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Classify the following medical document. | TITLE: CCU Progress Note
Chief Complaint:
24 Hour Events:
- No overnight events
- Comfortable on room air.
- Requesting to go home
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
... | Physician |
Classify the following medical document. | Admission Date: [**2178-10-24**] Discharge Date: [**2178-10-30**]
Date of Birth: [**2135-7-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
chest pain
Major Surgical or Invasive Proc... | Discharge summary |
Classify the following medical document. | micu npn 1900-0700
patient received at 1900 from am shift. micu team had finished putting in r subclavian quad lumen. cxr showing that it was not in the correct position. dr [**Last Name (STitle) **] coming down to assist in rewiring line. cxr done and line ok per resident samone [**Doctor Last Name **]. r ij lin... | Nursing/other |
Classify the following medical document. | Admission Date: [**2159-9-18**] Discharge Date: [**2159-9-20**]
Date of Birth: [**2084-12-10**] Sex: M
Service: MEDICINE
Allergies:
Enalapril
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
s/p right carotid angiography and stenting
Major Surgical or Invasive Procedure:
Right c... | Discharge summary |
Classify the following medical document. | TITLE: [**Hospital Unit Name 10**] Resident Progress Note
Chief Complaint:
24 Hour Events:
- off neosynephrine, only on levophed
- checking daily LFTs and amylase/lipase as is s/p ERCP
- Echo results [**8-22**] showed hyperdynamic LV, EF >75%, mild LVH, no
focal wall motion abnormality
- CVP was 22... | Physician |
Classify the following medical document. | TITLE:
Chief Complaint: Hypoxia
HPI:
This is a 45 year old Armenian female transferred from the BMT service
with worsening hypoxia. She was in her usual state of health until mid
[**Month (only) 93**], she began to have fevers, chills, nightsweats. This was
accompanied by a non-productive cough, na... | Physician |
Classify the following medical document. | Mr. [**Known firstname 20**] [**Known lastname **] is a 86 yo man with h/o CAD s/p MI and CABG in [**2136**],
chronic AFib with V-pacing, chronic systolic CHF with EF 20%, multiple
recent admission to the CCU for ICD firing, readmitted from [**Hospital **]
rehab for left sided chest pain. He reports that he h... | Nursing |
Classify the following medical document. | Admission Date: [**2137-9-11**] Discharge Date: [**2137-9-14**]
Date of Birth: [**2062-9-1**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Esoph... | Discharge summary |
Classify the following medical document. | TSICU
HPI:
66F with hx of [**Hospital 1571**] transferred from [**Location (un) 78**] after having
worst HA of life at 4p while at church. She denied N/V, CP, SOB,
LOC. Was found to have SAH at OSH, Dilantin loaded and started on
Nimodipine. She was then transferred here for further evaluation.
Chief ... | Physician |
Classify the following medical document. | Chief Complaint:
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
58 yo man with with h/o ETOH abuse. Quit drinking on [**5-27**]. Had
some gait difficu... | Physician |
Classify the following medical document. | TITLE:
Chief Complaint:
24 Hour Events:
Echo - Left ventricular cavity enlargement with extensive regional
systolic dysfunction c/w CAD (mid-LAD distribution, LVEF = 25-30). Mild
aortic regurgitation. Pulmonary artery systolic hypertension. Mild
mitral regurgitation. CT surgery, will likely get CABG W... | Physician |
Classify the following medical document. | Chief Complaint:
24 Hour Events:
EKG - At [**2148-12-2**] 08:50 AM
History obtained from Medical records
Patient unable to provide history: Sedated
Allergies:
Ace Inhibitors
Cough;
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2148-12-2**] 02:00 PM
Vancomycin - [**2148-12-2*... | Physician |
Classify the following medical document. | TITLE:
Chief Complaint: 56 year old woman with metastatic breast cancer to
bone, lung and brain, presenting with worsening lower extremity edema,
found to be hypoxic and with new large right pleural effusion.
24 Hour Events:
THORACENTESIS - At [**2162-5-2**] 02:11 PM
Allergies:
Taxol (Intraven.) (Pac... | Physician |
Classify the following medical document. | Admission Date: [**2120-8-28**] Discharge Date: [**2120-9-6**]
Date of Birth: [**2043-6-19**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins / Sulfa (Sulfonamides) / Iodine
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Pt presented s/p fall w/bilaterall lower ext weaknes... | Discharge summary |
Classify the following medical document. | Chief Complaint: Acute respiratory failure, pneumonia
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
PICC LINE - START [**2105-12-10**] 10:... | Physician |
Classify the following medical document. | TITLE:
Chief Complaint:
24 Hour Events:
Extubated yesterday, required racemic epi for upper airway sounds,
briefly without gag reflex following extubation. T max of 100.1. Amio
400 TID started. Tele: 3 short runs of NSVT.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Bactrim (S... | Physician |
Classify the following medical document. | Admission Date: [**2135-7-30**] Discharge Date: [**2135-8-6**]
Date of Birth: [**2082-12-21**] Sex: M
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: Patient is a 52-year-old man
with a history of HIV, now viral counts are undetectable, and
350 CD4 count who presents with bloody diarrhea thre... | Discharge summary |
Classify the following medical document. | Admission Date: [**2120-8-16**] Discharge Date: [**2120-8-20**]
Date of Birth: [**2067-7-3**] Sex: M
Service: MEDICINE
Allergies:
Tetracycline / Clarithromycin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterizat... | Discharge summary |
Classify the following medical document. | Chief Complaint:
24 Hour Events:
BLOOD CULTURED - At [**2119-6-27**] 12:26 AM
FEVER - 102.8
F - [**2119-6-27**] 12:24 AM
- Conjugated hyperbilirubinemia
- Vitamin K 5mg PO x1
- ID - Continue antibiotics, continue surveillance cultures. Persistent
fevers not concerning at this point. If continues, consi... | Physician |
Classify the following medical document. | 55 y.o. male with PMHx of DM, HTN, CAD s/p IMI with 3 stents to RCA and
recently diagnosed RCC who was transferred from [**Hospital3 **]for
ongoing work-up of acute renal failure and change in mental status.
.
Patient was admitted to [**Hospital3 **]Hospital on [**2165-4-16**] for chest
and abdominal pai... | Nursing |
Classify the following medical document. | [**2156-2-6**] 5:37 PM
IVC GRAM/FILTER Clip # [**0-0-**]
Reason: High clinical suspicion PEpersitent hypoxia of sudden onsetP
Contrast: OPTIRAY Amt: 40
********************************* CPT Codes ********************************
* [**Numeric Identifier 1623**] INTER... | Radiology |
Classify the following medical document. | 65 yo M without medical history presenting for evaluation of shortness
of breath, nausea and vomiting. 5-6 days prior to admission he
developed paroxysmal cough. He obtained Tessalon Perles and an
antibiotic from a local allergist. Over the weekend, he developed
prominent GI symptoms w/ persistent nausea,... | Nursing |
Classify the following medical document. | Admission Date: [**2144-7-1**] Discharge Date: [**2144-7-6**]
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / aspirin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 88 year... | Discharge summary |
Classify the following medical document. | SICU
HPI:
70yo M w/ persistent abd pain, poor po intake, w/ gallstone
pancreatitis, complicated by abdominal compartment syndrome following
ERCP, ARDS, septic vasodilatory shock, Cdiff, and ARF. Now with
necrotizing pancreatitis s/p drain placement and multiple
necrosectomies.
.
SURGERIES:
ex... | Physician |
Classify the following medical document. | Chief Complaint: septic shock
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
42 y/o F w/CVID, Hep C cirrhosis, adm with C.diff sepsis.
24 Hour Events:
... | Physician |
Classify the following medical document. | TITLE: MICU Progress Note
Chief Complaint:
24 Hour Events:
Pt remained intubated. Spoke w/ son who says that goal is for family
meeting on Tuesday at [**Hospital3 **] where family will discuss goals of
care with [**Hospital3 **] staff. Indicated that they may move towards do
not hospitalize, CMO. Did ... | Physician |
Classify the following medical document. | Chief Complaint:
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
PEEP weaned to 8. FiO2 down to 40%. Was 9L neg on CVVH. CVVH taken off
... | Physician |
Classify the following medical document. | Admission Date: [**2138-9-29**] Discharge Date: [**2138-10-4**]
Date of Birth: [**2138-9-29**] Sex: M
Service: NB
[**Known lastname **] [**Known lastname 61773**] [**Known lastname 60891**] was born at 36-4/7 weeks gestation
by spontaneous vaginal delivery after induction for pregnanc... | Discharge summary |
Classify the following medical document. | 48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware
removal course c/b post-op resp failure, asp pna, and L lung collapse,
arf,, a-fib / flutter, and etoh withdrawal, extubated [**8-22**]
Hypernatremia (high sodium)
Assessment:
Sodium level =142 this am
Action:
Pt given 250cc
s fr... | Nursing |
Classify the following medical document. | CVICU
HPI:
53 y.o. M POD # 7 from CABGx1(SVG to PLB)/AVR (porcine), complicated
by respiratory failure (significant smoking history) and pneumonia. In
addition, post-op EtOH withdrawal.
Chief complaint:
PMHx:
PMH: Biscuspid AV with AS and AI, Sleep apnea (Did not tolerate CPAP),
HTN, Hyperlipid... | Physician |
Classify the following medical document. | Unit No: [**Numeric Identifier 67488**]
Admission Date: [**2156-8-16**]
Discharge Date: [**2156-8-23**]
Date of Birth: [**2082-9-9**]
Sex: M
Service: GU
CHIEF COMPLAINT: Bladder cancer.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 67489**] is a 73-year-old
man with known bladder cancer diagnosed on [**215... | Discharge summary |
Classify the following medical document. | Admission Date: [**2165-8-19**] Discharge Date: [**2165-8-24**]
Date of Birth: [**2088-8-5**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Briefly, this is a 74-year-old
male with a past medical history of hypertension and type 2
diabetes who felt chest discomfort and increasing pounding in
his chest.
... | Discharge summary |
Classify the following medical document. | 34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p
Bakri balloon placement now admitted to [**Hospital Unit Name 4**] for closer
monitoring.
BRIEF HISTORY :
34yo G8P6 admitted with vaginal bleeding. The patient was diagnosed
with non-viable pregnancy in [**Month (only) 2877**] with bleedi... | Nursing |
Classify the following medical document. | Chief Complaint: subdural hematoma, respiratory failure
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
82 y/o M w/afib, s/p AVR, diastolic CHF, admitted wit... | Physician |
Classify the following medical document. | TITLE: Physician Resident Progress Note
Chief Complaint:
24 Hour Events:
-started meropenem and discontinued ceftriaxone
-consulted EP, will check ICD tomorrow
-6 p.m., noted to be more hypoxemic, blood gas 7.50/37/50
-gave Lasix and placed on non-rebreather without improvement
-7 p.m. intubated fo... | Physician |
Classify the following medical document. | Admission Date: [**2195-12-8**] Discharge Date: [**2195-12-16**]
Date of Birth: [**2143-6-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedur... | Discharge summary |
Classify the following medical document. | Chief Complaint: Hypotension, suspected pneumonia
HPI:
Mrs. [**Known lastname 10048**] is a 71 year old female with past medical history of
congestive heart failure, back pain, psychotic depression, and GERD who
presented from her nursing home with fevers and change in mental
status. Per report from ED ... | Physician |
Classify the following medical document. | TITLE:
Chief Complaint:
24 Hour Events:
-K improved by PM lytes
-[**9-25**] f/u scheduled with heme/onc
-touched base with SW and case manager-working on rehab vs home health
nurse [**First Name (Titles) **] [**Last Name (Titles) **] anticipated monday.
-will need to t/b with heme/onc in regards to... | Physician |
Classify the following medical document. | Admission Date: [**2189-12-24**] Discharge Date: [**2189-12-30**]
Date of Birth: [**2124-7-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Scapular pain
Major Surgical or Inva... | Discharge summary |
Classify the following medical document. | TITLE:
Chief Complaint:
24 Hour Events:
-HD on [**5-21**]
-pressures steady with one drop to systolic of 79, improved with 500 cc
bolus
-expect floor transfer on [**5-22**] if pressures remain stable
Allergies:
Penicillins
swelling
itchi
Last dose of Antibiotics:
Infusions:
Other ... | Physician |
Classify the following medical document. | Admission Date: [**2108-7-10**] Discharge Date: [**2108-7-12**]
Date of Birth: [**2025-11-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Quinine / Latex
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Aortic va... | Discharge summary |
Classify the following medical document. | Chief Complaint:
HPI:
53yo male with esophageal ca s/p esophagogastrectomy in [**2184**] and s/p
multiple stents (last one on [**2188-7-28**]) tx from OSH for management of food
impaction. Pt has been vomnitting all his food and meds for 1 day. He
was admitted to the ICU for elective intubation and EGD.... | Physician |
Classify the following medical document. | SICU
HPI:
57M with h/o hep C cirrhosis s/p OLT [**12-31**] complicated by hepatic artery
thrombosis and biliary ischemia, s/p ERCP/CBD stent [**10-2**],
re-transplanted [**2124-10-25**] with subsequent hepaticojejunostomy for bile
leak [**2124-11-5**], admitted for hypotension, WBC 32 likely from C-diff ... | Physician |
Classify the following medical document. | Admission Date: [**2140-10-17**] Discharge Date: [**2140-10-22**]
Date of Birth: [**2084-5-2**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
.
HPI... | Discharge summary |
Classify the following medical document. | Chief Complaint:
24 Hour Events:
FEVER - 102.3
F - [**2191-8-25**] 08:00 PM
-dilantin level within normal ranges after adjusting for low albumin
(14)
-sputum cultures show 2+ gram - and 1+ gram positive consistent with
MRSA
-no neuro recs left
-nutrition consulted but did not leave TPN recs yet
... | Physician |
Classify the following medical document. | CCU NURSING 1730-1900
S. INTUBATED
O. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA
CV: PT RETURNED FROM CATH LAB AT ~1730 S/P CARDIAC ARREST W/? PEA RHYTHM, SBP 40/ FOR SUSTAINED PERIOD AFTER UNABLE TO CROSS OCCLUDED LAD LESION VIA R BRACHIAL APPROACH. INTUBATED, IABP PLACED IN L FEMORAL SITE, PA CATHETER ... | Nursing/other |
Classify the following medical document. | Chief Complaint: 51 yof with h/o ESLD [**12-26**] ETOH cirrhosis c/b HRS
requiring HD admitted for possible KL transplant.
24 Hour Events:
- did large volume para - 4.5 liters removed and fluid sent for
analysis which showed 130 WBC / 510 RBC / 0 PMN / 27 L / 66 macrophages
/ protein 2.7
- dobhoff clo... | Physician |
Classify the following medical document. | Chief Complaint:
24 Hour Events:
- films ordered will not be ready until wednesday
- pt scheduled for transfer to [**Male First Name (un) 1174**] tomorrow
- chest tube switched to water seal
- repeat CXR no increase in size of PTX
S: Pt doing okay this am, breathing comfortably, no CP/ABD pain. Had
... | Physician |
Classify the following medical document. | Admission Date: [**2185-8-29**] Discharge Date: [**2185-9-2**]
Date of Birth: [**2105-4-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Quinolones / Vancomycin Analogues / Levaquin
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Bronchial stenosis
Major Surgical or Invasive Pro... | Discharge summary |
Classify the following medical document. | [**Age over 90 **] y/o M ([**Hospital1 328**] speaking only) with hx of HTN, hyperlipidemia, GERD
and CKD presented from home with increasing confusion. Mr. [**Known lastname 14418**]
became acutely confused while at synagogue. He stood up, was clutching
his head, complaining that he could not see or hear. [*... | Nursing |
Classify the following medical document. | [**2137-4-26**] 4:55 PM
MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # [**Clip Number (Radiology) 41666**]
MRV HEAD W/O CONTRAST
Reason: repeat MRI for VST
Admitting Diagnosis: CAVERNOUS SINUS THROMBOSIS
Contrast: MAGNEVIST Amt: 17
_________________________________________________________... | Radiology |
Classify the following medical document. | [**2109-12-22**] 7:35 PM
MR HEAD W & W/O CONTRAST Clip # [**Clip Number (Radiology) 27735**]
Reason: Invasive sinusitis? Brain abscess?
Contrast: MAGNEVIST Amt: 20
______________________________________________________________________________
... | Radiology |
Classify the following medical document. | CRITICAL CARE ATTENDING
01:00
I saw and examined Ms. [**Known lastname 6072**] with Dr. [**Last Name (STitle) 6369**], whose note reflects
my input. I would add/emphasize that this [**Age over 90 **]-year-old woman presents
from rehab (after a recent discharge) with altered mental status and
dyspnea. H... | Physician |
Classify the following medical document. | Chief Complaint: Elective intbuation for bronchoscopy
Reason for ICU admission: hypoxia
HPI:
Ms [**Known lastname 11669**] is an 81 year old woman with past medical history
significant for chronic low back pain, coronary artery disease,
hypertension, hyperlipidemia, and question of vasculitis, transferr... | Physician |
Classify the following medical document. | Chief Complaint: resp failure
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
CARDIOVERSION/DEFIBRILLATION - At [**2167-10-19**] 11:50 AM
... | Physician |
Classify the following medical document. | Admission Date: [**2130-7-3**] Discharge Date: [**2130-7-6**]
Service: Medicine Intensive Care Unit - Green
CHIEF COMPLAINT: The patient came in with hematemesis,
melanotic stools.
HISTORY OF PRESENT ILLNESS: This is an 83 year old female
with past medical history of cerebrovascular accident,
congestive ... | Discharge summary |
Classify the following medical document. | CVICU
HPI:
52yoM POD # 1 from AVR (25 StJude Mech)/Asc Ao replacement/CABG
x1(LIMA-LAD)
PMHx:
Complete Heart Block(PPM), Postop DVT in LUE [**3-20**] following lead
extraction, Hyperlipidemia, s/p Dual chamber pacemaker '[**87**], s/p
replacement PM generator '[**96**], s/p Lead extraction & reimpl... | General |
Classify the following medical document. | [**2136-2-13**] 1:08 PM
CT ABD & PELVIS WITH CONTRAST Clip # [**Clip Number (Radiology) 26937**]
Reason: Changes from reference CT scan. ? continued abdominal proces
Admitting Diagnosis: ISCHEMIC BOWEL
Contrast: OMNIPAQUE Amt: 130
_________________________________________________... | Radiology |
Classify the following medical document. | MICU Intern Progress Note:
24 Hour Events:
FEVER - 103.0
F - [**2170-5-17**] 12:00 AM
- HIV, pcp negative
[**Name Initial (PRE) **] sent [**Doctor First Name **], ANCA
- changed CTX to Cefepime
- continues to [**Last Name (LF) **], [**First Name3 (LF) **] far cultures negative
Allergies:
Atorvasta... | Physician |
Classify the following medical document. | Hyponatremia (low sodium, hyposmolality)
Assessment:
SIADH associated with TBI. Serum Na 143 with serum osmolality 302
Action:
Q 4hour Na & osmolality monitored
Salt tabs 2 grams TID continue
3% saline infusion discontinued
Mannitol dosing changed to 12.5 gm Q 12 hours
Neuro checks Q2 hour; dil... | Nursing |
Classify the following medical document. | Admission Date: [**2199-12-26**] [**Year/Month/Day **] Date: [**2199-12-30**]
Date of Birth: [**2119-1-27**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Cephalosporins / Flagyl
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
s/p Fall
Major Surgical or ... | Discharge summary |
Classify the following medical document. | TITLE:
Chief Complaint:
24 Hour Events:
INVASIVE VENTILATION - STOP [**2196-4-19**] 11:17 AM
received from EW at 1421
- MR head final read: Small acute infarcts in the left occipital and
right posterior temporal lobes. Embolic etiology should be considered.
- Stroke team consulted; recs: MRA (or CTA)... | Physician |
Classify the following medical document. | Chief Complaint: Shock , MODS
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
44F admitted with multiorgan failure secondary to diffuse
microangiopathy an... | Physician |
Classify the following medical document. | Chief Complaint: CML with GVHD
24 Hour Events:
NASAL SWAB - At [**2124-10-15**] 01:15 PM
rapid respiratory viral culture
PICC LINE - START [**2124-10-15**] 04:32 PM
dressing changed
PICC LINE - STOP [**2124-10-15**] 04:37 PM
dressing changed
- Speech and swallow cancelled as he had passed his last one... | Physician |
Classify the following medical document. | Chief Complaint: Respiratory Distress
24 Hour Events:
-No CVVH done yesterday as line became clotted. Pt. remained
intubated, weaned off sedation. Started on high dose lactulose with
good effect.
VAC was changed on [**4-17**] by ortho, stable.
Allergies:
No Known Drug Allergies
Last dose of An... | Physician |
Classify the following medical document. | BONE MARROW SCAN Clip # [**Clip Number (Radiology) 77369**]
Reason: 30YR OLD WOMAN WITH ESRD ON HD, S/P TIB/FIB FX WITH HARDWARE INFECTION S/P HARDWARE REMOVAL WITH EX-FIX
______________________________________________________________________________
... | Radiology |
Classify the following medical document. | Chief Complaint:
24 Hour Events:
BLOOD CULTURED - At [**2192-8-28**] 03:08 PM
-40mg IV lasix with good urine output (approx 500cc)
-medications changed to PO if possible to avoid excess urine, decreased
free water flushes with TFs
-switched to AC overnight for persistent apnea
Allergies:
Aspirin
... | Physician |
Classify the following medical document. | T/Sicu Nsg Note
0700>>[**2197**]
Events- Second left pleural CT for persistent pneumotx
weaned from levo after additional IVF(FFP)
improved MAP..CPP values
tolerating small doses fentanyl w/effect>>improved sedation
CT for many scans including TLS...pnd
resolving met acidosis
N... | Nursing/other |
Classify the following medical document. | Chief Complaint: respiratory and renal failure
24 Hour Events:
DIALYSIS CATHETER - STOP [**2117-7-23**] 04:30 PM
placed in IR
UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At
[**2117-7-23**] 04:30 PM
- Pt's position was being changed, and her tunneled HD line was pulled
out. CVVH stopped. Re... | Physician |
Classify the following medical document. | Admission Date: [**2182-5-8**] Discharge Date: [**2182-5-14**]
Date of Birth: [**2120-10-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Decreased exercise tollerance.
Major ... | Discharge summary |
Classify the following medical document. | Admission and NPN 01-0700:
This is a 54 yo male pt with a hx of HCV, hepatocellular CA, cirrhosis, etho, who has been living in a nursing home transitioning to hospice. Plan was for pt to go back to [**Country 1948**] where he would likely die soon. Instructions were that he wanted to remain full code in hopes that he ... | Nursing/other |
Classify the following medical document. | Admission Date: [**2186-11-24**] Discharge Date: [**2186-11-28**]
Date of Birth: [**2108-3-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Accupril / Celebrex
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
"spitting up dark vomit"
Major Surgical or Invasive Procedure:... | Discharge summary |
Classify the following medical document. | Neonatology Attending Admission Note
Infant known to [**Hospital1 21**] NICU as was delivered and initially admitted here ([**2170-12-8**]). Subsequently transferred later on delivery day to [**Hospital3 50**] for surgical management of imperforate anus. Has done well s/p colostomy for imperforate anus and transferr... | Nursing/other |
Classify the following medical document. | Admission Date: [**2185-3-9**] Discharge Date: [**2185-4-20**]
Date of Birth: [**2145-10-21**] Sex: F
Service: SURGERY
Allergies:
Sulfonamides / Zithromax / Biaxin / Plaquenil / Amantadine /
Amoxicillin / Fish Product Derivatives / Hydromorphone / Ativan
/ Versed / Tegaderm / Zyrtec / ... | Discharge summary |
Classify the following medical document. | Chief Complaint:
24 Hour Events:
TRANSTHORACIC ECHO - At [**2196-1-13**] 09:00 AM
- ENT deferred inpatient consult and recommended that patient follow-up
as an oupatient for work-up of hoarseness, should be arranged when he
is closer to discharge (clinic x27500)
- Morphine 2 mg iv x1 and q6 h prn for ... | Physician |
Classify the following medical document. | [**2170-6-26**] 12:02 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # [**Clip Number (Radiology) 77183**]
CT PELVIS W/CONTRAST
Reason: fx, solid organ injury
Field of view: 44 Contrast: OPTIRAY Amt: 130
______________________________________________________________________________
[**Hos... | Radiology |
Classify the following medical document. | `
Pt 55 y/o m who presented from [**Hospital 108**] Hospital with mental status
changes, lethargy, Tmax of 103, and hyperglycemia
FS 560. Pt went
unresponsive while at [**Name (NI) 108**], pt was nasally intubated and Tx to
[**Hospital1 54**]. [**9-15**]: PT had MRI/MRA of head, neck and pelvis. PT was ... | Nursing |
Classify the following medical document. | Chief Complaint: shortness of breath, hypoxia
HPI:
This is a 56 yo F with h/o metastatic melanoma who was admitted on
[**2187-7-9**] for IL-2 therapy and now is transferred to the [**Hospital Unit Name 4**] in the
setting of shortness of breath and hypoxia. Began IL-2 in PM of [**7-9**]
and has since g... | Physician |
Classify the following medical document. | Chief Complaint:
24 Hour Events:
INVASIVE VENTILATION - STOP [**2124-9-14**] 05:23 PM
- recieved 1uPRBC and 1u PLT
- CBI for hematuria
- ambisome decresed to 250 q24 (from 400) given concern for hematuria
- ID: check stool for c diff
- CXR: Dense right upper lobe consolidation with volume loss, new s... | Physician |
Classify the following medical document. | [**2156-6-14**] 2:16 PM
CT CHEST W/O CONTRAST Clip # [**Clip Number (Radiology) 81612**]
Reason: Pls eval for interval change, possible same-time interventio
Admitting Diagnosis: S/P PEDESTRIAN STRUCK
_________________________________________________________________________... | Radiology |
Classify the following medical document. | [**2108-9-18**] 10:25 AM
CT CHEST W&W/O C ; CTA ABD W&W/O C & RECONS Clip # [**Clip Number (Radiology) 26518**]
Reason: evidence of pancreatic mass/insulinoma
Admitting Diagnosis: RULE OUT INSULINOMA
Contrast: OPTIRAY Amt: 200
___________________________________________________________________... | Radiology |
Classify the following medical document. | Attending Physician: [**Name10 (NameIs) 449**]
Referral date: [**2110-12-6**]
Medical Diagnosis / ICD 9: [**Last Name (un) 10353**] / 959.9
Reason of referral: eval and treat, CPT, risk to fall
History of Present Illness / Subjective Complaint: 79F adm to outside
hospital s/p fall down flight of stairs w... | Rehab Services |
Classify the following medical document. | Chief Complaint: fevers, leukocytosis
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
53M severe COPD - fractured his right elbow [**9-18**] and underwent ex... | Physician |
Classify the following medical document. | Chief Complaint: 79M with CHF, afib, Alzheimer's admitted with
influenza
24 Hour Events:
On pressure support most of day; did well but switched back to AC in
evening
Held coumadin, will need to be started on heparin gtt once INR no
longer supratherapeutic
Started on tube feeds; will watch lytes clo... | Physician |
Classify the following medical document. | CVICU
HPI:
86yoM s/p CABG/MVR [**4-19**]
EF 70 Cr 1.8 Wt 68.5K HgbA1c 6.3
[**Last Name (un) **]: ASA 325', Diltiazem SR 240', Furosemide 80", Metolazone 2.5 Q
M-W-F, Metoprolol 25', Warfarin 2alt4mg, Potassium 20'''
Coumadin - atrial fibrillation - started [**5-13**] (1),
On Fondaparinux sq due to ... | Physician |
Classify the following medical document. | Admission Date: [**2141-11-5**] Discharge Date: [**2142-2-18**]
Date of Birth: [**2141-11-5**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Name2 (NI) 4027**] #2, is the
former 1070 gm male newborn Twin B who was admitted to the
Neonatal Intensive Care Unit for m... | Discharge summary |
Classify the following medical document. | Admission Date: [**2159-3-4**] Discharge Date: [**2159-3-8**]
Date of Birth: [**2115-11-6**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 13561**]
Chief Complaint:
left upper and lower extremity numbn... | Discharge summary |
Classify the following medical document. | TITLE:
Chief Complaint:
24 Hour Events:
Pt. started on standing haldol as per neuroloy recs, but patient had QT
prolongation to 0.49, so patient was changed to zyprexa 5mg QID.
Treatment with cidofovir was initiated yesterday, with probenecid for
renal protection
Patient to get an EEG today
Alle... | Physician |
Classify the following medical document. | Trauma, s/p multiple stab wounds to head, chest, right arm & axilla,
abdomen, and right buttocks. Pt is s/p Exp Lap with repair of liver
laceration & repair of gastrotomy; and repair RUE brachial vein.
Assessment:
Pt sedated on propofol and Fentanyl infusion- not responding to noxious
stimulation, no cou... | Nursing |
Classify the following medical document. | ADMISSION NOTE:
The patient is a 64-year-old female who began having crampy spasmodic
abdominal pain accompanied by nausea and dry heaves about three days
ago. She denies passage of flatus for 2-3 days, last BM was 3 days ago.
She denies fever and chills. The pain is remniscent of an episode of
food pois... | Nursing |
Classify the following medical document. | Chief Complaint: hypoxia, change in mental status
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
66F with small cell lung ca diagnosed by biopsy of neck so... | Physician |
Classify the following medical document. | Chief Complaint:
24 Hour Events:
- LDH at 700
- PM Lytes: Lactate 3.4 (from 1.1), K 3.2, P 1.0
- HCT 33.6 from 38.1
- UOP to 30/hr from 60/hr
- Received 4 L of fluids
- Received: 14 g CaGluc, 60 KPhos, 2 Pkt Neutra Phos, 54 oral K Meq
Allergies:
No Known Drug Allergies
Last dose of Antibio... | Physician |
Classify the following medical document. | Mrs [**Last Name (STitle) 12830**] is an 88 yr. old woman, who fell at home on [**1-14**]. she
underwent hip surgery on [**1-16**]. pt. also broke her humerous and uses a
sling when oob.
Pt. is very HOH and hears best from her left ear.
Pt. is alert and orientated.
She was sent to [**Hospital3 **] for re... | Nursing |
Classify the following medical document. | TITLE:
History of Present Illness
- gave 2 units PRBC, IVF (750 cc)
- held all antii-hypertensives
- HR initially 110s atrial tachycardia, fell to 70s and sinus with
fluids, alternating between these two rhythms with stable BP
Medications
Unchanged
Physical Exam
BP 90-112/53-82, HR 69-134, RR... | Physician |
Classify the following medical document. | Admission Date: [**2128-3-19**] Discharge Date: [**2128-4-9**]
Date of Birth: [**2050-6-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
77 y.o. male with two weeks of RLE claudication... | Discharge summary |
Classify the following medical document. | [**2151-2-2**] 2:32 PM
ABDOMINAL AORTA Clip # [**Clip Number (Radiology) 56800**]
Reason: SMA aneurysm identified in the CT angio of abdomen.For coil
Contrast: OPTIRAY Amt: 55
********************************* CPT Codes ********************************
* [**Numeric ... | Radiology |
Classify the following medical document. | [**2166-11-17**] 12:54 PM
BILIARY CATH CHECK Clip # [**Clip Number (Radiology) 46741**]
Reason: r/o biliary obstruction
Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM
Contrast: OPTIRAY Amt: 20
********************************* CPT Codes ********************************... | Radiology |
Classify the following medical document. | 24 Hour Events: 79y F presenting with large L frontal and occipital
intraparenchymal hemorrhage
No major events overnight
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Ciprofloxacin - [**2148-12-8**] 02:23 AM
Vancomycin - [**2148-12-9**] 08:38 AM
Infusions:
Other ICU medication... | Physician |
Classify the following medical document. | Admission Date: [**2131-3-21**] Discharge Date: [**2131-4-12**]
Date of Birth: [**2082-11-8**] Sex: F
Service: PLASTIC
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 36263**]
Chief Complaint:
left thigh infection
Major Surgical or Invasive Procedure:
[**2131-... | Discharge summary |
Classify the following medical document. | TITLE:
Chief Complaint:
24 Hour Events:
- three way foley placed for continuous bladder irrigation. Some clots
came out, was pink tinged, then completely clear.
- CT scan, got versed with it; somnolent afterwards; also got zyprexa
yesterday am
- Neuro feels large posterior infarct may be in last d... | Physician |
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