Datasets:
metaboulie
/
c2n2_2018_processed

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100035.txt
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senna 8.6 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ) as needed for Constipation .
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acetaminophen 325 mg Tablet Sig : Two ( 2 ) Tablet PO Q6H ( every 6 hours ) as needed for pain / fever .
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carvedilol 12.5 mg Tablet Sig : Two ( 2 ) Tablet PO BID ( 2 times a day ) .
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docusate sodium 100 mg Capsule Sig : One ( 1 ) Capsule PO BID ( 2 times a day ) .
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furosemide 40 mg Tablet Sig : Two ( 2 ) Tablet PO BID ( 2 times a day ) .
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lisinopril 10 mg Tablet Sig : Two ( 2 ) Tablet PO DAILY ( Daily ) .
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olanzapine 5 mg Tablet , Rapid Dissolve Sig : [ * * 11 - 25 * * ] Tablet , Rapid Dissolves PO QHS ( once a day ( at bedtime ) ) as needed for sleep .
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calcium carbonate 200 mg ( 500 mg ) Tablet , Chewable Sig : One ( 1 ) Tablet , Chewable PO BID ( 2 times a day ) .
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100035.txt
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cholecalciferol ( vitamin D3 ) 400 unit Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ) .
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100035.txt
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acetaminophen 500 mg Tablet Sig : Two ( 2 ) Tablet PO TID ( 3 times a day ) as needed for pain / fever .
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100035.txt
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lidocaine 5 % ( 700 mg/patch ) Adhesive Patch , Medicated Sig : One ( 1 ) Adhesive Patch , Medicated Topical DAILY ( Daily ) : 12 hours on and 12 hours off every 24 hour period .
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100035.txt
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ipratropium bromide 0.02 % Solution Sig : One ( 1 ) neb Inhalation every six ( 6 ) hours .
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100035.txt
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albuterol sulfate 2.5 mg /3 mL ( 0.083 % ) Solution for Nebulization Sig : One ( 1 ) neb Inhalation every six ( 6 ) hours .
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100035.txt
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albuterol sulfate 2.5 mg /3 mL ( 0.083 % ) Solution for Nebulization Sig : One ( 1 ) neb Inhalation Q2H ( every 2 hours ) as needed for SOB .
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100035.txt
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topiramate 25 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ) for 3 days : 1 [ * * Hospital1 * * ] until [ * * 3 - 22 * * ] PM then increase to 2 tablets [ * * Hospital1 * * ] for 7 days then 3 tablets [ * * Hospital1 * * ] ongoing .
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100035.txt
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tramadol 50 mg Tablet Sig : One ( 1 ) Tablet PO Q6H ( every 6 hours ) as needed for back pain .
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100035.txt
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fluticasone - salmeterol 250 - 50 mcg/dose Disk with Device Sig : One ( 1 ) inh Inhalation [ * * Hospital1 * * ] ( 2 times a day ) .
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100035.txt
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lorazepam 2 mg/mL Syringe Sig : 1 - 2 mg Injection twice a day as needed for seizure that last longer than 5 minutes .
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100035.txt
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Discharge Disposition : Extended Care
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100035.txt
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Facility : [ * * Hospital6 979 * * ] - [ * * Location ( un ) 246 * * ]
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100035.txt
238
Discharge Diagnosis : Anoxic Brain Injury s/p PEA arrest x2 Status Asthmaticus Ventilator Associated Pneumonia Chronic Systolic Heart Failure L1 compression fracture Seizures after hypoxic brain injury
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100035.txt
239
Discharge Condition : Mental Status : Confused - sometimes .
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100035.txt
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Level of Consciousness : Alert and interactive .
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100035.txt
241
Activity Status : Ambulatory - requires assistance or aid ( walker or cane ) because he has poor motor planning
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100035.txt
242
Discharge Instructions : You came to the hospital after having a cardiac arrest and an asthma exacerbation .
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100035.txt
243
You had another cardiac arrest in our hospital and were admitted to the MICU .
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100035.txt
244
You required intubation but were able to wean off the machine and breathe on your own .
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100035.txt
245
We treated you for pneumonia and asthma .
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100035.txt
246
Your mental status slowly improved , though you did have 2 seizures , last on [ * * 3 - 18 * * ] .
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100035.txt
247
You were started on s eizure medications for this .
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100035.txt
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100035.txt
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Please take your medications as prescribed and follow up with your doctors [ * * Name5 ( PTitle ) 7928 * * ] .
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100035.txt
250
Followup Instructions : Department : PULMONARY FUNCTION LAB When : WEDNESDAY [ * * 2115 - 4 - 3 * * ] at 1 : 10 PM With : PULMONARY FUNCTION LAB [ * * Telephone/Fax ( 1 ) 609 * * ] Building : [ * * Hospital6 29 * * ] [ * * Location ( un ) * * ] Campus : EAST Best Parking : [ * * Hospital Ward Name 23 * * ] Garage
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100035.txt
251
Department : MEDICAL SPECIALTIES When : WEDNESDAY [ * * 2115 - 4 - 3 * * ] at 1 : 30 PM With : DR [ * * Last Name ( STitle ) * * ]/DR [ * * Last Name ( STitle ) * * ] [ * * Telephone/Fax ( 1 ) 612 * * ] Building : SC [ * * Hospital Ward Name 23 * * ] Clinical Ctr [ * * Location ( un ) * * ] Campus : EAST Best Parking : [ * * Hospital Ward Name 23 * * ] Garage
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100035.txt
252
Department : COGNITIVE NEUROLOGY UNIT When : THURSDAY [ * * 2115 - 4 - 11 * * ] at 1 PM With : [ * * First Name11 ( Name Pattern1 ) * * ] [ * * Last Name ( NamePattern4 ) 6403 * * ] , MD [ * * Telephone/Fax ( 1 ) 1690 * * ] Building : Ks [ * * Hospital Ward Name 860 * * ] Building ( [ * * Hospital Ward Name 1826 * * ]/[ * * Hospital Ward Name 1827 * * ] Complex ) [ * * Location ( un ) * * ] Campus : EAST Best Parking : Main Garage
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100035.txt
253
Admission Date : [ * * 2174 - 4 - 18 * * ] Discharge Date : [ * * 2174 - 5 - 17 * * ]
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100039.txt
254
Date of Birth : [ * * 2135 - 11 - 15 * * ] Sex : F
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100039.txt
255
Service : MEDICINE
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100039.txt
256
Allergies : Prochlorperazine / Heparin Agents
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100039.txt
257
Attending : [ * * First Name3 ( LF ) 3918 * * ] Chief Complaint : Abdominal Pain
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100039.txt
258
Major Surgical or Invasive Procedure : Upper GI series with small bowel follow through Right heart catheterization IR guided paracentesis
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100039.txt
259
History of Present Illness : 38 yo F w/ h/o ALL in remission s/p cord transplant in [ * * 1 - 13 * * ] , anthracycline - induced cardiomyopathy ( EF 15 - 20 % [ * * 1 - 14 * * ] ) and recurrent nausea and vomiting who presents with abdominal pain , N/V x1 week
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100039.txt
260
Of note , the pt was admitted here from [ * * Date range ( 1 ) * * ] with nausea and vomitting of unclear etiology .
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100039.txt
261
When discharged , she was tolerating good PO and had planned f/u with neuro for ? abdominal migraine and GI for possible other contributing factors including food sensitivities and gastroparesis .
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100039.txt
262
In the ED , VS : 98.8 94 138/100 16 100 % and [ * * 10 - 15 * * ] pain .
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100039.txt
263
CT A/P showed a small umbilical hernia ; interval increase in size and mild fat stranding and interval increase in ascites compared to recent prior imaging .
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100039.txt
264
WBC 12.4 with no left shift , bili 2.1 up from 1.1 , Cr 2.7 up from 2.3 .
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100039.txt
265
Surgery was consulted give CT finding and did not feel there was an indication for surgery .
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100039.txt
266
She received iv zofran and morphine 4mg iv and 1L IVF .
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100039.txt
267
On arrival to the floor , patient reports [ * * 11 - 14 * * ] total body pain and nausea .
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100039.txt
268
She has had ice chips today but threw them up in the ED .
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100039.txt
269
Review of Systems : ( + ) Per HPI ( - ) Review of Systems : Denies fevers , chest pain , SOB , diarrhea , constipation , dysuria , HA , change in vision or dizziness .
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100039.txt
270
Past Medical History : ONCOLOGIC HISTORY : ALL : - initially presented in [ * * 2172 - 8 - 5 * * ] right chest and right upper extremity pain and paresthesias and visual blurriness .
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100039.txt
271
WBC 149 , 000 ; received leukapheresis , started on hydroxyurea .
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100039.txt
272
Dx'ed with precursor B - cell ALL .
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100039.txt
273
- underwent phase I induction with daunorubicin , vincristine , dexamethasone , L - asparaginase , MTX ; phase II with cyclophosphamide , cytarabine , mercaptopurine , MTX - Bone Marrow Aspirate/Biopsy on [ * * 2172 - 10 - 26 * * ] showed no morphologic
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100039.txt
274
evidence of residual leukemia - underwent allo double cord blood SCT [ * * 2173 - 1 - 11 * * ] , course complicated by neutropenic fever and acute skin GVHD
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100039.txt
275
OTHER MEDICAL HISTORY : - Embolic stroke in [ * * 3 - /2174 * * ] on coumadin - Cardiomyopathy due to early anthracycline - related cardiotoxicity [ * * 10/2172 * * ] - Chronic kidney disease stage III/IV , baseline creatinine ~2.0 - 2.2 - Asthma - HTN - Cervical Intraepithelial neoplasia - C - section in [ * * 2165 * * ]
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100039.txt
276
Social History : Smoke : never EtOH : Occasional in past , none currently Drugs : Never Lives/works : Single , has two children ( ages 7 and 18 ) .
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100039.txt
277
Lives in [ * * Location 686 * * ] .
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100039.txt
278
Was previously employed at [ * * Company 59330 * * ] , hasn't been working since being diagnosed with ALL in [ * * 2172 - 8 - 5 * * ] .
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100039.txt
279
Family History : Mother with gastric cancer , passed at the age of 40 Father with HTN .
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100039.txt
280
Physical Exam : VS : 98 145/76 87 15 100 % RA GEN : well appearing F in NAD HEENT : slight dry MM , sclera anicteric , PERRL Cards : RR S1/S2 normal .
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100039.txt
281
prominent S3 Pulm : CTAB Abd : Hyperactive BS .
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100039.txt
282
Initially soft when palpating with stethoscope over all 4 quadrants then suddenly exquisitely tender on right .
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100039.txt
283
No guarding initially .
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[ "No", "guarding", "initially", "." ]
100039.txt
284
Unable to assess for HSM .
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[ "Unable", "to", "assess", "for", "HSM", "." ]
100039.txt
285
Extremities : wwp , no edema .
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100039.txt
286
PTs 2+ .
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100039.txt
287
Neuro : CNs II - XII grossly intact .
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100039.txt
288
normal gait Psych : overly dramatic affect
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100039.txt
289
Pertinent Results : On admission : [ * * 2174 - 4 - 18 * * ] 02 : 00PM BLOOD WBC - 12.4 * RBC - 3.78 * Hgb - 11.4 * Hct - 36.3 MCV - 96 MCH - 30.2 MCHC - 31.4 RDW - 16.5 * Plt Ct - 212 [ * * 2174 - 4 - 18 * * ] 02 : 00PM BLOOD Neuts - 67.3 Lymphs - 23.8 Monos - 7.7 Eos - 0.5 Baso - 0.7 [ * * 2174 - 4 - 18 * * ] 04 : 30PM BLOOD PT - 30.1 * PTT - 29.4 INR ( PT ) - 3.0 * [ * * 2174 - 4 - 18 * * ] 02 : 00PM BLOOD UreaN -
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100039.txt
290
30 * Creat - 2.7 * Na - 142 K - 4.8 Cl - 99 HCO3 - 31 AnGap - 17 [ * * 2174 - 4 - 18 * * ] 02 : 00PM BLOOD ALT - 15 AST - 18 AlkPhos - 127 * TotBili - 2.1 * [ * * 2174 - 4 - 18 * * ] 02 : 00PM BLOOD Lipase - 63 * [ * * 2174 - 4 - 18 * * ] 02 : 00PM BLOOD cTropnT - <0.01 [ * * 2174 - 4 - 18 * * ] 02 : 00PM BLOOD Albumin - 3.8 Calcium - 9.3 Phos - 4.8 * Mg - 2.0
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100039.txt
291
On discharge : [ * * 2174 - 5 - 17 * * ] 12 : 00AM BLOOD WBC - 19.1 * RBC - 3.86 * Hgb - 11.3 * Hct - 37.7 MCV - 98 MCH - 29.3 MCHC - 30.0 * RDW - 17.8 * Plt Ct - 419 [ * * 2174 - 5 - 17 * * ] 12 : 00AM BLOOD Neuts - 81.3 * Lymphs - 11.4 * Monos - 6.9 Eos - 0.1 Baso - 0.3 [ * * 2174 - 5 - 17 * * ] 12 : 00AM BLOOD PT - 31.2 * PTT - 28.6 INR ( PT ) - 3.1 * [ * * 2174 - 5 - 17 * * ] 12 : 00AM BLOOD Fibrino -
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100039.txt
292
162 [ * * 2174 - 5 - 17 * * ] 12 : 00AM BLOOD Glucose - 152 * UreaN - 78 * Creat - 2.9 * Na - 137 K - 4.7 Cl - 95 * HCO3 - 31 AnGap - 16 [ * * 2174 - 5 - 17 * * ] 12 : 00AM BLOOD ALT - 51 * AST - 41 * LD ( LDH ) - 327 * AlkPhos - 107 * TotBili - 0.7 [ * * 2174 - 5 - 13 * * ] 12 : 11PM BLOOD cTropnT - <0.01 [ * * 2174 - 5 - 17 * * ] 12 : 00AM BLOOD Albumin - 3.8 Calcium - 8.7 Phos - 2.1 * Mg - 2.7 * UricAcd
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100039.txt
293
- 8.7 * [ * * 2174 - 4 - 27 * * ] 02 : 51AM BLOOD calTIBC - 246 * Ferritn - 107 TRF - 189 * [ * * 2174 - 5 - 2 * * ] 05 : 55AM BLOOD [ * * Doctor First Name * * ] - NEGATIVE dsDNA - NEGATIVE [ * * 2174 - 4 - 28 * * ] HHV - 8 DNA , QL PCR Not Detected [ * * 2174 - 4 - 27 * * ] QUANTIFERON ( R ) - TB GOLD NEGATIVE NEGATIVE [ * * 2174 - 4 - 29 * * ] ACE , SERUM 30 [ * * 10/2130 * * ] U/L
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100039.txt
294
Micro : [ * * 2174 - 4 - 25 * * ] 1 : 07 pm PERITONEAL FLUID GRAM STAIN ( Final [ * * 2174 - 4 - 25 * * ] ) : NO POLYMORPHONUCLEAR LEUKOCYTES SEEN .
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100039.txt
295
NO MICROORGANISMS SEEN .
[ 0, 0, 0, 0 ]
[ "NO", "MICROORGANISMS", "SEEN", "." ]
100039.txt
296
FLUID CULTURE ( Final [ * * 2174 - 4 - 28 * * ] ) : NO GROWTH .
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[ "FLUID", "CULTURE", "(", "Final", "[", "*", "*", "2174", "-", "4", "-", "28", "*", "*", "]", ")", ":", "NO", "GROWTH", "." ]
100039.txt
297
ANAEROBIC CULTURE ( Final [ * * 2174 - 5 - 1 * * ] ) : NO GROWTH .
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[ "ANAEROBIC", "CULTURE", "(", "Final", "[", "*", "*", "2174", "-", "5", "-", "1", "*", "*", "]", ")", ":", "NO", "GROWTH", "." ]
100039.txt
298
ACID FAST CULTURE ( Preliminary ) : NO MYCOBACTERIA ISOLATED .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "ACID", "FAST", "CULTURE", "(", "Preliminary", ")", ":", "NO", "MYCOBACTERIA", "ISOLATED", "." ]
100039.txt
299
ACID FAST SMEAR ( Final [ * * 2174 - 4 - 30 * * ] ) : NO ACID FAST BACILLI SEEN ON DIRECT SMEAR .
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100039.txt