910	DVT	She did have lower extremity swelling, left greater than   right, and therefore, we did lower extremity Dopplers to evaluate for DVT.	Affirmed	Recent	Patient
1911	Delirium	DELIRIUM due to medical decondition.	Affirmed	Recent	Patient
1912	atrial fibrillation	HISTORY OF PRESENT ILLNESS:  The patient is a **AGE[90+]-year-old female with past   medical history significant for ATRIAL FIBRILLATION, history of DVTs, and   hypertension who presents to the Emergency Department after 2 episodes of   coffee-ground emesis.	Affirmed	Historical	Patient
1913	Mucous membranes are moist	MUCOUS MEMBRANES ARE MOIST.	Affirmed	Recent	Patient
1914	cyanosis	Extremities:  No edema or CYANOSIS.	Negated	Recent	Patient
1915	marked intrahepatic and common bile duct   dilation	CT of the abdomen and pelvis without contrast performed **DATE[Mar 24 2008], which   revealed interval development of MARKED INTRAHEPATIC AND COMMON BILE DUCT   DILATION.	Affirmed	Recent	Patient
1916	aortic valve is thickened	The   AORTIC VALVE IS THICKENED.	Affirmed	Recent	Patient
1917	focal sensory or motor deficits	No FOCAL SENSORY OR MOTOR DEFICITS.	Negated	Recent	Patient
1918	acute distress	GENERAL: She is not in any ACUTE DISTRESS.	Negated	Recent	Patient
1919	voiding without difficulty	intake and VOIDING WITHOUT DIFFICULTY and ambulating   independently.	Affirmed	Recent	Patient
1920	INTRACRANIAL PATHOLOGY	IMPRESSION:   NO INTRACRANIAL PATHOLOGY IDENTIFIED.	Negated	Recent	Patient
1921	rales	No RALES, rhonchi or wheezes.	Negated	Recent	Patient
1922	Dyslipidemia	DYSLIPIDEMIA.	Affirmed	Recent	Patient
1923	left major coronary artery cerebrovascular accident	Status post LEFT MAJOR CORONARY ARTERY CEREBROVASCULAR ACCIDENT which   occurred which occurred post left anterior descending artery stenting.	Affirmed	Recent	Patient
1924	some shortness of breath	The patient has   also had SOME SHORTNESS OF BREATH which worsens with exertion.	Affirmed	Recent	Patient
1925	increasing pain	If she has any new tingling, any   weakness, INCREASING PAIN, or change in color of her finger, she should   immediately return to the department, otherwise, I feel she is safe for   discharge at this time.	Affirmed	Not particular	Patient
1926	Internal and external hemorrhoids 	FINDINGS:INTERNAL AND EXTERNAL HEMORRHOIDS were found.	Affirmed	Recent	Patient
1927	DRUG ALLERGIES	ALLERGIES:  NO KNOWN DRUG ALLERGIES.	Negated	Historical	Patient
1928	scleral   icterus	She subsequently became extremely   jaundiced over the next few days with change in her skin color and SCLERAL   ICTERUS.	Affirmed	Recent	Patient
1929	CONGESTIVE HEART FAILURE	CONGESTIVE HEART FAILURE.	Affirmed	Recent	Patient
1930	atrial fibrillation	The patient with history of CHF and ATRIAL FIBRILLATION.	Affirmed	Historical	Patient
1931	FLATTENING OF THE LATERAL FEMORAL CONDYLE	RIGHT KNEE:      FLATTENING OF THE LATERAL FEMORAL CONDYLE.	Affirmed	Recent	Patient
1932	Abdomen is soft, nontender, nondistended	Abdomen:  ABDOMEN IS SOFT, NONTENDER, NONDISTENDED, positive bowel sounds.	Affirmed	Recent	Patient
1933	tricuspid valve is normal	The TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
1934	vomiting	She should return to the Emergency Department if she experiences nausea,   VOMITING, increased abdominal pain, shortness of breath, or chest pain.	Affirmed	Not particular	Patient
1935	Pupils equal reactive to light on both sides	HEENT:  PUPILS EQUAL REACTIVE TO LIGHT ON BOTH SIDES.	Affirmed	Recent	Patient
1936	lower extremity   edema	He had positive peripheral pulses, LOWER EXTREMITY   EDEMA with 1+ bilaterally.	Affirmed	Recent	Patient
1937	Head normocephalic and atraumatic	HEENT:  HEAD NORMOCEPHALIC AND ATRAUMATIC.	Affirmed	Recent	Patient
1938	difficulty breathing	She denies any chest pain and denies DIFFICULTY BREATHING.	Negated	Recent	Patient
1939	hematuria	times 10 days for suspected   urinary tract infection, especially given her coexistent HEMATURIA and   urethral injury.	Affirmed	Recent	Patient
1940	URI symptoms	She also   states that she has had URI SYMPTOMS over the last week, including rhinorrhea     and mild sore throat.	Affirmed	Recent	Patient
1941	mitral valve is normal	The MITRAL VALVE IS NORMAL.	Affirmed	Recent	Patient
1942	ALLERGIES:  CODEINE	ALLERGIES:  CODEINE.	Affirmed	Recent	Patient
1943	liver transplant	S_O_H  Counters Report Type Record Type Subgroup Classifier  173,hAKYNFFZXnF0 RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  CT THORAX  WITHOUT CONTRAST   **DATE[Mar 02 08]     1250 HOURS    CLINICAL HISTORY:     Patient status post LIVER TRANSPLANT.	Affirmed	Historical	Patient
1944	Mild to moderate mitral regurgitation	02) MILD TO MODERATE MITRAL REGURGITATION.	Affirmed	Recent	Patient
1945	nauseous	She was also NAUSEOUS.	Affirmed	Recent	Patient
1946	trace pulmonic regurgitation	There is TRACE PULMONIC REGURGITATION.	Affirmed	Recent	Patient
1947	PE	Anticoagulation: Given his thoracic aortic aneurysm, he has a conservative  goal INR of 2-2.5 for his PE.	Affirmed	Recent	Patient
1948	tricuspid   valve is normal	The TRICUSPID   VALVE IS NORMAL.	Affirmed	Recent	Patient
1949	DVTs	The patient with history of atrial fibrillation and DVTS;   on anticoagulation.	Affirmed	Historical	Patient
1950	Anxiety	PAST MEDICAL HISTORY:     ANXIETY.	Affirmed	Historical	Patient
1951	lymph nodes in  the mediastinum and hilar regions are calcified	The LYMPH NODES IN  THE MEDIASTINUM AND HILAR REGIONS ARE CALCIFIED.	Affirmed	Recent	Patient
1952	diarrhea	Chief complaint is nausea, vomiting, and DIARRHEA.	Affirmed	Recent	Patient
1953	Large Hiatal hernia	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) Severe Esophagitis s/p biopsy  2) LARGE HIATAL HERNIA  3) Gastritis in the antrum s/p biopsy  4) Normal duodenum      PLAN:  1) Follow-up: as scheduled referring MD  2) Await biopsy results  3) Follow-up of helicobacter pylori  status, treat if indicated  4) Protonix 40mg qd    REPEAT EXAM:  EGD in ; As needed    __________________________________  **NAME[YYY ZZZ], MD  I was present during the entire procedure.	Affirmed	Recent	Patient
1954	aortic root size is mildly dilated	The AORTIC ROOT SIZE IS MILDLY DILATED.	Affirmed	Recent	Patient
1955	Right ventricular wall thickness is normal	RIGHT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
1956	Alzheimer disease	The patient with history of ALZHEIMER DISEASE.	Affirmed	Historical	Patient
1957	diarrhea	Does not   give a history of deafness and denies any recent nausea, vomiting and   DIARRHEA.	Negated	Recent	Patient
1958	ABDOMEN:  Soft, nondistended, and nontender	ABDOMEN:  SOFT, NONDISTENDED, AND NONTENDER.	Affirmed	Recent	Patient
1959	lethargic	Apparently, she was switched from warfarin to Lovenox at   the previous hospital assuming the patient was less LETHARGIC.	Affirmed	Recent	Patient
1960	paralysis	PAST MEDICAL HISTORY:     Her past medical history is significant for multiple sclerosis, pneumonia,   DVT of the lower extremity, hypothyroidism, hard of hearing, vitiligo, and   her PARALYSIS from her multiple sclerosis.	Affirmed	Historical	Patient
1961	seizure disorder	History of SEIZURE DISORDER.	Affirmed	Historical	Patient
1962	chest pain	She says she has had intermittent lower back   pain, intermittent CHEST PAIN, and dyspnea on exertion.	Affirmed	Recent	Patient
1963	esophagus was entirely normal	The ESOPHAGUS WAS ENTIRELY NORMAL without  signs of inflammation or Barrett's esophagus.	Affirmed	Recent	Patient
1964	JVD	Neck - Supple no JVD, lymph node, or cervical lymphadenopathy.	Negated	Recent	Patient
1965	Left ventricular size is normal	Wall Thickness:  1.0 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Palpitations  TWO DIMENSIONAL ECHOCARDIOLOGY:   LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
1966	hematuria	No HEMATURIA or   dysuria.	Negated	Recent	Patient
1967	stridor	Denies shortness of breath, STRIDOR, or air hunger.	Negated	Recent	Patient
1968	5/5 motor strength in all extremities	5/5 MOTOR STRENGTH IN ALL EXTREMITIES.	Affirmed	Recent	Patient
1969	aortic root size is   mildly dilated	The AORTIC ROOT SIZE IS   MILDLY DILATED.	Affirmed	Recent	Patient
1970	TYPE 2 DIABETES	TYPE 2 DIABETES.	Affirmed	Historical	Patient
1971	normal range   of motion in her hand with good capillary refill	The patient has NORMAL RANGE   OF MOTION IN HER HAND WITH GOOD CAPILLARY REFILL, and no signs of infection.	Affirmed	Recent	Patient
1972	Diverticulosis was found in the sigmoid colon	FINDINGS:  DIVERTICULOSIS WAS FOUND IN THE SIGMOID COLON.	Affirmed	Recent	Patient
1973	paresthesia	No PARESTHESIA or paralysis.	Negated	Recent	Patient
1974	lightheadedness	She   will call Dr. **NAME[ZZZ] at that same number if there is any newer increased   shortness of breath, new onset of chest pain, LIGHTHEADEDNESS, dizziness,   fainting, ankle swelling, abdominal bloating/weight gain of 2 pounds in 24   hours or 4 pounds in a week or less.	Affirmed	Not particular	Patient
1975	CHEST PAIN	S_O_H  Counters Report Type Record Type Subgroup Classifier  2,Jckg4kV7gxiM DS DS 5004  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   GENERAL MEDICINE  DISCHARGE SUMMARY     PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  **ROOM  ATTENDING PHYSICIAN:  **NAME[ZZZ M YYY]  ADMISSION DATE:  **DATE[Jan 25 2008]  DISCHARGE DATE:  **DATE[Jan 26 2008]        ADMISSION DIAGNOSIS:  CHEST PAIN.	Affirmed	Recent	Patient
1976	Thickened mitral valve	04) THICKENED MITRAL VALVE.	Affirmed	Recent	Patient
1977	abdominal cramping	Currently, the   patient has some mild nausea and his ABDOMINAL CRAMPING is much improved at   this time.	Affirmed	Recent	Patient
1978	Overall left ventricular function is normal	OVERALL LEFT VENTRICULAR FUNCTION IS NORMAL, with an estimated ejection   fraction of 60-65 %.	Affirmed	Recent	Patient
1979	severely malnourished	The patient was seen by GI Nutrition, and felt that the patient   was SEVERELY MALNOURISHED, and would benefit from jejunal tube feeds.	Affirmed	Recent	Patient
1980	acute distress	General - No ACUTE DISTRESS.	Negated	Recent	Patient
1981	Allograft pancreas, needle biopsy-  moderate to early severe acute cellular rejection (Grade IV-V)	_______________________________________________________________  FINAL DIAGNOSIS:  Allograft pancreas, needle biopsy-  moderate to early severe acute cellular rejection (Grade IV-V).	Affirmed	Recent	Patient
1982	bilateral small pleural effusions	FINDINGS:     Gross cardiomegaly, severe pulmonary edema, bibasilar atelectasis    and BILATERAL SMALL PLEURAL EFFUSIONS are present.	Affirmed	Recent	Patient
1983	tobacco	SOCIAL HISTORY:  Former TOBACCO.	Negated	Historical	Patient
1984	change in  bowel habits	The indication for this procedure is CHANGE IN  BOWEL HABITS.	Affirmed	Recent	Patient
1985	Left atrial   size is moderately enlarged	LEFT ATRIAL   SIZE IS MODERATELY ENLARGED.	Affirmed	Recent	Patient
1986	chest x-ray was obtained and found to be unremarkable	Also, the patient later complained of a cough and shortness of breath so a   CHEST X-RAY WAS OBTAINED AND FOUND TO BE UNREMARKABLE.	Affirmed	Recent	Patient
1987	Right ventricular size is normal	RIGHT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
1988	mild tenderness in   the periumbilical area	Examination of his abdomen revealed a soft abdomen with MILD TENDERNESS IN   THE PERIUMBILICAL AREA.	Affirmed	Recent	Patient
1989	anterior septum appears to be hypokinetic	The ANTERIOR SEPTUM APPEARS TO BE HYPOKINETIC.	Affirmed	Recent	Patient
1990	Depression	DEPRESSION.	Affirmed	Historical	Patient
1991	Chest X-Ray: No acute disease	CHEST X-RAY: NO ACUTE DISEASE.	Affirmed	Recent	Patient
1992	vomiting	UUU]'s the night before with VOMITING and diarrhea.	Affirmed	Recent	Other
1993	SCIATICA	SCIATICA.	Affirmed	Recent	Patient
1994	Left ventricular wall thickness is normal	LEFT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
1995	abdominal pain	She also   had ABDOMINAL PAIN at that time, as well as hyponatremia.	Affirmed	Recent	Patient
1996	pericardial effusion	No PERICARDIAL EFFUSION is   seen.	Negated	Recent	Patient
1997	esophageal stricture	There was no evidence of stricture, mucosal scalloping or  ESOPHAGEAL STRICTURE.	Negated	Recent	Patient
1998	chest pain	She refused nitroglycerin for her   CHEST PAIN, as she stated that it worsened her headaches significantly.	Affirmed	Recent	Patient
1999	Coronary artery disease	CORONARY ARTERY DISEASE.	Affirmed	Historical	Patient
2000	TMs   are translucent bilaterally	TMS   ARE TRANSLUCENT BILATERALLY.	Affirmed	Recent	Patient
2001	Right ventricular   wall thickness is normal	RIGHT VENTRICULAR   WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
2002	abdominal pain	He uses Advil with good relief   of his symptoms, otherwise, has no specific diagnosis for his ABDOMINAL PAIN   and had never sought treatment for this specific complaint.	Affirmed	Recent	Patient
2003	acute pancreatitis with calcifications	On **DATE[Jul 05 2007], at   the outside hospital, she got an abdominal CT with contrast which showed   ACUTE PANCREATITIS WITH CALCIFICATIONS.	Affirmed	Recent	Patient
2004	nausea	for NAUSEA.	Affirmed	Recent	Patient
2005	neck is supple,   nontender	The NECK IS SUPPLE,   NONTENDER.	Affirmed	Not particular	Patient
2006	acute fractures detected in the right  femur	RIGHT FEMUR: There are no ACUTE FRACTURES DETECTED IN THE RIGHT  FEMUR.	Negated	Recent	Patient
2007	Segmental left ventricular function is normal	SEGMENTAL LEFT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
2008	SICKLE CELL CRISIS	SICKLE CELL CRISIS.	Affirmed	Recent	Patient
2009	NECK:     NO FINDINGS TO SUGGEST FDG AVID MALIGNANCY	IMPRESSION:     NECK:     NO FINDINGS TO SUGGEST FDG AVID MALIGNANCY.	Affirmed	Recent	Patient
2010	Internal hemorrhoids  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) INTERNAL HEMORRHOIDS    2) Otherwise normal exam    PLAN:  1) Follow-up: as scheduled referring MD    REPEAT EXAM:  Colonoscopy in 10 year(s).	Affirmed	Recent	Patient
2011	foreign body sensation	The patient is a **AGE[in 60s]-year-old woman with esophageal strictures who presents   with two days of a FOREIGN BODY SENSATION.	Affirmed	Recent	Patient
2012	diarrhea	He   was brought into the Emergency Department by his coworkers after he had   vomiting and DIARRHEA.	Affirmed	Recent	Patient
2013	Mild tricuspid regurgitation	04) MILD TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
2014	wheezes	The lungs are clear to auscultation bilaterally, no WHEEZES or   rales.	Negated	Recent	Patient
2015	afebrile	PHYSICAL EXAMINATION:    VITAL SIGNS: On exam, the patient was AFEBRILE 36.6, heart rate of 55, blood   pressure 122/78, respiratory rate of 12, oxygen saturation 99% on room air.	Affirmed	Recent	Patient
2016	hemodynamically stable	The patient remained   HEMODYNAMICALLY STABLE.	Affirmed	Recent	Patient
2017	dizziness	No headache or DIZZINESS.	Negated	Recent	Patient
2018	Right hemothorax remains completely opacified	RIGHT HEMOTHORAX REMAINS COMPLETELY OPACIFIED.	Affirmed	Recent	Patient
2019	Paradoxical septal motion	02) PARADOXICAL SEPTAL MOTION consistent with post-operative septal motion.	Affirmed	Recent	Patient
2020	Overall left ventricular   function is normal	OVERALL LEFT VENTRICULAR   FUNCTION IS NORMAL, with an estimated ejection fraction of 60-65 %.	Affirmed	Recent	Patient
2021	COPD	The patient is a **AGE[in 40s]-year-old male with a history of COPD, tobacco use,   presents to the Emergency Department with complaint of chest tightness,   pressure, as well as complaint of shortness of breath and wheezing at home.	Affirmed	Historical	Patient
2022	DVT of the lower extremity	PAST MEDICAL HISTORY:     Her past medical history is significant for multiple sclerosis, pneumonia,   DVT OF THE LOWER EXTREMITY, hypothyroidism, hard of hearing, vitiligo, and   her paralysis from her multiple sclerosis.	Affirmed	Historical	Patient
2023	Skin:  Warm and moist without lesion	SKIN:  WARM AND MOIST WITHOUT LESION.	Affirmed	Recent	Patient
2024	Neck was nontender	NECK: NECK WAS NONTENDER __________.	Affirmed	Recent	Patient
2025	moderate aortic regurgitation	COLOR FLOW DOPPLER:   There is MODERATE AORTIC REGURGITATION.	Affirmed	Recent	Patient
2026	tricuspid valve is normal	The   TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
2027	abdominal pain	HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 70s]-year-old male who came to the ED   complaining of ABDOMINAL PAIN for one week.	Affirmed	Recent	Patient
2028	chest pain	She denies any abdominal pain, no CHEST PAIN or shortness of   breath, she has had no particular sick contacts, and she has been using   over-the-counter remedies with no specific relief.	Negated	Recent	Patient
2029	loss of height involving L1-L2, L2-L3, L3-L4 and L4- L5 with  disc desiccation	There  is LOSS OF HEIGHT INVOLVING L1-L2, L2-L3, L3-L4 AND L4- L5 WITH  DISC DESICCATION.	Affirmed	Recent	Patient
2030	foreign body	There was no FOREIGN BODY.	Negated	Recent	Patient
2031	SMALL BOWEL, RESECTION	kas  _______________________________________________________________  FINAL DIAGNOSIS:  SMALL BOWEL, RESECTION    BENIGN FRAGMENTS OF SMALL INTESTINE.	Affirmed	Recent	Patient
2032	mobile   filamentous mass attached to the left ventricular apical endocardium 	There is MOBILE   FILAMENTOUS MASS ATTACHED TO THE LEFT VENTRICULAR APICAL ENDOCARDIUM most   likely a ruptured chordae, however, other pathology can not be excluded.	Affirmed	Recent	Patient
2033	bibasilar atelectasis  	FINDINGS:     Gross cardiomegaly, severe pulmonary edema, BIBASILAR ATELECTASIS    and bilateral small pleural effusions are present.	Affirmed	Recent	Patient
2034	expiratory wheezing throughout with moderate air entry	Lungs reveal EXPIRATORY WHEEZING THROUGHOUT WITH MODERATE AIR ENTRY.	Affirmed	Recent	Patient
2035	arthralgia	No myalgia or ARTHRALGIA.	Negated	Recent	Patient
2036	good capillary refill in all his digits	He   has got GOOD CAPILLARY REFILL IN ALL HIS DIGITS and normal sensation in all   his digits.	Affirmed	Recent	Patient
2037	Mild aortic root dilation	05) MILD AORTIC ROOT DILATION.	Affirmed	Recent	Patient
2038	good grip strength	She does have GOOD GRIP STRENGTH and is able to resist   extension of her thumb, although, there is some pain.	Affirmed	Recent	Patient
2039	Right ventricular wall thickness is normal	RIGHT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
2040	pain	She states that the   PAIN is actually worse than her chest PAIN at this point.	Affirmed	Recent	Patient
2041	bowel sounds	Abdomen - Soft, nontender, nondistended, positive   BOWEL SOUNDS, no mass or organomegaly.	Affirmed	Recent	Patient
2042	intracranial hemorrhage	FINDINGS: No INTRACRANIAL HEMORRHAGE can be identified.	Negated	Recent	Patient
2043	Atrial fibrillation	MEDICAL HISTORY:   ATRIAL FIBRILLATION, hypertension, arthritis, coronary artery disease, GERD,   cataracts, and cancer of the left eyelid.	Affirmed	Historical	Patient
2044	liver is cirrhotic	ABDOMEN:  The LIVER IS CIRRHOTIC.	Affirmed	Recent	Patient
2045	difficult to keep focused	Again, his review of systems is limited by the fact that he is not terribly   cooperative and he is DIFFICULT TO KEEP FOCUSED.	Affirmed	Recent	Patient
2046	LUNGS:  CTP	LUNGS:  CTP.	Affirmed	Recent	Patient
2047	murmurs	The heart was in a regular rate and rhythm with no MURMURS or   rubs.	Negated	Recent	Patient
2048	CIRRHOTIC MORPHOLOGY OF THE LIVER AND SMALL UPPER ABDOMINAL  LYMPH NODES ARE LIKELY THE SEQUELA OF CHRONIC UNDERLYING LIVER  DISEASE	CIRRHOTIC MORPHOLOGY OF THE LIVER AND SMALL UPPER ABDOMINAL  LYMPH NODES ARE LIKELY THE SEQUELA OF CHRONIC UNDERLYING LIVER  DISEASE.	Affirmed	Recent	Patient
2049	infection	The patient was transferred to **INSTITUTION for   explantation of a pacemaker system that was felt to be involved by the   INFECTION.	Affirmed	Recent	Patient
2050	cataracts	MEDICAL HISTORY:   Atrial fibrillation, hypertension, arthritis, coronary artery disease, GERD,   CATARACTS, and cancer of the left eyelid.	Affirmed	Historical	Patient
2051	trace aortic regurgitation	SPECTRAL DOPPLER:   There is TRACE AORTIC REGURGITATION.	Affirmed	Recent	Patient
2052	noncalcified pulmonary nodule  or mass	There is no evidence of NONCALCIFIED PULMONARY NODULE  OR MASS.	Negated	Recent	Patient
2053	sputum production	She denies any cough or SPUTUM PRODUCTION.	Negated	Recent	Patient
2054	antiphospholipid antibody syndrome	HOSPITAL COURSE:  Ms. **NAME[AAA] is a **AGE[in 60s]-year-old Caucasian woman with a significant history of   ANTIPHOSPHOLIPID ANTIBODY SYNDROME and lupus anticoagulant who was initially   admitted to an outside hospital on **DATE[Jan 09 2008] with mental status changes   and was found to have a subacute subdural hematoma and promptly transferred   to **INSTITUTION.	Affirmed	Recent	Patient
2055	acute fracture	No ACUTE FRACTURE shown.	Negated	Recent	Patient
2056	frequent urination	The patient   continues to have disturbances for FREQUENT URINATION from diuresis.	Affirmed	Recent	Patient
2057	decreased mental status	While in the ED, the patient was given Unasyn 3 g IV to cover for a   possible aspiration pneumonia given her DECREASED MENTAL STATUS and vomiting.	Affirmed	Recent	Patient
2058	bone mineralization is normal	The BONE MINERALIZATION IS NORMAL.	Affirmed	Recent	Patient
2059	Mild pulmonic regurgitation	06) MILD PULMONIC REGURGITATION.	Affirmed	Recent	Patient
2060	pericardial  or pleural effusions	No PERICARDIAL  OR PLEURAL EFFUSIONS.	Negated	Recent	Patient
2061	Borderline pulmonary hypertension	04) BORDERLINE PULMONARY HYPERTENSION.	Affirmed	Recent	Patient
2062	Normal left ventricular size and function	FINAL IMPRESSIONS:   01) NORMAL LEFT VENTRICULAR SIZE AND FUNCTION.	Affirmed	Recent	Patient
2063	vomited	She has been taking nifedipine but has VOMITED it   back up.	Affirmed	Recent	Patient
2064	diverticulitis	Also history of DIVERTICULITIS and colon problems.	Affirmed	Historical	Patient
2065	equal and reactive pupils	HEENT examination reveals normocephalic   and atraumatic head, EQUAL AND REACTIVE PUPILS, and intact extraocular   movements.	Affirmed	Recent	Patient
2066	pseudoaneurysm	The patient   underwent bilateral upper extremity duplex scan on **DATE[Nov 16 2007], which   revealed no evidence of active PSEUDOANEURYSM, AVF, or hematoma in the right   neck and shoulder region.	Negated	Recent	Patient
2067	panic attacks	She also has a   possible history of PANIC ATTACKS.	Affirmed	Historical	Patient
2068	rhonchi	No wheezes, rales or RHONCHI.	Negated	Recent	Patient
2069	irritation at the L5 nerve root	She also has EMGs that show IRRITATION AT THE L5 NERVE ROOT,   resulting in her sciatic and pain in her left leg.	Affirmed	Historical	Patient
2070	arthritis	MEDICAL HISTORY:   Atrial fibrillation, hypertension, ARTHRITIS, coronary artery disease, GERD,   cataracts, and cancer of the left eyelid.	Affirmed	Historical	Patient
2071	mania	She denies any symptoms of psychosis or   MANIA, OCD.	Negated	Recent	Patient
2072	Segmental left ventricular   function is normal	SEGMENTAL LEFT VENTRICULAR   FUNCTION IS NORMAL.	Affirmed	Recent	Patient
2073	Left ventricular wall thickness is   increased	LEFT VENTRICULAR WALL THICKNESS IS   INCREASED, consistent with left ventricular hypertrophy.	Affirmed	Recent	Patient
2074	coronary artery disease	REASON FOR ADMISSION:  This is an **AGE[in 80s]-year-old female with a history of   CORONARY ARTERY DISEASE who presented on **DATE[Dec 9 2007], with stabbing chest   pain that radiating to both shoulders.	Affirmed	Recent	Patient
2075	tachycardic	The heart is TACHYCARDIC with a regular   rhythm.	Affirmed	Recent	Patient
2076	pulmonary nodules	PAST MEDICAL HISTORY:  Significant for Alzheimer disease, hypertension,   atrial fibrillation, history of DVTs, anticoagulation, coronary artery   disease, COPD, history of anemia, history of PULMONARY NODULES, and history   of cellulitis.	Affirmed	Historical	Patient
2077	ambulating   independently	intake and voiding without difficulty and AMBULATING   INDEPENDENTLY.	Affirmed	Recent	Patient
2078	aortic valve is normal	The AORTIC VALVE IS NORMAL.	Affirmed	Recent	Patient
2079	decreased appetite	The   patient has DECREASED APPETITE with 30-pound weight loss and some diarrhea   from C. diff.	Affirmed	Recent	Patient
2080	sick contacts	She denies any abdominal pain, no chest pain or shortness of   breath, she has had no particular SICK CONTACTS, and she has been using   over-the-counter remedies with no specific relief.	Negated	Recent	Patient
2081	HIV	DISCHARGE INSTRUCTIONS:  The patient has been instructed to continue close  followup with the **NAME[UUU CCC] regarding his HIV management after discharge  from the TCU.	Affirmed	Historical	Patient
2082	vaginal bleeding	Assessment of this Patient:  She is a **AGE[in 70s]-year-old female with a history of   multiple sclerosis, and paralysis with a history of urinary tract infections   and urinary incontinence with chronic Foley, who had been reported to have   VAGINAL BLEEDING, however, was found to have blood at the urethral meatus,   consistent with urethral trauma.	Affirmed	Recent	Patient
2083	some slow   bleeding, oozing from this site	There is not much widening; however, there is SOME SLOW   BLEEDING, OOZING FROM THIS SITE.	Affirmed	Recent	Patient
2084	wheezes	No WHEEZES or rales.	Negated	Recent	Patient
2085	Thickened aortic valve with mild regurgitation	03) THICKENED AORTIC VALVE WITH MILD REGURGITATION.	Affirmed	Recent	Patient
2086	diverticula	There was no  evidence of ulceration, mass or DIVERTICULA.	Negated	Recent	Patient
2087	pericardial   effusion	No PERICARDIAL   EFFUSION is seen.	Negated	Recent	Patient
2088	trace tricuspid   regurgitation	There is TRACE TRICUSPID   REGURGITATION.	Affirmed	Recent	Patient
2089	pericardial or  pleural effusions	There are no PERICARDIAL OR  PLEURAL EFFUSIONS.	Negated	Recent	Patient
2090	esophagitis	The patient had an EGD on **DATE[Sep 23 2007], by Dr. **NAME[RRR],   showing ESOPHAGITIS, ulcerative jejunitis, and status post feeding tube   placement.	Affirmed	Recent	Patient
2091	varicella	REASON FOR ADMISSION:    Past medical history is positive for hyperlipidemia, hypothyroidism, weakness   and difficulty with ambulation, aortic/mitral disease, spinal stenosis,   cataracts, measles, mumps, and VARICELLA in the past.	Affirmed	Historical	Patient
2092	pleural effusion	It showed atelectasis versus pneumonia in the left lower lobe   involving PLEURAL EFFUSION.	Affirmed	Recent	Patient
2093	aortic   root size is normal	The AORTIC   ROOT SIZE IS NORMAL.	Affirmed	Recent	Patient
2094	fluid   in the fissure in the right lung	There is a small amount of FLUID   IN THE FISSURE IN THE RIGHT LUNG.	Affirmed	Recent	Patient
2095	Nondilated left ventricle with hypertrophy and overall preserved  systolic function	FINAL IMPRESSIONS:   01) NONDILATED LEFT VENTRICLE WITH HYPERTROPHY AND OVERALL PRESERVED  SYSTOLIC FUNCTION.	Affirmed	Recent	Patient
2096	nausea	HISTORY OF PRESENT ILLNESS:  The patient is an **AGE[in 80s]-year-old female presenting with worsening dizziness,   headache, NAUSEA, as well as leg weakness.	Affirmed	Recent	Patient
2097	DIARRHEA	DIARRHEA.	Affirmed	Recent	Patient
2098	clubbing	EXTREMITIES:  No CLUBBING or cyanosis.	Negated	Recent	Patient
2099	JVD	No JVD.	Negated	Recent	Patient
2100	Motor   is intact	MOTOR   IS INTACT.	Affirmed	Recent	Patient
2101	pass   out	She had definite   presyncope with lightheadedness and dizziness as if she was going to PASS   OUT.	Affirmed	Not particular	Patient
2102	thyromegaly	Neck - Supple, no lymphadenopathy, THYROMEGALY, or JVD.	Negated	Recent	Patient
2103	Alcohol	ALCOHOL:  Two wine glasses of wine per day.	Affirmed	Historical	Patient
2104	mild to moderate mitral regurgitation	COLOR FLOW DOPPLER:   There is MILD TO MODERATE MITRAL REGURGITATION.	Affirmed	Recent	Patient
2105	rhinorrhea	He is developing some   URI symptoms including cough and RHINORRHEA.	Affirmed	Recent	Patient
2106	colon polyps	The indication for this procedure is family  history of COLON POLYPS and screening.	Affirmed	Historical	Family member
2107	lungs are clear to auscultation bilaterally	LUNGS: All LUNGS ARE CLEAR TO AUSCULTATION BILATERALLY.	Affirmed	Recent	Patient
2108	high fever	He denies any sputum production   or HIGH FEVER.	Negated	Recent	Patient
2109	mental status changes	HOSPITAL COURSE:  Ms. **NAME[AAA] is a **AGE[in 60s]-year-old Caucasian woman with a significant history of   antiphospholipid antibody syndrome and lupus anticoagulant who was initially   admitted to an outside hospital on **DATE[Jan 09 2008] with MENTAL STATUS CHANGES   and was found to have a subacute subdural hematoma and promptly transferred   to **INSTITUTION.	Affirmed	Recent	Patient
2110	COPD exacerbation	The patient presents with a complaint of   shortness of breath, likely COPD EXACERBATION but also complains of some   chest tightness, pressure.	Affirmed	Recent	Patient
2111	alert	Neurologically, she is ALERT and oriented times three.	Affirmed	Recent	Patient
2112	Right ventricular function is normal	RIGHT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
2113	Right ventricular size is normal	RIGHT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
2114	acute distress	General - alert and oriented times three, in no ACUTE DISTRESS.	Negated	Recent	Patient
2115	mitral regurgitation	SPECTRAL DOPPLER:   There is trace MITRAL REGURGITATION.	Affirmed	Recent	Patient
2116	worthlessness 	The patient denies WORTHLESSNESS or self-esteem or anhedonia.	Negated	Recent	Patient
2117	status post CABG	PAST MEDICAL HISTORY:  Past medical history of coronary artery disease, STATUS POST CABG,   hypertension, and peripheral vascular disease.	Affirmed	Historical	Patient
2118	SYNCOPE	SYNCOPE.	Affirmed	Recent	Patient
2119	shortness of breath	The patient presents with a complaint of   SHORTNESS OF BREATH, likely COPD exacerbation but also complains of some   chest tightness, pressure.	Affirmed	Recent	Patient
2120	BIVENTRICULAR HEART FAILURE	S_O_H  Counters Report Type Record Type Subgroup Classifier  15,lTbBEIQc6gg4 DS DS 1509  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   CARDIOLOGY   DEATH SUMMARY  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  **ROOM  ATTENDING PHYSICIAN:  **NAME[YYY XXX ZZZ]  ADMISSION DATE:  **DATE[Apr 10 2008]  DATE OF DEATH:  **DATE[Apr 13 08]  CAUSE OF DEATH:  BIVENTRICULAR HEART FAILURE.	Affirmed	Recent	Patient
2121	frequency	GENITOURINARY:  No dysuria or FREQUENCY.	Negated	Recent	Patient
2122	cranial nerves are intact	The CRANIAL NERVES ARE INTACT and as per his   extremity exam.	Affirmed	Recent	Patient
2123	diplopia	In general, he denies any   changes in vision or DIPLOPIA, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no rash.	Negated	Recent	Patient
2124	free  fluid in the pelvis	There is no FREE  FLUID IN THE PELVIS.	Negated	Recent	Patient
2125	weakness	No focal numbness or WEAKNESS, though she does have pain on movement of   her index and middle fingers.	Negated	Recent	Patient
2126	jaundiced	Her son saw her on **DATE[Mar 19], and at that time, the patient was   not JAUNDICED by his examination.	Negated	Recent	Patient
2127	ALLERGIES	ALLERGIES - NONE.	Negated	Historical	Patient
2128	Paranasal sinuses and mastoid air   cells are normal	PARANASAL SINUSES AND MASTOID AIR   CELLS ARE NORMAL in appearance.	Affirmed	Recent	Patient
2129	carpal or metacarpal fracture or dislocation	There is no evidence of any CARPAL OR METACARPAL FRACTURE OR DISLOCATION.	Negated	Recent	Patient
2130	anhedonia	The patient denies worthlessness or self-esteem or ANHEDONIA.	Negated	Recent	Patient
2131	coffee-ground emesis	At the time of discharge, the patient had no further   episodes of COFFEE-GROUND EMESIS or any signs of active bleeding.	Negated	Recent	Patient
2132	chronic   kidney insufficiency	The patient is known to have CHRONIC   KIDNEY INSUFFICIENCY.	Affirmed	Historical	Patient
2133	mild pain	There is some MILD PAIN   to ________ tenderness.	Affirmed	Recent	Patient
2134	lateral wall is hypokinetic	The LATERAL WALL IS HYPOKINETIC.	Affirmed	Recent	Patient
2135	vital signs were within normal limits	She was afebrile and VITAL SIGNS WERE WITHIN NORMAL LIMITS as   documented in the nursing report.	Affirmed	Recent	Patient
2136	Pupils equal round and reactive to light	PUPILS EQUAL ROUND AND REACTIVE TO LIGHT.	Affirmed	Recent	Patient
2137	schizophrenia	Schizophrenia:  The patient has a long history of SCHIZOPHRENIA, is on   multiple medications.	Affirmed	Historical	Patient
2138	Right ventricular wall thickness is normal	RIGHT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
2139	tricuspid valve is normal	The TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
2140	Thickened aortic valve	04) THICKENED AORTIC VALVE.	Affirmed	Recent	Patient
2141	tricuspid valve is normal	The TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
2142	sickle cell pain	She still mainly has back pain which she quotes as   7/10 and is typical of her SICKLE CELL PAIN.	Affirmed	Recent	Patient
2143	afebrile	The patient remained   AFEBRILE and had a normal white blood count throughout her stay.	Affirmed	Recent	Patient
2144	Right ventricular size is moderately dilated	RIGHT VENTRICULAR SIZE IS MODERATELY DILATED.	Affirmed	Recent	Patient
2145	anxiety	It was felt that her   delusion was due to her medical decondition with some component of   dissociative disorder and borderline personality disorder as well as   depression and ANXIETY.	Affirmed	Recent	Patient
2146	viral meningitis	I believe the patient to have a VIRAL MENINGITIS.	Affirmed	Recent	Patient
2147	mild to moderate tricuspid regurgitation	COLOR FLOW DOPPLER:   There is MILD TO MODERATE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
2148	mild to moderate mitral regurgitation	SPECTRAL DOPPLER:   There is MILD TO MODERATE MITRAL REGURGITATION.	Affirmed	Recent	Patient
2149	MULTILEVEL DEGENERATIVE DISCS AND DISC BULGES WHICH IS MOST  PRONOUNCED AT L4-L5 WITH MODERATE CANAL COMPROMISE AND  ENCROACHMENT ON THE BILATERAL RECESSES AND MODERATE RIGHT NEURAL  FORAMINAL NARROWING	IMPRESSION:       MULTILEVEL DEGENERATIVE DISCS AND DISC BULGES WHICH IS MOST  PRONOUNCED AT L4-L5 WITH MODERATE CANAL COMPROMISE AND  ENCROACHMENT ON THE BILATERAL RECESSES AND MODERATE RIGHT NEURAL  FORAMINAL NARROWING.	Affirmed	Recent	Patient
2150	calcaneal stress _____________ foot fracture   	Of note, the patient also had a recent lower   extremity x-ray which revealed a CALCANEAL STRESS _____________ FOOT FRACTURE     and the Dopplers revealed that he had a new left lower extremity DVT.	Affirmed	Recent	Patient
2151	marked distal gastric wall   thickening	The patient's known malignancy at the level of the gastric   pylorus and the antrum is again shown with MARKED DISTAL GASTRIC WALL   THICKENING.	Affirmed	Recent	Patient
2152	atrial   flutter	A **AGE[90+]-year-old female presents to the Emergency Department with ATRIAL   FLUTTER.	Affirmed	Recent	Patient
2153	paradoxical septal motion	There is PARADOXICAL SEPTAL MOTION   consistent with abnormal electrical activation.	Affirmed	Recent	Patient
2154	severe pulmonary edema	FINDINGS:     Gross cardiomegaly, SEVERE PULMONARY EDEMA, bibasilar atelectasis    and bilateral small pleural effusions are present.	Affirmed	Recent	Patient
2155	Sessile polyp in the descending colon	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) 5mm sessile polyp in the transverse colon    2) 5mm SESSILE POLYP IN THE DESCENDING COLON  3) 6mm Sessile polyp in the rectum  4) Hemorrhoids  5) Otherwise normal exam    PLAN:  1) Await biopsy results    REPEAT EXAM:  Colonoscopy with internval depending on biopsy results    ______________________________  **NAME[YYY ZZZ], M.D.  I was present during the entire procedure.	Affirmed	Recent	Patient
2156	hypotensive	She was found to be   HYPOTENSIVE with a systolic blood pressure in the 90s.	Affirmed	Recent	Patient
2157	coffee-ground emesis	GI:  The patient was admitted after 2 episodes of COFFEE-GROUND EMESIS, NG   lavage revealed only 50 cc of coffee grounds, but no bright red blood.	Affirmed	Recent	Patient
2158	Normal pulmonary artery systolic pressures	03) NORMAL PULMONARY ARTERY SYSTOLIC PRESSURES.	Affirmed	Recent	Patient
2159	Right ventricular function is normal	RIGHT VENTRICULAR FUNCTION IS NORMAL.	Affirmed	Recent	Patient
2160	multiple sclerosis	PAST MEDICAL HISTORY:     Her past medical history is significant for MULTIPLE SCLEROSIS, pneumonia,   DVT of the lower extremity, hypothyroidism, hard of hearing, vitiligo, and   her paralysis from her MULTIPLE SCLEROSIS.	Affirmed	Historical	Patient
2161	neurologically intact	A splint was   placed and the patient was NEUROLOGICALLY INTACT after this was performed.	Affirmed	Recent	Patient
2162	tricuspid   valve is normal	The TRICUSPID   VALVE IS NORMAL.	Affirmed	Recent	Patient
2163	shortness of breath	He has had progressive SHORTNESS OF BREATH over the last several   days.	Affirmed	Recent	Patient
2164	Mild right atrial enlargement	07) 8)  MILD RIGHT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
2165	cyanosis	No clubbing or CYANOSIS.	Negated	Recent	Patient
2166	Mild to moderate tricuspid regurgitation	06) MILD TO MODERATE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
2167	apparent distress	GENERAL:  In general, she is in no APPARENT DISTRESS lying on her back with   sullen facies.	Negated	Recent	Patient
2168	Left ventricular wall thickness is   increased	LEFT VENTRICULAR WALL THICKNESS IS   INCREASED, consistent with severe left ventricular hypertrophy.	Affirmed	Recent	Patient
2169	pain	The PAIN is non-radiating.	Affirmed	Recent	Patient
2170	arthralgias	Denied any myalgias or ARTHRALGIAS.	Negated	Recent	Patient
2171	dizziness	However because of the   patient's persistent complaints of DIZZINESS and inability to walk and fear   of further fall, it may not be appropriate to send her home, especially in   the early hours of Friday night.	Affirmed	Recent	Patient
2172	rales	No wheezes, RALES or rhonchi.	Negated	Recent	Patient
2173	post-operative septal motion	02) Paradoxical septal motion consistent with POST-OPERATIVE SEPTAL MOTION.	Affirmed	Recent	Patient
2174	cyanosis	The extremities have   no CYANOSIS, clubbing, or edema.	Negated	Recent	Patient
2175	trace mitral regurgitation	COLOR FLOW DOPPLER:   There is TRACE MITRAL REGURGITATION.	Affirmed	Recent	Patient
2176	enlarged axillary intrathoracic lymph nodes	There are no ENLARGED AXILLARY INTRATHORACIC LYMPH NODES.	Negated	Recent	Patient
2177	somewhat constipated	She states that she is SOMEWHAT CONSTIPATED.	Affirmed	Recent	Patient
2178	agitated	The patient was not lethargic or AGITATED during the   hospitalization.	Negated	Recent	Patient
2179	abdominal pain	No chest pain, no shortness of breath, and no ABDOMINAL PAIN.	Negated	Recent	Patient
2180	depression	PSYCHOLOGICAL:  No DEPRESSION.	Negated	Recent	Patient
2181	ENHANCEMENT ALONG THE MEDIAL  ASPECT OF THE LEFT UNCUS	PROGRESSION OF ENHANCEMENT IN THE PONTINE MEDULLARY JUNCTION,  AND A NEW, MORE CONSPICUOUS AREA OF ENHANCEMENT ALONG THE MEDIAL  ASPECT OF THE LEFT UNCUS ALL OF WHICH IS SUSPICIOUS FOR METASTATIC  DISEASE.	Affirmed	Recent	Patient
2182	aortic root size is   normal	The AORTIC ROOT SIZE IS   NORMAL.	Affirmed	Recent	Patient
2183	fracture in her left hip	REASON FOR ADMISSION:  The patient is a very pleasant **AGE[in 50s]-year-old Caucasian   female who fell approximately 4 feet in **DATE[Sep 2006] at which time she injured   her back as well as sustained a FRACTURE IN HER LEFT HIP.	Affirmed	Recent	Patient
2184	clubbing	The extremities have   no cyanosis, CLUBBING, or edema.	Negated	Recent	Patient
2185	small   gastric ulcer on the incisura	Incidentally, on the EGD, there was a SMALL   GASTRIC ULCER ON THE INCISURA.	Affirmed	Recent	Patient
2186	cholangitis	Initially, there was some concern   for CHOLANGITIS, and the patient was started on Zosyn and Flagyl.	Affirmed	Recent	Patient
2187	esophagus and esophagogastric-junction were normal	FINDINGS:  The ESOPHAGUS AND ESOPHAGOGASTRIC-JUNCTION WERE NORMAL in appearance.	Affirmed	Recent	Patient
2188	LV diastolic dysfunction	There is E/A reversal across the   mitral valve consistent with LV DIASTOLIC DYSFUNCTION.	Affirmed	Recent	Patient
2189	right wrist is tender over the radius, as well as the dorsal   and volar surface	EXTREMITIES: The RIGHT WRIST IS TENDER OVER THE RADIUS, AS WELL AS THE DORSAL   AND VOLAR SURFACE.	Affirmed	Recent	Patient
2190	nausea	Does not   give a history of deafness and denies any recent NAUSEA, vomiting and   diarrhea.	Negated	Recent	Patient
2191	trace pulmonic regurgitation	There is TRACE PULMONIC REGURGITATION.	Affirmed	Recent	Patient
2192	headache	S_O_H  Counters Report Type Record Type Subgroup Classifier  162,9VJSVs8NGvo/ RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  XRAY CHEST FRONTAL AND LATERAL VIEWS   **DATE[Aug 03 07]     1440 HOURS    CLINICAL HISTORY:     Dizziness and HEADACHE.	Affirmed	Recent	Patient
2193	hypoxia	At this   time, the decision was made to admit the patient to a step-down bed for   further treatment and evaluation of the coffee-ground emesis and HYPOXIA.	Affirmed	Recent	Patient
2194	polyps	pre-SBTx work up, r/o POLYPS cancer, colitis    DESCRIPTION OF OPERATION:  After explaining the risks of, the benefits of, and alternatives to ileoscopy,  informed consent was obtained from the informed patient.	Affirmed	Recent	Patient
2195	syncope	S_O_H  Counters Report Type Record Type Subgroup Classifier  96,wt04WoaKovpB ER ER 1001  E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]         **INSTITUTION   EMERGENCY DEPARTMENT  PATIENT NAME:  **NAME[AAA, BBB M]  ACCOUNT #:  **ID-NUM  DATE OF SERVICE:  **DATE[Nov 05 07]  PRIMARY CARE PHYSICIAN: A  N  This is a **AGE[in 20s]-year-old female who was seen by me in the emergency room after   she presented with SYNCOPE.	Affirmed	Recent	Patient
2196	mitral regurgitation	COLOR FLOW DOPPLER:   There is trace MITRAL REGURGITATION.	Affirmed	Recent	Patient
2197	DVTs	HISTORY OF PRESENT ILLNESS:  The patient is a **AGE[90+]-year-old female with past   medical history significant for atrial fibrillation, history of DVTS, and   hypertension who presents to the Emergency Department after 2 episodes of   coffee-ground emesis.	Affirmed	Historical	Patient
2198	coffee-ground emesis	HISTORY OF PRESENT ILLNESS:  The patient is a **AGE[90+]-year-old female with past   medical history significant for atrial fibrillation, history of DVTs, and   hypertension who presents to the Emergency Department after 2 episodes of   COFFEE-GROUND EMESIS.	Affirmed	Recent	Patient
2199	hemodynamically stable	The patient has been HEMODYNAMICALLY STABLE over the last 24 to   48 hours with blood pressures ranging 130s to 140s/70s.	Affirmed	Recent	Patient
2200	cyanosis	Extremities:  No clubbing, CYANOSIS or edema.	Negated	Recent	Patient
2201	aspiration   pneumonia 	There was a concern for a possible ASPIRATION   PNEUMONIA given the patient's vomiting and poor mental status.	Affirmed	Recent	Patient
2202	Right ventricular function is severely decreased	RIGHT VENTRICULAR FUNCTION IS SEVERELY DECREASED.	Affirmed	Recent	Patient
2203	polyps	There was no evidence of POLYPS or mass.	Negated	Recent	Patient
2204	pulmonic regurgitation	There is trace PULMONIC REGURGITATION.	Affirmed	Recent	Patient
2205	alert	He was awake, ALERT, and oriented.	Affirmed	Recent	Patient
2206	mild pulmonic regurgitation	There is MILD PULMONIC REGURGITATION.	Affirmed	Recent	Patient
2207	some distress	GENERAL: The patient was in SOME DISTRESS, holding her right wrist, but,   otherwise, she was alert, oriented, and pleasant.	Affirmed	Recent	Patient
2208	ambulate	She did scrape up her knees, but she was   able to AMBULATE.	Affirmed	Recent	Patient
2209	JVD	No lymphadenopathy, thyromegaly or JVD.	Negated	Recent	Patient
2210	small external hemorrhoids	Digital rectal exam was performed and showed SMALL EXTERNAL HEMORRHOIDS.	Affirmed	Recent	Patient
2211	otitis	She appeared well and had   unremarkable vital signs, no signs of meningitis, OTITIS, pharyngitis, or   pneumonia.	Negated	Recent	Patient
2212	Left ventricular wall thickness is   increased	LEFT VENTRICULAR WALL THICKNESS IS   INCREASED, consistent with left ventricular hypertrophy.	Affirmed	Recent	Patient
2213	excessive bruising	She will alert the physician if any of the following are   noted:  Nosebleeds, EXCESSIVE BRUISING, pink, red, or tea-colored urine,   bright red or tarry black stools, unusual headaches, or stomach pain.	Affirmed	Not particular	Patient
2214	abdominal pain	We spoke with Dr. **NAME[TTT SSS], who was   covering for the patient's primary care physician, Dr. **NAME[ZZZ], and the   patient will be brought in for 23-hour observation and the patient may also   have a CT of the abdomen and pelvis while she is in the hospital to evaluate   her persistent ABDOMINAL PAIN.	Affirmed	Recent	Patient
2215	coffee-ground emesis 	At this   time, the decision was made to admit the patient to a step-down bed for   further treatment and evaluation of the COFFEE-GROUND EMESIS and hypoxia.	Affirmed	Recent	Patient
2216	mild amount of   pain	General:  The patient is awake, alert, lucid, appears to be in MILD AMOUNT OF   PAIN, in no acute distress.	Affirmed	Recent	Patient
2217	pulmonary artery size is normal	The PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
2218	loose bowel movement	Initially, given the   patient's symptoms as well as the LOOSE BOWEL MOVEMENT, I did perform a   rectal exam which was heme-negative.	Affirmed	Recent	Patient
2219	Right atrial size is moderately enlarged	RIGHT ATRIAL SIZE IS MODERATELY ENLARGED.	Affirmed	Recent	Patient
2220	SUBARACHNOID HEMORRHAGE	TRANSFER DIAGNOSIS(ES):  STATUS POST COILING FOR LEFT POSTERIOR INTERNAL   CAROTID ARTERY ANEURYSM AND SUBARACHNOID HEMORRHAGE.	Affirmed	Recent	Patient
2221	cataracts	REASON FOR ADMISSION:    Past medical history is positive for hyperlipidemia, hypothyroidism, weakness   and difficulty with ambulation, aortic/mitral disease, spinal stenosis,   CATARACTS, measles, mumps, and varicella in the past.	Affirmed	Historical	Patient
2222	Normal terminal ileum  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS(ES):  1) Internal and external hemorrhoids  2) NORMAL TERMINAL ILEUM    3) Normal colonoscopy  4) No additional lesions  5) Normal colonoscopy otherwise    PLAN:  1) Continue surveillance  2) Yearly hemoccult  3) Yearly rectal exams    REPEAT EXAM:  Colonoscopy in 5 year(s).	Affirmed	Recent	Patient
2223	Hypertension	HYPERTENSION.	Affirmed	Recent	Patient
2224	murmurs	No MURMURS, rubs, or   gallops.	Negated	Recent	Patient
2225	Thickened aortic valve	03) THICKENED AORTIC VALVE.	Affirmed	Recent	Patient
2226	coronary disease	Given his risk factors   including tobacco use, as well as age for CORONARY DISEASE, we did perform an   EKG.	Affirmed	Recent	Patient
2227	vomiting	He has   some nausea, VOMITING, diarrhea alternated with constipation.	Affirmed	Recent	Patient
2228	Left ventricular size is normal	LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
2229	arthralgias	Musculoskeletal - No ARTHRALGIAS or myalgias.	Negated	Recent	Patient
2230	back pain	She still mainly has BACK PAIN which she quotes as   7/10 and is typical of her sickle cell pain.	Affirmed	Recent	Patient
2231	Congestive Heart Failure	Wall Thickness:  1.5 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: CONGESTIVE HEART FAILURE  TWO DIMENSIONAL ECHOCARDIOLOGY:   This was a technically difficult study.	Affirmed	Recent	Patient
2232	Segmental left ventricular   function is normal	SEGMENTAL LEFT VENTRICULAR   FUNCTION IS NORMAL.	Affirmed	Recent	Patient
2233	regular rate and rhythm	The heart was in a REGULAR RATE AND RHYTHM with no murmurs or   rubs.	Affirmed	Recent	Patient
2234	Mucous membranes are moist	MUCOUS MEMBRANES ARE MOIST.	Affirmed	Recent	Patient
2235	mild   aortic stenosis	There is MILD   AORTIC STENOSIS.	Affirmed	Recent	Patient
2236	bioprosthetic valve is in the mitral position	A   BIOPROSTHETIC VALVE IS IN THE MITRAL POSITION.	Affirmed	Recent	Patient
2237	afebrile	The patient has been   AFEBRILE.	Affirmed	Recent	Patient
2238	Arrhythmia	ARRHYTHMIA is certainly another possibility.	Affirmed	Recent	Patient
2239	motion of the mitral   valve prosthesis appears normal	The MOTION OF THE MITRAL   VALVE PROSTHESIS APPEARS NORMAL.	Affirmed	Recent	Patient
2240	Extraocular movements are intact	EXTRAOCULAR MOVEMENTS ARE INTACT.	Affirmed	Recent	Patient
2241	sciatica	ED COURSE:  The patient was felt to have SCIATICA.	Affirmed	Recent	Patient
2242	trace mitral regurgitation	COLOR FLOW DOPPLER:   There is TRACE MITRAL REGURGITATION.	Affirmed	Recent	Patient
2243	Right   ventricular size is normal	RIGHT   VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
2244	atelectasis along the right middle lobe  	In  addition, there are clips from prior wedge resection within the  right upper lobe and ATELECTASIS ALONG THE RIGHT MIDDLE LOBE    adjacent to clips also fromthe patient's surgery.	Affirmed	Recent	Patient
2245	food impaction	She has a history of a FOOD IMPACTION eight years ago which required   endoscopy to clear it.	Affirmed	Historical	Patient
2246	foreign   body visualized in the upper pharynx	No FOREIGN   BODY VISUALIZED IN THE UPPER PHARYNX.	Negated	Recent	Patient
2247	Left ventricular wall thickness is increased	LEFT VENTRICULAR WALL THICKNESS IS INCREASED, consistent with mild left   ventricular hypertrophy.	Affirmed	Recent	Patient
2248	mitral valve is normal	The MITRAL VALVE IS NORMAL.	Affirmed	Recent	Patient
2249	extremely   jaundiced 	She subsequently became EXTREMELY   JAUNDICED over the next few days with change in her skin color and scleral   icterus.	Affirmed	Recent	Patient
2250	BRAIN LESION	NEWLY DIAGNOSED BRAIN LESION.	Affirmed	Recent	Patient
2251	bilirubin   trended down	GI - The patient had a PTC drain placed on **DATE[Mar 25 2008], and her BILIRUBIN   TRENDED DOWN from approximately 30 to 11.	Affirmed	Recent	Patient
2252	back   pain	She admits to mild nausea   during this episode while she was at the **INSTITUTION and denies any BACK   PAIN, denies fevers, denies cough, or cold symptoms.	Negated	Recent	Patient
2253	cough	Also, the patient later complained of a COUGH and shortness of breath so a   chest x-ray was obtained and found to be unremarkable.	Affirmed	Recent	Patient
2254	PERRLA	Eyes PERRLA, EOMI.	Affirmed	Recent	Patient
2255	pleural fluid	8 cc of  cloudy yellow PLEURAL FLUID are received.	Affirmed	Recent	Patient
2256	new onset of chest pain	Call also for any weight gain   greater than three pounds per day or five pounds per week, any unusual   rashes, nausea, vomiting, fever associated with chill, temperature elevation   greater than 101 degrees Fahrenheit, sustained or low-grade temperature   greater than 100 degrees Fahrenheit, NEW ONSET OF CHEST PAIN,   light-headedness, or dizziness, new or increased shortness of breath, severe   calf pain, burning on urination or severe depression.	Affirmed	Not particular	Patient
2257	brain parenchyma and the  globes are normal	FINDINGS:     NECK:  The visualized portions of the BRAIN PARENCHYMA AND THE  GLOBES ARE NORMAL.	Affirmed	Recent	Patient
2258	hypoxia	Given his   HYPOXIA, I was concerned for a possible pneumonia; however, a chest x-ray did   show pulmonary edema which is new for this patient.	Affirmed	Recent	Patient
2259	stomach pain	She will alert the physician if any of the following are   noted:  Nosebleeds, excessive bruising, pink, red, or tea-colored urine,   bright red or tarry black stools, unusual headaches, or STOMACH PAIN.	Affirmed	Not particular	Patient
2260	Pharynx - Clear with moist mucous membranes	PHARYNX - CLEAR WITH MOIST MUCOUS MEMBRANES.	Affirmed	Recent	Patient
2261	chest pain	The chief complaint is CHEST PAIN.	Affirmed	Recent	Patient
2262	mitral valve is normal	The   MITRAL VALVE IS NORMAL.	Affirmed	Recent	Patient
2263	rectal ischemia	Also throughout this hospital course, the patient had the following   complications:  sepsis, respiratory failure with trach placement,   thrombocytopenia, rectal sheath hematoma with intraabdominal bleed status   post iliac and epigastric embolization of arteries, renal failure secondary   to ureteral obstruction with bilateral nephrostomy tube placement, right MCA   CVA, RECTAL ISCHEMIA and further complications related to her underlying   hypercoagulable state.	Affirmed	Recent	Patient
2264	head was atraumatic	The HEAD WAS ATRAUMATIC.	Affirmed	Recent	Patient
2265	pulmonary artery size is normal	The PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
2266	aortic root size is mildly dilated	The AORTIC ROOT SIZE IS MILDLY DILATED.	Affirmed	Recent	Patient
2267	Left ventricular size is normal	9  cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Syncope And Collapse  TWO DIMENSIONAL ECHOCARDIOLOGY:   LEFT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
2268	lupus anticoagulant	HOSPITAL COURSE:  Ms. **NAME[AAA] is a **AGE[in 60s]-year-old Caucasian woman with a significant history of   antiphospholipid antibody syndrome and LUPUS ANTICOAGULANT who was initially   admitted to an outside hospital on **DATE[Jan 09 2008] with mental status changes   and was found to have a subacute subdural hematoma and promptly transferred   to **INSTITUTION.	Affirmed	Recent	Patient
2269	trace mitral regurgitation	There is TRACE MITRAL REGURGITATION.	Affirmed	Recent	Patient
2270	Lungs   - CTP	LUNGS   - CTP, no rales, rhonchi, or wheezes.	Affirmed	Recent	Patient
2271	thyromegaly	No lymphadenopathy,   THYROMEGALY, or JVD.	Negated	Recent	Patient
2272	DIABETES	DIABETES SECONDARY TO NECROTIZING PANCREATITIS.	Affirmed	Recent	Patient
2273	polyphagia	ENDOCRINE:  Denies any polyuria or POLYPHAGIA.	Negated	Recent	Patient
2274	chest   pain	Follow up ____________ and   the patient is advised to call the PCP if there are any symptoms of CHEST   PAIN of shortness of breath or any signs of bleeding.	Affirmed	Not particular	Patient
2275	aortic   valve is thickened	The AORTIC   VALVE IS THICKENED.	Affirmed	Recent	Patient
2276	Coronary artery disease	CORONARY ARTERY DISEASE status post coronary artery bypass graft in **DATE[Apr   2007] with complication of mediastinitis and embolization resulting in   amputation of left upper extremity above elbow.	Affirmed	Historical	Patient
2277	Right ventricular wall thickness is normal	RIGHT VENTRICULAR WALL THICKNESS IS NORMAL.	Affirmed	Recent	Patient
2278	left-sided weakness	HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 50s]-year-old male who presents to the   Emergency Department complaining of LEFT-SIDED WEAKNESS and confusion.	Affirmed	Recent	Patient
2279	Right atrial size is normal	RIGHT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
2280	normal sinus rhythm	The patient remained afebrile with stable vital signs   which were a temperature of 36.1, heart rate 75, in NORMAL SINUS RHYTHM,   respirations 60, oxygenation 95% on two liters, blood pressure was 111/52 in   the left arm.	Affirmed	Recent	Patient
2281	blood pressure is currently controlled 	The patient's BLOOD PRESSURE IS CURRENTLY CONTROLLED with the regimen   detailed above and it is appropriate to continue those antihypertensive   agents, as well as to continue seizure prophylaxis and appropriate bowel   regimen.	Affirmed	Recent	Patient
2282	fevers	Once transferred to the Step-Down Unit she developed FEVERS and blood   culture, urinalysis and urine culture were sent.	Affirmed	Recent	Patient
2283	wheezes	No WHEEZES, rales, or rhonchi.	Negated	Recent	Patient
2284	Moderately dilated left ventricle with wall motion as described above  and severely decreased systolic function	FINAL IMPRESSIONS:   01) MODERATELY DILATED LEFT VENTRICLE WITH WALL MOTION AS DESCRIBED ABOVE  AND SEVERELY DECREASED SYSTOLIC FUNCTION.	Affirmed	Recent	Patient
2285	Nondilated left ventricle with severely hypokinetic mid anteroseptum and  apical anterior wall and low normal systolic function	FINAL IMPRESSIONS:   01) NONDILATED LEFT VENTRICLE WITH SEVERELY HYPOKINETIC MID ANTEROSEPTUM AND  APICAL ANTERIOR WALL AND LOW NORMAL SYSTOLIC FUNCTION.	Affirmed	Recent	Patient
2286	Multiple small erosions were found in  the antrum	MULTIPLE SMALL EROSIONS WERE FOUND IN  THE ANTRUM.	Affirmed	Recent	Patient
2287	awake	She was afebrile with   stable vitals; AWAKE, alert, and oriented in no acute distress.	Affirmed	Recent	Patient
2288	gallops	Cardiovascular - Regular rate and rhythm, no murmurs, rubs, GALLOPS.	Negated	Recent	Patient
2289	vasovagal	HOSPITAL COURSE & PLAN:   Examination is consistent to be most likely VASOVAGAL.	Affirmed	Recent	Patient
2290	tricuspid valve is normal	The   TRICUSPID VALVE IS NORMAL.	Affirmed	Recent	Patient
2291	Right ventricular size is   normal	RIGHT VENTRICULAR SIZE IS   NORMAL.	Affirmed	Recent	Patient
2292	NAUSEA 	NAUSEA AND VOMITING.	Affirmed	Recent	Patient
2293	Esophagitis	FINDINGS:  ESOPHAGITIS was found.	Affirmed	Recent	Patient
2294	Moderately dilated left ventricle with segmental abnormalities as  described above and moderate to severely decreased systolic function	02) MODERATELY DILATED LEFT VENTRICLE WITH SEGMENTAL ABNORMALITIES AS  DESCRIBED ABOVE AND MODERATE TO SEVERELY DECREASED SYSTOLIC FUNCTION.	Affirmed	Recent	Patient
2295	Altered mental status	ALTERED MENTAL STATUS was likely secondary to high dose of   opioids at home for chronic pain syndrome.	Affirmed	Recent	Patient
2296	Agitation	AGITATION was noted.	Affirmed	Recent	Patient
2297	fatigue	The patient had been complaining   of some generalized FATIGUE and was brought in under the Congestive Heart   Failure Service Dr. **NAME[ZZZ].	Affirmed	Recent	Patient
2298	Diverticulosis was found in the  sigmoid colon	DIVERTICULOSIS WAS FOUND IN THE  SIGMOID COLON.	Affirmed	Recent	Patient
2299	chills	She denies fever, CHILLS, or other constitutional symptoms.	Negated	Recent	Patient
2300	dysuria	GU - No frequency, urgency, or DYSURIA.	Negated	Recent	Patient
2301	aortic valve is   thickened and calcified	The AORTIC VALVE IS   THICKENED AND CALCIFIED.	Affirmed	Recent	Patient
2302	5/5 motor and sensation bilaterally upper   and lower extremities	She is following   commands in four extremities and 5/5 MOTOR AND SENSATION BILATERALLY UPPER   AND LOWER EXTREMITIES.	Affirmed	Recent	Patient
2303	alcohol use	SOCIAL HISTORY:  The patient denies ALCOHOL USE.	Negated	Historical	Patient
2304	mitral valve is normal	The MITRAL VALVE IS NORMAL.	Affirmed	Recent	Patient
2305	Right ventricular size is normal	RIGHT VENTRICULAR SIZE IS NORMAL.	Affirmed	Recent	Patient
2306	constitutional symptoms	She denies fever, chills, or other CONSTITUTIONAL SYMPTOMS.	Negated	Recent	Patient
2307	thymoma	S_O_H  Counters Report Type Record Type Subgroup Classifier  180,a0r+7WaVW8z7 RAD RAD   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      EXAMINATION PERFORMED:  PET / CT TUMOR IMAGING SKULL THROUGH THIGH   **DATE[Jan 12 08]     1130 HOURS    CLINICAL HISTORY:     **AGE[in 50s]-year-old male with a history of THYMOMA.	Affirmed	Recent	Patient
2308	mild mitral regurgitation	There is MILD MITRAL REGURGITATION.	Affirmed	Recent	Patient
2309	normal   sinus rhythm	She was continued on Sotalol to maintain her NORMAL   SINUS RHYTHM.	Affirmed	Recent	Patient
2310	Heart tones regular	HEART TONES REGULAR.	Affirmed	Recent	Patient
2311	Sickle cell crisis	CHIEF COMPLAINT:  SICKLE CELL CRISIS.	Affirmed	Recent	Patient
2312	normocephalic	HEENT:  Exam was NORMOCEPHALIC and atraumatic.	Affirmed	Recent	Patient
2313	murmurs	No MURMURS, rubs, or gallops.	Negated	Recent	Patient
2314	tonsillar exudate	There is no TONSILLAR EXUDATE appreciated.	Negated	Recent	Patient
2315	Skin is warm and moist without lesion	SKIN IS WARM AND MOIST WITHOUT LESION.	Affirmed	Recent	Patient
2316	following   commands in four extremities	She is FOLLOWING   COMMANDS IN FOUR EXTREMITIES and 5/5 motor and sensation bilaterally upper   and lower extremities.	Affirmed	Recent	Patient
2317	Left renal calculi	S_O_H  Counters Report Type Record Type Subgroup Classifier  215,3X50GyvEldaI SP SP   E_O_H  [Report de-identified (Safe-harbor compliant) by De-ID v.6.14.02]      PATIENT HISTORY:  LEFT RENAL CALCULI.	Affirmed	Recent	Patient
2318	tiny right pleural effusion	FINDINGS:     There may be a TINY RIGHT PLEURAL EFFUSION.	Affirmed	Recent	Patient
2319	PARATHYROID GLANDS	C.     NO PARATHYROID GLANDS ARE  SEEN.	Negated	Recent	Patient
2320	Normal left ventricular size	02) NORMAL LEFT VENTRICULAR SIZE and function.	Affirmed	Recent	Patient
2321	anemic	The patient was not ANEMIC.	Negated	Recent	Patient
2322	bulging disks	HISTORY OF PRESENT ILLNESS:  This is a **AGE[in 40s]-year-old female with a past medical   history significant for chronic low-back pain as well as per her report three   BULGING DISKS.	Affirmed	Historical	Patient
2323	Small external hemorrhoidal tags	SMALL EXTERNAL HEMORRHOIDAL TAGS.	Affirmed	Recent	Patient
2324	pulmonic valve is normal	The PULMONIC VALVE IS NORMAL.	Affirmed	Recent	Patient
2325	thrombus identified within   the common femoral, superficial femoral, or popliteal veins	This was done on **DATE[Jul 13 2007], and there was no THROMBUS IDENTIFIED WITHIN   THE COMMON FEMORAL, SUPERFICIAL FEMORAL, OR POPLITEAL VEINS.	Negated	Recent	Patient
2326	Sclerae anicteric	SCLERAE ANICTERIC.	Affirmed	Recent	Patient
2327	Trivial pericardial effusion	09) 10)  TRIVIAL PERICARDIAL EFFUSION seen.	Affirmed	Recent	Patient
2328	infection	It was   planned to follow up in the **INSTITUTION for reimplantation of the   pacemaker once the INFECTION is completely resolved.	Affirmed	Recent	Patient
2329	Hypertension 	Wall Thickness:  1.3 cm (0.7-1.1 cm)      REFERRING DIAGNOSIS: Chronic Airway Obstruction 496; Systolic Heart Failure;  Obesity 278.0; HYPERTENSION 401.9  TWO DIMENSIONAL ECHOCARDIOLOGY:   Left ventricular size is normal.	Affirmed	Historical	Patient
2330	esophagitis	This   was found to be consistent with an upper GI bleed secondary to ESOPHAGITIS   versus gastritis versus peptic ulcer disease versus **NAME[UUU] wise tear.	Affirmed	Recent	Patient
2331	tingling on her fifth finger   on the outside	She does have some TINGLING ON HER FIFTH FINGER   ON THE OUTSIDE.	Affirmed	Recent	Patient
2332	Lungs were clear to auscultation	LUNGS WERE CLEAR TO AUSCULTATION.	Affirmed	Recent	Patient
2333	able to resist   extension of her thumb, although, there is some pain	She does have good grip strength and is ABLE TO RESIST   EXTENSION OF HER THUMB, ALTHOUGH, THERE IS SOME PAIN.	Affirmed	Recent	Patient
2334	moderate to severe tricuspid regurgitation	There is MODERATE TO SEVERE TRICUSPID REGURGITATION.	Affirmed	Recent	Patient
2335	Normal duodenum  	<<PROCEDUREIMAGES>>    COMPLICATIONS:  None    POSTOPERATIVE DIAGNOSIS:  1) Severe Esophagitis s/p biopsy  2) Large Hiatal hernia  3) Gastritis in the antrum s/p biopsy  4) NORMAL DUODENUM      PLAN:  1) Follow-up: as scheduled referring MD  2) Await biopsy results  3) Follow-up of helicobacter pylori  status, treat if indicated  4) Protonix 40mg qd    REPEAT EXAM:  EGD in ; As needed    __________________________________  **NAME[YYY ZZZ], MD  I was present during the entire procedure.	Affirmed	Recent	Patient
2336	OSTEOPOROSIS	OSTEOPOROSIS.	Affirmed	Historical	Patient
2337	anemia	GI  ROS is -ve for change in bowel habit, bleeding (occult nor overt), change in  weight, ANEMIA or any "alarm" symptom or sign.	Negated	Recent	Patient
2338	pneumonia in the left lower lobe	It showed atelectasis versus PNEUMONIA IN THE LEFT LOWER LOBE   involving pleural effusion.	Affirmed	Recent	Patient
2339	Regular rate and rhythm	Cardiovascular - REGULAR RATE AND RHYTHM, no murmurs, rubs, gallops.	Affirmed	Recent	Patient
2340	subtle, nodular enhancement medial to the left uncus	In addition, there is  SUBTLE, NODULAR ENHANCEMENT MEDIAL TO THE LEFT UNCUS (series 19  image 12), a finding that is more conspicuous than **DATE[Aug 2007].	Affirmed	Recent	Patient
2341	Psychiatric history	PSYCHIATRIC HISTORY.	Affirmed	Historical	Patient
2342	Right atrial size is normal	RIGHT ATRIAL SIZE IS NORMAL.	Affirmed	Recent	Patient
2343	rash	In general, he denies any   changes in vision or diplopia, no changes in hearing, no neck pain, no   meningismus, no chest pain, no palpitations, no shortness of breath, no   cough, no abdominal pain, no nausea, vomiting, or diarrhea, no hematuria or   dysuria, no myalgia or arthralgia, no paresthesias or paralysis, no RASH.	Negated	Recent	Patient
2344	diarrhea	No abdominal pain, nausea, vomiting or DIARRHEA.	Negated	Recent	Patient
2345	RIGHT HIP FRACTURE	RIGHT HIP FRACTURE STATUS POST HEMIARTHROPLASTY.	Affirmed	Recent	Patient
2346	mucous membranes moist	HEENT - Normocephalic and atraumatic, MUCOUS MEMBRANES MOIST.	Affirmed	Recent	Patient
2347	aortic root size is normal	The AORTIC ROOT SIZE IS NORMAL.	Affirmed	Recent	Patient
2348	Left atrial size is mildly   enlarged	LEFT ATRIAL SIZE IS MILDLY   ENLARGED.	Affirmed	Recent	Patient
2349	OSTEOCHONDRAL IRREGULARITY WITHIN THE 45 DEGREE FLEXION ZONE  OF THE LATERAL FEMORAL CONDYLE COMPATIBLE WITH OSTEOCHONDRAL  LESION. INCREASED SCLEROSIS WITHIN THIS REGION	OSTEOCHONDRAL IRREGULARITY WITHIN THE 45 DEGREE FLEXION ZONE  OF THE LATERAL FEMORAL CONDYLE COMPATIBLE WITH OSTEOCHONDRAL  LESION.	Affirmed	Recent	Patient
2350	severely hypertensive 	He was also   SEVERELY HYPERTENSIVE by the paramedics.	Affirmed	Recent	Patient
2351	pulmonic valve is   normal	The PULMONIC VALVE IS   NORMAL.	Affirmed	Recent	Patient
2352	biliary dilatation	An MRI done on the same day showed no   BILIARY DILATATION and positive for cholecystolithiasis.	Negated	Recent	Patient
2353	right leg pain and swelling	He was readmitteed on **DATE[Jul 3 07] with  RIGHT LEG PAIN AND SWELLING and was found to have an occulded graft.	Affirmed	Recent	Patient
2354	metastatic lesion	This may  represent METASTATIC LESION or myeloma.	Affirmed	Recent	Patient
2355	focal infection	The patient had no signs of a FOCAL INFECTION.	Negated	Recent	Patient
2356	nausea	Return to the Emergency Department or PCP if he develops NAUSEA, vomiting,   fevers or chills.	Affirmed	Not particular	Patient
2357	mitral regurgitation	03) None MITRAL REGURGITATION.	Negated	Recent	Patient
2358	acute   distress	PHYSICAL EXAMINATION:  On examination, the patient is a well-developed white female in no ACUTE   DISTRESS.	Negated	Recent	Patient
2359	Mitral annular calcification	06) MITRAL ANNULAR CALCIFICATION.	Affirmed	Recent	Patient
2360	vomiting	He   was brought into the Emergency Department by his coworkers after he had   VOMITING and diarrhea.	Affirmed	Recent	Patient
2361	The pulmonary artery size is normal	THE PULMONARY ARTERY SIZE IS NORMAL.	Affirmed	Recent	Patient
2362	Mild right atrial enlargement	04) MILD RIGHT ATRIAL ENLARGEMENT.	Affirmed	Recent	Patient
2363	oriented times three	Neurologic:  Alert and ORIENTED TIMES THREE.	Affirmed	Recent	Patient
2364	Left ventricular size (venous   ventricle) is small	Left ventricular size (venous   ventricle) is small.	Affirmed	Recent	Patient
2365	Abdomen is soft nontender	ABDOMEN: ABDOMEN IS SOFT NONTENDER.	Affirmed	Recent	Patient
2366	masses	No MASSES,   splenomegaly.	Negated	Recent	Patient
2367	Left ventricular size is small	LEFT VENTRICULAR SIZE IS SMALL.	Affirmed	Recent	Patient
2368	dizziness	HISTORY OF PRESENT ILLNESS:  The patient is an **AGE[in 80s]-year-old female presenting with worsening DIZZINESS,   headache, nausea, as well as leg weakness.	Affirmed	Recent	Patient
2369	colorectal cancer	for COLORECTAL CANCER and poloyps.	Affirmed	Not particular	Patient
2370	rectal exam was performed and showed no abnormalities	Digital RECTAL EXAM WAS PERFORMED AND SHOWED NO ABNORMALITIES.	Affirmed	Recent	Patient
2371	chronic SVC  occlusion	;    HISTORY:  The patient is a **AGE[in 60s]-year-old gentleman with a past medical history  significant for ESRD, HIV, chronic thoracic aortic aneurysm, CHRONIC SVC  OCCLUSION, and recent diagnosis of PE who was discharged on **DATE[Jul 2 2007]  after right groin AV fistula placement.	Affirmed	Historical	Patient
2372	Cervical spine is nontender	CERVICAL SPINE IS NONTENDER but remains immobilized.	Affirmed	Recent	Patient
2373	meningismus	No neck pain or MENINGISMUS.	Negated	Recent	Patient
2374	aortic valve is normal	The AORTIC VALVE IS NORMAL.	Affirmed	Recent	Patient
2375	coronary   ischemia	ED COURSE:  Because of the patient's coronary artery disease history and his symptoms, it   was thought that his symptoms were most likely secondary to CORONARY   ISCHEMIA.	Affirmed	Recent	Patient
2376	aortic root   size is normal	The AORTIC ROOT   SIZE IS NORMAL.	Affirmed	Recent	Patient