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###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Mr. ___ is a ___ year old man with HTN, DM,HL, CAD and b/l hearing
loss presenting with new onset exertional angina abnormal stress
test who was found to have three vessel CAD.
# Unstable Angina/CAD: Mr. ___ had been experiencing progressive
exertional, substernal chest pain and was sent for outpatient
studies by his neurologist. He had an abnormal stress test and
perfusion study showing a large reversible moderate severity
perfusion defect involving the Lcx territory, so he was sent to
the ER, where troponin was <0.01 and his EKG showed no ST
segment elevations. He was admitted and underwent a cardiac
catheterization that showed three vessel CAD. He was then seen
by cardiac surgery for evaluation of cardiac ___ bypass graft
surgery. This was scheduled for ___, after a 5 day
plavix wash-out period. He was discharged with chlorhexidine
washes for ___ night and ___ morning, as well as
mupirocen nasal cream BID, and the time and place to present for
admission on ___ morning. He was also set up for ___ as he
expressed concern about being able to complete his pre-op
regimen and take his medication as prescribed. His Lisinopril
was held from discharge until after surgery as he had a mild
increase in creatinine. His plavix was held. His home atenoll
was converted to metoprolol and aspirin was started; these
medications were continued until surgery. His atorvastatin dose
was increased to 80mg daily, which was also continued.
# Travel plasn: A medical note was provided as he was no longer
able to travel as anticipated.
============================================
TRANSITIONAL ISSUES
============================================
Mr ___ is a ___ year old man with HTN, DM,HLD and b/l hearing loss
presenting with new onset exertional angina who was found to
have 3 vessel CAD.
- CAD: Seen by Cardiac surgery and planned for surgery on
___. Will need chlorhexidine wash ___
morning before coming in. Will need to use Mupirocin cream ___
tube in each nostril) twice a day between now and then.
- Atenolol switched to metoprolol.
- HbA1c 7.1%
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, HL {Hyperlipidemia}, CAD {Coronary arteriosclerosis}, b/l hearing
loss {Bilateral hearing loss}, exertional angina {Exercise-induced angina}, abnormal stress
test {Cardiovascular stress test abnormal}, three vessel CAD {Triple vessel disease of the heart}, Unstable Angina {Preinfarction syndrome}, CAD {Coronary arteriosclerosis}, progressive {Patient's condition worsened}, exertional {Chest pain on exertion}, substernal chest pain {Retrosternal pain}, studies {Evaluation procedure}, abnormal stress test {Cardiovascular stress test abnormal}, perfusion study {Radionuclide myocardial perfusion study}, perfusion defect {Myocardial perfusion defect}, Lcx {Structure of circumflex branch of left coronary artery}, troponin {Troponin measurement}, EKG {Electrocardiographic procedure}, ST
segment elevations {ST segment elevation}, cardiac
catheterization {Cardiac catheterization}, three vessel CAD {Triple vessel disease of the heart}, evaluation {Evaluation procedure}, cardiac {Heart structure}, bypass graft {Coronary artery bypass grafting}, surgery {Surgical procedure}, nasal {Administration of drug or medicament via nasal route}, after surgery {Postoperative state}, increase in creatinine {Serum creatinine above reference range}, plavix {Administration of prophylactic clopidogrel}, held {Recommendation to stop drug treatment}, converted {Change of medication}, aspirin {Administration of aspirin}, medications {Administration of drug or medicament}, surgery {Surgical procedure}, increased {Increasing dosage of medication}, Travel {Travel abroad}, travel {Travel abroad}, HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, HLD {Hyperlipidemia}, b/l hearing loss {Bilateral hearing loss}, exertional angina {Exercise-induced angina}, 3 vessel CAD {Triple vessel disease of the heart}, CAD {Coronary arteriosclerosis}, surgery {Surgical procedure}, nostril {Structure of anterior naris}, HbA1c {Hemoglobin A1c measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. celecoxib 200 mg oral PRN gout attack
5. Clopidogrel 75 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Colchicine 0.6 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Nitroglycerin SL 0.4 mg SL PRN chest pain
RX *nitroglycerin [Nitrostat] 0.4 mg 1 tablet(s) sublingually
every 5 minutes x 3 tablets Disp #*12 Tablet Refills:*0
4. Mupirocin Nasal Ointment 2% 1 Appl NU BID Duration: 5 Days
RX *mupirocin calcium [Bactroban Nasal] 2 % 0.5 (One half) tube
in each nostril twice a day Disp #*6 Tube Refills:*0
5. Allopurinol ___ mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
This replaces atenolol
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. Colchicine 0.6 mg PO DAILY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Mental Status: Confused - mildly, occasionally. Oriented x3.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Home With Service {Home health aide service management}, Coronary Artery Disease {Coronary arteriosclerosis}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, Oriented x3 {Oriented to person, time and place}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ due to
chest pain. A cardiac catheterization revealed that you have
coronary artery disease in the main three vessels in your heart.
The recommended treatment is a coronary artery bypass graft
(CABG) surgery. You were seen by the Cardiac Surgeons who plan
to perform the surgery on ___.
Do not take plavix, NSAIDS (including celecoxib, ibuprofen), or
lisinopril until instructed to by your doctor after surgery.
Atenolol was also switched to metoprolol. Continue to take your
other medications, including metoprolol and aspirin, as
prescribed.
Please return to the hospital on ___ 6:00 AM as
instructed by the Cardiac Surgery team, and follow their
direction about soap scrubs and cream application in preparation
for surgery. Nurses ___ visit your home to check on you
tomorrow.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team
###RESPONSE: chest pain {Chest pain}, cardiac catheterization {Cardiac catheterization}, coronary artery disease {Coronary arteriosclerosis}, three vessels in your heart {Triple vessel disease of the heart}, coronary artery bypass graft {Coronary artery bypass grafting}, CABG {Coronary artery bypass grafting}, surgery {Surgical procedure}, surgery {Coronary artery bypass grafting}, Do not take {Patient medication education}, after surgery {Postoperative state}, switched {Change of medication}, medications {Patient medication education}, aspirin {Administration of aspirin}, preparation
for surgery {Preoperative education}, home {Home health aide service management} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending: ___.
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
Cardiac cath on ___ with DES to circumflex artery.
###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, Shortness of breath {Dyspnea}, Cardiac cath {Cardiac catheterization}, circumflex artery {Structure of circumflex branch of left coronary artery} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ M with a history of PVD, AAA repair, s/p CEA, HTN who was
seen by his outpatient Cardiologist 5 days ago. Per report, he
had a stress echo (official results not available). Patient was
set up for outpatient cath next week, but in the interim was
admitted to ___ with pulmonary edema. He had acute shortness of
breath on night of ___ and called EMS.
.
Presented to OSH complaining of shortness of breath x 5 days,
that has been getting progressively worse. One day prior to
admission to OSH he was short of breath climbing the stairs in
his house. That evening, while watching TV he had sudden onset
SOB. No CP, no palpitations. No nausea or vomiting. Patient did
become diaphoretic.
.
EMS noted BP 225/94, HR 130s, tachypneic. He was started on
CPAP, nebs, nitro gtt, lasix. Patient was admitted to the CCU at
OSH. Required 5L O2 nasal cannula.
Troponins of 0.112 --> 0.224 --> 0.305. CK 67-->48. CKMB 2.0-->
2.6. Cardiac index 3.0 --> 5.4. Of note, patient has not been
taking his home medications (including monopril, librium, and
simvastatin) per MD from the ___. ___ reason for this is unclear.
The patient is being transferred to ___ for catheterization.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He endoreses exertional buttock and calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for current absence of
chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations, syncope or presyncope.
###RESPONSE: PVD {Peripheral vascular disease}, AAA repair {Repair of aneurysm of abdominal aorta}, CEA {Carotid endarterectomy}, HTN {Hypertensive disorder, systemic arterial}, stress echo {Stress echocardiography}, cath {Cardiac catheterization}, pulmonary edema {Pulmonary edema}, shortness of
breath {Dyspnea}, EMS {Emergency treatment management}, shortness of breath {Dyspnea}, short of breath {Dyspnea}, SOB {Dyspnea}, CP {Chest pain}, palpitations {Palpitations}, nausea {Nausea}, vomiting {Vomiting}, diaphoretic {Excessive sweating}, BP {Blood pressure finding}, HR {Finding of heart rate}, tachypneic {Tachypnea}, on
CPAP {Dependence on continuous positive airway pressure ventilation}, lasix {Diuretic therapy}, O2 nasal cannula {Oxygen administration by nasal cannula}, Troponins {Troponin measurement}, Cardiac {Heart structure}, catheterization {Cardiac catheterization}, review of systems {Review of systems}, stroke {Cerebrovascular accident}, TIA {Transient ischemic attack}, deep venous thrombosis {Deep venous thrombosis}, pulmonary embolism {Pulmonary embolism}, bleeding {Bleeding}, surgery {Surgical procedure}, myalgias {Muscle pain}, joint pains {Joint pain}, cough {Cough}, hemoptysis {Hemoptysis}, black
stools {Dark stools}, red stools {Red stools}, fevers {Fever}, chills {Chill}, rigors {Rigor}, buttock {Pain in buttock}, calf pain {Pain in calf}, review of systems {Review of systems}, negative {No abnormality detected}, Cardiac review of systems {Cardiovascular physical examination}, chest pain {Chest pain}, paroxysmal nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, ankle
edema {Ankle edema}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
___ M with a history of PVD, AAA repair, s/p CEA, HTN who was
seen by his outpatient Cardiologist 5 days ago. Per report, he
had a stress echo (official results not available). Patient was
set up for outpatient cath next week, but in the interim was
admitted to ___ with pulmonary edema. He had acute shortness of
breath on night of ___ and called EMS.
.
Presented to OSH complaining of shortness of breath x 5 days,
that has been getting progressively worse. One day prior to
admission to OSH he was short of breath climbing the stairs in
his house. That evening, while watching TV he had sudden onset
SOB. No CP, no palpitations. No nausea or vomiting. Patient did
become diaphoretic.
.
EMS noted BP 225/94, HR 130s, tachypneic. He was started on
CPAP, nebs, nitro gtt, lasix. Patient was admitted to the CCU at
OSH. Required 5L O2 nasal cannula.
Troponins of 0.112 --> 0.224 --> 0.305. CK 67-->48. CKMB 2.0-->
2.6. Cardiac index 3.0 --> 5.4. Of note, patient has not been
taking his home medications (including monopril, librium, and
simvastatin) per MD from the ___. ___ reason for this is unclear.
The patient is being transferred to ___ for catheterization.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He endoreses exertional buttock and calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for current absence of
chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations, syncope or presyncope.
###RESPONSE: PVD {Peripheral vascular disease}, AAA repair {Repair of aneurysm of abdominal aorta}, CEA {Carotid endarterectomy}, HTN {Hypertensive disorder, systemic arterial}, stress echo {Stress echocardiography}, cath {Cardiac catheterization}, pulmonary edema {Pulmonary edema}, shortness of
breath {Dyspnea}, EMS {Emergency treatment management}, shortness of breath {Dyspnea}, short of breath {Dyspnea}, climbing the stairs {Difficulty walking up stairs}, SOB {Dyspnea}, CP {Chest pain}, palpitations {Palpitations}, nausea {Nausea}, vomiting {Vomiting}, diaphoretic {Excessive sweating}, BP {Blood pressure finding}, HR {Finding of heart rate}, tachypneic {Tachypnea}, on
CPAP {Dependence on continuous positive airway pressure ventilation}, lasix {Diuretic therapy}, O2 nasal cannula {Oxygen administration by nasal cannula}, Troponins {Troponin measurement}, Cardiac {Heart structure}, catheterization {Cardiac catheterization}, review of systems {Review of systems}, stroke {Cerebrovascular accident}, TIA {Transient ischemic attack}, deep venous thrombosis {Deep venous thrombosis}, pulmonary embolism {Pulmonary embolism}, bleeding {Bleeding}, surgery {Surgical procedure}, myalgias {Muscle pain}, joint pains {Joint pain}, cough {Cough}, hemoptysis {Hemoptysis}, black
stools {Dark stools}, red stools {Red stools}, fevers {Fever}, chills {Chill}, rigors {Rigor}, buttock {Pain in buttock}, calf pain {Pain in calf}, review of systems {Review of systems}, negative {No abnormality detected}, Cardiac review of systems {Cardiovascular physical examination}, chest pain {Chest pain}, paroxysmal nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, ankle
edema {Ankle edema}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Nonecontributory.
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
On Admission:
___ 09:05PM WBC-7.9 RBC-3.98* HGB-12.6* HCT-38.3* MCV-96
MCH-31.7 MCHC-32.9 RDW-16.1*
___ 09:05PM PLT COUNT-176
___ 09:05PM GLUCOSE-117* UREA N-27* CREAT-1.0 SODIUM-140
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
___ 09:05PM MAGNESIUM-2.2
___ 09:05PM CK-MB-NotDone cTropnT-0.01
___ 09:05PM CK(CPK)-49
.
Cardiac cath:
1. Selective coronary angiography of this left dominant system
revealed
three vessel coronary artery disease. The LMCA was calcified
with
minimal disease. The LAD had moderate disease, an ostial 90%
stenosis
at the diagonal artery near the ostium. The LCX had an 80%
stenosis at
the mid segment. The RCA was non dominant with diffuse high
grade
disease.
2. Resting hemodynamics demonstrated elevated LV filling
pressures,
moderate pulmonary artery hypertension, and a low cardiac index
(1.9).
3. Stenting of mid LCX with Xience 3x8
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Diastolic dysfunction.
3. Moderate pulmonary hypertension.
4. Stenting of LCX with drug eluting stent.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, coronary angiography {Angiography of coronary artery}, left {Catheterization of left heart}, three vessel coronary artery disease {Triple vessel disease of the heart}, LMCA {Structure of left coronary artery main stem}, calcified {Pathologic calcification, calcified structure}, minimal {Symptom mild}, disease {Disease}, LAD {Structure of anterior descending branch of left coronary artery}, disease {Disease}, ostial 90%
stenosis {Coronary ostium stenosis}, diagonal artery {Structure of diagonal branch of anterior descending branch of left coronary artery}, LCX {Structure of circumflex branch of left coronary artery}, mid segment {Structure of mid portion of circumflex branch of left coronary artery}, RCA {Right coronary artery structure}, diffuse high
grade
disease {Diffuse disease of coronary artery}, hemodynamics {Hemodynamic measurements}, elevated {Increased pressure}, LV {Left cardiac ventricular structure}, pressures {Pressure}, moderate pulmonary artery hypertension {Moderate pulmonary hypertension}, low cardiac index {Decreased cardiac index}, Stenting {Insertion of arterial stent}, mid LCX {Structure of mid portion of circumflex branch of left coronary artery}, Two vessel coronary artery disease {Double coronary vessel disease}, Diastolic dysfunction {Diastolic dysfunction}, Moderate pulmonary hypertension {Moderate pulmonary hypertension}, Stenting {Insertion of arterial stent}, LCX {Structure of circumflex branch of left coronary artery}, drug eluting stent {Endovascular insertion of drug eluting stent} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ M with a history of PVD, AAA repair, s/p CEA, HTN who
presented with acute SOB, likely flash pulmonary edema, but ? of
NSTEMI with elevated trops at ___.
.
# CORONARIES: Patient recently admitted to ___ for shortness of
breath and was found to have pulmonary edema with borderline
Troponing I. He denied any chest pain, diaphoresis, leg
swelling. He was discharged with cardiology follow up and now is
admitted for further work up and cath. He was chest pain free
overnight and in the cardiac cath was found to have ostial 90%
stenosis at the diagonal artery near the ostium. The LCX had an
80% stenosis at the mid segment. Since he has RCA atrophied with
a dominant LCV it was stented with a 3x5 Cypher stent. Since the
ostial lession was very small Dr. ___ not to stent it.
He was re-started on lisinopril, metoprolol and his statin,
aspirin and plavix were continued.
.
# PUMP: Patient had ECHO in ___ with normal cardiac function
and per report had another at ___. He was euvolemic throughout
the admission.
.
# RHYTHM: NSR throughout admission.
.
# Hypertension. Patient had hypertensive emergency with flash
pulm edema on presentation to ___. He was weaned quickly off
BIPAP and nitro gtt and has been stable for > 24 hrs. He
diuresed well and on admission was euvolemic. Per his report his
PCP at the ___ stopped his antihypertensive, fosinopril ___
months ago. He is currently normotensive and was transfered on
captopril. We started metoprolol due to CAD and re-started
low-dose lisinopril instead of captopril.
.
# Hyperlipidemia: recently stopped lipitor for ? myalgias.
Patient was discharged on pravastatin, since he rememebered
similar problems with simavastain.
.
FEN: Cardiac diet.
.
ACCESS: PIV's.
.
PROPHYLAXIS:
-DVT ppx with heparin SQ
-Pain management with tylenol.
.
CODE: Full code.
.
DISPO: Home.
###RESPONSE: PVD {Peripheral vascular disease}, AAA repair {Repair of aneurysm of abdominal aorta}, CEA {Carotid endarterectomy}, HTN {Hypertensive disorder, systemic arterial}, SOB {Dyspnea}, flash pulmonary edema {Acute pulmonary edema}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, elevated trops {Troponin I above reference range}, shortness of
breath {Dyspnea}, pulmonary edema {Pulmonary edema}, Troponing {Troponin measurement}, chest pain {Chest pain}, diaphoresis {Excessive sweating}, leg
swelling {Leg swelling symptom}, cardiology {Cardiology service}, work up {Evaluation procedure}, cath {Cardiac catheterization}, chest pain {Chest pain}, cardiac cath {Cardiac catheterization}, ostial 90%
stenosis {Coronary ostium stenosis}, diagonal artery {Structure of diagonal branch of anterior descending branch of left coronary artery}, LCX {Structure of diagonal branch of anterior descending branch of left coronary artery}, mid segment {Structure of mid portion of circumflex branch of left coronary artery}, RCA {Right coronary artery structure}, atrophied {Atrophy}, stented {Placement of stent in coronary artery}, Cypher stent {Endovascular insertion of drug eluting stent}, lession {Lesion}, stent {Placement of stent}, aspirin {Administration of aspirin}, ECHO {Echocardiography}, normal cardiac function {Normal cardiac function}, euvolemic {Normal blood volume}, NSR {Normal sinus rhythm}, Hypertension {Hypertensive disorder, systemic arterial}, hypertensive emergency {Hypertensive emergency}, flash
pulm edema {Acute pulmonary edema}, weaned quickly off
BIPAP {Dual pressure spontaneous ventilation support weaning protocol}, stable {Patient's condition stable}, diuresed {Diuretic therapy}, euvolemic {Normal blood volume}, PCP {Primary care management}, antihypertensive {Antihypertensive therapy}, normotensive {Normal blood pressure}, CAD {Coronary arteriosclerosis}, re-started
low-dose lisinopril {Restart of medication}, Hyperlipidemia {Hyperlipidemia}, myalgias {Muscle pain}, problems {Problem}, Cardiac {Cardiac care}, diet {Dietary finding}, PROPHYLAXIS {Preventive procedure}, DVT {Deep venous thrombosis}, ppx {Administration of prophylactic anticoagulant}, heparin {Heparin therapy}, Pain management {Pain management}, tylenol {Administration of analgesic} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
ALENDRONATE - 70 mg po q ___
CHLORDIAZEPOXIDE HCL - 25 mg po daily PRN anxiety
FOSINOPRIL - 10 mg po qhs (STOPPED 2 Months prior)
SIMVASTATIN - 40 mg po qhs (STOPPED 2 Months prior)
MULTIVITAMIN po qd
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
___.
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Vitamin D 2,000 unit Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*0*
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Coronary Artery Disease s/p cardiac cath with DES to circumflex
artery.
Discharge Condition:
Stable,
###RESPONSE: Coronary Artery Disease {Coronary arteriosclerosis}, cardiac cath {Cardiac catheterization}, DES {Endovascular insertion of drug eluting stent}, circumflex
artery {Structure of circumflex branch of left coronary artery}, Stable {Patient's condition stable} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were electively admitted at the ___ for cardiac cath after
your abnormal stress test. You had multiple-vessel disease and
had a drug diluting (Xience) stent placed to one of your heart
arteries (circumflex artery). You will need to be in aspirin and
plavix for a year and have close cardiology follow up (See
appointments below).
.
If you have chest pain, palpitations, shortness of breath, groin
pain, bleeding or anything else that cocerns you, please come to
our ER.
.
Your medications were left unchanged, but:
* You were started on lisinopril (5 mg Daily) to protect your
heart and blood pressure control. If the ___ can provide you with
a similar ACE inhibitor would be ok to switch, but talk to your
PCP or Dr. ___ there first.
* You were started on pravastatin, that is similar to Lipitor or
Crestor, but cause muscle pain less often. We will need to try
several medications to see which one you are able to tolerate,
but your cholesterol must be tightly controlled.
* You were started on low-dose beta-blocker to protect your
heart. You are being discharge in low-dose atenolol.
* You are being put on maintainance dose of Vitamin D to
decrease further your cardiovascular read.
* You were started on Aspirin and Plavix. YOU MUST NOT STOP them
for any reason, unless specifically ordered by a physician. You
cannot run out of this medicaion. Feel free to call Dr. ___
you have any problems filling it!
###RESPONSE: cardiac cath {Cardiac catheterization}, abnormal stress test {Cardiovascular stress test abnormal}, vessel disease {Coronary arteriosclerosis}, drug diluting (Xience) stent placed {Endovascular insertion of drug eluting stent}, heart
arteries {Coronary artery structure}, circumflex artery {Structure of circumflex branch of left coronary artery}, aspirin {Administration of aspirin}, cardiology {Cardiology service}, appointments {Follow-up arranged}, chest pain {Chest pain}, palpitations {Palpitations}, shortness of breath {Dyspnea}, groin
pain {Inguinal pain}, bleeding {Bleeding}, ER {Emergency treatment management}, to protect {Administration of prophylactic drug or medicament}, heart {Heart structure}, blood pressure {On treatment for hypertension}, talk {Discussion}, PCP {Primary care management}, muscle pain {Muscle pain}, protect {Administration of prophylactic drug or medicament}, heart {Heart structure}, cardiovascular read {Cardiovascular monitoring}, Aspirin {Administration of aspirin}, YOU MUST NOT STOP them {Recommendation to continue with drug treatment}, problems {Problem} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Wound erythema
Major Surgical or Invasive Procedure:
___: Feeding tube placement
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Wound erythema {Wound erythema}, Feeding tube placement {Insertion of feeding tube into small intestine} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ with history of ETOH cirrhosis s/p combined liver &
kidney transplant ___, ___ c/b biliary stricture and
chronic rejection now s/p re-transplant ___ with multiple
re-admissions since then most recently for PNA (discharged
___ who now presents with ___ erythema and
purulent drainage c/f surgical site infection. He first noticed
the erythema and drainage yesterday, and denies fevers, chills,
rigors, sweats, abdominal pain, nausea, SOB or change in bowel
and bladder habits. On exam he has multiple well-healed surgical
incisions excepting the medial RLQ oblique incision which has a
1
cm draining superficial dehiscence in the middle of an otherwise
well-healing scar. There is erythema the length of the incision
and palpable induration. Purulent fluid is readily expressed,
particularly from the medial pole of the wound. WBC is 9.5, Cr
1.9 (last 1.6 on ___, LFTs are mildly elevated consistent with
the last measured values on ___.
###RESPONSE: ETOH cirrhosis {Alcoholic cirrhosis}, liver {Transplanted liver present}, kidney transplant {Transplanted kidney present}, biliary stricture {Biliary stricture}, chronic rejection {Chronic graft rejection}, transplant {Transplantation}, PNA {Pneumonia}, erythema {Erythema}, purulent drainage {Purulent discharge}, surgical site infection {Surgical site infection}, erythema {Erythema}, drainage {Discharge}, fevers {Fever}, chills {Chill}, rigors {Rigor}, sweats {Sweating}, abdominal pain {Abdominal pain}, nausea {Nausea}, SOB {Dyspnea}, change in bowel {Altered bowel function}, bladder habits {Alteration in patterns of urinary elimination}, surgical
incisions {Surgical incision wound}, RLQ {Structure of right lower quadrant of abdomen}, incision {Abdomen incision}, draining {Wound discharge}, dehiscence {Dehiscence}, healing scar {Healing scar}, erythema {Erythema}, incision {Surgical incision wound}, induration {Induration}, Purulent fluid {Purulent discharge}, wound {Wound} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
___ gunshot wounds in ___ status post exploratory
laparotomy and colostomy.
___ colostomy was reversed.
___, he had a history of small-bowel obstruction with
multiple surgeries that retrieved most of his small bowel.
___, laparotomy again had multiple surgeries again for
small
bowel obstruction.
___, he had a right knee arthroscopy.
___, diagnosis of cirrhosis and bleeding varices.
___, he had hepatorenal syndrome and liver failure and he
had his combined liver and kidney transplant at ___.
H/o cholangitis, multiple ERCP with plastic/metal stents.
___ cystoscopy to remove a stent that was placed that was
causing urosepsis (this resulted in a lawsuit against ___).
___, he underwent a lysis of adhesions at ___.
___ cholangitis/ s/p ERCP and stent placement.
___. Hepaticojejunostomy with Roux-en-Y.
___ PTC and liver biopsy with chronic rejection.
___ Orthotropic Deceased Donor Liver Transplant
Hepatic encephalopathy
Gout
Depression
Insomnia
###RESPONSE: gunshot wounds {Gunshot wound}, exploratory
laparotomy {Exploratory laparotomy}, colostomy {Colostomy}, colostomy {Colostomy}, small-bowel obstruction {Small bowel obstruction}, surgeries {Surgical procedure}, small bowel {Structure of small intestine}, laparotomy {Laparotomy}, surgeries {Surgical procedure}, small
bowel obstruction {Small bowel obstruction}, knee arthroscopy {Arthroscopy of knee joint}, cirrhosis {Cirrhosis of liver}, bleeding varices {Bleeding varices}, hepatorenal syndrome {Hepatorenal syndrome}, liver failure {Hepatic failure}, liver {Transplanted liver present}, kidney transplant {Transplanted kidney present}, cholangitis {Cholangitis}, ERCP {Endoscopic retrograde cholangiopancreatography}, stents {Placement of stent}, cystoscopy {Transurethral cystoscopy}, stent {Removal of stent}, lysis of adhesions {Lysis of adhesions}, cholangitis {Cholangitis}, ERCP {Endoscopic retrograde cholangiopancreatography}, stent placement {Placement of stent}, liver biopsy {Biopsy of liver}, chronic rejection {Chronic rejection of liver transplant}, Orthotropic Deceased Donor Liver Transplant {Orthotopic transplantation of whole liver}, Hepatic encephalopathy {Hepatic encephalopathy}, Gout {Inflammatory disorder due to increased blood urate level}, Depression {Depressive disorder}, Insomnia {Insomnia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Mother - dementia (___)
Father - diabetes/prostate cancer (___)
2 Children, 3 Grandchildren all healthy
###RESPONSE: dementia {Dementia}, diabetes {Diabetes mellitus}, prostate cancer {Carcinoma of prostate} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS: 97.3 83 123/81 14 100%RA
GEN: NAD, well-nourished, appropriately groomed.
NEURO: AOx3, CN II-XII grossly intact
HEENT: Sclerae anicteric, trachea midline, no JVD
CV: RRR no MRG, 2+ peripheral pulses bilaterally
RESP: CTAB no WRC, no respiratory distress
GI: Extensive abdominal scarring from previous surgical
incisions. Medial RLQ oblique incision with a 1 cm draining
superficial dehiscence in the middle of an otherwise
well-healing
scar. Erythema the length of the incision with palpable
induration. Purulent fluid readily expressed, particularly from
the medial pole of the wound. Abdomen otherwise soft, non-tender
and non-distended. No rebound tenderness or guarding. Dull to
percussion. Bowel sounds normoactive. Rectal exam deferred
EXT: WWP no CCE
LAB VALUES:
Lactate: 5.5
139 111 35
-------------< 138
5.5 16 1.9
ALT: 57 AP: 231 Tbili: 2.2 Alb: 3.7
AST: 25 Lip: 19
9.5 ___ > 10.1 / 31.2 < 205 ___
N:83.1 L:9.0 M:6.7 E:0.2 Bas:0.2 ___: 0.8 Absneut: 7.88
Abslymp: 0.85 Absmono: 0.64 Abseos: 0.02 Absbaso: 0.02
___: 12.2 PTT: 24.7 INR: 1.1
IMAGING/STUDIES:
N/A
###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, GEN {General examination of patient}, NAD {No abnormality detected}, well-nourished {Well nourished}, NEURO {Neurological examination}, AOx3 {Oriented to person, time and place}, CN II {Optic nerve structure}, XII {Hypoglossal nerve structure}, grossly intact {Normal nervous system function}, HEENT {Physical examination procedure}, Sclerae anicteric {White sclera}, trachea {Tracheal structure}, JVD {Jugular venous engorgement}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, 2+ peripheral pulses {Peripheral pulses normal}, RESP {Examination of respiratory system}, CTAB {Normal breath sounds}, distress {Distress}, GI {Examination of digestive system}, abdominal scarring {Abdominal skin scar}, surgical
incisions {Surgical incision wound}, RLQ {Structure of right lower quadrant of abdomen}, incision {Abdomen incision}, draining {Wound discharge}, dehiscence {Dehiscence}, healing
scar {Healing scar}, Erythema {Erythema}, incision {Surgical incision wound}, induration {Induration}, Purulent fluid {Purulent discharge}, wound {Wound}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, percussion {Percussion}, Bowel sounds {Normal bowel sounds}, Rectal exam {Rectal examination}, EXT {Examination of limb}, WWP {Normal tissue perfusion} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 11:57AM BLOOD WBC-9.5# RBC-3.24* Hgb-10.1* Hct-31.2*
MCV-96 MCH-31.2 MCHC-32.4 RDW-17.0* RDWSD-58.5* Plt ___
___ 03:55AM BLOOD WBC-5.3 RBC-2.87* Hgb-9.0* Hct-26.8*
MCV-93 MCH-31.4 MCHC-33.6 RDW-16.8* RDWSD-56.2* Plt ___
___ 11:26AM BLOOD WBC-6.0# RBC-3.53* Hgb-10.9* Hct-33.4*
MCV-95 MCH-30.9 MCHC-32.6 RDW-18.7* RDWSD-63.1* Plt ___
___ 11:57AM BLOOD Glucose-138* UreaN-35* Creat-1.9* Na-139
K-5.5* Cl-111* HCO3-16* AnGap-18
___ 03:55AM BLOOD Glucose-101* UreaN-32* Creat-1.6* Na-137
K-5.1 Cl-110* HCO3-15* AnGap-17
___ 04:40AM BLOOD Glucose-112* UreaN-33* Creat-1.7* Na-136
K-5.1 Cl-109* HCO3-15* AnGap-17
___ 11:26AM BLOOD Glucose-111* UreaN-43* Creat-1.8*# Na-139
K-4.8 Cl-112* HCO3-17* AnGap-15
___ 11:26AM BLOOD ALT-34 AST-13 AlkPhos-185* TotBili-1.7*
___ 03:55AM BLOOD tacroFK-12.6
___ 04:20AM BLOOD tacroFK-11.6
___ 04:40AM BLOOD tacroFK-8.1
___ 11:57 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 12:25 pm SWAB
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Final ___:
LACTOBACILLUS SPECIES. MODERATE GROWTH.
ENTEROCOCCUS SP.. SPARSE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
Work-up of organism(s) listed discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, CULTURE {Blood culture}, Blood Culture {Blood culture}, GRAM STAIN {Gram stain method}, CULTURE {Microbial culture}, culture {Microbial culture}, culture {Microbial culture}, CULTURE {Microbial culture} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ PMH EtOH cirrhosis, s/p combo liver/kidney trx (___)
c/bbiliary strict and chronic rejection requiring
___, recently hospitalized for PNA, was
readmitted for incision wound infection. Wound was I&D'd in the
ED and he was admitted to transplant surgery where he was
started on broad spectrum antibiotics pending blood and
incision/wound cultures. The wound was packed with Iodiform.
Wound culture initially isolated 2+ GPRs. He was afebrile and
would improved. Final culture data was unable until after
patient discharged on Augmentin to complete a weeks course.
Wound measured 2cm x 1cm. Normal saline damp to dry dressings
were to be done bid. Blood cultures drawn were unfinalized, but
negative to date. Of note, after patient was discharged, his
wound culture was finalized as VRE. The plan was to switch to
Linezolid for 7 days. His outpatient coordinator was notified
and was to call in the Linezolid to pharmacy and call the
patient.
While in patient, nutrition recommended tube feeds for poor po
intake. A post pyloric feeding tube was placed and tube feeds
were started (Nepro). ___ provided teaching to the patient and
his wife on ___ and supplies were delivered to the patient.
Vital signs remained stable, LFTs improved some more. At time of
discharge to home, his immunosuppression was set as tacrolimus
3mg twice daily as his tacrolimus level was not back. Tacrolimus
level was inaccurately reported and it was felt that the level
reported was his roommate's and vice versa. So, his dose was
increased to 3.5mg twice daily for a presumed level of 6.9 which
was on the low side and was more consistent with the prior day
of 8.1. Also, fluconazole was renally dosed and decreased to
200mg daily to start ___. Next lab draw was set for ___.
___ services were arranged in addition to ___. He was
discharged to home appearing alert and in NAD.
###RESPONSE: EtOH cirrhosis {Alcoholic cirrhosis}, liver {Transplanted liver present}, kidney {Transplanted kidney present}, PNA {Pneumonia}, incision wound infection {Postoperative wound infection}, Wound {Wound}, I&D {Incision AND drainage}, antibiotics {Antibiotic therapy}, incision/wound cultures {Wound microscopy, culture and sensitivities}, wound {Wound}, Wound culture {Wound microscopy, culture and sensitivities}, improved {Patient's condition improved}, culture {Microbial culture}, Wound {Wound}, Blood cultures {Blood culture}, wound culture {Wound microscopy, culture and sensitivities}, poor po
intake {Decrease in appetite}, post pyloric feeding {Insertion of feeding tube into small intestine}, teaching {Patient education}, Vital signs {Vital signs finding}, stable {Normal vital signs}, improved {Patient's condition improved}, immunosuppression {Immunosuppression}, alert {Mentally alert}, NAD {No abnormality detected} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NPH 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Sodium Bicarbonate 650 mg PO TID
3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
4. Omeprazole 40 mg PO DAILY
5. PredniSONE 12.5 mg PO DAILY
6. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
7. Tacrolimus 3.5 mg PO Q12H
8. ValGANCIclovir 450 mg PO EVERY OTHER DAY
9. Allopurinol ___ mg PO DAILY
10. amLODIPine 10 mg PO DAILY
11. Cyanocobalamin 1000 mcg PO EVERY 4 WEEKS (___)
12. Docusate Sodium 100 mg PO BID
13. Escitalopram Oxalate 15 mg PO DAILY
14. Fluconazole 400 mg PO Q24H
15. Multivitamins 1 TAB PO DAILY
16. Mycophenolate Sodium ___ 720 mg PO BID
17. Senna 8.6 mg PO BID:PRN constipation
18. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
19. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
End date ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*9 Tablet Refills:*0
2. Fluconazole 200 mg PO Q24H
3. NPH 10 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
4. Omeprazole 20 mg PO DAILY
5. PredniSONE 10 mg PO DAILY Duration: 7 Days
follow taper
6. Sulfameth/Trimethoprim DS 1 TAB PO EVERY OTHER DAY
7. Tacrolimus 3.5 mg PO Q12H (changed to 3.5 twice daily from
3mg twice daily on ___ for level of 6.9
8. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
Maximum 6 of the 325 mg tablets daily
9. Allopurinol ___ mg PO DAILY
10. amLODIPine 10 mg PO DAILY
11. Cyanocobalamin 1000 mcg PO EVERY 4 WEEKS (___)
12. Docusate Sodium 100 mg PO BID
Hold for loose bowel movements or more than 2 bowel movements
daily
13. Escitalopram Oxalate 15 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Mycophenolate Sodium ___ 720 mg PO BID
16. Senna 8.6 mg PO BID:PRN constipation
Hold for loose bowel movements or more than 2 bowel movements
daily
17. Sodium Bicarbonate 650 mg PO TID
18. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
19. TraZODone 25 mg PO HS:PRN insomnia
20. ValGANCIclovir 450 mg PO EVERY OTHER DAY
21.Tube Feed Orders
Tubefeeding: Nepro or Equivalent
Full strength; Goal rate: 50 ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 50 ml water q6h
Dispense 1 month supply; Refill: 5
###RESPONSE: mg {Blood magnesium measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Severe malnutrition (decreased grip strength)
liver transplant
transplant incision abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Home With Service {Home health aide service management}, Severe malnutrition {Nutritional marasmus}, liver transplant {Transplanted liver present}, transplant incision abscess {Postoperative wound abscess}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Please call the transplant clinic at ___ for fever >
101, chills, nausea, vomiting, diarrhea, constipation, inability
to tolerate food, fluids or medications, feeding tube clogs,
yellowing of skin or eyes, increased abdominal pain, incisional
redness, drainage or bleeding, dizziness or weakness, decreased
urine output or dark, cloudy urine, swelling of abdomen or
ankles, or any other concerning symptoms.
You will have labwork drawn every ___ and ___ as
arranged by the transplant clinic, with results to the
transplant clinic (Fax ___ . CBC, Chem 10, AST, ALT,
Alk Phos, T Bili, Trough Tacro level.
**On the days you have your labs drawn, do not take your
Tacrolimus until your labs are drawn. Bring your Tacrolimus with
you so you may take your medication as soon as your labwork has
been drawn.
Please note that the Fluconazole dose has been decreased to
200mg daily.
You have been prescribed an antibiotic (augmentin) for your
abdominal incision infection
Follow your medication card, keep it updated with any dosage
changes, and always bring your card with you to any clinic or
hospital visits.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotions or powder near the
incision.
Continue NS damp to dry dressing to the incision open area.
Monitor for increased redness, drainage, foul odor or other
concerns.
Complete Augmentin course as prescribed.
No tub baths or swimming
No driving if taking narcotic pain medications
Avoid direct sun exposure. Wear protective clothing and a hat,
and always wear sunscreen with SPF 30 or higher when you go
outdoors.
Drink enough fluids to keep your urine light in color.
You have had a feeding tube placed and have started tube feeds
to help with nutrition. Please continue the tube feeds as
ordered in addition to flushes. Monitor for clogging of the tube
or any increase in diarrhea or blood sugars that are hard to
manage.
Check your blood sugars and blood pressure at home. Report
consistently elevated values to the transplant clinic
Do not increase, decrease, stop or start medications without
consultation with the transplant clinic at ___. There
are significant drug interactions with anti-rejection
medications which must be considered in medication management
following transplant
Refer to transplant binder, and there is always someone on call
at the transplant clinic with any questions that may arise
###RESPONSE: clinic {Outpatient care management}, fever {Fever}, chills {Chill}, nausea {Nausea}, vomiting {Vomiting}, diarrhea {Diarrhea}, constipation {Constipation}, fluids {Tolerating oral fluid}, feeding tube clogs {Blocked endotracheal tube}, yellowing of skin {Yellow skin}, eyes {Scleral icterus}, abdominal pain {Abdominal pain}, redness {Redness of skin over lesion}, drainage {Discharge}, bleeding {Bleeding}, dizziness {Dizziness}, weakness {Asthenia}, decreased
urine output {Decreased urine output}, cloudy urine {Cloudy urine}, swelling of abdomen {Swollen abdomen}, ankles {Ankle region structure}, CBC {Complete blood count}, antibiotic {Antibiotic therapy}, abdominal incision {Abdomen incision}, infection {Local infection of wound}, incision {Surgical incision wound}, incision {Surgical incision wound}, dressing {Application of dressing}, incision {Surgical incision wound}, redness {Redness of skin over lesion}, drainage {Discharge}, odor {Wound odor}, taking narcotic pain medications {Narcotics education}, diarrhea {Diarrhea}, blood sugars {Glucose measurement, blood}, blood sugars {Glucose measurement, blood}, blood pressure {Blood pressure monitoring}, drug interactions {Drug interaction}, transplant {Transplantation} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending: ___.
Chief Complaint:
Fatigue, dyspnea on exertion and lightheadedness.
Major Surgical or Invasive Procedure:
___ - aortic valve replacement, coronary artery bypass
grafts x2(LIMA>LAD,SVG>RCA)
___ - Left and right heart catheterization, coronary
angiogram left ventriculogram
###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, Fatigue {Fatigue}, dyspnea on exertion {Dyspnea on exertion}, lightheadedness {Lightheadedness}, aortic valve replacement {Replacement of aortic valve}, coronary artery bypass
grafts {Coronary artery bypass grafting}, LIMA {Structure of left internal thoracic artery}, LAD {Structure of anterior descending branch of left coronary artery}, SVG {Aortocoronary artery bypass graft with saphenous vein graft}, RCA {Right coronary artery structure}, Left {Catheterization of left heart}, right heart catheterization {Catheterization of right heart}, coronary
angiogram {Angiography of coronary artery}, left ventriculogram {Left ventriculogram} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
This ___ year old white male with known aortic stenosis is
followed with serial echocardiograms. Most recently these
revealed an aortic valve area of 0.7cm2, a bicuspid valve and
LVEF of 30%. She was referred for surgical evaluation after
recent new onset heart failure.
###RESPONSE: aortic stenosis {Aortic valve stenosis}, echocardiograms {Echocardiography}, aortic valve {Aortic valve structure}, surgical {Surgical procedure}, evaluation {Evaluation procedure}, heart failure {Heart failure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
Hypertension
Noninsulin dependent diabetes mellitus
Aortic Stenosis/Aortic Insufficiency
Mitral Regurgitation
Gastroesophageal Reflux Disease
degenerative joint disease
tonsillectomy
###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, Noninsulin dependent diabetes mellitus {Diabetes mellitus type 2}, Aortic Stenosis {Aortic valve stenosis}, Aortic Insufficiency {Aortic valve regurgitation}, Mitral Regurgitation {Mitral valve regurgitation}, Gastroesophageal Reflux Disease {Gastroesophageal reflux disease}, degenerative joint disease {Osteoarthritis}, tonsillectomy {Tonsillectomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Mother died of MI at ___; father died of CVA at ___
###RESPONSE: died {Dead}, MI {Myocardial infarction}, died {Dead}, CVA {Cerebrovascular accident} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Admission:
Pulse:91 Resp: 20 O2 sat: 100% RA
B/P Right: 108/63 Left: 104/65
Height: 68" Weight: 175 lbs
General:NAD; slow to process and answer questions
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable;teeth
in poor repair
Neck: Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur ___ SEm radiates throughout
precordium to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [x]chronic mild venous stasis brawniness
above
ankles bil.
Neuro: Grossly intact;MAE ___ strengths;nonfocal exam; has mild
cognitive deficits
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: NP Left: NP
___ Right: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid: murmur radiates to both carotids
###RESPONSE: Pulse {Finding of pulse rate}, Resp {Examination of respiratory system}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, B/P {Blood pressure finding}, Right {Right upper arm structure}, Left {Left upper arm structure}, Height {Height / growth finding}, Weight {Weight finding}, General {General examination of patient}, NAD {No abnormality detected}, Skin {Examination of skin}, Dry {Xeroderma}, intact {Intact skin}, HEENT {Physical examination procedure}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, anicteric sclera {White sclera}, unremarkable {No abnormality detected}, teeth {Structure of dentition}, repair {Surgical repair}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Full ROM {Normal movement of neck}, JVD {Jugular venous engorgement}, Chest {Examination of respiratory system}, Lungs {Examination of respiratory system}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, Irregular {Irregular heart beat}, Murmur {Murmur}, precordium {Structure of precordium}, carotids {Carotid artery structure}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-distended {Normal abdominal contour}, non-tender {Abdominal tenderness}, bowel sounds {Normal bowel sounds}, HSM {Hepatosplenomegaly}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, Extremities {Examination of limb}, Warm {Warm skin}, well-perfused {Normal tissue perfusion}, Edema {Edema}, Varicosities {Venous varices}, chronic {Chronic disease}, mild {Symptom mild}, venous stasis {Venous stasis}, ankles {Ankle region structure}, Neuro {Neurological examination}, Grossly intact {Normal nervous system function}, MAE {Does move all four limbs}, mild {Symptom mild}, cognitive deficits {Impaired cognition}, Femoral {Structure of femoral artery}, Right: 2 {Pulse present in right femoral artery}, Left: 2 {Pulse present in left femoral artery}, DP {Structure of dorsalis pedis artery}, Right: NP {Absence of pulse in right dorsalis pedis artery}, Left: NP {Absence of pulse in left dorsalis pedis artery}, Radial {Structure of radial artery}, Right {Structure of right radial artery}, 2+ {Normal radial pulse}, Left {Structure of left radial artery}, 2+ {Normal radial pulse}, Carotid {Carotid artery structure}, murmur {Murmur}, carotids {Carotid artery structure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ ECHO
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis (LVEF = ___ %). The right
ventricular cavity is mildly dilated with moderate impairment
with focal hypokinesis of the apical free wall. The ascending
aorta is moderately dilated. The descending thoracic aorta is
mildly dilated. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is severe
aortic valve stenosis (valve area 0.8-1.0cm2). Moderate to
severe (3+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen.
POSTBYPASS
The patient is receiving dobutamine at 7ucg/kg/min.
RV systolic function is improved. There is now mild RV
hypokinesis with minimal focality. LV systolic function is
marginally improved, LVEF ~25%. There is a well seated, well
fumctioning bioprosthesis in the aortic position. There is a
mild perivalvular leak. TR is now mild (1+). The remaining study
is otherwise unchanged from prebypass.
___ 06:00AM BLOOD WBC-10.0 RBC-3.42* Hgb-8.7* Hct-26.8*
MCV-78* MCH-25.3* MCHC-32.4 RDW-16.0* Plt ___
___ 07:00AM BLOOD WBC-16.0* RBC-3.71* Hgb-9.1* Hct-29.8*
MCV-80* MCH-24.6* MCHC-30.6* RDW-15.6* Plt ___
___ 06:00AM BLOOD Glucose-166* UreaN-26* Creat-1.1 Na-139
K-3.5 Cl-98 HCO3-33* AnGap-12
___ 06:45PM BLOOD UreaN-31* Creat-1.1 K-3.7
___ 05:41PM BLOOD Type-ART pO2-72* pCO2-45 pH-7.37
calTCO2-27 Base XS-0
___ 12:30PM BLOOD %HbA1c-7.6*
###RESPONSE: ECHO {Echocardiography}, atrial septal defect {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, left
ventricular cavity is moderately dilated {Dilatation of left cardiac ventricle}, left ventricular {Left cardiac ventricular structure}, hypokinesis {Behavior showing reduced motor activity}, right
ventricular cavity is mildly dilated {Dilatation of right cardiac ventricle}, impairment {Impairment}, hypokinesis {Behavior showing reduced motor activity}, apical {Structure of apex of heart}, wall {Cardiac wall structure}, ascending
aorta {Ascending aorta structure}, dilated {Dilatation}, descending thoracic aorta {Structure of descending thoracic aorta}, dilated {Dilatation}, atheroma {Atheroma}, descending
thoracic aorta {Structure of descending thoracic aorta}, aortic valve leaflets {Structure of cardiac valve leaflet}, aortic valve leaflets {Structure of cardiac valve leaflet}, thickened {Increased thickness}, severe
aortic valve stenosis {Severe stenosis of aortic valve}, aortic regurgitation {Aortic valve regurgitation}, mitral valve
leaflets are mildly thickened {Thickened mitral leaflet}, Mild (1+) mitral regurgitation {Mild mitral valve regurgitation}, RV {Right cardiac ventricular structure}, improved {Patient's condition improved}, RV
hypokinesis {Hypokinetic right ventricular wall}, LV {Left cardiac ventricular structure}, improved {Patient's condition improved}, aortic {Aortic structure}, perivalvular leak {Prosthetic cardiac paravalvular leak}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, K {Blood potassium measurement}, pH {pH measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Mr. ___ was admitted to the ___ on ___ for a cardiac
catheterization in anticipation of his aortic valve surgery. His
cardiac catheterization revealed three vessel coronary artery
disease. Mr. ___ was worked-up in the usual preoperative
manner and was ready for surgery.
On ___ he was taken to the Operating Room where he
underwent coronary artery bypass grafting to two vessels and an
aortic valve replacement using a tissue prosthesis. (Please see
operative note for details.) He weaned from bypass on
Dobutamine,Propofol and Neosynephrine in stable condition.
Postoperatively he was taken to the intensive care unit for
monitoring.
Over the next ___ hours he had awoke neurologically intact and
was extubated. Pressors were weaned off and he remained stable.
Beta blockade and aspirin were resumed. On postoperative day
one, he was transferred to the step down unit for further
recovery. He was gently diuresed towards his preoperative
weight. The physical therapy service was consulted for
assistance with his postoperative strength and mobility.
Oxygenation remained low and a CXR revealed what appeared to be
a large left effusion. A left lung thoracentesis was performed
on ___ yielding 500 mL of serosanguinous fluid. A repeat CXR
demonstrated an elevated left diaphragm with atelectasis and
resolution of the effusion. His oxygenation improved and he
felt better.
He was discharged to a rehabilitation facility for further
recovery prior to going home. He will continue on diuretics for
a week as he remained above his preoperative weight.
Arrangements were made for follow up with his cardiology,
medical and surgical providers.
###RESPONSE: cardiac
catheterization {Cardiac catheterization}, aortic valve surgery {Aortic valve and adjacent structure operations}, cardiac catheterization {Cardiac catheterization}, three vessel coronary artery
disease {Triple vessel disease of the heart}, surgery {Surgical procedure}, coronary artery bypass grafting to two vessels {Coronary artery bypass grafts x 2}, aortic valve replacement {Replacement of aortic valve}, tissue {Body tissue structure}, operative {Surgical procedure}, stable condition {Patient's condition stable}, taken to the intensive care unit {Patient transfer to intensive care unit}, monitoring {Monitoring procedure}, neurologically intact {Normal nervous system function}, extubated {Removal of endotracheal tube}, Pressors {Hypotensive therapy}, stable {Patient's condition stable}, aspirin {Administration of aspirin}, postoperative {Postoperative state}, diuresed {Diuretic therapy}, weight {Weight finding}, physical therapy {Physical therapy assessment}, postoperative {Postoperative state}, CXR {Plain chest X-ray}, left {Left lung structure}, effusion {Pleural effusion}, left lung {Left lung structure}, thoracentesis {Thoracentesis}, CXR {Plain chest X-ray}, elevated {Elevation}, left diaphragm {Structure of left dome of diaphragm}, atelectasis {Atelectasis}, effusion {Pleural effusion}, improved {Patient's condition improved}, rehabilitation {Rehabilitation therapy}, diuretics {Diuretic therapy}, weight {Weight finding}, cardiology {Cardiology service}, surgical {Surgical procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Furosemide 20mg daily, citalopram 20mg daily, glipizide 5mg
daily, metformin 1000mg daily, omeprazole 20mg daily,
simvastatin 80mg daily, diphenoxylate-atropine 25prn-prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Ipratropium-Albuterol ___ mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
11. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
coronary aretery disease
s/p coronary artery bypass
acute systolic heart failure
Hypertension
Non insulin dependent Diabetes Mellitus
Aortic Stenosis/Aortic Insufficiency
Mitral Regurgitation
Gastroesophageal Reflux Disease
degenerative joint disease
Discharge Condition:
Good
###RESPONSE: coronary aretery disease {Coronary arteriosclerosis}, coronary artery bypass {Coronary artery bypass grafting}, acute systolic heart failure {Acute systolic heart failure}, Hypertension {Hypertensive disorder, systemic arterial}, Non insulin dependent Diabetes Mellitus {Diabetes mellitus type 2}, Aortic Stenosis {Aortic valve stenosis}, Aortic Insufficiency {Aortic valve regurgitation}, Mitral Regurgitation {Mitral valve regurgitation}, Gastroesophageal Reflux Disease {Gastroesophageal reflux disease}, degenerative joint disease {Osteoarthritis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
Report any fever greater then 100.5.
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
No lotions, creams or powders to incision.
Shower daily,gently pat the wound dry.
No bathing or swimming for 1 month.
Take all medications as directed.
No driving for 1 month or while taking narcotics..
.
###RESPONSE: Monitor {Monitoring for signs and symptoms of infection}, wounds {Wound}, signs of infection {Monitoring for signs and symptoms of infection}, redness {Redness of skin over lesion}, drainage {Wound discharge}, increased pain {Increased pain}, fever {Fever}, weight gain {Weight gain}, incision {Surgical incision wound}, wound {Wound}, medications {Patient medication education}, while taking narcotics {Narcotherapy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
- Exploratory laparotomy, resection of hepatic flexure, and
right colostomy ___ (___)
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Exploratory laparotomy {Exploratory laparotomy}, resection {Excision}, hepatic flexure {Structure of right colic flexure}, colostomy {Colostomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ presenting to ___ as transferred from OSH s/p MVC. On
arrival the patient had AMS and could not provide any history.
Per EMS and OSH records the patient was driving a truck while
shooting up heroin and struck a tree. At OSH, underwent imaging
that showed non-displaced sacral fracture, L5 transverse process
fracture and abdominal free air. He was transferred to ___ for
trauma evaluation, and taken to the OR emergently for Ex-lap.
Postoperatively, he was transferred to the trauma ICU for close
monitoring.
###RESPONSE: AMS {Altered mental status}, imaging {Imaging}, non-displaced {Undisplaced fracture}, sacral fracture {Fracture of sacrum}, transverse process
fracture {Closed fracture lumbar vertebra, transverse process}, abdominal free air {Pneumoperitoneum}, Ex-lap {Exploratory laparotomy}, Postoperatively {Postoperative state}, monitoring {Monitoring procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
None
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Non contributory
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Admission Physical Exam
VS - T: 97.8 HR: 106 BP: 132/79 RR: 20 100% on PSV
General: Intubated and sedated
HEENT: PERRL, NCAT
Neck: Ecchymosis over left neck, supple
CV: Mild tachycardia, regular rhythm
Lungs: CTAB
Abdomen: Soft, colostomy pink without any output
GU: Foley in place
Ext: Warm, well perfused
Neuro: Moving all extremities, localizes pain
Skin: No rash
###RESPONSE: Physical Exam {Physical examination procedure}, VS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, General {General examination of patient}, Intubated {Intubation}, sedated {Sedated}, HEENT {Physical examination procedure}, PERRL {Pupils equal and reacting to light}, NC {Normal head}, Neck {Physical examination procedure}, Ecchymosis {Ecchymosis}, supple {Normal movement of neck}, CV {Cardiovascular physical examination}, tachycardia {Tachycardia}, regular rhythm {Normal sinus rhythm}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, colostomy {Colostomy present}, pink {Pink skin}, GU {Examination of genitourinary system}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, Neuro {Neurological examination}, all extremities {All extremities}, pain {Pain}, Skin {Examination of skin}, rash {Eruption of skin} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 06:15PM GLUCOSE-131* UREA N-27* CREAT-1.2 SODIUM-145
POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-24 ANION GAP-18
___ 06:15PM CALCIUM-8.1* PHOSPHATE-4.4 MAGNESIUM-1.5*
___ 06:15PM WBC-2.8*# RBC-3.11*# HGB-9.6*# HCT-30.0*#
MCV-97# MCH-30.9 MCHC-32.0 RDW-12.9 RDWSD-45.3
___ 06:15PM PLT SMR-LOW PLT COUNT-87*#
___ 06:15PM ___ PTT-43.4* ___
___ 01:21PM COMMENTS-GREEN TOP
___ 01:21PM LACTATE-2.9*
___ 01:06PM URINE HOURS-RANDOM
___ 01:06PM URINE UCG-NEGATIVE
___ 01:06PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-POS amphetmn-POS oxycodn-NEG mthdone-NEG
___ 01:06PM URINE COLOR-Amber APPEAR-Clear SP ___
___ 01:06PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-40 BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG
___ 01:06PM URINE RBC-126* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:06PM URINE HYALINE-19*
___ 01:06PM URINE CA OXAL-MOD
___ 01:06PM URINE MUCOUS-RARE
___ 01:00PM GLUCOSE-129* UREA N-27* CREAT-1.1 SODIUM-142
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-20* ANION GAP-22*
___ 01:00PM estGFR-Using this
___ 01:00PM ALT(SGPT)-61* AST(SGOT)-81* CK(CPK)-918* ALK
PHOS-122 TOT BILI-1.2
___ 01:00PM LIPASE-13
___ 01:00PM ALBUMIN-4.2
___ 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:00PM WBC-8.2 RBC-5.96 HGB-18.3* HCT-53.9* MCV-90
MCH-30.7 MCHC-34.0 RDW-12.7 RDWSD-41.2
___ 01:00PM NEUTS-84* BANDS-5 LYMPHS-7* MONOS-4* EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-7.30* AbsLymp-0.57*
AbsMono-0.33 AbsEos-0.00* AbsBaso-0.00*
___ 01:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 01:00PM PLT SMR-NORMAL PLT COUNT-207
___ 01:00PM ___ PTT-32.4 ___
###RESPONSE: GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, CALCIUM {Blood calcium measurement}, PHOSPHATE {Phosphate, total measurement}, MAGNESIUM {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PLT {Platelet count}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}, URINE {Urinalysis}, URINE {Urinalysis}, UCG-NEGATIVE {Urine chorionic gonadotrophin measurement}, URINE {Urinalysis}, URINE {Urinalysis}, COLOR {Color finding}, PROTEIN {Measurement of protein in urine}, GLUCOSE {Glucose measurement, urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, URINE {Urinalysis}, RBC {Red blood cell count}, WBC {White blood cell count}, AST {Aspartate aminotransferase measurement}, URINE {Urinalysis}, URINE {Urinalysis}, URINE {Urinalysis}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, CK(CPK {Creatine kinase measurement}, PHOS {Phosphate, total measurement}, TOT BILI {Bilirubin, total measurement}, LIPASE {Triacylglycerol lipase measurement}, ALBUMIN {Albumin measurement}, ETHANOL {Blood ethanol measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PLT {Platelet count}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ presenting to ___ as transferred from OSH s/p MVC. On
arrival the patient had AMS and could not provide any history.
Per EMS and OSH records the patient was driving a truck while
shooting up heroin and struck a tree. At OSH, underwent imaging
that showed non-displaced sacral fracture, L5 transverse process
fracture and abdominal free air secondary to an ascending colon
perforation. He was transferred to ___ for trauma evaluation,
and taken to the OR emergently for Ex-lap. Postoperatively, he
was transferred to the trauma ICU for close monitoring. His ICU
course is summarized below with transitional issues consistent
of a) postoperative fevers, seconadry to a feculent peritonitis
and GNRs bacteremia treated with Zosyn. b) intermittent
agitation secondary to withdrawal symptims in setting of chronic
heroin use. Per APS and psychiatry, he was started on methadone
10TID, Haldol 2.5 q2H prn for agitation, added a basal rate of
.05 to dPCA, in addition to resumed his home psychiatric meds.
The patient was extubated onPD#1, advanced diet to clears, and
transferred to the surgical ward for further management. His
hospital course is summarized below
###RESPONSE: AMS {Altered mental status}, imaging {Imaging}, non-displaced {Undisplaced fracture}, sacral fracture {Fracture of sacrum}, transverse process
fracture {Closed fracture lumbar vertebra, transverse process}, abdominal free air {Pneumoperitoneum}, ascending colon
perforation {Traumatic perforation of ascending colon}, trauma {Traumatic injury}, evaluation {Evaluation procedure}, Ex-lap {Exploratory laparotomy}, Postoperatively {Postoperative state}, monitoring {Monitoring procedure}, postoperative fevers {Postoperative fever}, feculent peritonitis {Fecal peritonitis}, GNRs bacteremia {Bacteremia caused by Gram-negative bacteria}, agitation {Feeling agitated}, withdrawal symptims {Withdrawal symptom}, chronic
heroin use {Chronic drug abuse}, agitation {Feeling agitated}, extubated {Removal of endotracheal tube} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion Dose is Unknown PO BID
2. Lorazepam Dose is Unknown PO QHS
3. Gabapentin 300 mg PO TID
4. MethylPHENIDATE (Ritalin) 20 mg PO DAILY
5. QUEtiapine Fumarate 25 mg PO Frequency is Unknown
6. Venlafaxine XR 225 mg PO Frequency is Unknown
Discharge Medications:
1. Venlafaxine XR 225 mg PO DAILY
2. QUEtiapine Fumarate 25 mg PO QHS
3. Gabapentin 400 mg PO TID
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
___ will receive a 1 week supply. Please call the Surgery Clinic
to make an appointment for refills
5. MethylPHENIDATE (Ritalin) 20 mg PO DAILY
6. Morphine SR (MS ___ 60 mg PO Q12H
Taper:
60mg BID x 3 days
45mg BID x 3 days
30mg BID x 3 days
15mg BID x 3 days
15mg QD x 3 days
7. Wheelchair
Wheelchair
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Traumatic injury, colonic perforation, scapular fracture, sacral
fracture, L5 transverse process fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
###RESPONSE: Traumatic injury {Traumatic injury}, colonic perforation {Perforation of colon}, scapular fracture {Fracture of scapula}, sacral
fracture {Fracture of sacrum}, transverse process fracture {Closed fracture lumbar vertebra, transverse process}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Out of Bed with assistance {Difficulty getting off a bed} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
___ were admitted to ___ and
underwent an exploratory laparotomy, resection of
hepatic flexure, and right colostomy. ___ are recovering well
and are now ready for discharge. Please follow the instructions
below to continue your recovery:
Monitoring Ostomy output/ Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
OSTOMY DISCHARGE INSTRUCTIONS:
Patient D/C instructions:
___ have a new colostomy. The most common complication from a
new colostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. ___ must measure
your colostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc. If
___ find that your output has become too much or too little,
please call the office for advice. The office nurse or nurse
practitioner can recommend medications to increase or slow the
colostomy output. Keep yourself well hydrated, if ___ notice
your colostomy output increasing, take in more electrolyte drink
such as Gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If ___ notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. ___ may eat a
regular diet with your new colostomy. However it is a good idea
to avoid fatty or spicy foods and follow diet suggestions made
to ___ by the ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. ___
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until ___ are comfortable caring
for it on your own.
Currently your colostomy is allowing the surgery in your large
intestine to heal, which does take some time. ___ will come back
to the hospital for reversal of this colostomy when decided by
Dr. ___ will follow-up in the clinic, and the
surgeon will decide when will be the best time for your second
surgery. Until this time there is healthy intestine that is
still functioning as it normally would and it will produce mucus
and some may leak or ___ may feel as though ___ need to have a
bowel movement and ___ may sit on the toilet and empty this
mucus, it is normal.
Rehab D/C instructions:
To the Rehab:
Thank ___ for participating in the care of this patient. This
patient has had multiple teaching sessions with both the
Wound/Ostomy nurses and with the staff nurses and should have a
good idea of how to care for their own ostomy. They have also
been given several items that will assist them in their own
care, such as instruction sheets, ostomy supplies, and ostomy
output measuring tools. However, we would like to stress a few
important points to assist ___ in the care of this patient.
Bowel Function:
Ø It is important to encourage the patient to monitor their
bowel function closely every day. The patient should continue
to record their colostomy output (as much as physically
possible) and the amount of fluid they have taken in, just as
they were taught in the hospital. A urinal or hat should be
used to record their ostomy output daily.
o The patient has been taught to use a daily measurement chart
to record their I&Os. This chart should be continued to be
used at least until their follow-up appointment. If their ostomy
output is less than 500 ml or greater than 1200 ml of liquid
stool in a day, it is very important to call the doctors office
with this information.
o Continue to reinforce to the patient that the major risk
with an colostomy is dehydration related to fluid loses. Daily
fluid intake is ___ glasses of fluids, including electrolyte
enhanced beverages. In the hot weather, encourage them to take
in increased amounts of fluid and closely measure
their colostomy output.
o Watch for signs and symptoms of dehydration including: dry
mouth or tongue, decrease in urination, urine darker in color,
dizzy when he/she stands, cramps in his/her abdomen or legs,
dizziness, increased thirst, or weakness.
Stoma Care:
Ø It is also important to monitor the appearance of the stoma.
The tissue of the stoma should be moist, pink or red in color.
o If the stoma has color changes from pink / red to dark
purplish /blue in color, becomes swollen, or a large amount of
continuous bleeding into the pouch, and or at the Mucocutaneous
Junction (Stomal Incision). this is not normal. Call the
patients doctors office for assistance.
If ___ or the patient has any questions regarding the care of
the patients ostomy, please refer to the instructions provided
to the patient by the wound/ostomy nurses.
___ the patient develops the following bowel symptoms please call
the surgeons office or go to the nearest emergency room if
severe: increasing abdominal distension and cramps, nausea,
vomiting, inability to tolerate food or liquids, decrease
in ostomy output, or have no output from ostomy for ___ hours
Please call the Acute Care Surgery Clinic if ___ develop fevers,
chills, nausea, vomiting, decreased or no ostomy output, or
other concerns. The phone number is ___.
###RESPONSE: exploratory laparotomy {Exploratory laparotomy}, resection {Excision}, hepatic flexure {Structure of right colic flexure}, colostomy {Colostomy}, ready for discharge {Ready for discharge}, loose stool {Loose stool}, colostomy {Colostomy}, colostomy {Colostomy}, placement {Implantation procedure}, dehydration {Dehydration}, stoma {Stoma}, stool {Stool finding}, small intestine {Structure of small intestine}, large
intestine {Structure of large intestine}, measure
your colostomy output {Monitoring of stoma output}, stoma {Stoma}, colostomy {Colostomy}, colostomy output increasing {High output stoma}, monitor yourself for signs and symptoms
of dehydration {Dehydration monitoring}, dizziness {Dizziness}, standing {Orthostatic body position}, weakness {Asthenia}, dry mouth {Xerostomia}, headache {Headache}, fatigue {Fatigue}, evaluation {Evaluation procedure}, regular diet {Normal diet}, colostomy {Colostomy}, stoma {Stoma}, stoma {Stoma}, intestine {Intestinal structure}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, Monitor {Monitoring for signs and symptoms of infection}, skin {Examination of skin}, stoma {Stoma}, bulging {Bulging}, signs of infection {Monitoring for signs and symptoms of infection}, colostomy {Colostomy}, surgery {Surgical procedure}, large
intestine {Structure of large intestine}, colostomy {Colostomy}, intestine {Intestinal structure}, teaching {Patient education}, record their colostomy output {Monitoring of stoma output}, liquid
stool {Liquid stool}, colostomy {Colostomy}, dehydration {Dehydration}, measure
their colostomy output {Monitoring of stoma output}, signs {Sign}, dehydration {Dehydration}, dry
mouth {Xerostomia}, tongue {Tongue structure}, decrease in urination {Decreased urine output}, urine darker in color {Urine: dark/concentrated}, dizzy {Dizziness}, stands {Orthostatic body position}, cramps {Cramp}, abdomen {Stomach cramps}, legs {Cramp in lower limb}, dizziness {Dizziness}, increased thirst {Increased thirst}, weakness {Asthenia}, stoma {Stoma}, tissue {Body tissue structure}, stoma {Stoma}, stoma {Stoma}, swollen {Swelling}, bleeding {Bleeding}, Mucocutaneous
Junction {Structure of mucocutaneous junction}, Incision {Surgical incision wound}, abdominal distension {Swollen abdomen}, cramps {Cramp}, nausea,
vomiting {Nausea and vomiting}, inability to tolerate food or liquids {Nausea and vomiting}, fevers {Fever}, chills {Chill}, nausea, vomiting {Nausea and vomiting} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
ciprofloxacin
Attending: ___.
Chief Complaint:
SCROTAL/PERINEAL ABSCESS
Major Surgical or Invasive Procedure:
1. Exam under anesthesia.
2. Debridement of scrotal and perineal abscess.
###RESPONSE: ciprofloxacin {Allergy to ciprofloxacin}, SCROTAL {Abscess of scrotum}, PERINEAL {Perineal structure}, ABSCESS {Abscess}, Exam under anesthesia {Physical examination under general anesthesia}, Debridement {Debridement}, scrotal {Abscess of scrotum}, perineal {Perineal structure}, abscess {Abscess} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ h/o afib on Coumadin, MI s/p stent, CHF (LVEF ___,
HLD, HTN, solitary kidney (donated), Crohn's, BPH managed with
chronic indwelling foley; transferred from ___ with
right
scrotal abscess.
Patient presented to his see his urologist (___)
at ___ yesterday for a poorly draining foley. Following
the catheter change, there was reportedly drainage of purulent
material and as such he was transferred to their ED for further
evaluation. He was admitted to the medicine service there for
treatment of his infection. On admission, ___ 24, febrile to
102. UA data not available in outside records, though started on
ceftriaxone/flagyl for empiric treatment.
When found to have right scrotal fluctuance, there was an
ultrasound performed that showed right scrotal abscess with
concern for fluid and gas extending into the perineum. Due to
concern for Fournier's gangrene, he was transferred to ___ for
further assessment.
###RESPONSE: afib {Atrial fibrillation}, MI {Myocardial infarction}, s/p stent {Placement of stent in coronary artery}, CHF {Congestive heart failure}, HLD {Hyperlipidemia}, HTN {Hypertensive disorder, systemic arterial}, Crohn's {Crohn's disease}, BPH {Benign prostatic hyperplasia}, foley {Catheterization of urinary bladder}, scrotal abscess {Abscess of scrotum}, see his urologist {Seen by urologist}, poorly draining foley {Decreased urine output}, catheter change {Replacement of indwelling catheter of urinary bladder}, drainage of purulent
material {Purulent discharge}, evaluation {Evaluation procedure}, infection {Infectious disease}, febrile {Fever}, UA {Urinalysis}, scrotal {Scrotal structure}, fluctuance {Fluctuant}, ultrasound {Ultrasonography}, scrotal abscess {Abscess of scrotum}, perineum {Perineal structure}, Fournier's gangrene {Fournier's gangrene}, assessment {Evaluation procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
Afib on coumadin
MI s/p stent ___ ago
HLD
HTN
Single kidney
Crohn's disease
Anal fissure
L donor nephrectomy
Hernia repair
###RESPONSE: Afib {Atrial fibrillation}, MI {Myocardial infarction}, s/p stent {Placement of stent in coronary artery}, HLD {Hyperlipidemia}, HTN {Hypertensive disorder, systemic arterial}, kidney {Kidney structure}, Crohn's disease {Crohn's disease}, Anal fissure {Anal fissure}, L {Left kidney structure}, donor nephrectomy {Donor nephrectomy}, Hernia repair {Hernia repair} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Son- DM and renal failure
###RESPONSE: DM {Diabetes mellitus}, renal failure {Renal failure syndrome} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
Perineal incision packed w/ ___ plain nugauze. Edges pink,
clean, w/out evidence infection, necrosis.
Perineal ___ drain in place; ___ wick removed. Hemiscrotum
Incision c/d/i w/out evidence hematoma or infection
Lower extremities w/out edema or pitting and no report of calf
pain
Foley catheter in place; secured to medial thigh
###RESPONSE: Physical Exam {Physical examination procedure}, WdWn {Well nourished}, NAD {No abnormality detected}, AVSS {Vital signs finding}, Interactive {Does communicate}, cooperative {Cooperative mental state}, soft {Abdomen soft}, Nt {Abdominal tenderness}, Nd {Swollen abdomen}, Perineal incision {Incision of perineum}, packed w/ ___ plain nugauze {Application of gauze swab}, infection {Local infection of wound}, necrosis {Necrosis}, Perineal {Perineal structure}, drain in place {Insertion of drain}, Incision {Incision}, hematoma {Hematoma}, infection {Infectious disease}, Lower extremities {Lower limb structure}, edema {Edema}, pitting {Pitting edema}, pain {Pain}, Foley {Catheterization of urinary bladder}, medial thigh {Structure of medial surface of thigh} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 07:10AM BLOOD WBC-12.3* RBC-3.33* Hgb-8.3* Hct-26.2*
MCV-79* MCH-24.9* MCHC-31.7* RDW-17.6* RDWSD-50.4* Plt ___
___ 06:58AM BLOOD WBC-9.9 RBC-3.12* Hgb-8.0* Hct-25.0*
MCV-80* MCH-25.6* MCHC-32.0 RDW-18.0* RDWSD-53.3* Plt ___
___ 06:30PM BLOOD WBC-12.7* RBC-3.34* Hgb-8.3*# Hct-27.0*#
MCV-81* MCH-24.9* MCHC-30.7* RDW-18.0* RDWSD-53.1* Plt ___
___ 06:30PM BLOOD Neuts-74.2* Lymphs-15.5* Monos-6.7
Eos-3.0 Baso-0.2 Im ___ AbsNeut-9.45* AbsLymp-1.97
AbsMono-0.85* AbsEos-0.38 AbsBaso-0.03
___ 07:10AM BLOOD Glucose-100 UreaN-12 Creat-1.0 Na-135
K-4.3 Cl-99 HCO3-29 AnGap-11
___ 06:58AM BLOOD Glucose-75 UreaN-12 Creat-0.8 Na-136
K-4.0 Cl-105 HCO3-24 AnGap-11
___ 06:30PM BLOOD Glucose-89 UreaN-15 Creat-0.8 Na-135
K-4.1 Cl-105 HCO3-25 AnGap-9
___ 07:10AM BLOOD Phos-3.9 Mg-1.6
___ 06:40PM BLOOD Lactate-0.8
___ 05:18PM URINE Color-Straw Appear-Clear Sp ___
___ 06:40PM URINE Color-Straw Appear-Clear Sp ___
___ 05:18PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 06:40PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 05:18PM URINE RBC-2 WBC-16* Bacteri-FEW Yeast-NONE
Epi-0
___ 06:40PM URINE RBC-5* WBC-50* Bacteri-FEW Yeast-NONE
Epi-0
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL {BACTEROIDES FRAGILIS GROUP}; FUNGAL
CULTURE-PRELIMINARY EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ 10:30 pm SWAB PERINEAL SWAB.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, URINE Color-Straw {Normal urine color}, URINE Color-Straw {Normal urine color}, URINE Blood {Blood in urine}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, URINE Blood {Blood in urine}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, RBC {Red blood cell count}, WBC {White blood cell count}, RBC {Red blood cell count}, WBC {White blood cell count}, CULTURE {Blood culture}, Blood Culture {Blood culture}, URINE {Urine culture}, URINE CULTURE {Urine culture}, CULTURE {Blood culture}, Blood Culture {Blood culture}, GRAM STAIN {Gram stain method}, WOUND {Wound}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, URINE {Urine culture}, URINE CULTURE {Urine culture}, CULTURE {Blood culture}, Blood Culture {Blood culture}, CULTURE {Blood culture}, Blood Culture {Blood culture}, PERINEAL {Perineal structure}, GRAM STAIN {Gram stain method}, WOUND {Wound}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, FUNGUS ISOLATED {Sample fungus isolated}, tissue {Body tissue structure}, biopsy {Biopsy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
This patient was admitted to the urology service following
debridement of scrotal and perineal abscess. See operative
report for full details. The patient tolerated the procedure
well and recovered in the PACU before transfer to the surgical
floor. He was admitted on zosyn/clindamycin for antibiotic
therapy, with BID packing changes of anterior and posterior
perineal wounds. On POD1, he was attempted to be narrowed to
unasyn, though spiked a fever to ___ and was again re-broadened
to zosyn/clindamycin. On POD2, he was narrowed to Bactrim
empirically for better MRSA coverage and remained afebrile
through the time of discharge.
With respect to anticoagulation, the patient was seen by the
cardiology service, and the decision was made to restart the
patient's ASA and Plavix immediately postoperatively, as he
remained on it to the time of surgery and experienced no
bleeding complications. He did, however, remain off of his
Coumadin for the duration of his hospital stay, and was
instructed to restart at home dose 2d after discharge.
His foley catheter remained in place for the duration of his
stay. His diet was advanced as tolerated following surgery. At
discharge, patient's pain was well controlled with oral pain
medications, tolerating regular diet, ambulating without
assistance, and voiding without difficulty. Incision at
discharge without erythema or hematoma. He will follow-up with
his home urologist, ___ at ___, as
directed and complete a course of Bactrim. He will also follow
up with general surgery for perineal ___ removal. ___ was
set up to assist with packing changes and drain care.
###RESPONSE: debridement {Debridement}, scrotal {Abscess of scrotum}, perineal {Perineal structure}, abscess {Abscess}, operative {Surgical procedure}, procedure {Procedure}, PACU {Postanesthesia care}, surgical {Surgical procedure}, antibiotic
therapy {Antibiotic therapy}, packing changes {Change of dressing}, perineal {Perineal structure}, wounds {Wound}, fever {Fever}, MRSA {Methicillin resistant Staphylococcus aureus infection}, afebrile {Fever}, anticoagulation {Anticoagulant therapy}, cardiology service {Cardiology service}, surgery {Surgical procedure}, bleeding {Bleeding}, foley {Catheterization of urinary bladder}, diet {Dietary finding}, surgery {Surgical procedure}, pain was well controlled {Demonstrates adequate pain control}, oral {Administration of drug or medicament via oral route}, pain
medications {Administration of analgesic}, regular diet {Normal diet}, ambulating without
assistance {Independent walking}, voiding without difficulty {Normal micturition}, Incision {Incision}, erythema {Erythema}, hematoma {Hematoma}, follow-up {Follow-up status}, follow
up {Follow-up status}, surgery {Surgical procedure}, perineal {Perineal structure}, removal {Removal}, packing changes {Change of dressing}, drain care {Drainage tube care management} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Tartrate 25 mg PO BID
2. Simvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Warfarin 5 mg PO DAILY16
6. Feosol (ferrous sulfate;<br>iron, carbonyl) 325 mg (65 mg
iron) oral BID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Simvastatin 80 mg PO QPM
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg ONE
tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0
6. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4hrs Disp #*35 Tablet
Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
9. Acetaminophen 650 mg PO TID
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Duration: 3
Doses
ONE Tablet(s) sublingually as instructed for chest pain x three
PRN
11. Feosol (ferrous sulfate;<br>iron, carbonyl) 325 mg (65 mg
iron) oral BID
12. Warfarin 5 mg PO DAILY16
resume on ___.
13. MESALAMINE
You may resume your mesalamine unless otherwise explicitly
advised.
###RESPONSE: mg {Blood magnesium measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PREOPERATIVE DIAGNOSES:
1. Scrotal abscess.
2. Perineal abscess.
POSTOPERATIVE DIAGNOSES:
1. Scrotal abscess.
2. Perineal abscess.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Home With Service {Home health aide service management}, Scrotal abscess {Abscess of scrotum}, Perineal {Perineal structure}, abscess {Abscess}, Scrotal abscess {Abscess of scrotum}, Perineal {Perineal structure}, abscess {Abscess}, Mental Status {Mental state finding}, Level of Consciousness {Finding of level of consciousness}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
-You will be discharged home with ___ services for wound care
and packing changes.
-Please also reference the instructions provided by nursing on
Foley care/hygiene.
For your safety and the safety of others; PLEASE DO NOT drive,
operate dangerous machinery, or consume alcohol while taking
narcotic pain medications and while you have the
drain/foley/scrotal packing.
-Your FOLEY should be secured to the catheter secure on your
thigh at ALL times.
-Follow up with UROLOGY for wound check and post-op evaluation
as directed. Surgery service will arrange outpatient follow-up
for the ___ drain removal.
-ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor.
-___ scrotum/phallus supported/elevated. Use a
jock-supporter/strap or jockey-type briefs or tight,
tighty-whities to facilitate this; Subsequently you may
transition to loose fitting briefs or boxer-briefs for
support--they should be cotton and/or breathable.
-Do NOT use penis for intercourse/sex until explicitly advised
by your urologist that is may be ok to do so.
-You may want to coordinate your showers with your ___ provider
and the planned dressing changes.
-You may shower, but do NOT bathe, swim or otherwise immerse
your incision.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain >4.
Replace Tylenol with narcotic pain medication. Max daily Tylenol
dose is from 3gm to 4gm depending on your kidney function, note
that narcotic pain medication also contains Tylenol
(acetaminophen)
-Colace has been prescribed to avoid post-surgical constipation
and constipation related to narcotic pain medication,
discontinue if loose stool or diarrhea develops. Colace is a
stool "softener"- it is NOT a laxative
-Resume your home medications, except as noted.
-DO NOT RESUME medications like VIAGRA, LEVITRA or CIALIS.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
###RESPONSE: wound care {Wound care}, packing changes {Change of dressing}, instructions provided by nursing {Nursing care education, guidance, counseling}, Foley care/hygiene {Urinary catheter care education}, while taking
narcotic pain medications {Narcotics education}, foley {Catheterization of urinary bladder}, scrotal {Scrotal structure}, packing {Packing of wound}, FOLEY {Catheterization of urinary bladder}, thigh {Thigh structure}, Follow up {Follow-up status}, wound check {Wound assessment}, post-op {Postoperative state}, evaluation {Evaluation procedure}, Surgery service {Surgical follow-up}, outpatient follow-up {Outpatient care management}, drain removal {Removal of drain}, medication
changes {Change of medication}, post-operative course {Postoperative state}, scrotum {Scrotal structure}, phallus supported {Fitting of external prosthetic device on penis}, elevated {Elevation}, supporter {Support}, support {Support}, penis {Penile structure}, intercourse/sex until explicitly advised {Recommendation to limit sexual activity}, dressing changes {Change of dressing}, incision {Incision}, pain medication {Administration of analgesic}, pain medication {Administration of analgesic}, breakthough pain {Breakthrough pain}, pain medication {Administration of analgesic}, kidney {Kidney structure}, pain medication {Administration of analgesic}, post-surgical {Postoperative state}, constipation {Constipation}, constipation {Constipation}, pain medication {Administration of analgesic}, loose stool {Loose stool}, diarrhea {Diarrhea}, fever {Fever}, vomiting {Vomiting}, redness {Redness of skin over lesion}, swelling {Swelling}, incision {Incision} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Penicillins / Morphine / adhesive tape / Iodine-Iodine
Containing
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
###RESPONSE: Penicillins {Allergy to penicillin}, Morphine {Allergy to morphine}, adhesive tape {Allergy to adhesive agent}, Iodine-Iodine {Allergy to iodine compound}, Headache {Headache} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Patient is a ___ yo woman with PMHx sig. for CVA, CAD s/p
multiple PCIs, DM, and HTN who presented to ___
___ for a severe headache, blurry vision, and concern
for increased gait instability. Her headache started 4 AM this
morning, waking her up from sleep. The headache starts in the
back and goes all over her head, described as a "very bad" pain,
rating ___. Her headache is triggered wtih getting up,
relieved by sitting down. Her headaches ia also associated with
nausea and dry heaves, no vomiting. When she got out of bed,
she leaned forward, falling into the door. She was lightheaded
and leaning to right and left. Of note, pt had previously been
on coumadin for ___ years; this was discontinued 3 months ago.
At OSH, she was hypertensive to sbp 200, which resolved on its
own. She had a neg head CT scan and was transferred for neuro
eval and MRI.
In the ED, initial VS were: 98.4 76 146/99 18 95% RA. Labs were
notable for ESR 16. She had an LP. MRI head showed "No
evidence of acute infarct. Tiny DWI signal intensity at the
right frontal lobe (10:18) is likely T2 shinethrough. Chronic
microvascular ischemic changes seen in the paraventricular white
matter. no aneurysm or dissection seen. No evidence of
hemorrhage." The patient received percocet. Vitals prior to
transfer to the floor were: 98.4 76 146/99 18 95% RA.
Currently, she feels that her gait is back to baseline.
Review of Systems:
(+) Per HPI plus: night sweats, rhinorrhea, postnasal drip
cough, chronic joint pains, residual weakness in L leg and arm
and tingling in L leg from stroke
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, or congestion. Denies chest pain
or tightness, palpitations. Denies shortness of breath Denies
nausea, vomiting, diarrhea, constipation, or abdominal pain. No
dysuria, urinary frequency. Denies rashes. All other review of
systems negative.
###RESPONSE: CVA {Cerebrovascular accident}, CAD {Coronary arteriosclerosis}, PCIs {Percutaneous coronary intervention}, DM {Diabetes mellitus}, HTN {Hypertensive disorder, systemic arterial}, headache {Headache}, blurry vision {Blurring of visual image}, gait instability {Unsteady when walking}, headache {Headache}, headache {Headache}, head {Head structure}, pain {Pain}, headache {Headache}, sitting {Sitting position}, headaches {Headache}, nausea {Nausea}, dry heaves {Retching}, vomiting {Vomiting}, lightheaded {Lightheadedness}, hypertensive {Hypertensive disorder, systemic arterial}, resolved {Problem resolved}, head CT {Computed tomography of head}, MRI {Magnetic resonance imaging}, VS {Vital signs finding}, Labs {Laboratory test}, LP {Lumbar puncture}, MRI head {Magnetic resonance imaging of head}, acute infarct {Acute infarct}, right frontal lobe {Right frontal lobe structure}, microvascular {Structure of small blood vessel (organ)}, ischemic changes {Ischemia}, white
matter {Cerebral white matter structure}, aneurysm {Aneurysm}, dissection {Dissecting hemorrhage}, hemorrhage {Hemorrhage}, Vitals {Vital signs finding}, baseline {Baseline state}, Review of Systems {Review of systems}, night sweats {Night sweats}, rhinorrhea {Nasal discharge}, postnasal drip {Posterior rhinorrhea}, cough {Cough}, joint pains {Joint pain}, weakness {Asthenia}, L leg {Structure of left lower limb}, arm {Left upper arm structure}, tingling {Pins and needles}, L leg {Structure of left lower limb}, stroke {Cerebrovascular accident}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, sinus tenderness {Tenderness over frontal sinus}, congestion {Nasal congestion}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, shortness of breath {Dyspnea}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, dysuria {Dysuria}, urinary frequency {Increased frequency of urination}, rashes {Eruption of skin}, review of
systems {Review of systems}, negative {No abnormality detected} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
CVA in ___, residual weakness in L leg and arm and tingling in
L leg
CAD s/p multiple PCIs
DM2
HTN
h/o breast cancer, s/p lumpectomy in ___
###RESPONSE: CVA {Cerebrovascular accident}, weakness {Asthenia}, L leg {Structure of left lower limb}, arm {Left upper arm structure}, tingling {Pins and needles}, L leg {Structure of left lower limb}, CAD {Coronary arteriosclerosis}, PCIs {Percutaneous coronary intervention}, DM2 {Diabetes mellitus type 2}, HTN {Hypertensive disorder, systemic arterial}, breast cancer {Malignant neoplasm of breast}, lumpectomy {Excision of mass} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Two sons have had CABG.
###RESPONSE: CABG {Coronary artery bypass grafting} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Vitals: 147/67, 70, 98RA
Gen: NAD, AOX3
HEENT: PERRL, EOMI, MMM, sclera anicteric, not injected
Neck: no LAD, no JVD
Cardiovascular: RRR normal s1, s2, no murmurs appreciated
Respiratory: bibasilar crackles, no wheezing
Abd: normoactive bowel sounds, soft, non-tender, non distended
Extremities: No edema, 2+ DP pulses
Neurological: CN II-XII intact, normal attention, sensation
normal, babinski down-going bilaterally, MS ___ in BUEs and BLEs
though slightly weaker on LLE, ataxic gait leaning to both
sides, unable to perform Romberg as unstead with eyes open
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
###RESPONSE: Vitals {Vital signs finding}, RA {Breathing room air}, Gen {General examination of patient}, NAD {No abnormality detected}, AOX3 {Oriented to person, time and place}, HEENT {Physical examination procedure}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, sclera anicteric {White sclera}, Neck {Physical examination procedure}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, Cardiovascular {Cardiovascular physical examination}, RRR {Normal heart rate}, normal s1, s2 {Heart sounds normal}, murmurs {Murmur}, Respiratory {Examination of respiratory system}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, wheezing {Wheezing}, Abd {Examination of abdomen}, normoactive bowel sounds {Normal bowel sounds}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, distended {Swollen abdomen}, Extremities {Examination of limb}, edema {Edema}, DP {Structure of dorsalis pedis artery}, Neurologic {Neurological examination}, CN II-XII intact {Normal central nervous system}, sensation
normal {Normal sensation}, babinski down-going {Plantar reflex normal}, LLE {Structure of left lower limb}, ataxic gait {Ataxic gait}, Romberg {Romberg sign}, Integument {Examination of skin}, Warm {Warm skin}, rash {Eruption of skin}, ulceration {Ulcer}, anxious {Anxiety} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
Admission labs:
___ 08:24PM WBC-8.6 RBC-4.09* HGB-13.6 HCT-38.8 MCV-95
MCH-33.2* MCHC-34.9 RDW-13.5
___ 08:24PM NEUTS-52.4 ___ MONOS-5.4 EOS-3.8
BASOS-1.3
___ 08:24PM GLUCOSE-89 UREA N-22* CREAT-1.3* SODIUM-141
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-17
___ 08:24PM ___ PTT-22.6 ___
Discharge Labs
___ 06:50AM BLOOD WBC-10.6 RBC-3.70* Hgb-12.2 Hct-35.9*
MCV-97 MCH-33.0* MCHC-34.1 RDW-14.0 Plt ___
___ 07:14AM BLOOD ___ PTT-95.9* ___
___ 08:24PM BLOOD ESR-16
___ 06:50AM BLOOD Glucose-87 UreaN-27* Creat-1.5* Na-147*
K-4.1 Cl-113* HCO3-25 AnGap-13
___ 06:50AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.2
___ 08:24PM BLOOD CRP-1.3
___ 10:46AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:46AM URINE Blood-SM Nitrite-NEG Protein-150
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
___ 10:46AM URINE ___ Bacteri-MANY
Yeast-NONE ___
MRI ___
IMPRESSION:
1. Punctate acute infarcts in the right hemisphere, which could
be along ACA/MCA and MCA/PCA watershed territories or be within
the MCA territory.
2. Chronic infarct of the superior right frontal lobe, MCA
territory.
3. Multifocal high-grade stenoses involving the right MCA M2
divisions. Other milder probably atherosclerotic disease as
described above.
4. Findings compatible with underlying chronic small vessel
ischemic disease.
CTA ___
IMPRESSION: Mild stenoses of the superior and inferior M2
divisions of the right MCA, improved compared to recent MRA.
This could be due to improvement in vasospasm or technical
differences in evaluation of stable atherosclerotic
irregularity.
Carotid Doppler ___
Right ICA stenosis <40%.
Left ICA stenosis 60-69%.
Echocardiogram ___
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is an abnormal
systolic flow contour at rest, but no left ventricular outflow
obstruction. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: No cardiac source of embolism seen. Normal global
and regional biventricular systolic function. Calcified aortic
and mitral valves without significant stenosis or regurgitation.
Negative bubble study.
EKG ___
Sinus rhythm. Normal tracing. Compared to the previous tracing
of ___
ventricular ectopy and left atrial abnormality are no longer
seen.
___
___ yo woman with PMHx sig. for CVA, CAD s/p multiple PCIs, DM,
and HTN who presented to ___ for a
severe headache, blurry vision, and concern for increased gait
instability.
She was transferred to ___ for further neurologic evaluation
and MRI given concern for severe headache or neck pain ___
radiating to bioccipital and bitemporal areas, with hypertension
to 200 mmHg and vomiting at ___. along with history of a
prior stroke, despite normal CT there.
MRI revealed punctate infarcts of the right hemisphere within
MCA or distal MCA watersheds. Therefore, Mrs. ___ was
admitted to Neurology for further workup.
Headache improved and no new neurologic deficits were noted -
gait instability at baseline per patient.
CTA was reassuring with respect to intracranial MCA stenosis,
despite such on MRA. Carotid ultrasound revealed less than 40% R
internal carotid stenosis. There was no known history of atrial
fibrillation and echo demonstrated no thrombi or atrial septal
defect.
Headache may have related to underlying vasospasm, explaining
improved MCA territory stenosis from MRA to CTA. Headache may
have also related to uncontrolled hypertension. GIven that no
embolic source was found, this was seen as the most likely
explanation. Verapamil was started and initial heparin IV
therapy was stopped. On final assessment probable migraine with
vasospasm was thought most likely. Aspirin and simvastatin are
to continued. She is discharged for follow-up with Dr. ___
in clinic.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, PTT {Partial thromboplastin time, activated}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, MRI {Magnetic resonance imaging of head}, acute infarcts {Acute infarct}, right hemisphere {Right cerebral hemisphere structure}, ACA {Structure of anterior cerebral artery}, MCA {Structure of middle cerebral artery}, MCA {Structure of middle cerebral artery}, PCA {Structure of posterior cerebral artery}, MCA {Structure of middle cerebral artery}, infarct {Infarct}, right frontal lobe {Right frontal lobe structure}, MCA {Structure of middle cerebral artery}, stenoses {Stenosis}, M2
divisions {Structure of middle cerebral artery M2 segment}, atherosclerotic disease {Atherosclerosis}, small vessel {Structure of small blood vessel (organ)}, ischemic disease {Ischemia}, CTA {Computed tomography angiography with contrast}, stenoses {Stenosis}, M2
divisions {Structure of middle cerebral artery M2 segment}, right MCA {Structure of right middle cerebral artery}, improved {Patient's condition improved}, MRA {Magnetic resonance angiography of vascular structure of head}, vasospasm {Vasospasm}, atherosclerotic {Atherosclerosis}, Carotid {Carotid artery structure}, Doppler {Doppler ultrasound}, ICA stenosis {Internal carotid artery stenosis}, ICA stenosis {Internal carotid artery stenosis}, Echocardiogram {Echocardiography}, left atrium {Left atrial structure}, normal in size {Normal size}, atrial septal defect {Atrial septal defect}, patent foramen ovale {Patent foramen ovale}, color Doppler {Color Doppler ultrasound}, Left ventricular wall {Left cardiac ventricular structure}, thickness {Normal thickness}, cavity {Structure of cavity of left cardiac ventricle}, size {Normal size}, regional/global systolic function are normal {Normal left ventricular systolic function and wall motion}, Tissue Doppler imaging {Doppler ultrasonography of heart tissue}, left
ventricular {Left cardiac ventricular structure}, left ventricular outflow
obstruction {Left ventricular outflow tract obstruction}, ventricular septal defect {Ventricular septal defect}, Right
ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Finding of right ventricular wall motion}, aorta at the sinus, {Structure of sinus of Valsalva}, arch {Aortic arch structure}, aortic valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve leaflets {Structure of leaflet of mitral valve}, pulmonary
artery {Pulmonary artery structure}, pericardial effusion {Pericardial effusion}, embolism {Embolism}, Normal global
and regional biventricular systolic function {Normal left ventricular systolic function and wall motion}, Calcified {Pathologic calcification, calcified structure}, aortic {Aortic valve structure}, mitral valves {Mitral valve structure}, stenosis {Stenosis}, regurgitation {Mitral valve regurgitation}, EKG {Electrocardiographic procedure}, Sinus rhythm {Sinus rhythm}, ventricular ectopy {Ventricular premature complex}, left atrial abnormality {Left atrial abnormality}, CVA {Cerebrovascular accident}, CAD {Coronary arteriosclerosis}, PCIs {Percutaneous coronary intervention}, DM {Diabetes mellitus}, HTN {Hypertensive disorder, systemic arterial}, headache {Headache}, blurry vision {Blurring of visual image}, gait
instability {Unsteady when walking}, neurologic evaluation {Neurological examination}, MRI {Magnetic resonance imaging}, headache {Headache}, neck pain {Neck pain}, radiating {Radiating pain}, bioccipital {Occipital region structure}, bitemporal {Structure of temporal region}, hypertension {Hypertensive disorder, systemic arterial}, vomiting {Vomiting}, stroke {Cerebrovascular accident}, MRI {Magnetic resonance imaging}, infarcts {Infarct}, right hemisphere {Right cerebral hemisphere structure}, MCA {Structure of middle cerebral artery}, MCA {Structure of middle cerebral artery}, watersheds {Watershed infarct}, Headache {Headache}, improved {Patient's condition improved}, neurologic deficits {Neurological deficit}, gait instability {Unsteady when walking}, CTA {Computed tomography angiography with contrast}, intracranial {Intracranial structure}, MCA {Structure of middle cerebral artery}, stenosis {Stenosis}, Carotid ultrasound {Ultrasonography of carotid artery}, carotid stenosis {Carotid artery stenosis}, atrial
fibrillation {Atrial fibrillation}, echo {Echocardiography}, thrombi {Thrombus}, atrial septal
defect {Atrial septal defect}, Headache {Headache}, vasospasm {Vasospasm}, improved {Patient's condition improved}, MCA {Structure of middle cerebral artery}, stenosis {Stenosis}, MRA {Magnetic resonance angiography of vascular structure of head}, CTA {Computed tomography angiography with contrast}, Headache {Headache}, hypertension {Hypertensive disorder, systemic arterial}, heparin IV
therapy {Heparin therapy}, migraine {Migraine}, vasospasm {Vasospasm} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Metformin 500 mg bid
Isosorbide mono 20 mg daily
Metoprolol 100 mg TID
Simvastatin 40 mg daily
Lisinopril 40 mg daily
Furosemide 40 mg daily
Caltrate 600 + D
Asa 81 mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*50 Tablet, Chewable(s)* Refills:*2*
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*40 Tablet(s)* Refills:*2*
3. verapamil 240 mg Cap,24 hr Sust Release Pellets Sig: One (1)
Cap,24 hr Sust Release Pellets PO once a day.
Disp:*30 Cap,24 hr Sust Release Pellets(s)* Refills:*2*
4. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute:
-Punctate acute infarcts in the right hemisphere, which could be
along ACA/MCA and MCA/PCA watershed territories or be within the
MCA territory.
-Vasospasm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Home With Service {Home health aide service management}, acute infarcts {Acute infarct}, right hemisphere {Right cerebral hemisphere structure}, ACA {Structure of anterior cerebral artery}, MCA {Structure of middle cerebral artery}, MCA {Structure of middle cerebral artery}, PCA {Structure of posterior cerebral artery}, MCA {Structure of middle cerebral artery}, Vasospasm {Vasospasm}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were admitted to the hospital with unusual headache. Your
brain MRI showed a very small infarct in the frontal and
parietal areas; called "watershed infarct" that was likely due
to vasoconstriction. You will need to be on a medication called
verapamil to prevent further strokes.
###RESPONSE: headache {Headache}, brain MRI {Magnetic resonance imaging of brain}, infarct {Infarct}, frontal {Frontal region structure}, parietal areas {Parietal region structure}, watershed infarct {Watershed infarct}, strokes {Cerebrovascular accident} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending: ___.
Chief Complaint:
Patient admitted for weight reduction surgery.
Major Surgical or Invasive Procedure:
Status Post Laparoscopic Gastric Band
###RESPONSE: surgery {Surgical procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ has class III morbid obesity with weight of 288.4 lbs
as of ___ (his initial screen weight on ___ was 285.9
lbs), height of 61 inches and BMI of 54.7. His previous weight
loss efforts have included 7 months of Weight Watchers in ___
losing 25 lbs that he maintained for 2 months and 5 months of
Slim-Fast in ___ without any results. He has not taken
prescription weight loss medications or used over-the-counter
appetite suppressants/herbal supplements. He does not remember
his weight at age ___ or his lowest adult weight but he weighed
232 lbs on ___ and 289 lbs on ___, his highest adult
weight.
###RESPONSE: morbid obesity {Morbid obesity}, weight
loss {Weight loss}, prescription {Prescription}, weight loss {Weight loss} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
hypothyroidism with h/o Graves'
disease s/p ablation, severe sleep disordered breathing with
recommendation for CPAP by recent sleep study, fatty liver by
ultrasound, hyperlipidemia, neurofibromatosis, testicular
torsion, colitis likely diverticular disease hospitalized x 2
and
lower back and knee pain
###RESPONSE: hypothyroidism {Hypothyroidism}, Graves'
disease {Graves' disease}, ablation {Destructive procedure}, sleep study {Sleep studies}, fatty liver {Steatosis of liver}, ultrasound {Ultrasonography}, hyperlipidemia {Hyperlipidemia}, neurofibromatosis {Neurofibromatosis}, testicular
torsion {Torsion of testis}, colitis {Colitis}, diverticular disease {Diverticular disease}, lower back {Low back pain}, knee pain {Pain of knee region} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Family history is noted for mother living with heart
disease, thyroid disease and obesity; grandparent deceased of
heart disease.
###RESPONSE: heart
disease {Heart disease}, thyroid disease {Disorder of thyroid gland}, obesity {Obesity}, heart disease {Heart disease} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
His blood pressure was 127/82, pulse 94, respirations 16 and O2
saturation 94% on room air. On physical examination ___
was
casually dressed and in no distress. His skin was warm, dry, no
rashes, + neurofibromas on face (small), trunk/abdomen medium
size with ___ spots on abdomen (large at RMQ, smaller
area LLQ); tattoos bilateral lower extremities with lesion right
anterior mid-shin. Anicteric sclerae, conjunctiva clear, pupils
were equal round and reactive to light, fundi difficult to
visualize, mucous membranes were moist, tongue pink and
oropharynx was without exudates or hyperemia. Trachea was in the
midline and the neck was supple without adenopathy, thyromegaly
or carotid bruits. Chest was symmetric and the lungs were clear
to auscultation, no wheezes, air movement was fair to good.
Cardiac exam was regular rate and rhythm, normal S1 and S2, no
murmurs, rubs or gallops. The abdomen was obese but soft and
non-tender, non-distended, + bowel sounds, no masses or hernias,
there was small healed incision scar umbilicus. There was no
spinal tenderness or flank pain. There was no edema of the lower
extremities, no venous stasis or clubbing, perfusion was good.
There was no evidence of joint swelling or inflammation of the
joints. There were no focal neurological deficits and his gait
was normal.
###RESPONSE: blood pressure {Blood pressure finding}, pulse {Normal pulse}, O2
sat {Oxygen saturation measurement}, on room air {Breathing room air}, physical examination {Physical examination procedure}, distress {Distress}, skin {Examination of skin}, warm {Warm skin}, rashes {Eruption of skin}, neurofibromas on face {Neurofibroma of face}, trunk {Trunk structure}, abdomen {Skin structure of anterior abdominal wall}, abdomen {Skin structure of anterior abdominal wall}, tattoos {Tattoo of skin}, lower extremities {Lower limb structure}, lesion {Lesion}, shin {Shin structure}, Anicteric {White sclera}, conjunctiva {Conjunctival structure}, pupils {Pupil finding}, mucous membranes were moist {Moist oral mucosa}, oropharynx {Oropharyngeal structure}, exudates {Exudate}, hyperemia {Hyperemia}, Trachea {Tracheal structure}, neck {Neck structure}, supple {Normal movement of neck}, adenopathy {Lymphadenopathy}, thyromegaly {Goiter}, carotid bruits {Carotid bruit}, Chest {Examination of respiratory system}, lungs were clear
to auscultation {Normal breath sounds}, wheezes {Wheezing}, Cardiac {Cardiovascular physical examination}, regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, abdomen {Examination of abdomen}, obese {Obese}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds {Normal bowel sounds}, hernias {Herniated structure}, incision {Incision}, scar {Scar}, umbilicus {Umbilical structure}, tenderness {Tenderness}, pain {Pain}, edema {Edema}, lower
extremities {Lower limb structure}, venous stasis {Venous stasis}, clubbing {Clubbing}, perfusion {Perfusion}, joint swelling {Joint swelling}, joints {Joint structure}, neurological deficits {Neurological deficit}, gait {Gait normal} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 12:36PM BLOOD Hct-43.9
___ 07:05AM BLOOD WBC-6.0 RBC-4.53* Hgb-12.1* Hct-37.3*
MCV-82 MCH-26.7* MCHC-32.5 RDW-13.7 Plt ___
___ 07:05AM BLOOD Plt ___
###RESPONSE: Hct {Hematocrit determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Patient admitted and underwent a laparoscopic gastric band. He
tolerated this procedure very well. Postoperative course was
complicated by urinary retention. Urology was consulted as
reinsertion of foley catheter was difficult. He will go home
with a foley catheter and appointment has been made for him with
urology to discontinue catheter in one week.
Pain is well controlled on roxicet. Slowly progressed to
bariatric stage 3 with good tolerance. Discharge instructions
reviewed and discussed.
Will follow up with Dr. ___ in 2 weeks.
###RESPONSE: laparoscopic gastric band. {Laparoscopic adjustable gastric banding}, procedure {Procedure}, urinary retention {Retention of urine}, foley {Catheterization of urinary bladder}, foley {Catheterization of urinary bladder}, Pain is well controlled {Demonstrates adequate pain control}, Discharge instructions {Final inpatient visit with instructions at discharge}, follow up {Follow-up arranged} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Levothyroxine 300 mcg daily for
hypothyroid; Citalopram 20 mg daily for depression (not taking);
Simvastatin 40 mg daily for hyperlipidemia; Ibuprofen 800 mg
three times daily with meals as needed for back, knee pain;
Betamethasone 0.05% lotion to affected skin at bedtime;
multivitamins with minerals daily and vitamin D
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Oxycodone-Acetaminophen ___ mg/5 mL Solution Sig: ___ MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*500 ML(s)* Refills:*0*
5. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day as
needed for constipation.
Disp:*500 ml* Refills:*0*
6. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: obesity
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
###RESPONSE: obesity {Obesity}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance
diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals once a day. No gummy vitamins.
3. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
4. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
###RESPONSE: Discharge Instructions {Final inpatient visit with instructions at discharge}, fever {Fever}, chest pain {Chest pain}, shortness of breath {Dyspnea}, abdominal pain {Abdominal pain}, pain {Pain}, pain medication {Administration of analgesic}, nausea {Nausea}, vomiting {Vomiting}, abdominal bloating {Abdominal bloating}, drainage {Discharge}, incisions {Incision}, redness {Redness of skin over lesion}, swelling {Swelling}, incisions {Incision}, Diet {Dietary finding}, diet {Dietary finding}, diet {Dietary finding}, pain {Pain}, operation {Surgical procedure}, drowsy {Drowsy}, impair your ability to drive a motor vehicle or operate
machinery safely {Patient should not drive or operate machinery}, take a stool softener {Administration of laxative}, constipation {Constipation}, a normal bowel
pattern {Normal bowel habits}, bleeding {Bleeding}, ulcers {Ulcer}, digestive system {Structure of digestive system}, exercise {Exercises}, abdominal exercises {Abdominal exercises}, drainage {Discharge}, incisions {Incision}, cover with
clean, dry gauze {Application of dressing}, surgery {Surgical procedure}, increased pain {Increased pain}, swelling {Swelling}, redness {Redness of skin over lesion}, drainage {Discharge}, incision {Incision} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Azithromycin /
Tequin / Keflex / Penicillins
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
###RESPONSE: Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, Codeine {Allergy to codeine}, Azithromycin {Allergy to azithromycin}, Keflex {Allergy to cefalexin}, Penicillins {Allergy to penicillin}, Chest pain {Chest pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ y/o man with long hx of GERD who presented to the ED after
experiencing intermittant chest pain associated with dizziness
over the preceding two days. He was unsure if this was GERD
associted pain or not, and felt recent initiation of SSRI may
have contributed, but symptoms persisted, so he called ___ at
the recommendation of an RN from his PCP's office. He was
given ASA (4 baby asa) by EMS and he reported immediate relief
of his chest pain.
In the ED, found to have VSS. ECG with ? old inferior infarct.
No ischemic changes. Trop flat times two. Had planned obs and
stress test, but not able to do on ___, so admitted.
ROS: at current: denies dizziness, sob, nausea, cp. Denies
recent blood in stool or tarry stools. All other systems
reviewed and negative.
###RESPONSE: GERD {Gastroesophageal reflux disease}, chest pain {Chest pain}, dizziness {Dizziness}, GERD {Gastroesophageal reflux disease}, pain {Pain}, PCP {Primary care management}, relief {Feeling relief}, chest pain {Chest pain}, VSS {Vital signs finding}, ECG {Electrocardiographic procedure}, old inferior infarct {Old inferior myocardial infarction}, No ischemic changes {Electrocardiogram: no myocardial ischemia}, stress test {Electrocardiogram with exercise test}, dizziness {Dizziness}, sob {Dyspnea}, nausea {Nausea}, blood in stool {Hematochezia}, tarry stools {Melena} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
HTN
GERD
HCL
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, GERD {Gastroesophageal reflux disease} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
Subsets and Splits