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Vital signs
BP 120/75 , Wt 228 lb
Physical Exam
108/70
GENERAL : Healthy appearing overweight female
NECK : No thyromegaly , no nodes
CHEST Clear lungs , NL frame
COR : RRR , NL S1S2 , no murmur , rubs , or gallops .
BIMAN c no adnexal masses , no CMT
EXT : No edema
NEURO : NL MS , NL gait
Labs reviewed
EKG done and unchanged from 8/82
Assessment and Plan
1 .
Chest pain , Headaches and shortness of breath #NAME? No evidence of USA .
All likely secondary to anxiety and grief over father's death .
Patient reassured .
Will continue cardiac medications .
Return to cardiac rehab on Thursday .
Will add . 5mg klonipin during the day as needed .
Continue 1mg klonipin at night .
Patient declines psychotherapy .
Also , will restart nexium as some of chest pain may be recurrence of reflux .
2 .
DM #NAME? Encouraged patient to take glucophage as prescribed .
She is worried she will always have DM .
Discussed with patient importance of controlling BSs now and losing remaining weight .
She will continue to monitor home FSBS .
3 .
Obesity #NAME? Impressive 90 pound weight loss .
Patient very encourage .
Continue with smaller meals .
4 . Hyperlipidemia #NAME? Patient will restart lipitor .
Follow up fasting cholesterol and SGOT .
5 . CAD #NAME? Continue Imdur , aspirin and lipitor .
Cardiac rehab . | {"AGE": [], "CONTACT": [], "DATE": ["Thursday", "8/82"], "DEVICE": [], "DLN": [], "HOSPITAL": [], "ID": [], "LOCATION": [], "NAME": [], "ORGANIZATION": [], "PHONE": [], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
Record date: 2089-01-27
Potomac Valley Hospital
Preadmission Testing Area
History & Physical Examination
and Anesthesia Assessment
Yvonne Easton, N.P.
Jenna Corona, N.P.
Xochitl Narvaez, N.P.
Frederick Q. Valladares, M.D.
Medical Director
January 27, 2089
Medical Record Number: 8751045 Francisco, Xue
Procedure: The patient is a 56-year-old Spanish-speaking female scheduled for laparoscopic cholecystectomy. Surgery is scheduled on January 28, 2089 by Dr. Xavier Israel kenneth Xenos.
Chief Complaint & Present Illness: Patient briefly evaluated on 12/30/88 as part of preoperative evaluation for a laparoscopic cholecystectomy then scheduled for 12/31/88. Over the past year patient has had difficulty with right upper quadrant pain as well as epigastric pain. These episodes tend to happen more frequently after she has had a rich meal. Other symptoms that occurred include nausea and vomiting. Patient denies jaundice. Today, patient states that she still has some abdominal tenderness greatest at the right costal margin and radiating into right flank.
At the time of evaluation on 12/30/88 patients had symptoms of URI and LRI. She reported back/green sputum, mild shortness of breath and increased use of her grandson's inhaler. After consultation with Dr. Valladares it was decided that patient should be evaluated by her primary care provider for further treatment of her respiratory tract infection and then follow-up with surgeon to reschedule her surgery. Patient reports that she went to University Hospital and there they treated her with antibiotics and inhaler. Unfortunately patient is unable to recall the name of the antibiotic or the inhaler. Currently she denies any symptoms of sputum production, cough, shortness of breath, or wheezing. Also denies fever, chills, nausea, vomiting, and diarrhea.
Patient does have a history of coronary artery disease. She is status post an MI 11/82. Patient had cardiac catheterization at OSH 12/3/82 that reportedly showed a critical mid right lesion and a mild left main and left anterior descending lesion. 12/09/82 patient underwent cardiac catheterization at PVH and a PTCA was done. Patient did well until 10/83 when she was admitted to PVH with symptoms of chest tenderness, left arm pain, tachycardia, palpitations, diaphoresis, dry mouth, shortness of breath, dizziness, and darkening of revision. Patient did rule out for MI by serial enzymes and there are no changes seen on her ECG. Patient denies any difficulty with chest pain or left arm pain since that time. She has had episodes of shortness of breath with exertion however, these seem more related to her respiratory status rather than her cardiac disease.
Stress test done 1/26 showed a normal exercise capacity (METS=7), ECG nondiagnostic for ischemia and the perfusion images were suggestive of anterior ischemia although body habitus limited the interpretation.
Past Medical History: Significant medical problems include:
1. Hypertension
2. CAD, status post MI 2082, status post PTCA 2082
3. Asthma (no hospitalizations or intubations)
4. Arthritis
5. Systemic Lupus Erythematosus (with clinical manifestations of arthralgia, TTP and a high urine titer)
6. Chronic low back pain, history of herniated discs
7. Depression
Past Surgical History: Prior surgery includes:
1. Status post cardiac catheterization and PTCA, 9/82
2. Status post D&C secondary to prolonged menstrual bleeding
3. Status post tubal ligation
4. Status post T&A
Family History: There is no family history of adverse reactions to general anesthesia.
Brother: alive, CAD
Brother: alive, kidney disease
2 brothers: both alive, diabetes
Sister: deceased age 38, breast CA
Medications:
paxil 20 mg q.d.
atenolol 25 mg q.d.
prednisone 10 mg q.d.
hydroxychloroquine q.d.
nifedipine XR 60 mg q.d.
isosorbide 10 mg t.i.d.
asthma inhaler (patient unable to recall name)
aspirin
Allergies: NKA
denies food and environmental allergies
Social History:
Smoking: denies
Alcohol use: denies
Substance Abuse: denies
Allergen Exposure (blood products/pregnancy): none in last 3 months
Exercise: going up and down stairs usually, shortness of breath, expanses released when she rests at the top of the stair and drinks water; able to do light housework
Occupation: Firefighter
Marital Status: divorced, four children
Review of Systems:
General: negative
HEENT: currently, LRI symptoms have resolved and patient feels much better
Cardiovascular: see HPI
Respiratory: patient reports a diagnosis of asthma however her primary care provider (Dr. Younker X1-1335) who has seen patient for two years does not recall patient having any diagnosis of asthma
Neurological: 9/81 patient admitted to PVH with thrombocytopenia purpura. Suffered a cerebral thrombus with infarction. Symptoms at the time of admission were severe headache, facial numbness, and facial droop as well as mutism. Patients underwent plasma phosphor uses and became acutely hypoxic and hypotensive requiring emergent intubation. Was felt that patient's symptoms or secondary to a transfusion reaction. No residual symptoms.
Gastrointestinal: negative
Hepatobiliary: negative
Renal/Genitourinary: negative
Musculoskeletal: arthritis affecting hands, and hips, knees, ankles, and elbows
Peripheral Vascular: negative
Endocrine/metabolic: history of SLE
Heme/Onc: negative
Psychiatric: negative
Skin: negative
Vital Signs:
BP: 149/75 mm Hg
P: 61 bpm
SaO2: 98%
Temp: 98.2 degrees F
Resp: 16 rpm
Ht: 64 inches
Wt: 196.6 pounds
Exam:
General: well developed, well nourished female
HEEN&T: buffalo hump, fair range of motion, no masses, neck veins flat, no bruits
Airway: Mallampatti Class I
Teeth: in good repair
Lungs: clear to auscultation
Heart: regular rhythm, no murmurs, S1=S2, no gallop
Abdomen: diffuse abdominal tenderness with increased tenderness to palpation at costal margin right upper quadrant and radiating into flank, soft, not distended, normal bowel sounds, no organomegaly or palpable masses
GU/Rectal: no CVA tenderness
Lymphatics: no lymphadenopathy
Peripheral Vascular:
carotids: 2+ bilateral no bruits
radials: 2+ bilateral
Neurological:
cranial nerves: II-XII grossly intact
Extremities: no edema, lower extremities
Skin: no ulcers or rashes observed
Assessment:
ASA Physical Status II
56-year-old female with a history of CAD, SLE, hypertension, arthritis, asthma and chronic low back pain presents for laparoscopic cholecystectomy. Patient originally scheduled for surgery on 12/31/88 however because of LRI surgery was postponed. Patient much improved, lungs clear, no wheezing, no shortness of breath. It has only been three-week since her infection and therefore increased airway reactivity may be an issue. Dr. Hoffman explained this to patient. Dr. Hoffman also reviewed with patient medications to take prior to surgery 1/28/89. Currently, patient denies any symptoms of cardiac ischemia. Does have chronic chest pain/tenderness which is reproducible by palpation. Patient states that this is not her "cardiac pain".
Plan:
Proposed Anesthetic: general
Monitors: standard
Pain Management: oral
Autologous blood: none
Premedication: stress steroid dosing
Usual Medications: paxil, atenolol, prednisone, hydroxychloroquine, nifedipine, Naprosyn, isosorbide, asthma inhaler, aspirin
Medications to be held on day of surgery: hydroxychloroquine, Naprosyn, aspirin
Diabetic medications: not applicable
NSAIDS: will stop as of 1/27/89
Aspirin: will stop as of 1/27/89
NPO: after midnight the evening before surgery
Ancillary Studies:
Pending
_______________________________________________
Jenna Q. Corona, MSN, RN, CS
PATA Medical Director Note:
I have reviewed this preanesthetic assessment and concur with the assessment and recommended plan with the following exceptions:
signed: ____________________________________________________________
Attending Surgeon Reassessment Note:
I have reviewed the above history and physical exam and agree with the findings. Additional comments:
signed: ___________________________________________________________ | {"AGE": ["56", "38", "56"], "CONTACT": ["1-1335"], "DATE": ["2089-01-27", "January 27, 2089", "January 28, 2089", "12/30/88", "12/31/88", "12/30/88", "11/82", "12/3/82", "12/09/82", "10/83", "1/26", "2082", "2082", "9/82", "9/81", "12/31/88", "1/28/89", "1/27/89", "1/27/89"], "ID": ["8751045"], "LOCATION": ["Potomac Valley Hospital", "University Hospital", "PVH", "PVH", "PVH"], "NAME": ["Yvonne Easton", "Jenna Corona", "Xochitl Narvaez", "Frederick Q. Valladares", "Francisco, Xue", "Xavier Israel kenneth Xenos", "Valladares", "Younker", "Hoffman", "Hoffman", "Jenna Q. Corona"], "PROFESSION": ["Firefighter"]} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"AGE": [], "CONTACT": [], "DATE": [], "ID": [], "LOCATION": [], "NAME": [], "PROFESSION": []} |
Fracture of the femoral neck occurred in one patient during PSL therapy , although the relationship between the fracture and PSL therapy was uncertain . | {"drugs": [{"name": "PSL", "reaction": ["Fracture of the femoral neck"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"drugs": [{"name": "", "reaction": []}]} |
OSA
Obesity
Osteoporosis
Avascular necrosis of R hip/knee
Depression
Psoriasis
Meds on Admit :
acyclovir 200mg po TID
albuterol inhaler 90mcg/spray inh q4-6h PRN
Albuterol Nebulizer 3ml ( 0.083% ) neb q4h PRN
azithromycin 250mg tab po MWF
Bactrim single strength 1 tab po MWF
calcium citrate 600 mg po bid
Cellcept 500mg po bid
colistin 150 mg inhaled qd
Cozaar 100mg po qd
doxycycline 100mg po bid
Lasix 40 mg po qd
Lipitor 40mg po qd
magnesium gluconate 1000mg po tid
multivitamins 1 tab po qd
Nexium 20mg po qd
Norvasc 5 mg po qd
pamidronate 60mg iv q 6 months
potassium chloride 20mEq po bid
prednisone 15mg po qd
Prograf 1mg 6 caps po bid
Reglan 5mg po qac , qhs
Toprol XL 50 mg po qd
vitamin d 50000 IU po q week
Allergies :
NKDA
Family Hx :
Breast cancer - relatives
Social Hx :
Lives in Florida w/ wife . | {"AGE": [], "CONTACT": [], "DATE": [], "DEVICE": [], "DLN": [], "HOSPITAL": [], "ID": [], "LOCATION": ["Florida"], "NAME": [], "ORGANIZATION": [], "PHONE": [], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
Salicylate -induced hepatotoxicity is reviewed . | {"drugs": [{"name": "Salicylate", "reaction": ["hepatotoxicity"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"drugs": [{"name": "", "reaction": []}]} |
Record date: 2076-09-08
CARDIOLOGY
LAURENS MEMORIAL HOSPITAL
Reason for visit:
Positive stress test.
Interval History:
The patient is a seventy-four year old man with multiple coronary risk factors. As part of a work-up for his prostate cancer, stress test was performed on 6/30/76. Myocardial scans showed old inferolateral MI with mild ischemia. EF was 50%. The patient denies any cardiac symptoms such as chest discomfort, SOB, palpitations, or dizziness.
Past medical history:
Prostate CA - RXT
DVT
Hypertension
PVD
DM x 2-3 yrs.
COPD
h/o vocal cord polyp resection - 2064
Medications (Confirmed):
ASA 81 mg po qd
docusate sodium 100 mg po tid
free text medications
gabapentin 100mg po tid
glyburide 10mgqam, 5 mg. qpm po qd
HCTZ
Lipitor 20mg po qd
lisinopril 10 mg po qd
metformin hydrochloride 500 mg po bid
Prilosec 40mg po qd
Toprol XL
Family history:
Negative for CAD.
Social history:
The patient was a CPA and is now retired. He lives with his wife.
Review of systems:
Due to back pain, his physical activity is pretty much limited. He quit smoking in 1/76.
Physical examination:
-BMI: 34.6 Obese, high risk
-Pulse: 72
-height: 66 in.
-weight: 214 lbs.
-Neck: JVP was not distended. Carotid upstroke was normal.
-Chest: Breath sounds were coarse.
-Cardiac: There was an S1 and S2.
-Abdomen: Obese
-Extremities: FA 2+/1+ with bilateral bruit. DP not palpable. Distal capillary filling - good.
-Neuro:
-BP: 125/60
EKG:
NSR @ 73 bpm. Mild non-specific STT wave changes.
Selected recent labs:
Liver and Pancreatic Enzymes
Date ALT/SGPT AST/SGOT
09/06/76 28 25
Lipid/Thyroid
Date LDL
09/06/76 145
Immunology
Date HGBA1C
09/06/76 6.80
Assessment and plan:
It looks like Mr. Quin has had an MI sometime in the past. Myocardial scans showed only mild ischemia in the territory of the prior MI. Since he is asymptomatic, I would continue medical therapy. For some reason, he has not started Lipitor. His LDL is markedly elevated. My target LDL would be below 70. For his myocardial protection, I have suggested that he increase the dose of Toprol from 25 mg. qd to 50 mg. qd.
Changes to Medications this visit
glyburide 10mgqam, 5 mg. qpm po qd Start: 09/08/2076
metformin hydrochloride 500 mg po bid Start: 09/08/2076
lisinopril 10 mg po qd Start: 09/08/2076
Toprol XL 25 mg po qd Start: 09/08/2076
Lipitor 20mg po qd Start: 09/08/2076
Prilosec 40mg po qd Start: 09/08/2076
docusate sodium 100 mg po tid Start: 09/08/2076
HCTZ 12.5 mg po qd Start: 09/08/2076
ASA 81 mg po qd Start: 09/08/2076
free text medications morphine Start: 09/08/2076
gabapentin 100mg po tid Start: 09/08/2076
Disposition:
Follow-up in one year.
CC: Eddie Zajac, M.D.
Signed electronically by Freddie-Verne Urie MD on Sep 13, 2076 | {"AGE": ["seventy-four"], "CONTACT": [], "DATE": ["2076-09-08", "6/30/76", "2064", "1/76", "09/06/76", "09/06/76", "09/06/76", "09/08/2076", "09/08/2076", "09/08/2076", "09/08/2076", "09/08/2076", "09/08/2076", "09/08/2076", "09/08/2076", "09/08/2076", "09/08/2076", "09/08/2076", "Sep 13, 2076"], "ID": [], "LOCATION": ["LAURENS MEMORIAL HOSPITAL"], "NAME": ["Quin", "Eddie Zajac", "Freddie-Verne Urie"], "PROFESSION": ["CPA"]} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"AGE": [], "CONTACT": [], "DATE": [], "ID": [], "LOCATION": [], "NAME": [], "PROFESSION": []} |
Etoh - none .
Family History
Brother with DM .
Review of Systems
No dizziness , F/C , cough , SOB , CP , dysuria , joint pain .
Physical Exam
BP : 162/78 T : 98.6 P : 84 RR : 18
GENERAL : Appears sleepy in her bed .
SKIN : NL turgor , no abnormal lesions
CHEST : Clear lungs , NL frame
COR : NL S1S2 , no murmur , rubs , or gallops .
ABD : Hypoactive BS ;
diffuse tenderness but no guarding or rebound ;
no HSM .
EXT : No edema , clubbing , or cyanosis
NEURO : NL MS
Assessment and Plan
1 .
Nausea/vomiting : Most likely secondary to her gastroparesis .
Her amylase and lipase are also elevated , raising the question of pancreatitis as well .
Will check abd-pelvic CT .
NPO with IVF .
Continue Reglan and erythromycin .
GI has been consulted for further recommendations .
Morphine prn abdominal pain .
2 .
DM : Continue glucophage .
Adjust insulin depending on BS .
3 .
HTN : Continue lisinopril and atenolol .
_____________________________________________
Mildred D . Yunker , M.D .
Record date : 2087-09-03
Kekela Internal Medicine Intern Admission Note
Patient Name : Gillis , Betty
MRN : 8308652 | {"AGE": [], "CONTACT": [], "DATE": ["2087-09-03"], "DEVICE": [], "DLN": [], "HOSPITAL": ["Kekela"], "ID": ["8308652"], "LOCATION": [], "NAME": ["Mildred D . Yunker", "Gillis , Betty"], "ORGANIZATION": [], "PHONE": [], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
Development of an extensive skin rash following a single dose of MTX may be an early warning sign for life-threatening bone marrow aplasia . | {"drugs": [{"name": "MTX", "reaction": ["extensive skin rash"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"drugs": [{"name": "", "reaction": []}]} |
( s)Flomax ( TAMSULOSIN ) 0.4 MG ( 0.4MG CAP.SR 24H Take 1 ) PO QD , take after meals #90 CAP.SRFolic Acid 1 MG ( 1MG TABLET Take 1 ) PO BID x 90 days #180 Tablet
( s)Glipizide 10 MG ( 10 MG TABLET Take 1 ) PO BID , Dr Willis #180 Tablet
( s)Glucophage ( METFORMIN ) 1000 MG ( 500MG TABLET Take 2 ) PO BID #360 Tablet
( s)Hydrochlorothiazide 25 MG ( 25MG TABLET Take 1 ) PO QD #90 Tablet
( s)Lipitor ( ATORVASTATIN ) 80 MG ( 80 MG TABLET Take 1 ) PO QHS , Dr Gil -increased September 2070 #90 Tablet
( s)Multivitamins 1 TAB PO QD #90 tablet
( s)Norvasc ( AMLODIPINE ) 10MG TABLET PO QD , Dr Garza #90 Tablet
( s)Ntg 1/150 ( NITROGLYCERIN 1/150 ( 0.4 Mg )) 1 TAB SL as directed #30 tablet
( s)One Touch PO Vasotec ( ENALAPRIL Maleate ) 20 MG ( 20MG TABLET Take 1 ) PO QD #90 Tablet
( s)Zantac ( RANITIDINE Hcl ) 150 MG ( 150MG TABLET Take 1 ) PO BID , prn #180 Tablet
( s)Habits Tobacco : no smokingReview of Systems No change in wt .
No chronic pain .
No headaches , visual disturbances , hearing problems .
No CP or palpitations .
No dyspnea , "cough,or wheezing .
No abdominal pain , nausea , vomiting , constipation , diarrhea , BRBPR , or melena .
No dysuria or difficulty with urination .
.
No joint pain or swelling .
No skin changes or rash .
Vital Signs BLOOD PRESSURE 134/70PULSE 60WEIGHT 208 lbExam Physical Exam General Appearance well-appearing , NAD .
Status post cardiac surgery scars in the past Skin No rashes or suspicious lesions .
HEENT PERRLA .
EOMI .
Sclerae non-icteric .
TMs are clear bilaterally .
OP is clear without erythema or exudate .
Neck is supple .
No LAD .
No thyromegaly .
Nodes/Lymphatic No nodes in cervical or supraclavicular area Chest CHEST:A& ;
P-normal bilaterally with good air movement .
No local rales or wheezing Cor/Cardiac regular rate , normal S1 , S2 .
No rubs , gallops , or murmurs .
Abdomen soft , nontender , nondistended , #NAME? sounds , no HSM Extremity warm , no C/C/E .
Bilateral knees without effusion.Pulses #NAME? good
Sensation-satisfactory fo light touch Neurological A+Ox3 . | {"AGE": [], "CONTACT": [], "DATE": ["September 2070"], "DEVICE": [], "DLN": [], "HOSPITAL": [], "ID": [], "LOCATION": [], "NAME": ["Garza", "Gil", "Willis"], "ORGANIZATION": [], "PHONE": [], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
CV : RRR , s1s2 , nl , II/VI SEM at LSB
Abd : soft , NT
Ext : no c/c/bil trace edema .
No foot ulcerations .
A/P :
1 .
HTN .
Stable , no change in regimen .
Dietary and exercise rec's reviewed .
2 .
DM .
A1C today 7.9 ( improved from 8.5 in 6/2089 "),
No change in regimen , being followed at MS .
Dietary and exercise rec's reviewed .
Home FS monitoring as directed .
3 .
Scheduled for f/up of diabetic retinopathy 1/12/90 at HDC .
Singh , M.D .
#NAME?
Record date : 2089-09-20
Personal Data and Overall Health
Mr . Parrish is 72 y.o . Unfortunatley had a stroke leaving him with L-hemiplegia in 2088 .
He is living independently with the help of a home health aide and friends .
Has seen Dr . Ashley of Cardiology , Dr . Scott or Opthalmology , Dr . Insley of Endocrinology , Dr . Lane of Neurology and Dr . Johnathan Kiefer of Neurology .
Reason for Visit
Established patient .
Annual PE .
Problems
hypertension
Pt .
has hypertension .
He is currently managed on Beta-blocker , ACE inhibitor , calcium channel blocker , and diuretic .
BP today is 150/90 .
Will plan to titrate BP meds .
Low-salt diet .
diabetes mellitus
Pt . | {"AGE": ["72"], "CONTACT": [], "DATE": ["2088", "6/2089", "1/12/90", "2089-09-20"], "DEVICE": [], "DLN": [], "HOSPITAL": ["HDC", "MS"], "ID": [], "LOCATION": [], "NAME": ["Ashley", "Insley", "Lane", "Johnathan Kiefer", "Singh", "Scott", "Parrish"], "ORGANIZATION": [], "PHONE": [], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
A 65-year-old woman , in the intensive care unit because of septic shock and acute renal failure , had a small-bowel obstruction due to Amphojel concretions . | {"drugs": [{"name": "Amphojel", "reaction": ["small-bowel obstruction"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"drugs": [{"name": "", "reaction": []}]} |
Most recent vascular lab studies dated November 29 , 2070 reveal an ABI of 0.96 on the right , 0.56 on the left .
I will keep you informed as to the status of Mr . Xuereb .
My concern is that if he does infect this PTFE graft we do not have any suitable autogenous conduit to perform an additional reconstruction and he would stand a very high chance of losing his limb at the knee level .
If I can be of any further assistance in the management of this or any of your other patients with vascular disease , particularly those in need of a minimally invasive vascular procedure , please feel free to contact me directly .
Sincerely ,
Shane R . Herring , M.D .
cc : Dirk O . Reece , M.D "., 9 Church Street , Pune , ME 99597
SH/truitt 89-05167655.doc
#NAME?
Record date : 2071-04-14
Patient Name : XUEREB , JAQUANTE ;
MRN : 1344351
Dictated on : 04/27/2071 by LILLIAN STEELE , N.P "., PH.D .
Mr . Xuereb returns to clinic for evaluation and management of recurrent ulcerations on the hypertrophic scar tissue along the medial aspect of the right lower extremity .
Today , on physical examination , the wound bed measured 1 cm x 0.7 cm .
The wound bed was covered with yellow biofilm , which was debrided .
The underlying wound bed contained moist red tissue with a few drops of bloody drainage .
The margin was clear .
IMPRESSION : There has been epithelialization of the wound along the medial aspect of the right knee .
There has been no further disruption of the epithelium overlying the hypertrophic scar tissue .
PLAN : We will continue with dressing changes every two to three days per the following protocol : spray the wound with AllClenz wound cleanser followed by irrigation with normal saline 30 cc x 3 ;
apply skin protectant to the periwound margin , Panafil paste 1/8 " thick to the wound bed , gauze dampened with normal saline ( cut-to-fit ), covered with DuoDerm secured with Medipore tape .
Mr . Xuereb will return to clinic in two weeks .
__________________________
Lillian Steele , N.P ., Ph.D .
DD:04/27/2071
DT:04/28/2071
FJ:801734 : 77
Record date : 2089-05-11
Patient Name : JARVIS,AMADOR [ MRN : 0907307PCC ]
Date of Visit : 05/11/2089
REASON FOR VISIT : Mr . Jarvis comes for a regular 6-month followup visit .
HISTORY OF PRESENT ILLNESS : He has been feeling extremely well without any illness or any unpleasant symptoms .
He is working hard as a production manager , and he will have some time off this spring .
He and his wife are planning a trip to Italy and Greece , and following this , they will spend mostly long weekends in New Mexico .
He has not had shortness of breath , orthopnea , or edema .
The pains in his hips and legs have not been bothering him . | {"AGE": [], "CONTACT": [], "DATE": ["DT:04/28/2071", "November 29 , 2070", "05/11/2089", "DD:04/27/2071", "2089-05-11", "spring", "2071-04-14", "04/27/2071"], "DEVICE": [], "DLN": [], "HOSPITAL": [], "ID": ["0907307PCC", "FJ:801734 : 77", "1344351", "89-05167655.doc"], "LOCATION": ["New Mexico", "Pune", "Greece", "ME", "9 Church Street", "Italy"], "NAME": ["Jarvis", "LILLIAN STEELE", "XUEREB , JAQUANTE", "Lillian Steele", "JARVIS,AMADOR", "Shane R . Herring", "Dirk O . Reece", "Xuereb"], "ORGANIZATION": [], "PHONE": [], "PROFESSION": ["production manager"], "ZIP": ["99597"]} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
Response of a promethazine -induced coma to flumazenil . | {"drugs": [{"name": "promethazine", "reaction": ["coma"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"drugs": [{"name": "", "reaction": []}]} |
CONCLUSION : While thrombosis has been reported with GnRH-a therapy in men with prostate cancer , its association with treatment in this benign case may have been a consequence of the massive tumor size . | {"drugs": [{"name": "GnRH-a", "reaction": ["thrombosis"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"drugs": [{"name": "", "reaction": []}]} |
Record date: 2098-07-20
July 20, 2098
Patricia Islam, M.D.
Redwood Area Hospital
34 Tamworth Place/Internal Medicine
Cass City, MS 25448
Re: Brady Duvall
MR #425-03-15-1
Dear Patricia:
I saw Brady Duvall again today. He has been very stable
clinically over these past six months. I believe this represents
a composite of the following three major changes in his medical
regimen. As you know, we have discontinued all beta blockers,
and this has been associated with a symptomatic stability. He
had biventricular pacing box placed, certainly contributing to
his overall improved status and he is now taking a regular dose
of Lasix. He is on 80 mg alternating with 40 mg per day. He
does have symptoms of fatigue, but his overall volume status is
quite reasonable. He is currently on Aldactone 25 mg daily and
Lasix 80 mg per day alternating with 40 mg per day, Captopril
6.25 mg p.o. t.i.d., Zocor, insulin, Glucophage, aspirin, and
mexiletine. His amiodarone has been discontinued. He does have
asymptomatic ventricular tachycardia, often paced out of this,
but I am reluctant to recommend ablation therapy for him at the
present time. He has not been shocked by his ICD.
Functionally he seems quite stable. He does have mild fatigue,
but is otherwise reasonably active. He will hopefully be
traveling to Miami this spring.
Physical examination today is of note for a weight of 184 lbs.
His blood pressure is 118/70, his resting pulse 69. His neck
veins are in fact, quite unimpressive. There is minimal jugular
distention, perhaps 6-7 cm. There is no hepatojugular reflux.
Re: Brady Duvall
MR #425-03-15-1 -2- 07/18/98
Lungs were clear. Examination of his heart reveals a quiet
precordium. S1 and S2 seem normal. No S3, no gallop and no
murmur or mitral regurgitation. Abdomen is benign without
palpable liver or spleen and there was no peripheral edema.
There are bilateral varicosities.
His electrocardiogram shows pace rhythm.
Mr. Brady Duvall is currently stable on this regimen.
Accordingly, I have made no changes. I have checked appropriate
electrolytes.
Many thanks for letting us participate in his care.
With best regards.
Sincerely,
U. L. Dana, M.D.
/paris
******** Not reviewed by Attending Physician ******** | {"AGE": [], "CONTACT": [], "DATE": ["2098-07-20", "July 20, 2098", "spring", "07/18/98"], "ID": ["425-03-15-1", "425-03-15-1"], "LOCATION": ["Redwood Area Hospital", "34 Tamworth Place", "Cass City", "MS", "25448", "Miami"], "NAME": ["Patricia Islam", "Brady Duvall", "Patricia", "Brady Duvall", "Brady Duvall", "Brady Duvall", "U. L. Dana", "paris"], "PROFESSION": []} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"AGE": [], "CONTACT": [], "DATE": [], "ID": [], "LOCATION": [], "NAME": [], "PROFESSION": []} |
Record date: 2097-08-21
Neil, Ruba
Internal Medicine Associates, Suite M
Shady Rest Care Center, 4th Floor , Room 483
Arroyo Grande, KS, 19741-6273
RE: ALAINA ROJAS
08/21/2097
Admission Note
87 yo woman with bilat leg swelling for several weeks; now with 1 week of redness L> R.
Problems:
Diabetes mellitus- HgB A1c7.6
Hypertension- adequate control
Hyperlipidemia
Chronic renal failure
Iron deficiency anemia
Allergies:
No known drug allergy
Medications:
vitamin d 1000 units po daily
glipizide 10 mg po bid take 30min before meals
Prandin 2 mg before each meal 2 week supply til mail order arrives
ferrous sulfate 325mg po bid
lisinopril 40 mg po daily
Norvasc 10mg po daily
metoprolol 25mg po take 3 tabs twice a day
lovastatin 10mg po qpm take with food
furosemide 20 mg po daily
Ecotrin 325 mg po daily
Family history:
She was born in Arroyo Grande. She had five children; four of them are alive, all living in the area. Husband died in 2080. Mother had Parkinson's disease. Sister had breast cancer at the age of 72.
Social history:
Continues to get out to the American Senior Center, except on one day. In the spring, she continues to get out, goes to bingo and continues to be very active. She gets out everyday. She is very active. Daughters are very involved with her. We have gone over in detail on this visit managing all of her issues. Continues to go to the club at Dekalb three times a week.
Review of systems:
No change in bowel habits, although she is a little bit constipated. Urine, no hematuria or urinary tract symptoms. Cardiac: No chest pain, shortness of breath, PND, or orthopnea. Pulmonary, no wheezes or asthma symptoms. HEENT: No ear or throat symptoms. Allergies: No new issues with that. Neurologic: No new issues. Psychiatric: Very anxious about all of the medications she has to take it as she was someone, who never needed pills. We tried to reassure her and spent the majority of this 45-minute visit on that coordinating her care.
Physical Exam:
Blood pressure: 130/82
Pulse: 57
Weight: 167 pounds
Office blood glucose fingerstick: 221 at noon
Skin: Warm and dry. No rashes
Neck: Carotids, normal upstroke without bruits
Nodes: Lymph nodes, no lymphadenopathy
Breasts: No masses, discharge, or tenderness
Chest: Lungs are entirely clear with no wheezes, rales, or rhonchi
Cor: No murmurs, rubs, or gallops, regular rate
Abdomen: Nontender without masses
Extrem: violaceous L shin without obvious streaking; swollen without tenderness. R shin present but not as severe
Labs: pending
Assessment and plan:
Admit for antibiotics IV
Ruba Neil, MD pager #34596
Signed electronically by Ruba Neil, MD
Document Status: Final | {"AGE": ["87", "72"], "CONTACT": ["34596"], "DATE": ["2097-08-21", "08/21/2097", "2080", "spring"], "ID": [], "LOCATION": ["Shady Rest Care Center", "Arroyo Grande", "KS", "19741-6273", "Arroyo Grande", "American Senior Center", "Dekalb"], "NAME": ["Neil, Ruba", "ALAINA ROJAS", "Ruba Neil", "Ruba Neil"], "PROFESSION": []} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"AGE": [], "CONTACT": [], "DATE": [], "ID": [], "LOCATION": [], "NAME": [], "PROFESSION": []} |
Was put on Lasix , excreted 28 lbs of fluids .
3 days ago started having increased DOE and SOB .
No CP .
Now able to walk only 10-15 ft w/o sob .
Able to walk up 1 flt of stairs or less .
Needs only 1 pillow to sleep at night .
Has committed some dietary indiscretions lately ( chicken sausage ).
No CP , night sweats , chills .
PMH :
Gout
IDDM2
Thrombocytopenia
Atrial Fibrillation
BPH
Chronic Renal Insufficiency
Hypercholesterolemia
Hyperhomocysteinemia
Hypertension
Patent Foramen Ovale ( PFO )
Basal Cell Carcinoma
Bursitis ,
Coronary Artery Disease ,
Labyrinthitis
Squamous Cell Carcinoma
Umbilical Hernia
PSH :
CABG
Bone marrow Biopsy
SCC removed from head 2094
Turp 2086
FH :
Brother s/p stent placement at age 78 , CHF
Another brother had diabetes and peripheral vascular disease .
SH :
SMOH : 30 pack yrs ;
Date quit : 2065
ETOH : Amount : about 10 drinks in his lifetime | {"AGE": ["78"], "CONTACT": [], "DATE": ["2094", "2065", "2086"], "DEVICE": [], "DLN": [], "HOSPITAL": [], "ID": [], "LOCATION": [], "NAME": [], "ORGANIZATION": [], "PHONE": [], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
5 – ;
Chronic decubitus ulcers presumed 2/2 immobility
6 – ;
HTN
7 – ;
CVA ( 12/2096 ) – ;
c/b significant residual speech/cognitive deficits
8 – ;
Gastroparesis – ;
presumed 2/2 longstanding DM .
s/p gastric emptying study 2/2098
9 - Cataracts
10 – ;
history of NSTEMI per some prior notes
MEDICATIONS ON ADMISSION : from discharge med list in September ;
have requested current med list from NGH .
Amlodipine 10 MG PO QPM
Cholestyramine Resin Dried 4 GM PO BID ( last dose : 09/14/98 09:00 am )
Hydralazine Hcl 50 MG PO Q6H ( last dose : 09/14/98 12:40 am )
Irbesartan ( Avapro ) 150 MG PO QD
Labetalol Hcl 300 MG PO TID ( last dose : 09/13/98 08:20 pm )
Simvastatin 40 MG PO QPM ( last dose : 09/13/98 08:00 pm )
Albuterol Nebulizer Solution 2.5 MG NEB Q6H prn
Calcium Acetate ( 1 Gelcap=667 Mg ) 667 MG PO TID ( last dose : 09/14/98 12:30 pm )
Docusate Sodium ( Colace ) 100 MG PO TID ( last dose : 09/14/98 12:30 pm )
Omeprazole 40 MG PO QD ( last dose : 09/14/98 09:00 am )
Polyethylene Glycol ( Miralax ) 17 GM PO QD prn
Sennosides ( Senna Tablets ) 2 TAB PO BID prn
Sevelamer ( Renagel ) 400 MG PO AC ( last dose : 09/14/98 12:30 pm )
Divalproex Sodium ( Depakote ) 250 MG PO QHS
Insulin Regular Inj SC AC ( Sliding Scale )
If BS < ;
= 200 give 0 Units
For BS from 201 to 250 give 4 Units
For BS from 251 to 300 give 6 Units
For BS from 301 to 350 give 8 Units
For BS from 351 to 400 give 10 Units | {"AGE": [], "CONTACT": [], "DATE": ["September", "12/2096", "2/2098", "09/13/98", "09/14/98"], "DEVICE": [], "DLN": [], "HOSPITAL": ["NGH"], "ID": [], "LOCATION": [], "NAME": [], "ORGANIZATION": [], "PHONE": [], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
Our case points to the need for increased awareness by the general pediatricians of the potential hazards of mineral oil use for chronic constipation . | {"drugs": [{"name": "mineral oil", "reaction": ["potential hazards"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"drugs": [{"name": "", "reaction": []}]} |
Record date : 2059-02-26
EDVISIT^ 01410301 ^ Vine Takeyah Thomey ^ 17/11/59 ^ Lindie Reynolds
patient and the resident , Dr .
HISTORY OF PRESENT ILLNESS : This is a 52 - year-old female who
while in the Antigua and Barbuda , 2 days later she began having a
Lindie Reynolds M.D .
D : 21/03/59
T : 21/03/59
Dictated By : Lindie Reynolds
eScription document:NN 3-1438887 BFFocus
Record date : 2094-06-24
MRN : 5797282
The patient is a 63 - year-old woman with a history of diabetes , hypertension ,
She had a negative sestamibi ETT in 2088 except she had a very low work capacity .
Record date : 2097-01-25
Name : Tollie Fought
MR# 060 1 56
Date of Admission : 28/09/96
Cardiologist : Dr Merina Bolton
ID/CC : 69 YO M with chest pain
This pleasant 69 YO M presents today after multiple episodes of sharp L anterior chest pain .
He had an anteroseptal MI in 2093 and when questioned he does not feel this pain is similar to his prior attack .
Worked as Armed forces logistics/support/administrative officer .
CXR:28/09/96
69 YOM with CP here for ROMI .
Joley Sophi , MD
Pager # 15379
Record date : 2060-09-10
EDVISIT^ 43276147 ^ Rochel Christine ^ 09/10/60 ^ Kumagai Skyy
The patient was seen with Dr .
HISTORY OF PRESENT ILLNESS : This is a 63-year-old gentleman with
Kumagai Skyy MD
D : 24/02/60
T : 24/02/60
Dictated By : Kumagai Skyy
eScription document : 0-9295747 BFFocus | {"AGE": ["69", "52", "63-year-old", "63"], "CONTACT": [], "DATE": ["24/02/60", "2094-06-24", "2088", "2097-01-25", "2059-02-26", "28/09/96", "2093", "2060-09-10", "09/10/60", "21/03/59", "17/11/59"], "DEVICE": [], "DLN": [], "HOSPITAL": [], "ID": ["5797282", "060 1 56", "01410301", "3-1438887", "0-9295747", "43276147"], "LOCATION": ["Antigua and Barbuda"], "NAME": ["Kumagai Skyy", "Rochel Christine", "Vine Takeyah Thomey", "Merina Bolton", "Joley Sophi", "Lindie Reynolds", "Tollie Fought"], "ORGANIZATION": [], "PHONE": ["15379"], "PROFESSION": ["Armed forces logistics/support/administrative officer"], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
A 15-year follow-up of phenytoin -induced unilateral gingival hyperplasia : a case report . | {"drugs": [{"name": "phenytoin", "reaction": ["unilateral gingival hyperplasia"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"drugs": [{"name": "", "reaction": []}]} |
Record date: 2095-02-16
EDVISIT^75659490^ROOT, PERCY^02/16/95^CARR, RACHEL
The patient was seen in conjunction with resident, Dr. Anderson.
PA's note was reviewed. The patient was seen and examined by
me. Please see the PA's note for details of the patient's past
medical, social, family history, review of systems, and physical
exam.
CHIEF COMPLAINT: Rash on legs.
HISTORY OF PRESENT ILLNESS: A 79-year-old man brought in by his
family complaining of a pruritic rash on his bilateral ankles and
today, both ankles are slightly more swollen than usual. He has
no difficulty breathing, no chest pain. The patient used to live
in England 4 days ago, arrived in Frankenmuth to live now
permanently with his family here. He has a history of "heart
problems for which he is taking Lasix, enalapril, and amlodipine
and is compliant with these medications. He says initially his
legs were not swollen. It was only today that the family
happened to notice as he was complaining of a rash that he had
slightly increased swelling of these ankles bilaterally. The
patient's daughter reports that she bought him new long underwear
and noticed that the rash began where the underwear elastic band
hit his ankles in that similar distribution, there is pruritus
with evidence of excoriation. He also does have evidence of
chronic venous stasis changes in his legs. The leg swelling is
equal bilaterally does not extend to the calf and is minimal.
The patient reports that he coughs when he is out in the cold
Frankenmuth air, but does not produce any sputum. Has baseline
orthopnea and PND of 3 pillows which has not changed. He has had
no worsening shortness of breath and no chest pain.
PAST MEDICAL HISTORY: Significant for hypertension, TIA. He has
no history of DVT.
PAST SURGICAL HISTORY: No significant surgical procedures.
SOCIAL HISTORY: He is a past smoker, does not drink or use
drugs. Lives with his family.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Otherwise, negative.
ALLERGIES: Has no allergies.
PHYSICAL EXAMINATION: He is awake, alert, in no distress,
afebrile. Normal and stable vital signs, saturating 96-97% on
room air. His exam is unremarkable except for excoriation to the
bilateral ankles with chronic venous stasis changes bilaterally
and trace 1-2+ edema bilaterally equal and the ankles only down
to the mid foot. He has strong and equal, 2+ dorsalis pedis
pulses in the feet. The rest of his examination is unremarkable
with clear lungs and breath sounds.
EMERGENCY DEPARTMENT COURSE: The patient said has no plans to
get a doctor in America. He filled out an application
for Frankenmuth Care on arrival to the Emergency Department. I spoke
with him and his family at length about the need to immediately
get a primary care doctor. He was given the numbers for the
Tobey Hospital and Heritage Residence. He has about 3 weeks of his
medications left and he is told that he will need to see ____.
The family understands the urgency of this situation.
PRIMARY DIAGNOSIS: Today is dermatitis. He is told to continue
his medications as prescribed to elevate the feet to decrease the
swelling.
DISPOSITION: Discharged in satisfactory condition to follow up
with the primary care physician.
______________________________
CARR, RACHEL M.D.
D: 02/17/95
T: 02/17/95
Dictated By: CARR, RACHEL
eScription document:2-8880418 IFFocus
******** Not reviewed by Attending Physician ******** | {"AGE": ["79"], "CONTACT": [], "DATE": ["2095-02-16", "02/16/95", "02/17/95", "02/17/95"], "ID": ["75659490", "2-8880418"], "LOCATION": ["England", "Frankenmuth", "Frankenmuth", "America", "Frankenmuth Care", "Tobey Hospital", "Heritage Residence"], "NAME": ["ROOT, PERCY", "CARR, RACHEL", "Anderson", "CARR, RACHEL", "CARR, RACHEL"], "PROFESSION": []} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"AGE": [], "CONTACT": [], "DATE": [], "ID": [], "LOCATION": [], "NAME": [], "PROFESSION": []} |
Severe akathisia during olanzapine treatment of acute schizophrenia . | {"drugs": [{"name": "olanzapine", "reaction": ["Severe akathisia"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"drugs": [{"name": "", "reaction": []}]} |
HGB 10.6 L ( 07-26-1978.5 ) gm/dl
RBC 3.64 L ( 4.511-25-1976 ) mil/cmm
MCH 29 ( 02-07-2008.0 ) pg/rbc
RDW 20.1 H ( 02-23-1984.5 ) %
Report from last PET CT study 9/18 :
6/8/97
Regino Caprio is a 64 yoM w/ Stage IIIB diffuse large B-cell lymphoma s/p 4 cycles of CHOP and 1 cycle of R-ICE who presents now for cycle 2 of R-ICE .
Ludivina Safe Internal Medicine
Pager 28902
ALLENDALE COUNTY HOSPITAL
In brief , this is a 64 yo man w/ Stage IIIB diffuse large B-cell lymphoma s/p 4 cycles of CHOP and 1 cycle of R-ICE her now for his cycle 2 of R-ICE .
Redd Shanelle Allexis MD , PhD
Pager 2-8406
Record date : 2084-06-15
Geovana Carolina
Record date : 2092-01-28
Name : Naomi Bach
MRN : 8709-17-2001
Date of Admission : 28-Jan-2092
Other WEATHERFORD REGIONAL HOSPITAL providers : Dr .
Admitting Intern : Helmut Lobe
CC : Pt is a 56 year old female with h/o SLE , interstitial nephritis , GERD , h/o positive stress s/p RCA angioplasty 2083 , and chronic abdominal pain who presents with c/o two weeks of intermittent chest pain .
In WEATHERFORD REGIONAL HOSPITAL ED , pt describes the pain as like a bleeding scar and states my heart is bloated through her daughter who acted as her interpreter .
Pt originally from Long prairie , Slovakia ( Slovak Republic ) .
She does not work anymore but did work in Engineer , building services .
29-Jan-2092 02:11 Accession# 9861E83073
WBC 7.5 ( 03-28-1994.0 ) th/cmm
HCT 40.3 ( 10-07-1990.0 ) %
HGB 13.2 ( 01-11-1975.0 ) gm/dl
29-Jan-2092 02:19 Accession# 5430T48403
Plasma Carbon Dioxide 27.7 ( 11-04-2003.9 ) mmol/L
Calcium 10 ( 04-16-2004.5 ) mg/dl
Troponin-T <0.01 ( 0.05-26-1979 ) ng/ml
28-Jan-2092 18:22 Accession# 9795F69223
28-Jan-2092 17:51 Accession# 0097V49971
Dissection Protocol CT of 28-Jan-2092 : reveals no evidence of aortic dissection . | {"AGE": ["56", "64"], "CONTACT": [], "DATE": ["01-11-1975.0", "07-26-1978.5", "02-23-1984.5", "29-Jan-2092", "2092-01-28", "28-Jan-2092", "2083", "6/8/97", "2084-06-15", "10-07-1990.0", "04-16-2004.5", "9/18", "03-28-1994.0", "11-04-2003.9", "02-07-2008.0"], "DEVICE": [], "DLN": [], "HOSPITAL": ["WEATHERFORD REGIONAL HOSPITAL", "ALLENDALE COUNTY HOSPITAL"], "ID": ["9795F69223", "9861E83073", "5430T48403", "0097V49971"], "LOCATION": ["Long prairie", "Slovakia ( Slovak Republic"], "NAME": ["Redd Shanelle Allexis", "Regino Caprio", "Geovana Carolina", "Ludivina Safe", "Helmut Lobe", "Naomi Bach"], "ORGANIZATION": [], "PHONE": ["28902", "2-8406"], "PROFESSION": ["Engineer , building services"], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
The use of methotrexate ( MTX ) has been contraindicated for treatment of severe psoriasis in HIV infection on the basis of six previously reported cases in which MTX appeared to potentiate opportunistic infections and accelerate HIV disease . | {"drugs": [{"name": "MTX", "reaction": ["accelerate HIV disease"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"drugs": [{"name": "", "reaction": []}]} |
No dysphonia .
Palate elevates symmetrically .
Tongue and palate midline , no fasciculations .
Shoulder shrug equal bilaterally 5/5 .
Motor : normal bulk and tone , no tremor , no drift , leads with L arm on orbiting
Del Bic Tri WE WF FE FF IO HF HE KF KE DF PF
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Coord : normal finger to nose , heel to shin
Sens : normal light touch , pinprick , vibration
Reflexes : 2+ c downgoing toes
LABS
NA 135
K 3.1(L )
CL 99(L )
CO2 27.5
BUN 27(H )
CRE 1.4
GLU 368(H )
WBC 11.5(H )
HCT 42.2
MCV 84
PLT 226
PT 12.9
PTT 21.8(L )
STUDIES
Head CT/CTA prelim read negative
MRI prelim read #NAME? L insular infarct
A/P
50 yo RHM with 45 minute episode of dysarthria and L hand tingling , now asymptomatic with normal neurologic exam .
1 ) Neuro
#NAME? admit to RDA neurology
#NAME? continue ASA
#NAME? TTE , Holter
#NAME? continue HCTZ , atenolol , Norvasc
2 ) Renal
#NAME? has Cr 1.4 , was on glucophage , received contrast #NAME? > will need IVF | {"AGE": ["50"], "CONTACT": [], "DATE": [], "DEVICE": [], "DLN": [], "HOSPITAL": [], "ID": [], "LOCATION": [], "NAME": [], "ORGANIZATION": [], "PHONE": [], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
The association with prolonged unopposed estrogen-like stimulation with tamoxifen as a possible factor in the development of ovarian endometrioid carcinoma is discussed . | {"drugs": [{"name": "tamoxifen", "reaction": ["ovarian endometrioid carcinoma"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"drugs": [{"name": "", "reaction": []}]} |
ALLERGIES : NKDA : No Known Drug Allergies
Exam :
VS : 97.3 , 82 regular , 127/63 , 20-24 , 98% on 8LNC
General : Pleasant man in NAD on nasal oxygen .
Speaks a few words at a time .
Here with his family .
Neck : Supple , no JVD
Lungs : Distant , clear , expansion symmetric .
Heart : RRR without appreciable MRG
Abd : Soft , nontender , nondistended
GU : Circumcised ;
hypospadias with very small urethral orifice
Sacrum : Area of redness over the sacrum with soft skin but no skin breakdown , drainage , or fluctuance
Extr : WWP , + trace digital clubbing .
Nail beds pink with brisk capillary refill .
Assessment : 59-year-old man with end-stage pulmonary fibrosis , admitted now for lung transplant
Plan :
- Pre-op labs and studies including crossmatch for 10 units each PRBC , FFP , platelets
- OR for lung transplant ;
surgical consent signed and on chart
- Antibiotics/inductions meds in OR per Dr . Patterson ( ordered ;
availability confirmed )
- Urology re hypospadias
- SICU post-op
________________________
Nicholas Lange , MD
BCC Surgery PGY-1 14338
Record date : 2069-08-17
NAME : Vines , Stephen
MRN : 1672569
Mr .
Vines comes in today .
He has been feeling pretty well though he is
distressed at his 18-pound weight gain .
His sugars were in the 300s before starting
the insulin . | {"AGE": ["59-year-old"], "CONTACT": [], "DATE": ["2069-08-17"], "DEVICE": [], "DLN": [], "HOSPITAL": ["BCC"], "ID": ["1672569"], "LOCATION": [], "NAME": ["Vines", "Vines , Stephen", "Patterson", "Nicholas Lange"], "ORGANIZATION": [], "PHONE": ["14338"], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
On the left , strength was 5/5 throughout including : shoulder abduction , flexion and extension at the elbows , fingers , hips , knees , as well as ankle dorsiflexion and plantarflexion .
SENSATION : Diffusely intact to light touch , temperature throughout .
No evidence of extinction or neglect .
Decreased vibratory sensation in his lower extremities in stocking pattern , without involvement of upper extremities .
REFLEXES : The deep tendon reflexes were normal and symmetric at the triceps , biceps , brachioradialis , quadriceps and gastrocnemius/soleus .
Babinski sign absent bilaterally .
CEREBELLAR : The finger-to-nose , heel-to-shin were normal without dysmetria .
There was no truncal ataxia .
GAIT/STANCE : The stance and stride were normal , as was the ability to tandem , toe , and heel-walk .
The Romberg test was negative .
Labs/Studies :
01/08/2084 NA 140 , K 4 , CL 106 , CO2 27.1 , BUN 20 , CRE 1.04 , EGFR > ;
60 , GLU 172 ( H )
01/08/2084 ANION 7
01/08/2084 CA 8.9 , PHOS 2.1 ( L "), MG 1.4 , TBILI 0.5 , DBILI 0.2 , TP 6.1 , ALB 3.7 , GLOB 2.4
01/08/2084 ALT/SGPT 12 , AST/SGOT 20 , ALKP 87 , TBILI 0.5 , DBILI 0.2
01/08/2084 NT-BNP 4419 ( H )
01/08/2084 TROP-I Negative
01/08/2084 WBC 5.2 , RBC 3.39 ( L "), HGB 10.4 ( L "), HCT 30.8 ( L "), MCV 91 , MCH 30.6 , MCHC 33.6 , PLT 162
01/08/2084 RDW 16.5 ( H )
01/08/2084 METHOD Auto , %NEUT 72 ( H "), %LYMPH 19 ( L "), %MONO 5 , %EOS 3 , %BASO 1
01/08/2084 ANEUT 3.78 , ALYMP 0.93 ( L "), AMONS 0.25 , AEOSN 0.15 , ABASOP 0.05
01/08/2084 ANISO 1+ ( H "), HYPO None , MACRO None , MICRO None
01/08/2084 PT 18.8 ( H "), PT-INR 1.7 , PTT 28
01/08/2084 BB Sp EXP : 01/11/2084 23:59
Head CT/CTA Head and Neck ( Today ):
No evidence for intracranial hemorrhage , masses or large territorial infarction .
Left M1 segment filling defect likely represent a thrombus which is partially occlusive given the opacification of the distal MCA
branches .
This finding correlates with patient's given symptoms .
EKG ( Today ):
CXR ( Today ): Large heart
Assessment
:
63 year old RH man with history of CAD s/p STEMI 2077 s/p 8 stents including LAD , systolic CHF Class Ia with EF 20% s/p BiV ICD placement , diabetes , on Coumadin and ASA , presenting with history of right arm/leg weakness since this morning .
There have been no other neurological symptoms , and no general symptoms other than some lightheadedness .
Exam is notable for decreased strength in the right upper extremity and proximal lower extremity , without facial involvement . | {"AGE": ["63"], "CONTACT": [], "DATE": ["01/11/2084", "2077", "01/08/2084"], "DEVICE": [], "DLN": [], "HOSPITAL": [], "ID": [], "LOCATION": [], "NAME": [], "ORGANIZATION": [], "PHONE": [], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
Template:
{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
potassium chloride 20meq po QD QTY:90 Refills:3 Start : 8/2/20
hydrochlorothiazide 12.5 mg po qd QTY:90 Refills:3 Start : 10/16/23
tetracycline 500mg po QD QTY:90 Refills:3 Start : 9/11/21
lisinopril 30 mg po qd QTY:90 Refills:3 Start : 5/22/23
Prilosec 20mg po QD QTY:90 Refills:3 Start : 9/18/23
Celexa 20 mg 2 po qd Start : 11/2/24
Klonopin 0.5mg po 1/2 qd Start : 10/18/2125
Premarin 0.625mg po QD QTY:90 Refills:3 Start : 10/18/2125 End : 2/16/2130 #NAME? Inactivated
Seroquel 25 mg po 2tabs bid and 4 ab qhs Start : 8/13/2127
Lipitor 10mg po qd QTY:90 Refills:3 Start : 11/30/2129
Procedures
Influenza vaccine STATUS POST left arm , lot# N2453KM , Aventis .
Family history Negative in the interval .
Social history See detail above .
No smoking .
No alcohol .
No risk exposures .
Review of systems Episode of chest pain ;
vomiting episode ;
faint spell as described above .
She denies blood or melena now .
No dysuria .
Not much activity .
All other issues negative except as above #NAME? eye exam overdue and she promises to do it .
She does not have any self-breast exams in these two years from last mammogram .
Physical examination
Pulse 70 and regular
Blood pressure 130/88 on arrival , repeat 120/78 with large cuff
Weight 284 pounds
Height 5 feet 4-1/2 inches
General appearance Flat affect but spirits are no worse than previously and she does not appear unusually pale
Skin Chronic skin changes as before
Heent Negative icterus not particularly pale and conjunctiva .
Pharynx benign .
No obvious bleeding source
Neck Negative .
No jugular venous distension , bruits or change in thyroid | {"AGE": [], "CONTACT": [], "DATE": ["11/2/24", "8/2/20", "11/30/2129", "5/22/23", "8/13/2127", "10/16/23", "2/16/2130", "9/11/21", "9/18/23", "10/18/2125"], "DEVICE": [], "DLN": [], "HOSPITAL": [], "ID": ["N2453KM"], "LOCATION": [], "NAME": [], "ORGANIZATION": [], "PHONE": [], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
Case study : adverse response to clonidine . | {"drugs": [{"name": "clonidine", "reaction": ["adverse response"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"drugs": [{"name": "", "reaction": []}]} |
She also had several episodes of syncope , once after taking an additional dose of Lasix and another in the setting of over diuresis .
Repeat echo showed that her AS was not critical and she had significant LV outflow tract obstruction .
Other medical problems include severe COPD , trigeminal neuralgia , ruled out for temporal arteritis by several biopsies , R hip osteonecrosis , and bone spur of the right shoulder .
Mrs . Mitchell is S/P total hip replacement surgery , and had her rehab at North Mountain Hospital .
She had intercurrent admissions for overdiuresis and for flash pulmonary edema with over #NAME? and under-diuresis , respectively .
She currently takes Bumex 6 mg po bid , and with this , her weight has been 140-145 pounds , which is her target weight .
Her BUN and Cr are in the 25-40/1.3-1.7 range .
Since her last visit , she has done well at home .
Her breathing at home is intermittently difficult , especially if she rushes .
However , oximetry shows that she is in the mid 90's at rest , and that she drops down to high 80's to 90 with exertion .
She has had GI evaluation for anemia in the past , only revealing diverticulosis ;
her Hct was 28 recently , and Dr . Conway arranged for her to udnergo transfusion of one unit of PRBC .
She feels more energetic after this .
She takes Fe sulfate , but has some constipation from this .
She may require ENT surgery for vocal cord growth by Dr . Cherry .
This is being considered in consultation with her LMD Dr . Evelyn Conway , and her pulmonologist Dr . Geoffrey Lucas .
Medications ( Confirmed ):
Advair 500/50mcg spray inh bid
Ambien 5 mg po qhs
Bumex 4 mg po bid
Colace 100 mg po tid
Fosamax 70mg po qwk
Lescol 40mg po qhs
metoprolol 100 mg po tid
MiraLax 17 g 2 po qhs
Nexium 40mg po qd
Paxil 10mg po qd
Plavix 75mg po qd
Spiriva 18mcg/capsule inh qd
verapamil hydrochloride , SR ( extended release ) 120mg SR po qd
Zyrtec 10mg po qd
Allergies :
Penicillin allergy angioedema
Allergic drug reaction percodan , bactrim , pseudophed , leading to angioedema
Heparin induced thrombocytopenia HIT
Family history :
negative for CAD | {"AGE": [], "CONTACT": [], "DATE": [], "DEVICE": [], "DLN": [], "HOSPITAL": ["North Mountain Hospital"], "ID": [], "LOCATION": [], "NAME": ["Evelyn Conway", "Mitchell", "Cherry", "Geoffrey Lucas", "Conway"], "ORGANIZATION": [], "PHONE": [], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
#NAME? hold diuretics for ? prerenal component to renal failure
#NAME? consider evaluation for renal artery stenosis
Anemia : Patient's baseline Hct on d/c= 29 ;
remains at baseline
#NAME? recheck Fe studies
#NAME? guaiac stools
Ophtho : continue erythromycin ophtho ointment
Gen Care :
#NAME? PT/OT
#NAME? Access : R PICC line ( read on CXR as subclavian #NAME? too far ?)
#NAME? Proph : Nexium , coumadin
#NAME? Precautions : MRSA , aspiration
Ursula Isabella-Venegas , MD
# 25112
#NAME?
Record date : 2087-02-21
DAMERON EMERGENCY DEPT VISIT
" VALENZUELA,BRIAN 036-89-96-4 VISIT DATE : 02/21/87
The patient was seen by me in the emergency department on 02/21/87
with the resident .
The resident's notes were reviewed and the patient interviewed was examined by me .
The patient's complete
history is limited by change in mental status and multiple
sclerosis .
The patient was transferred from an Ellijay home .
PRESENTING COMPLAINT : Nausea and vomiting .
HISTORY OF PRESENTING COMPLAINT : The patient is a 49 -year-old with nausea and vomiting for the past 24 hours , rigid abdomen and no
bowel sounds .
He has had some feculent emesis over the last day .
REVIEW OF SYSTEMS : No fevers or chills , no bright red blood per
rectum or melena but did have liquid stool earlier today .
PAST MEDICAL HISTORY : Hypertension , multiple sclerosis and anemia .
PHYSICAL EXAMINATION : GENERAL : The patient is awake .
LUNGS :
Scattered rhonchi , otherwise clear .
HEART : Regular rate and
rhythm . | {"AGE": ["49"], "CONTACT": [], "DATE": ["2087-02-21", "02/21/87"], "DEVICE": [], "DLN": [], "HOSPITAL": ["DAMERON"], "ID": ["036-89-96-4"], "LOCATION": ["Ellijay"], "NAME": ["Ursula Isabella-Venegas", "VALENZUELA,BRIAN"], "ORGANIZATION": [], "PHONE": ["25112"], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
Record date: 2083-12-04
DLC EMERGENCY DEPT VISIT
STEPHENSON,BREDNA 928-19-46-1 VISIT DATE: 12/04/83
The patient was seen 12/04/83 with Dr. Key. The patient was
interviewed and examined by me. Resident's note reviewed and
confirmed. See chart for details.
HISTORY OF PRESENTING COMPLAINT: The patient is a 65 year old
woman with history of diabetes, hypertension, and coronary artery
disease who presents with one week of exertional dyspnea, and
orthopnea. Also complains of numbness and coolness in her left
lower extremity for the past 24 hours. No chest pain/back
pain/abdominal pain. No fever or chills.
PAST MEDICAL HISTORY: Diabetes, hypertension, hypothyroidism,
coronary artery disease. No prior documented history of congestive
heart failure.
MEDICATIONS: Atenolol, Imdur, Lasix, Lipitor, metformin,
Synthroid, Zantac, Vioxx, Lisinopril, Ecotrin, Avandia, Micronase.
SOCIAL HISTORY AND FAMILY HISTORY: Nonsmoker. Lives alone.
PHYSICAL EXAMINATION: No respiratory distress, afebrile, pulse 88,
respirations 15, blood pressure 148/89, pulse ox 98% on room air.
Cardiovascular examination is notable for JVP at 10 cm, regular
rate and rhythm with frequent premature beats and S3 gallop. She
has 2+ femoral pulse on the right, 1+ femoral pulse on the left.
She has 1+ dorsalis pedis on the right, absent dorsalis pedis pulse
on the left. She has symmetric 2+ radial pulses. Her lungs have
rales at both bases. Her breathing is nonlabored. Abdomen is soft
and nontender, no masses or bruits in the abdomen. Extremity
examination is notable for cool left lower extremity with 1+ edema
to the knee.
LABORATORY EVALUATION: Chest x-ray shows pulmonary edema.
Electrocardiogram shows normal sinus rhythm with frequent premature
ventricular contractions and nonspecific T wave abnormality with
change from prior electrocardiogram.
THERAPY RENDERED/COURSE IN ED: The plan is aspirin, heparin,
Lasix, Nitropaste, Cardiology consult, check cardiac enzymes,
troponin, BNP, echocardiogram and lower extremity noninvasive
vascular studies. Primary care physician, Dr. Patricia Quebedeaux,
notified.
Critical care time: 30 minutes.
FINAL DIAGNOSIS: 1. New onset congestive heart failure. 2. Cool
left lower extremity, rule out venous versus arterial thrombus.
DISPOSITION (including condition upon discharge): The patient is
currently in stable condition.
___________________________________ HE342/20225
BRODY OHARA, M.D. BO907 D:12/04/83
T:12/04/83
Dictated by: BRODY OHARA, M.D. BO907
******** Not reviewed by Attending Physician ******** | {"AGE": ["65"], "CONTACT": [], "DATE": ["2083-12-04", "12/04/83", "12/04/83", "12/04/83", "12/04/83"], "ID": ["928-19-46-1", "HE342/20225"], "LOCATION": ["DLC"], "NAME": ["STEPHENSON,BREDNA", "Key", "Patricia Quebedeaux", "BRODY OHARA", "BO907", "BRODY OHARA", "BO907"], "PROFESSION": []} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"AGE": [], "CONTACT": [], "DATE": [], "ID": [], "LOCATION": [], "NAME": [], "PROFESSION": []} |
Finger-nose adequate , no dysmetria , no ataxia .
Epicritic and protopathic sensations intact .
Deep tendon reflexes symmetrical 2+ in all extremities .
Babinski sign absent bilaterally .
Ankle clonus absent .
Assessment and Plan
Chest pressure and dyspnea .
The patient has known coronary vasospastic events for which she has consulted with cardiology .
The symptoms that she describes suggest possible symptomatic cardiac ischemia .
She had a baseline ECG today in my office that was normal .
I have instructed the patient to follow up with cardiology for further assessment and an ETT .
I will communicate with Dr . Wright .
The description of symptoms do not suggest unstable angina .
Glucose intolerance with post prandial hyperglycemia .
Continue metformin , well tolerated , HbA1c requested .
Hyperlipidemia .
On atorvastatin .
Target LDL < ;
70 , new values requested .
Hypertension .
Stable , continue current medications .
Microscopic hematuria with negative work up .
Surveillance UA and cytology requested .
Rhinopharyngitis .
Amoxicillin and fluticasone initiated .
Gynecology contact information provided .
Ophthalmology contact information provided .
Bone densitometry requested .
Labs requested .
Follow up after tests or in 3-6 months .
_____________________________ David Delgado , M.D .
Record date : 2060-07-28
GIPSON , ALEC
32707420
07/28/2060
Vernon Lozano , M.D .
CV Division , Ireton Medical Clinic | {"AGE": [], "CONTACT": [], "DATE": ["2060-07-28", "07/28/2060"], "DEVICE": [], "DLN": [], "HOSPITAL": ["Ireton Medical Clinic"], "ID": ["32707420"], "LOCATION": [], "NAME": ["GIPSON , ALEC", "Wright", "David Delgado", "Vernon Lozano"], "ORGANIZATION": [], "PHONE": [], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |
Recognition of a potential drug-induced Fanconi syndrome is important when managing pediatric oncology patients previously treated with ifosfamide . | {"drugs": [{"name": "ifosfamide", "reaction": ["Fanconi syndrome"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"drugs": [{"name": "", "reaction": []}]} |
Record date: 2093-11-20
977-82-23
Horn, Gregory
November 20, 2093 Endocrine/Diabetes
Present Illness:
Asked to see this 59 year old man with IPF, diagnosed in 2090, an admission to BCC last month with pneumonia, who presented with rapidly progressive respiratory distress last week and was admitted intubated to the MICU. He as treated with high dose Solumedrol and with antibiotics, and is improving nicely. He is extubated and has begun to eat.
Diabetes was diagnosed 14 years ago. He was treated with pioglitazone 45 mg qd, metformin 2000 mg in divided doses and a sulfonylurea until February of this year, when the sulfonylurea was replaced with insulin. For convenience with his travel schedule, his insulin has been 70/30 administered by pen, with 30 U before breakfast and 40 U before supper. He tests his BS before breakfast and supper only and reports that, since he has been more careful with his diet recently, they have been in the low 100 s and mid 100 s, respectively. His hemoglobin A1c was 7.4 % a month ago.
Retinopathy: He is due for his yearly appointment with his ophthalmologist. No retinopathy in the past.
Nephropathy: BUN/Cr 31/1.3 today. No microalbumin/creatinine ratio in CAS.
Neuropathy: He has occasional paresthesias in his feet.
Cardiac: He is s/p stent for coronary artery disease about 8-9 years ago.
Vascular: No claudication.
His IPF is treated with Mucomyst and gamma interferon, which he administers to himself.
Past Medical History:
Surgery: Coronary stent
Lung biopsy at time of diagnosis of IPF
Medical: Hypertension
Hyperlipidemia
GERD
Allergies: No known drug allergies.
Smoking History: No
Alcohol History: No
Family History:
There is a significant family history of diabetes, including his mother, maternal grandmother, one of his 5 siblings, and some paternal relatives as well.
Social History:
Lives with his wife and their adopted son, who is a Recruitment Officer.
Computer and Network Technicians for General Dynamics, covering 8 states. His job entails travel.
Review of Systems: above
Ears: Mild hearing loss.
Review of systems is otherwise negative.
Physical Exam:
Very pleasant, ruddy complexioned man in no distress.
BP: 148/78 P: 76, regular T: 98.0
Wt: 209 by history Ht: 5 7.5 by history
HEENT: Anicteric. Full EOM's.
Fundi: Not examined.
Carotids: Normal pulses, without bruits
Thyroid: Not palpable
Chest: Few rales anteriorly, L>R.
Heart: Normal S1; physiologic S2. No gallops. No murmurs
Abdomen: No hepatosplenomegaly. No masses. No tenderness. No palpable AAA.
Extremities: No edema. DP 2+ R, absent L. PT 2+,=. Good foot care.
Neurological: AJ 1+,=, with normal relaxation.
Impressions and Plan:
59 year old man with type 2 diabetes now on steroids for IPF flare, currently down to 125 mg q12h, given at noon and MN.
Having reviewed his recent data, would suggest that we change his current insulin to:
NPH 40 / Regular 10+ scale qAM before breakfast
Regular 10+ scale qPM before supper
NPH 30 at bedtime
QID Regular sliding scale
These initial doses will need to be adjusted based on experience and on any changes in the steroid doses.
I have no objection to resuming his pioglitazone, or substituting rosiglitazone while he is here, as long as you do not feel that volume overload is playing any role in his deterioration.
I would prefer not to resume the metformin while is at risk for acute respiratory deterioration with risk of acidosis.
Would change the steroid dosing to 8AM, 8 PM, hoping that we can also start to reduce the doses, PM first, if possible.
He appears to have an anemia that has at least a component of iron deficiency. If you agree, would start iron repletion. (Note that in addition to the iron studies, his MCV, though still normal, has come down over time.)
Thanks.
Nicholas Q. Vasquez, M.D., Ph.D. | {"AGE": ["59", "59"], "CONTACT": [], "DATE": ["2093-11-20", "November 20, 2093", "2090", "February"], "ID": ["977-82-23"], "LOCATION": ["BCC", "General Dynamics"], "NAME": ["Horn, Gregory", "Nicholas Q. Vasquez"], "PROFESSION": ["Recruitment Officer", "Computer and Network Technicians"]} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"AGE": [], "CONTACT": [], "DATE": [], "ID": [], "LOCATION": [], "NAME": [], "PROFESSION": []} |
Since amiodarone was first marketed in 1992 in Japan , the incidence of amiodarone-induced thyrotoxicosis ( AIT ) has been increasing . | {"drugs": [{"name": "amiodarone", "reaction": ["thyrotoxicosis"]}]} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"drugs": [{"name": "", "reaction": []}]} |
Synthroid ? 5 mcg five days per week and 10.5 mcg two days per
week , furosemide 20 mg p.o . q.d . p.r.n ., quinine sulfate 324 mg
p.o . h.s . ( for cramping ), nitroglycerin p.r.n ., Zoloft 15 mg p.o .
h.s ., lorazepam 15 mg p.o . q.h.s ., magnesium oxide 250 mg p.o .
q.d . and Ranitidine 150 mg p.o . p.r.n .
On examination she appears well .
Weight is 142 pounds .
Blood
pressure is 140/60 .
Heart rate is 50 and regular .
Neck veins
are 6 cm above the mid right atrium .
There are bilateral carotid
bruits .
Lungs are resonant to percussion and clear to
auscultation .
On cardiac exam the PMI is in the fifth
intercostal space at the midclavicular line .
There is a 1+ left
ventricular lift .
The first heart sound is normal .
The second
Benitez , Wonda MRN : 89276954
November 7 , 2086 - 2 -
is split physiologically .
There is a grade 2/6 mid systolic
murmur at the apex and a grade 2/6 systolic ejection murmur along
the left sternal border .
There is a fourth heart sound at the
apex .
Abdominal examination reveals no masses , no
hepatosplenomegaly .
Extremities are notable for 2+ bilateral
femoral pulses , palpable bilateral tibial artery bypass graft
pulses , absent bilateral popliteal pulses , 1+ right dorsalis
pedis , absent right posterior tibial and absent left pedal
pulses . | {"AGE": [], "CONTACT": [], "DATE": ["November 7 , 2086"], "DEVICE": [], "DLN": [], "HOSPITAL": [], "ID": ["89276954"], "LOCATION": [], "NAME": ["Benitez , Wonda"], "ORGANIZATION": [], "PHONE": [], "PROFESSION": [], "ZIP": []} | Instruction: You have to extract information from the text provided and fill in the template below.
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{"DATE": [], "NAME": [], "ID": [], "AGE": [], "LOCATION": [], "PROFESSION": [], "CONTACT": [], "HOSPITAL": [], "PHONE": [], "ZIP": [], "ORGANIZATION": [], "DEVICE": [], "DLN": []} |