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metaboulie
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c2n2_2018_with_prediction_test

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301
Electrolyte disturbances : Pt developed hypernatremia on [ * * 2172 - 9 - 4 * * ] most likley due to dehydration with free water deficit of 1.4L , started on D5W .
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Pt had hyponatremia and hyperkalemia on admission , both resolved .
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Unclear etiology of electrolyte disturbances on admission - hyponatremia thought to be secondary to possible adrenal insufficency ( now discarded ) or possibly SIADH .
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Low UNa does not exclude SIADH ; renal recommended rechecking urine lytes with saline load , whcih was not done in setting of pt??????s other medical issues .
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Hyperkalemia originally attributed to hypoaldosteronism and Type IV RTA , but unlikely per endocrine because of low urine sodium .
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SVC syndrome : Incomplete occlusion of SVC ; near complete occlusion of brachiocephalic veins .
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Clinically identified by upper extremity and facial swelling/plethora and mottled skin .
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Also with scleral edema .
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Unable to assess jugular venous distension given considerable swelling .
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312
Seen in appoximately 10 % cases of SSLC .
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313
Improved edema on exam compared to admission .
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SVC syndrome occurred after Y - stent placed .
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315
Possible that tumor pushing into trachea shifted to compress SVC after stent placement .
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316
She underwent radiation therapy and chemotherapy for decompression .
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319
Pleural effusion : s/p right pigtail catheter placement [ * * 2172 - 8 - 25 * * ] , removed [ * * 2172 - 8 - 31 * * ] .
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320
LDH effusion/serum 0.68 ( exudate by Light??????s criteria ) .
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Greatest concern for malignant effusion however cytology was nonspecific .
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[ 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1 ]
[ -100, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, -100 ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
322
Cultures of fluid all preliminary negative .
[ 0, 0, 0, 0, 0, 0, 0 ]
[ "Cultures", "of", "fluid", "all", "preliminary", "negative", "." ]
100509.txt
[ 2, 4819, 1685, 4171, 1948, 7249, 3055, 17, 3 ]
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[ 1, 1, 1, 1, 1, 1, 1, 1, 1 ]
[ -100, 0, 0, 0, 0, 0, 0, 0, -100 ]
[ "O", "O", "O", "O", "O", "O", "O" ]
[ "O", "O", "O", "O", "O", "O", "O" ]
323
.
[ 0 ]
[ "." ]
100509.txt
[ 2, 17, 3 ]
[ 0, 0, 0 ]
[ 1, 1, 1 ]
[ -100, 0, -100 ]
[ "O" ]
[ "O" ]
324
# .
[ 0, 0 ]
[ "#", "." ]
100509.txt
[ 2, 6, 17, 3 ]
[ 0, 0, 0, 0 ]
[ 1, 1, 1, 1 ]
[ -100, 0, 0, -100 ]
[ "O", "O" ]
[ "O", "O" ]
325
Pneumothorax : Developed pneumothorax in setting of re - intubation that resolved after chest tube placement .
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100509.txt
[ 2, 18860, 29, 2829, 18860, 1682, 3822, 1685, 1726, 16, 11546, 1760, 7888, 1970, 6429, 6813, 7730, 17, 3 ]
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[ 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1 ]
[ -100, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, -100 ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
326
.
[ 0 ]
[ "." ]
100509.txt
[ 2, 17, 3 ]
[ 0, 0, 0 ]
[ 1, 1, 1 ]
[ -100, 0, -100 ]
[ "O" ]
[ "O" ]
327
# .
[ 0, 0 ]
[ "#", "." ]
100509.txt
[ 2, 6, 17, 3 ]
[ 0, 0, 0, 0 ]
[ 1, 1, 1, 1 ]
[ -100, 0, 0, -100 ]
[ "O", "O" ]
[ "O", "O" ]
328
Pericardial effusion : Suspected by cardiology to be malignant effusion .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "Pericardial", "effusion", ":", "Suspected", "by", "cardiology", "to", "be", "malignant", "effusion", "." ]
100509.txt
[ 2, 15737, 10852, 29, 6926, 1772, 18478, 1701, 1765, 4754, 10852, 17, 3 ]
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[ 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1 ]
[ -100, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, -100 ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
329
Felt not to be large enough for percutaneous drainage .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "Felt", "not", "to", "be", "large", "enough", "for", "percutaneous", "drainage", "." ]
100509.txt
[ 2, 13146, 1888, 1701, 1765, 2892, 9757, 1725, 7769, 8869, 17, 3 ]
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1 ]
[ -100, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, -100 ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
330
EKG without signs of electrical alternans but does have low voltages .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "EKG", "without", "signs", "of", "electrical", "alternans", "but", "does", "have", "low", "voltages", "." ]
100509.txt
[ 2, 46, 19708, 2615, 5403, 1685, 6518, 3839, 1842, 2027, 4042, 1953, 2052, 26760, 17, 3 ]
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[ -100, 0, -100, 0, 0, 0, 0, 0, -100, 0, 0, 0, 0, 0, 0, -100 ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
331
Repeat ECHO done [ * * 2172 - 9 - 5 * * ] in setting of hypotension demonstrated no change in pericardial effusion .
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100509.txt
[ 2, 6646, 10268, 6168, 36, 13, 13, 21399, 1020, 16, 28, 16, 24, 13, 13, 38, 1682, 3822, 1685, 11864, 2857, 1982, 3113, 1682, 15737, 10852, 17, 3 ]
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332
.
[ 0 ]
[ "." ]
100509.txt
[ 2, 17, 3 ]
[ 0, 0, 0 ]
[ 1, 1, 1 ]
[ -100, 0, -100 ]
[ "O" ]
[ "O" ]
333
# Sinus Pause on telemetry : Pt had episodes of sinus pauses on tele night of [ * * 8 - 30 * * ] with turning to right side .
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100509.txt
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334
Occurred again [ * * 2172 - 9 - 4 * * ] again with re - positioning .
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100509.txt
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[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
335
Metoprolol was held and glucagon given in case this was due to beta blocker toxicity , but pauses decreased in frequency and duration on their own without intervention .
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100509.txt
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336
Cardiology consulted who felt it was vagally mediated .
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100509.txt
[ 2, 18478, 26071, 2386, 13146, 2021, 1734, 15533, 1716, 3356, 17, 3 ]
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[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
337
[ * * Month ( only ) 116 * * ] have been due to ETT tube displacement pressing on carotid when pt was turned .
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100509.txt
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338
.
[ 0 ]
[ "." ]
100509.txt
[ 2, 17, 3 ]
[ 0, 0, 0 ]
[ 1, 1, 1 ]
[ -100, 0, -100 ]
[ "O" ]
[ "O" ]
339
# Leukopenia / thrombocytopenia ?????? Most likely due to chemotherapy and no improvement in counts on neupogen .
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100509.txt
[ 2, 6, 27045, 18, 12467, 34, 34, 34, 34, 34, 34, 2261, 3536, 2741, 1701, 4365, 1690, 1982, 3978, 1682, 7138, 1755, 2408, 16462, 2129, 17, 3 ]
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340
She was repeatedly pan - cultured with negative results .
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100509.txt
[ 2, 4612, 1734, 14817, 5536, 16, 5038, 1715, 3055, 1890, 17, 3 ]
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[ 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1, 1 ]
[ -100, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, -100 ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
341
.
[ 0 ]
[ "." ]
100509.txt
[ 2, 17, 3 ]
[ 0, 0, 0 ]
[ 1, 1, 1 ]
[ -100, 0, -100 ]
[ "O" ]
[ "O" ]
342
# .
[ 0, 0 ]
[ "#", "." ]
100509.txt
[ 2, 6, 17, 3 ]
[ 0, 0, 0, 0 ]
[ 1, 1, 1, 1 ]
[ -100, 0, 0, -100 ]
[ "O", "O" ]
[ "O", "O" ]
343
Anemia : Normocytic and likely due to anemia of chronic disease given malignancy .
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100509.txt
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[ -100, 0, 0, 0, -100, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, -100 ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
[ "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O", "O" ]
344
Hemolysis labs were negative .
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[ "Hemolysis", "labs", "were", "negative", "." ]
100509.txt
[ 2, 17259, 2784, 1026, 1748, 3055, 17, 3 ]
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[ 1, 1, 1, 1, 1, 1, 1, 1 ]
[ -100, 0, 0, -100, 0, 0, 0, -100 ]
[ "O", "O", "O", "O", "O", "O" ]
[ "O", "O", "O", "O", "O", "O" ]
345
.
[ 0 ]
[ "." ]
100509.txt
[ 2, 17, 3 ]
[ 0, 0, 0 ]
[ 1, 1, 1 ]
[ -100, 0, -100 ]
[ "O" ]
[ "O" ]
346
# s/p cerebral aneurysm repair : History of cerebral aneurysm repair with a number of chronic changes on head CT .
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100509.txt
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347
Her antiepileptic medications were continued .
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100509.txt
[ 2, 3426, 18568, 7544, 1748, 7159, 17, 3 ]
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[ 1, 1, 1, 1, 1, 1, 1, 1 ]
[ -100, 0, 3, 12, 0, 0, 0, -100 ]
[ "O", "B-Drug", "I-Drug", "O", "O", "O" ]
[ "O", "B-Drug", "I-Drug", "O", "O", "O" ]
348
Medications on Admission : Home medications : Metoprolol Omeprazole Levetiracetam Carbatrol
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100509.txt
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349
Medications on transfer to [ * * Hospital Unit Name 153 * * ] [ * * 2172 - 8 - 27 * * ] : Furosemide 10 mg IV ONCE Duration : 1 Doses Carbamazepine 900 mg PO QPM Carbamazepine 400 mg PO QAM Artificial Tears Preserv .
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100509.txt
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350
Free 1 - 2 DROP BOTH EYES PRN dry eyes Potassium Phosphate IV Sliding Scale Insulin SC Sliding Scale Insulin Regular 10 UNIT IV ONCE , Dextrose 50 % 25 gm IV ONCE Duration : 1 Doses 08/20 @ 0608 Propofol 20 - 50 mcg/kg/min IV DRIP TITRATE TO moderate/heavy sedation Chlorhexidine Gluconate 0.12 % Oral Rinse 15 mL ORAL [ * * Hospital1 * * ] Hydrocortisone Na Succ .
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100509.txt
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351
100 mg IV Q8H Nicotine Patch 14 mg TD DAILY LeVETiracetam 500 mg IV BID Magnesium Sulfate IV Sliding Scale Calcium Gluconate IV Sliding Scale Potassium Chloride IV Sliding Scale Albuterol - Ipratropium [ * * 1 - 10 * * ] PUFF IH Q6H Pantoprazole 40 mg IV Q24H Heparin 5000 UNIT SC TID Fentanyl Citrate 25 - 100 mcg IV Q6H : PRN Sedation
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100509.txt
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352
Discharge Medications : Expired
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100509.txt
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353
Discharge Disposition : Expired
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100509.txt
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354
Discharge Diagnosis : Expired
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100509.txt
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355
Discharge Condition : Expired
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100509.txt
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356
Discharge Instructions : Expired
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100509.txt
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357
Followup Instructions : Expired
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100509.txt
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358
[ * * First Name8 ( NamePattern2 ) * * ] [ * * Last Name ( NamePattern1 ) 2437 * * ] MD [ * * MD Number ( 1 ) 2438 * * ]
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100509.txt
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359
Admission Date : [ * * 2171 - 3 - 26 * * ] Discharge Date : [ * * 2171 - 3 - 29 * * ]
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100511.txt
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360
Date of Birth : Sex : F
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100511.txt
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361
Service : GYN/ONCOLOGY
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100511.txt
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362
HISTORY OF PRESENT ILLNESS : The patient is a 58 year - old P3 who presented to Dr .
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100511.txt
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363
[ * * First Name ( STitle ) 1022 * * ] with a large pelvic mass .
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100511.txt
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364
She had a history of undergoing exploratory laparotomy for appendicitis in [ * * 2170 - 5 - 28 * * ] .
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100511.txt
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365
At that time a necrotic right fallopian tube was excised and the patient was noted to have a pelvic mass .
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100511.txt
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366
No further follow up until recently when she presented to [ * * Hospital6 1597 * * ] with severe anemia and a gastrointestinal bleed .
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100511.txt
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367
She had a transfusion with 7 units of whole blood .
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100511.txt
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368
She had a CT during her hospitalization , which revealed a large abdominal and pelvic mass .
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100511.txt
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369
She had a full gastrointestinal evaluation , which included an upper endoscopy , colonoscopy and small bowel follow through all of which were negative .
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100511.txt
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370
The patient states that during colonoscopy the right side of the colon could not be visualized due to the presence of the mass .
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100511.txt
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371
The patient complains of nausea and increased abdominal girth .
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372
She has chronic constipation and there is nothing new .
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100511.txt
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373
There is no other change in bowel or urinary habits .
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100511.txt
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374
She denies any vaginal bleeding and any weight loss .
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100511.txt
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375
PAST MEDICAL HISTORY : 1 .
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376
Hypertension .
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100511.txt
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377
2 .
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100511.txt
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378
Psoriasis .
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379
3 .
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100511.txt
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380
Chronic pain syndrome .
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100511.txt
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381
PAST SURGICAL HISTORY : Uterine embolization [ * * 2169 - 11 - 28 * * ] .
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100511.txt
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382
Tubal ligation in [ * * 2143 * * ] .
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100511.txt
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383
Decompression and fusion [ * * 2169 * * ] .
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100511.txt
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384
Appendectomy [ * * 2169 * * ] .
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100511.txt
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Multiple breast adenoma excisions .
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100511.txt
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ALLERGIES : No known drug allergies .
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100511.txt
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MEDICATIONS : 1 .
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100511.txt
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388
Tylenol .
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100511.txt
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389
2 .
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100511.txt
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Lasix .
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391
3 .
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100511.txt
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Ativan .
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100511.txt
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393
4 .
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100511.txt
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394
OxyContin .
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100511.txt
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395
5 .
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100511.txt
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396
Celexa .
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100511.txt
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397
6 .
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100511.txt
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398
Atarax .
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100511.txt
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399
7 .
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100511.txt
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