Training in progress, epoch 5

Llama3_peft_lora_4bit_1shot_without_val_091424.tsv

@@ -1,11 +1,11 @@
 text_id	subject	object	text	relation_type	sentence	sft_re
 383_TL0	ADMISSION	4/17/95	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	OVERLAP	[@Subject$]ADMISSION[@Subject$] DATE : [@Object$]4/17/95[@Object$] DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR [@Subject$]ADMISSION[@Subject$] : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst .	OVERLAP
-383_TL1	DISCHARGE	07/16/95	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	OVERLAP	ADMISSION DATE : 4/17/95 [@Subject$]DISCHARGE[@Subject$] DATE : [@Object$]07/16/95[@Object$] HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst .	AFTER
-383_TL10	Vassdiysey Medical Center	Vassdiysey Medical Center	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	OVERLAP	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from [@Subject$][@Object$]Vassdiysey Medical Center[@Object$][@Subject$] for rule out pancreatic pseudocyst .	BEFORE
+383_TL1	DISCHARGE	07/16/95	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	OVERLAP	ADMISSION DATE : 4/17/95 [@Subject$]DISCHARGE[@Subject$] DATE : [@Object$]07/16/95[@Object$] HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst .	The temporal relationship between the subject and object is AFTER
+383_TL10	Vassdiysey Medical Center	Vassdiysey Medical Center	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	OVERLAP	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from [@Subject$][@Object$]Vassdiysey Medical Center[@Object$][@Subject$] for rule out pancreatic pseudocyst .	The temporal relationship between the subject and object is BEFORE
 383_TL100	the pancreatic necrosis	Drainage	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	BEFORE	[@Object$]Drainage[@Object$] of [@Subject$]the pancreatic necrosis[@Subject$] was also done .	AFTER
 383_TL101	the procedure	An exploratory laparotomy	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	OVERLAP	[@Object$]An exploratory laparotomy[@Object$] was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated [@Subject$]the procedure[@Subject$] fairly well , and was transferred to the Intensive Care Unit .	AFTER
 383_TL102	transferred	the procedure	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	AFTER	The patient tolerated [@Object$]the procedure[@Object$] fairly well , and was [@Subject$]transferred[@Subject$] to the Intensive Care Unit .	AFTER
-383_TL103	the operating room	transferred	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	BEFORE	He was [@Object$]transferred[@Object$] to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to [@Subject$]the operating room[@Subject$] on 4/28/95 .	BEFORE
+383_TL103	the operating room	transferred	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	BEFORE	He was [@Object$]transferred[@Object$] to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to [@Subject$]the operating room[@Subject$] on 4/28/95 .	OVERLAP
 383_TL104	the Intensive Care Unit	transferred	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	AFTER	The patient tolerated the procedure fairly well , and was [@Object$]transferred[@Object$] to [@Subject$]the Intensive Care Unit[@Subject$] .	AFTER
-383_TL105	the Intensive Care Unit	the Intensive Care Unit	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	OVERLAP	The patient tolerated the procedure fairly well , and was transferred to [@Subject$][@Object$]the Intensive Care Unit[@Object$][@Subject$] .	OVERLAP
+383_TL105	the Intensive Care Unit	the Intensive Care Unit	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	OVERLAP	The patient tolerated the procedure fairly well , and was transferred to [@Subject$][@Object$]the Intensive Care Unit[@Object$][@Subject$] .	The temporal relationship between the subject and object is AFTER
 383_TL106	a prolonged course	the Intensive Care Unit	ADMISSION DATE : 4/17/95 DISCHARGE DATE : 07/16/95 HISTORY AND REASON FOR ADMISSION : Mr. Mass was a 56 year old white male who was transferred from Vassdiysey Medical Center for rule out pancreatic pseudocyst . Mr. Mass had a past medical history which included Wegener  and apos;s granulomatosis , history of an anterior myocardial infarction , and gallstone pancreatitis . He was admitted to Vassdiysey Medical Center with severe recurrent pancreatitis , nausea , vomiting , and abdominal pain . His amylase on admission there was 1,961 . The patient had two recent admissions for pancreatitis in January 1994 , and August 1994 . On his current admission , the patient was admitted to Free Medical Center . His amylase decreased to 51 , and the increased back to 151 on hospital day #10 . At that time , he spiked a temperature to 103 . He also became increasingly confused . A computerized tomography scan done on 4/16/95 showed a large  and quot; pseudocyst  and quot; . He was transferred to Ph University Of Medical Center for further surgical evaluation . and apos; HOSPITAL COURSE : The patient was admitted , placed on intravenous fluids . He was continued on his imipenem , intravenously . The patient was started on total parenteral nutrition . On 4/17/95 , GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct , involving the posteroseptal , anteroseptal areas . Left ventricular aneurysm was also noted ; however , no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function , with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase , which came back 53,230 . On 4/28/95 , the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 , on 4/27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc. and apos;s of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient  and apos;s deteriorating state , the patient was brought to the operating room on 4/28/95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus , the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy , and oversewing of the descending colon . Drainage of the pancreatic necrosis was also done . The patient tolerated the procedure fairly well , and was transferred to the Intensive Care Unit . In the Intensive Care Unit , the patient had a prolonged course . The patient was then extubated on postoperative day #2 , but remained pressor-dependent . He remained on imipenem , and Vancomycin was also started . Thereafter , the patient had a long and complicated postoperative course . He was eventually transferred to the floor , where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic/40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups , it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced , and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently , he was on a 28 day course of Vancomycin , ofloxacin , and Flagyl , for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07/15/95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas , which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata , going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics , most recently Granisetron , with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June , it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis ; however , long discussions with the patient and his wife , who was his health-care proxy , revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass , the rest of the surgical team , and the patient  and apos;s wife , with this same result . After discussion with the patient  and apos;s primary doctor , Dr. Douet at Vassdiysey Medical Center , it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note , given the patient  and apos;s do not resuscitate status and the risk for bleeding , the patient  and apos;s Coumadin was stopped without incident several weeks before transfer .	OVERLAP	In [@Object$]the Intensive Care Unit[@Object$] , the patient had [@Subject$]a prolonged course[@Subject$] .	OVERLAP

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