BioMed Research International / 2015 / Article / Tab 1

Research Article

Recognition and Evaluation of Clinical Section Headings in Clinical Documents Using Token-Based Formulation with Conditional Random Fields

Table 1

A sample of discharge summary.

Record date: 2088-07-03B
Name: Younger, T EugeneB
Date of Admission: 7/2/88B
I
CC: Lightheadedness, vertigo, and presyncopalsx × several episodesB
I
HPI:. 64 yoM w/significant PMH for CAD, HTN, GERD, and past cerebral embolism presents w/6 hour history of vertiginous symptoms, dizziness, lightheadedness, and feeling “like [he] was going to pass out”. The pt recalls…B
I
ROS: +tinnitus, −weakness/change in sensation, ataxia, aura-like sx, post-episode confusionB
I
PMH:B
CAD: 2075 PTCA w/Angioplasty to LAD, Stress (3/88): rev. anterolateral ischemia, Cath (5/88): 3v disease: RCA 90%, LAD 30% mid, 80% distal, D1 70%, D2 40% and 60%, LCx 30%, OM2 80%B
I
Meds (Updated 7/20)B
Atenolol 25/50 mg qAM/qPMI
ASA 325 mg qDI
ALL: NKDA, Intolerance to InderalB
I
FHx:B
+HTN: mother/brotherI
SocHx: Lives by himself separated.B
I
PE:B
VS:I
Gen: Well-nourished male, NADI
HEENT: MMM, OP clearI
Neck: JVP about 9 cm. I
I
LABS:B
Sodium     140 135–145 mmol/L  07/02/88 11:21  147(H) 10/08/82 13:24 I
Potassium     4.1  3.4–4.8 mmol/L   07/02/88 11:21 I
EKG: Sinus brady @ 60, w/LAD, ICVD (QRS 108), NS St/T wave changes.I
CXR: PendingI
I
Impression: 64 yo male w/significant CAD, past cerebral emboli, presents w/sx B
Plan:B
() Vertigo: Clinically peripheral disease. If central, would not expect to be affected by motion, be able to be eextinguished, and so forth. I
Fall precautionsI
R/o cardiac ischemia: Troponins, monitor, and so forthI
Betty Kaitlin Wood, MDI