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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: Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
###RESPONSE: Penicillins {Allergy to penicillin}, Dyspnea {Dyspnea} |
###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 PMH of AVR + single vessel CABG (___), pAF s/p
cardioversion, on sotalol, HTN, HLD p/w 1 day of worsening
dyspnea in the setting of gradual worsening over the past few
weeks. Her symptoms started around ___ and were associated
with diaphoresis, nausea, and pallor. She denied any chest
pain/pressure. She presented to ___ where her EKG showed
sinus rhythm and she was given ASA 300mg rectally. Her initial
TropT was elevated at 0.15. She had a CXR which showed
pulmonary vascular congestion without frank pulmonary edema.
Her lungs were noted to have diffuse wheezes which were felt to
be most likely ___ pulmonary edema. She was placed on BiPAP for
increased work of breathing and was transferred to ___ for
further management and potential ICU level of care.
On arrival to the ___ ED, her EKG was unchanged from her prior
one at ___. Her labs were notable for a WBC of 17 and Cr
rising from 1.3 to 1.4. Her CKMB was normal at 6, and her
initial Troponin was 0.21 which declined to 0.16. She was
initially on CPAP due to increased work of breathing with her
two VBGs being 7.37/48 and 7.4/42. ___ was weaned to 5LNC
after being given 20mg of IV lasix. She made 700cc of UOP over
the next 6 hours but developed increased WOB and was re-trialed
on BiPAP. She was redosed with 20mg of IV lasix. She was
hemodynamically stable throughout. She is transferred to the
CCU for further management.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
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.
Denies recent fevers, chills or rigors.
Denies exertional buttock or calf pain. All of the other review
of systems were negative.
###RESPONSE: AVR {Replacement of aortic valve}, single vessel {Single coronary vessel disease}, CABG {Coronary artery bypass grafting}, pAF {Paroxysmal atrial fibrillation}, cardioversion {Cardioversion}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, dyspnea {Dyspnea}, diaphoresis {Excessive sweating}, nausea {Nausea}, pallor {Pallor of skin of face}, chest
pain {Chest pain}, pressure {Tight chest}, EKG {Electrocardiographic procedure}, sinus rhythm {Sinus rhythm}, TropT was elevated {Troponin I above reference range}, CXR {Plain chest X-ray}, pulmonary vascular {Structure of pulmonary blood vessel}, congestion {Congestion}, pulmonary edema {Pulmonary edema}, lungs {Lung structure}, wheezes {Wheezing}, pulmonary edema {Pulmonary edema}, BiPAP {Bilevel positive airway pressure titration}, EKG {Electrocardiographic procedure}, WBC {White blood cell count}, Troponin {Troponin measurement}, on CPAP {Dependence on continuous positive airway pressure ventilation}, IV {Administration of drug or medicament via intravenous route}, lasix {Diuretic therapy}, BiPAP {Bilevel positive airway pressure titration}, IV {Administration of drug or medicament via intravenous route}, lasix {Diuretic therapy}, hemodynamically stable {Hemodynamically stable}, REVIEW OF SYSTEMS {Review of systems}, Cardiac {Heart disease}, review of systems {Review of systems}, chest pain {Chest pain}, dyspnea on exertion {Dyspnea on exertion}, paroxysmal nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, ankle edema {Ankle edema}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope}, stroke {Cerebrovascular accident}, TIA {Transient ischemic attack}, deep venous thrombosis {Deep venous thrombosis}, pulmonary embolism {Pulmonary embolism}, bleeding {Bleeding}, 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} |
###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 (+) HLD (-) DM
b/l cataracts s/p surgery
s/p cholecystectomy, hysterectomy
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, DM {Diabetes mellitus}, cataracts {Cataract}, cholecystectomy {Cholecystectomy}, hysterectomy {Hysterectomy} |
###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:
Father died of suspected MI @ ___. Mother died @ ___.
###RESPONSE: died {Dead}, MI {Myocardial infarction}, died {Dead} |
###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 EXAM:
Gen: Elderly woman with increased work of breathing, saturating
well on BiPAP
HEENT: NCAT EOMI MMM
NECK: +JVP to mid neck
CV: S1/S2, RRR ___ systolic murmur heard best at ___ IS MCL with
radiation to axilla
LUNGS: expiratory wheezing, bibasilar crackles
ABD: +BS soft NT/ND
EXT: no c/c/e
PULSES: 2+ pulses b/l
SKIN: warm and dry
NEURO: AAOx1-2
DISCHARGE EXAM:
Gen: No spontaneous respirations or chest wall movement noted
HEENT: Pupils fixed and dilated. Absent corneal reflexes.
CV: No heart sound appreciable on auscultation.
Lungs: No breath sounds on auscultation.
Patient pronounced dead at 16:51PM on ___.
###RESPONSE: Gen {General examination of patient}, BiPAP {Bilevel positive airway pressure titration}, HEENT {Physical examination procedure}, NC {Normal head}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, JVP {Finding of jugular venous pressure}, neck {Neck structure}, CV {Cardiovascular physical examination}, S2 {Normal second heart sound, S>2<}, RRR {Normal heart rate}, murmur {Murmur}, axilla {Axillary region structure}, LUNGS {Examination of respiratory system}, wheezing {Wheezing}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, ABD {Examination of abdomen}, BS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, PULSES {Normal pulse}, 2+ pulses {Peripheral pulses normal}, SKIN {Examination of skin}, warm {Warm skin}, dry {Xeroderma}, NEURO {Neurological examination}, Gen {General examination of patient}, spontaneous respirations {Spontaneous respiration}, chest wall {Chest wall structure}, Pupils fixed {Fixed dilatation of pupil}, dilated {Dilated pupil}, Absent corneal reflexes {Corneal reflex absent}, CV {Cardiovascular physical examination}, No heart sound {Heart sound inaudible}, auscultation {Auscultation}, Lungs {Lung structure}, No breath sounds {Absent breath sounds}, auscultation {Auscultation}, Patient pronounced dead {Patient status determination, deceased} |
###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:
___ 04:10AM BLOOD WBC-17.5* RBC-3.91* Hgb-12.8 Hct-35.6*
MCV-91 MCH-32.6* MCHC-35.8* RDW-13.6 Plt ___
___ 04:10AM BLOOD Neuts-84.5* Lymphs-8.2* Monos-6.4 Eos-0.7
Baso-0.2
___ 04:29AM BLOOD ___ PTT-25.0 ___
___ 04:29AM BLOOD Glucose-125* UreaN-38* Creat-1.3* Na-141
K-4.9 Cl-104 HCO3-22 AnGap-20
___ 04:29AM BLOOD CK-MB-6
___ 04:29AM BLOOD cTropnT-0.21*
___ 04:29AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.0
___ 04:38AM BLOOD ___ pO2-48* pCO2-48* pH-7.37
calTCO2-29 Base XS-1
___ 04:38AM BLOOD O2 Sat-81
PERTINENT LABS:
___ 09:07AM BLOOD WBC-16.4* RBC-3.91* Hgb-12.0 Hct-37.5
MCV-96 MCH-30.8 MCHC-32.0 RDW-14.2 Plt ___
___ 09:07AM BLOOD ___ PTT-21.2* ___
___ 09:07AM BLOOD Glucose-120* UreaN-128* Creat-5.0*#
Na-139 K-6.1* Cl-104 HCO3-17* AnGap-24*
___ 11:40AM BLOOD cTropnT-0.16* ___
___ 09:07AM BLOOD Calcium-8.6 Phos-11.4*# Mg-2.4
___ 11:40PM BLOOD Lactate-2.2*
___ 03:30PM BLOOD Lactate-1.9
DISCHARGE LABS: NONE, PATIENT MADE CMO AND EXPIRED
MICRO:
___ BLOOD CULTURE: PENDING
___ URINE CULTURE: NO GROWTH.
IMAGING:
___ ECG
Normal sinus rhythm. Left ventricular hypertrophy.
Intraventricular
conduction delay. No previous tracing available for comparison.
___ CHEST (PORTABLE AP)
FINDINGS: The patient is rotated to the left. The patient is
status post median sternotomy. There is moderate pulmonary
edema. More confluent opacity at the right lung base may relate
to vascular congestion however a consolidation due to pneumonia
is not excluded. No large pleural effusion is seen. There is no
evidence of pneumothorax. The cardiac silhouette is enlarged.
The aorta is calcified and tortuous.
___ Portable TTE
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Diastolic function
could not be assessed. There is a mild resting left ventricular
outflow tract obstruction. The right ventricular free wall is
hypertrophied. The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. A bioprosthetic aortic
valve prosthesis is present. The transaortic gradient is higher
than expected for this type of prosthesis. A paravalvular aortic
valve leak is probably present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is mild functional mitral stenosis (mean gradient 7 mmHg) due to
mitral annular calcification. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. The tricuspid regurgitation jet
is eccentric and may be underestimated. [Due to acoustic
shadowing, the severity of tricuspid regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
near-hyperdynamic left ventricular systolic function. The right
ventricle is dilated and hypokinetic with moderate tricuspid
regurgitation and moderate pulmonary hypertension. Bioprosthetic
AVR with high gradients - likely a combination of a relatively
small valve and hyperdynamic function. The leaflets as seen on
images #21 and #22 seem to move well although there is
significant calcification seen at ___ o'clock on the short axis
views. It is not clear if this is outside the valve or not. At
least mild mitral regurgitation. Mild calcific mitral stenosis.
Biatrial dilation.
___ CHEST (PORTABLE AP)
IMPRESSION: Interval worsening of pulmonary edema, without
effusions.
___ BILAT LOWER EXT VEINS
IMPRESSION: No evidence of deep venous thrombosis in the right
or left lower extremity veins.
___ ECG
Sinus rhythm. Prolonged Q-T interval. Left ventricular
hypertrophy. No major change from the previous tracing.
###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}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, 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}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, pH {pH measurement}, 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}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, ECG {Electrocardiographic procedure}, Normal sinus rhythm {Normal sinus rhythm}, Left ventricular hypertrophy {Left ventricular hypertrophy}, CHEST (PORTABLE AP {Plain x-ray of chest anteroposterior view}, median sternotomy {Median sternotomy}, pulmonary
edema {Pulmonary edema}, opacity {Abnormally opaque structure}, right lung base {Structure of base of right lung}, vascular {Blood vessel structure}, congestion {Congestion}, consolidation {Consolidation}, pneumonia {Pneumonia}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, cardiac {Heart structure}, enlarged {Enlargement}, aorta {Aortic structure}, calcified {Pathologic calcification, calcified structure}, TTE {Transthoracic echocardiography}, left atrium {Left atrial structure}, dilated {Dilatation}, atrial septal defect {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, mild symmetric left
ventricular hypertrophy {Mild left ventricular hypertrophy}, normal cavity {Normal size cardiac chamber}, regional/global systolic function {Normal left ventricular systolic function and wall motion}, left ventricular
outflow tract obstruction {Left ventricular outflow tract obstruction}, right ventricular {Right cardiac ventricular structure}, wall {Cardiac wall structure}, right ventricular cavity is mildly dilated {Dilatation of right cardiac ventricle}, wall {Cardiac wall structure}, hypokinesis {Behavior showing reduced motor activity}, aortic
valve {Aortic valve structure}, aortic
valve leak {Aortic valve regurgitation}, Mild (1+) aortic regurgitation {Mild mitral valve regurgitation}, mitral valve leaflets are mildly thickened {Thickened mitral leaflet}, mild functional mitral stenosis {Mild mitral valve stenosis}, mitral annular calcification {Mitral valve annular calcification}, Mild (1+) mitral regurgitation {Mild mitral valve regurgitation}, mitral
regurgitation {Mitral valve regurgitation}, tricuspid valve leaflets are mildly thickened {Tricuspid leaflet thickened}, Moderate [2+]
tricuspid regurgitation {Moderate tricuspid valve regurgitation}, tricuspid regurgitation {Tricuspid valve regurgitation}, tricuspid regurgitation {Tricuspid valve regurgitation}, pulmonary
artery systolic hypertension {Pulmonary hypertensive arterial disease}, pericardial effusion {Pericardial effusion}, Mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, right
ventricle is dilated {Dilatation of right cardiac ventricle}, hypokinetic {Hypokinetic right ventricular wall}, moderate tricuspid
regurgitation {Moderate tricuspid valve regurgitation}, moderate pulmonary hypertension {Moderate pulmonary hypertension}, Bioprosthetic
AVR {Repair of aortic valve with tissue graft}, leaflets {Structure of cardiac valve leaflet}, calcification {Pathologic calcification, calcified structure}, mild mitral regurgitation {Mild mitral valve regurgitation}, Mild calcific mitral stenosis {Mild mitral valve regurgitation}, Biatrial dilation {Atrial dilatation}, CHEST (PORTABLE AP {Plain x-ray of chest anteroposterior view}, pulmonary edema {Pulmonary edema}, effusions {Pleural effusion}, LOWER EXT VEINS {Structure of vein of lower limb}, deep venous thrombosis {Deep venous thrombosis}, right {Structure of vein of right lower limb}, left lower extremity veins {Structure of vein of left lower limb}, ECG {Electrocardiographic procedure}, Sinus rhythm {Sinus rhythm}, Prolonged Q-T interval {Prolonged QT interval}, Left ventricular
hypertrophy {Left ventricular hypertrophy} |
###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:
___ y/o F w/ hx of AVR, CABG in ___, PAF on sotalol, HTN, HLD w/
recent echo showing preserved ejection fraction with acute on
subacute worsening dyspnea in the setting of leukocytosis and
CXR findings c/w PNA, found to have volume overload on exam with
increased work of breathing initially requiring BiPAP but later
made comfort care only after unsuccessful attempts at diuresis
and development of acute renal failure.
ACTIVE ISSUES:
#ACUTE DECOMPENSATED DIASTOLIC HEART FAILURE: LVEF >55%, mild
symmetric LVH, MAC, +MR. ___ consistent with heart
failure exacerbation in the setting of PNA. She initially
responded to IV lasix boluses but quickly developed acute renal
failure and persistent oxygen requirement. PE was considered in
the differential given +D-dimer and increased WOB but LENIs were
negative for DVT and symptomatology was not consistent. Patient
and family was approached regarding elective intubation and
right heart cath but declined as this was felt to be too
invasive. After a meeting with the patient and her family
(including HCP), patient was made DNR/DNI. Medical team and
family agreed to try high dose IV Lasix and if this was
unsuccessful, patient would be made comfort care only.
Unfortunately, high dose IV diuresis was unsuccessful and
patient was made comfort care only on ___. Palliative care was
consulted to assist with comfort measures. Patient expired on
___ at 16:51PM with family at bedside.
#PNA: Patient presented with leukocytosis characterized by a
left shift. This in combination with her CXR which was
suggestive of a RLL opacification, was concerning for PNA. This
PNA also likely contributed if not caused her CHF exacerbation.
She was treated with CTX and azithromycin. Antibiotics were
withdrawn once patient was made comfort care only.
CHRONIC ISSUES:
#Atrial fibrillation: Patient remained in atrial fibrillation
throughout admission. She was continued on her home sotalol on
admission but this was withdrawn once patient was made CMO.
#HTN: Normotensive on admission. Home BP meds were held on
admission especially in the setting of diuresis.
#HLD: Stable, she was continued on her home pravastatin which
was discontinued once she was made CMO.
TRANSITIONAL ISSUES:
NONE
###RESPONSE: AVR {Replacement of aortic valve}, CABG {Coronary artery bypass grafting}, PAF {Paroxysmal atrial fibrillation}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, echo {Echocardiography}, dyspnea {Dyspnea}, leukocytosis {Leukocytosis}, CXR {Plain chest X-ray}, PNA {Pneumonia}, volume overload {Hypervolemia}, BiPAP {Bilevel positive airway pressure titration}, comfort care {Comfort measures}, diuresis {Diuresis}, acute renal failure {Acute kidney injury}, DECOMPENSATED DIASTOLIC HEART FAILURE {Decompensated cardiac failure}, mild
symmetric LVH {Mild left ventricular hypertrophy}, MAC {Mitral valve annular calcification}, MR {Mitral valve regurgitation}, heart
failure {Heart failure}, PNA {Pneumonia}, IV {Administration of drug or medicament via intravenous route}, lasix {Diuretic therapy}, acute renal
failure {Acute kidney injury}, PE {Pulmonary embolism}, DVT {Deep venous thrombosis}, intubation {Intubation}, right heart cath {Catheterization of right heart}, DNR {Not for resuscitation}, IV {Administration of drug or medicament via intravenous route}, comfort care {Comfort measures}, IV {Administration of drug or medicament via intravenous route}, diuresis {Diuresis}, comfort care {Comfort measures}, Palliative care {Palliative care}, comfort measures {Comfort measures}, PNA {Pneumonia}, leukocytosis {Leukocytosis}, left shift {Left shifted white blood cells}, CXR {Plain chest X-ray}, RLL {Structure of lower lobe of right lung}, opacification {Abnormally opaque structure}, PNA {Pneumonia}, PNA {Pneumonia}, CHF exacerbation {Exacerbation of congestive heart failure}, Antibiotics {Antibiotic therapy}, comfort care {Comfort measures}, Atrial fibrillation {Atrial fibrillation}, atrial fibrillation {Atrial fibrillation}, HTN {Hypertensive disorder, systemic arterial}, Normotensive {Normal blood pressure}, diuresis {Diuresis}, HLD {Hyperlipidemia} |
###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. Acetaminophen 650 mg PO Q8H:PRN pain
2. ALPRAZolam 0.5 mg PO QHS insomnia
3. Losartan Potassium 25 mg PO DAILY
4. Potassium Chloride 20 mEq PO DAILY
5. Pravastatin 40 mg PO QPM
6. Sotalol 80 mg PO BID
7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
Discharge Medications:
PATIENT EXPIRED
###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:
Expired
Discharge Diagnosis:
PATIENT EXPIRED
Discharge Condition:
PATIENT EXPIRED
###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:
PATIENT EXPIRED
###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: 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: 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:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
confusion, abnormal labs
Major Surgical or Invasive Procedure:
None
###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, confusion {Clouded consciousness} |
###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 ___ w/pmh chronic mild hypoNa likely ___ SIADH,
HTN, COPD and chronic etoh use disorder who presents with
confusion in the setting of worsening hypoNa.
History obtained from patient as well as her son and daughter
who were at bedside. Patient has a long history of chronic
asymptomatic hyponatremia (Na 130-132) thought to be due to
SIADH and chronic tea and toast potomania ("nibbles" and drinks
about 2 gallons of wine a week). Na was as low as 129 in ___
due to increased ETOH intake and very poor PO intake. After PCP
counseling and change in her diet (more salty soups), Na was
improved to low 130s. Per daughter in law, patient has been
increasing her ETOH intake recently with very little PO intake.
Family has noted increased confusion and forgetfulness over the
past 2 weeks. Denied any speech slurring, weakness, numbness,
recent falls.
Patient was taken to urgent care today for above sxs and noted
to have Na 125 from baseline around 130. She was sent to ___
ED for further eval. Of note yesterday patient was also taken to
___ UC yesterday for a rash on her face. She was given Keflex
and prednisone for possible shingles. She reports the rash was
initially itchy but never painful. Currently it feels well and
does not bother her.
In the ED, initial VS were: 98.9 88 123/54 16 96% RA
ED physical exam was recorded as:
Awake and alert but forgetful at times, moving all ext, CN
II-XII
CTAB, RRR and abd NTND soft
Ext wwp, 2+ pulses
No signs of trauma
rash on right side of face
ED labs were notable for:
Na 125
WBC 10.6
H/H 10.8/32.1
Urine sodium 42, Uosm 241
Imaging showed:
CXR:
No acute cardiopulmonary process seen.
Transfer VS were: 90 126/62 18 97% RA
When seen on the floor, she is alert and oriented times 3. She
is not sure why she is in the hospital. She denies any pain
anywhere, dysuria, abd pain, n/v, diarrhea, fever, chills.
Reports chronic cough. Requesting sleep aid and nicotine patch.
REVIEW OF SYSTEMS:
A ten point ROS was conducted and was negative except as above
in the HPI.
###RESPONSE: chronic {Chronic disease}, hypoNa {Hyponatremia}, SIADH {Syndrome of inappropriate vasopressin secretion}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, chronic etoh use disorder {Persistent alcohol abuse}, confusion {Clouded consciousness}, worsening {Patient's condition worsened}, hypoNa {Hyponatremia}, chronic {Chronic disease}, asymptomatic {Asymptomatic}, hyponatremia {Hyponatremia}, SIADH {Syndrome of inappropriate vasopressin secretion}, chronic {Chronic disease}, potomania {Hypo-osmolality and or hyponatremia}, drinks {Current drinker of alcohol}, increased ETOH intake {Problem drinker}, poor PO intake {Decrease in appetite}, counseling {Counseling}, diet {Dietary regime}, improved {Patient's condition improved}, ETOH {Alcohol abuse}, confusion {Clouded consciousness}, forgetfulness {Forgetful}, slurring {Slurred speech}, weakness {Asthenia}, numbness {Numbness}, falls {Falls}, baseline {Baseline state}, eval {Evaluation procedure}, rash on her face {Eruption of skin of face}, shingles {Herpes zoster}, rash {Eruption of skin}, itchy {Itching}, painful {Pain}, feels well {Well in self}, Awake {Awake}, alert {Mentally alert}, forgetful {Forgetful}, CN
II-XII {Examination of cranial nerve}, CTAB {Normal breath sounds}, RRR {Normal heart rate}, NTND {Abdominal tenderness}, soft {Abdomen soft}, 2+ pulses {Peripheral pulses normal}, signs {Sign}, trauma {Traumatic injury}, rash {Eruption of skin}, right side of face {Structure of right half of face}, labs {Laboratory test}, CXR {Plain chest X-ray}, No acute {No abnormality detected}, alert {Mentally alert}, oriented times 3 {Oriented to person, time and place}, pain {Pain}, dysuria {Dysuria}, abd pain {Abdominal pain}, diarrhea {Diarrhea}, fever {Fever}, chills {Chill}, chronic cough {Chronic cough}, REVIEW OF SYSTEMS {Review of systems}, ROS {Review of systems} |
###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:
Purpura [D69.2]
Alcohol dependence [F10.20]
Emphysematous COPD [J43.9]
Tobacco dependence [F17.200]
HYPERTENSION - ESSENTIAL, UNSPEC [I10]
Lisinopril
H/O solitary pulmonary nodule [___]
Hyponatremia [___.1] c/w SIADH
RLL consolidation of chest CT -resolved. ( ___
B12 deficiency, borderline [E53.8]
Asymptomatic PVD (peripheral vascular disease) [___.9]
SCREENING FOR COLON CANCER [___.11]
LICHEN SCLEROSUS ET ATROPHICUS
###RESPONSE: Purpura {Purpuric disorder}, Alcohol dependence {Alcohol dependence}, Emphysematous COPD {Pulmonary emphysema}, Tobacco dependence {Tobacco dependence syndrome}, HYPERTENSION - ESSENTIAL {Essential hypertension}, solitary pulmonary nodule {Solitary nodule of lung}, Hyponatremia {Hyponatremia}, SIADH {Syndrome of inappropriate vasopressin secretion}, RLL {Structure of lower lobe of right lung}, consolidation {Lung consolidation}, chest CT {Computed tomography of chest}, resolved {Problem resolved}, Asymptomatic {Asymptomatic}, PVD (peripheral vascular disease {Peripheral vascular disease}, SCREENING FOR COLON CANCER {Screening for malignant neoplasm of colon}, LICHEN SCLEROSUS {Lichen sclerosus} |
###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:
No family 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: Physical Exam:
On Admission:
Gen: NAD, A&O x3, lying in bed
Eyes: EOMI, sclerae anicteric
HEENT: MMM, OP clear. Erythematous patch on right facial and
cervical area, with no tenderness to palpation, no induration.
Small dry crusted areas on the overlying skin.
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
On Discharge:
VS: 97.8 134/59 66 18 91% RA
GEN: Well appearing in NAD, sitting up in bed
HEENT/Neck: Anicteric sclera, MMM, OP clear, neck supple.
HEART: RRR no m/r/g
LUNGS: CTAB no wheezes, rales, or crackles. Symmetric expansion
ABD: soft NT/ND +BS no rebound or guarding, dry cough throughout
exam, which patient states is her "smoker's cough."
EXT: warm well perfused, no pitting edema
NEURO: alert and oriented x3. Fluent speech. CN II-XII intact.
No focal deficits on strength testing.
###RESPONSE: Gen {General examination of patient}, NAD {No abnormality detected}, O x3 {Oriented to person, time and place}, lying in bed {Lying in bed}, EOMI {Normal ocular motility}, sclerae anicteric {White sclera}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, Erythematous {Erythema}, facial and
cervical {Face and/or neck structure}, tenderness {Tenderness}, palpation {Palpation}, induration {Induration of skin}, crusted areas {Crust on skin}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, pulses {Normal pulse}, edema {Edema}, Resp {Examination of respiratory system}, normal effort {Visible respiratory effort}, accessory muscle {Accessory skeletal muscle}, lungs {Lung structure}, CTA {Normal breath sounds}, GI {Examination of digestive system}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, MSK {Musculoskeletal system physical examination}, kyphosis {Kyphosis deformity of spine}, palpable {Palpation}, synovitis {Synovitis}, Skin {Examination of skin}, rash {Eruption of skin}, jaundice {Jaundice}, Neuro {Neurological examination}, Ox3 {Oriented to person, time and place}, facial droop {Weakness of face muscles}, Psych {Psychological assessment}, affect {Mood finding}, GEN {General examination of patient}, Well appearing {Well cared for appearance}, NAD {Distress}, HEENT {Physical examination procedure}, Neck {Physical examination procedure}, Anicteric sclera {White sclera}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, neck supple {Normal movement of neck}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, LUNGS {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, crackles {Respiratory crackles}, Symmetric expansion {Chest expansion normal}, ABD {Examination of abdomen}, soft {Abdomen soft}, +BS {Normal bowel sounds}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, dry cough {Dry cough}, exam {Examination of abdomen}, smoker's cough {Smokers' cough}, EXT {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, pitting edema {Pitting edema}, NEURO {Neurological examination}, alert {Mentally alert}, oriented x3 {Oriented to person, time and place}, Fluent speech {Finding of fluency of speech}, CN II-XII intact {Normal central nervous system}, No focal deficits {Normal nervous system function} |
###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:
___ 05:20PM URINE OSMOLAL-241
___ 05:20PM URINE HOURS-RANDOM CREAT-29 SODIUM-42
___ 01:40PM GLUCOSE-106* UREA N-14 CREAT-0.7 SODIUM-125*
POTASSIUM-4.7 CHLORIDE-89* TOTAL CO2-26 ANION GAP-15
___ 01:40PM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-1.8
___ 01:40PM OSMOLAL-283
___ 01:40PM WBC-10.6* RBC-3.47* HGB-10.8* HCT-32.1*
MCV-93 MCH-31.1 MCHC-33.6 RDW-14.2 RDWSD-48.2*
___ 01:40PM NEUTS-74.4* LYMPHS-14.6* MONOS-9.4 EOS-0.4*
BASOS-0.4 IM ___ AbsNeut-7.90* AbsLymp-1.55 AbsMono-1.00*
AbsEos-0.04 AbsBaso-0.04
___ 01:40PM PLT COUNT-300
CXR: No acute cardiopulmonary process seen.
CT chest (___):
1. 4 mm noncalcified pulmonary nodule is stable since ___.
Followup per ___ recommendations.
2. COPD.
On Discharge:
___ 06:50AM BLOOD WBC-5.7 RBC-3.14* Hgb-9.8* Hct-30.0*
MCV-96 MCH-31.2 MCHC-32.7 RDW-14.4 RDWSD-49.9* Plt ___
___ 07:15AM BLOOD Glucose-91 UreaN-12 Creat-0.6 Na-129*
K-4.0 Cl-93* HCO3-26 AnGap-14
___ 07:15AM BLOOD Mg-1.6
___ 06:20AM BLOOD VitB12-548 Folate-2.9
___ 01:40PM BLOOD Osmolal-283
___ 06:20AM BLOOD TSH-2.9
###RESPONSE: URINE OSMOLAL {Osmolality measurement, urine}, URINE {Evaluation of urine specimen}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, GLUCOSE {Glucose measurement, urine}, 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}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PLT COUNT {Platelet count}, CXR {Plain chest X-ray}, No acute {No abnormality detected}, pulmonary nodule {Nodule of lung}, stable {Symptom not changed}, COPD {Chronic obstructive lung disease}, 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}, BLOOD 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}, Mg {Blood magnesium measurement}, TSH {Thyroid stimulating hormone 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:
Patient is a ___ year old woman with history of mild chronic
hypoNa attributed to SIADH, HTN, COPD and etoh use disorder who
presents with confusion and worsening hypoNa.
#Acute metabolic encephalopathy:
#Hyponatremia:
Patient's confusion and forgetfulness is likely due to acute on
chronic hyponatremia ___ poor solute intake ("tea and toast", or
"wine and toast") as well as possible mild SIADH (elevated UNa
and UOsm). It is unclear why she would have SIADH, no
intrapulmonary process on CXR. She has a lung nodule which has
been stable on serial imaging. DDx also includes toxic metabolic
encephalopathy from chronic alcohol use vs alcohol withdrawal
(although currently not exhibiting any signs). Unlikely to be
infection (given clear CXR and UA), head trauma (no recent
history of head strike) medication side effects (not on any
culprit meds). Na improved to recent baseline with free water
restriction and salt tabs. She was encouraged to increase her
solute intake. TSH, B12, folate wnl. B1 pending on discharge.
Given her encephalopathy, ___ and OT were consulted and found
significant deficits concerning for her safety. Her MMSE was
___ suggestive of mild-moderate cognitive impairment. Her
family echoed these concerns about safety at home and she is now
discharged to rehab. She should have cognitive neurology follow
up as an outpatient.
#Facial Rash:
Mild cellulitis vs dermatitis with faint erythema, induration.
Does not appear to be shingles given lack of a dermatomal
distribution and no vescicular lesions. In the outpatient
setting was given Keflex and steroid. Her Keflex should be
continued through ___ to complete a ___TOH use disorder
#Fall safety risk:
Per daughter in law, patient has longstanding history of ETOH
use disorder (about 2 gallons a wine per week), with prior
history of falls (twice last year). She was able to ambulate
independently at home, however now needs help with paying bills.
Family is concerned about patient's ability to take care of
herself at home and have entertained the possibility of
placement. See above for evaluation. She did not trigger on
CIWA
#HTN: Continued Lisinopril 40 mg PO and amLODIPine 10 mg PO
DAILY
Chronic issues: COPD stable
- Continued ASA
- Continued vitamin B12 and D
# Code status: DNR/DNI (confirmed with pt/family)
Transitional:
- Patient will need to be scheduled for follow up with cognitive
neurology
- Continue Keflex through ___
###RESPONSE: chronic
hypoNa {Chronic hyponatremia}, SIADH {Syndrome of inappropriate vasopressin secretion}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, etoh use disorder {Alcohol abuse}, confusion {Clouded consciousness}, hypoNa {Hyponatremia}, Hyponatremia {Hyponatremia}, confusion {Clouded consciousness}, forgetfulness {Forgetful}, chronic hyponatremia {Chronic hyponatremia}, mild {Symptom mild}, SIADH {Syndrome of inappropriate vasopressin secretion}, SIADH {Syndrome of inappropriate vasopressin secretion}, CXR {Plain chest X-ray}, lung nodule {Nodule of lung}, stable {Symptom not changed}, imaging {Imaging}, toxic metabolic
encephalopathy {Toxic metabolic encephalopathy}, chronic alcohol use {Persistent alcohol abuse}, alcohol withdrawal {Alcohol withdrawal syndrome}, signs {Sign}, infection {Infectious disease}, clear {No abnormality detected}, CXR {Plain chest X-ray}, head trauma {Injury of head}, head strike {Injury of head}, medication side effects {Medication side effects present}, improved {Patient's condition improved}, baseline {Baseline state}, water
restriction {Fluid restriction}, TSH {Thyroid stimulating hormone measurement}, B12 {B12/folate level}, encephalopathy {Disorder of brain}, concerning for her safety {Safeguarding concern}, MMSE {Assessment using mini-mental state examination}, moderate cognitive impairment {Moderate cognitive impairment}, concerns about safety {Safeguarding concern}, neurology follow
up {Follow-up neurological assessment}, Facial Rash {Eruption of skin of face}, Mild {Symptom mild}, cellulitis {Cellulitis}, dermatitis {Inflammatory dermatosis}, erythema {Erythema}, induration {Induration}, shingles {Herpes zoster}, vescicular lesions {Vesicular eruption}, steroid {Steroid therapy}, TOH use disorder {Alcohol abuse}, Fall safety risk {At increased risk for falls}, ETOH
use disorder {Alcohol abuse}, falls {Falls}, able to ambulate {Able to walk}, evaluation {Evaluation procedure}, HTN {Hypertensive disorder, systemic arterial}, Chronic issues {Chronic disease}, COPD {Chronic obstructive lung disease}, stable {Patient condition unchanged}, DNR {Not for resuscitation} |
###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. Lisinopril 40 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Cyanocobalamin 1000 mcg PO 3X/WEEK (___)
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
do not take if you are having loose stools
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Nicotine Patch 7 mg TD DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID:PRN constipation
8. Sodium Chloride 1 gm PO BID
9. Thiamine 100 mg PO DAILY
10. TraZODone 25 mg PO QHS:PRN insomnia
11. amLODIPine 10 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Cyanocobalamin 1000 mcg PO 3X/WEEK (___)
14. Lisinopril 40 mg PO DAILY
15. Vitamin D 1000 UNIT 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:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute metabolic encephalopathy
Hyponatremia, SIADH
Mild cognitive impairment
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: metabolic encephalopathy {Metabolic encephalopathy}, Hyponatremia {Hyponatremia}, SIADH {Syndrome of inappropriate vasopressin secretion}, Mild cognitive impairment {Mild neurocognitive disorder}, 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 - requires assistance or aid {Finding of walking aid use}, walker {Uses zimmer frame}, cane {Uses single walking stick} |
###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:
Patient admitted with increased confusion at home and worsened
hyponatremia. Improved with fluid restriction. Found to have
cognitive impairment and safety concerns at home. Rehab
recommended as well as follow up with a neurologist. Please
encourage alcohol cessation, encourage salt intake, and water
restriction to 1.5-2L per day
###RESPONSE: confusion {Clouded consciousness}, hyponatremia {Hyponatremia}, Improved {Patient's condition improved}, fluid restriction {Fluid restriction}, cognitive impairment {Impaired cognition}, safety concerns {Safeguarding concern}, follow up {Follow-up arranged}, alcohol {Current drinker of alcohol}, water
restriction {Fluid restriction} |
###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: ORTHOPAEDICS
###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:
morphine / Dilaudid
Attending: ___.
Chief Complaint:
L distal femur nonunion
Major Surgical or Invasive Procedure:
L distal femur nonunion ORIF with plate ___, ___
###RESPONSE: morphine {Allergy to morphine}, L distal femur {Bone structure of distal left femur}, L distal femur {Bone structure of distal left femur}, nonunion {Nonunion of fracture}, ORIF {Open reduction of fracture of femur with internal fixation} |
###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 is a follow-up visit for ___ chief complaint is
left distal femur fracture history ___ is here today for
follow-up with regards to his distal femur fracture he recently
had a CT scan and is here today to discuss the findings.
Past medical history no changes since we last saw him.
Review of systems no fevers or chills.
###RESPONSE: distal femur fracture {Fracture of distal end of femur}, distal femur fracture {Fracture of distal end of femur}, CT scan {Computed tomography of left lower limb}, Review of systems {Review of systems}, fevers {Fever}, chills {Chill} |
###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
###RESPONSE: HTN {Hypertensive disorder, systemic arterial} |
###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:
NC
###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:
On discharge
General: well-appearing, breathing comfortably
CV: pink and well perfused
Abd: soft, non-tender, non-distended
LLE: Incision well approximated. Dressing clean and dry. Fires
FHL, ___, TA, GCS. SILT ___ n distributions. Toes WWP
distally.
###RESPONSE: General {General examination of patient}, well-appearing {Well cared for appearance}, breathing comfortably {Breathing easily}, CV {Cardiovascular physical examination}, well perfused {Normal tissue perfusion}, Abd {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, LLE {Structure of left lower limb}, Incision {Surgical incision wound}, Dressing {Application of dressing}, SILT {Light touch sensation present}, Toes {Structure of all toes}, 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:
___ 06:30AM BLOOD WBC-15.4* RBC-3.41* Hgb-9.8* Hct-30.6*
MCV-90 MCH-28.7 MCHC-32.0 RDW-13.5 RDWSD-44.4 Plt ___
___ 06:30AM BLOOD Glucose-322* UreaN-11 Creat-1.0 Na-134*
K-4.0 Cl-96 HCO3-24 AnGap-14
###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}, 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} |
###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:
The patient is well known to the service and has been undergoing
evaluation for left distal femur. He presented from home on
___ for scheduled left distal femur nonunion ORIF, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report.
After the procedure the patient was taken from the OR to the
PACU, but was hypotensive requiring temporary pressors while in
the PACU. He was weaned off pressors prior to arrival on floor
(POD0) and SBP remained at 100 with HR around 100. Home
Metoprolol was held given hypotensive on POD1 with SBP to ___.
He was treated with IVF and pressures normalized. Additionally,
___ Diabetes service was consulted for newly found
hyperglycemia.
He was initially given IV fluids and IV pain medications, but
progressed to a regular diet and oral medications on POD1. The
patient was given ___ antibiotics per routine. He is
on Apixaban at home and was switched to Enoxaparin ___. He
was restarted on home Apixaban on POD1. The patient's other home
medications were also continued throughout this hospitalization.
His intraoperative cultures did not grow any bacteria. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in left lower extremity, and will be
discharged on home Apixaban for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
###RESPONSE: evaluation {Evaluation procedure}, left distal femur {Bone structure of distal left femur}, left distal femur {Bone structure of distal left femur}, nonunion {Nonunion of fracture}, ORIF {Open reduction of fracture of femur with internal fixation}, procedure {Surgical procedure}, procedure {Surgical procedure}, PACU {Postanesthesia care}, hypotensive {Low blood pressure}, pressors {Hypotensive therapy}, PACU {Postanesthesia care}, pressors {Hypotensive therapy}, hypotensive {Hypotensive therapy}, IVF {Administration of intravenous fluids}, pressures normalized {Normal blood pressure}, Diabetes service was consulted {Referral to diabetes service}, hyperglycemia {Hyperglycemia}, given IV fluids {Administration of intravenous fluids}, pain medications {Administration of analgesic}, regular diet {Normal diet}, oral medications {Administration of drug or medicament via oral route}, antibiotics {Antibiotic therapy}, cultures {Microbial culture}, unremarkable {No abnormality detected}, pain was well controlled {Demonstrates adequate pain control}, oral medications {Administration of drug or medicament via oral route}, incisions {Surgical incision wound}, clean/dry/intact {Wound healing well}, voiding {Micturition finding}, moving bowels {Finding of defecation}, weight bearing {Weight-bearing}, left lower extremity {Structure of left lower limb}, DVT prophylaxis {Prevention of deep vein thrombosis}, follow up {Follow-up arranged}, discussion {Discussion}, instructions {Education}, instructions {Education}, follow-up care {Postoperative procedure education}, readiness for discharge {Ready for discharge} |
###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:
Apixaban 5 mg PO BID
Atorvastatin 40 mg PO QPM
Digoxin 0.125 mg PO DAILY
Gabapentin 300 mg PO TID
Metoprolol Succinate XL 100 mg PO DAILY Please HOLD for SBP <
100 or HR <
Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Calcium Carbonate 500 mg PO BID
4. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN Cough/Sore
Throat
5. Docusate Sodium 100 mg PO BID
6. Milk of Magnesia 30 ml PO BID:PRN Constipation
7. Multivitamins 1 TAB PO DAILY
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
PRN Disp #*50 Tablet Refills:*0
9. Senna 8.6 mg PO BID
10. Vitamin D 400 UNIT PO DAILY
11. Apixaban 5 mg PO BID
12. Atorvastatin 40 mg PO QPM
13. Digoxin 0.125 mg PO DAILY
14. Gabapentin 300 mg PO TID
15. Metoprolol Succinate XL 100 mg PO DAILY
Please HOLD for SBP < 100 or HR < 55.
16. Pantoprazole 40 mg PO Q12H
###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:
L distal femur nonunion
Discharge Condition:
AVSS
NAD
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
LLE: Incision well approximated. Dressing clean and dry. Fires
FHL, ___, TA, GCS. SILT ___ n distributions. Toes WWP
distally.
###RESPONSE: nonunion {Nonunion of fracture}, AVSS {Normal vital signs}, NAD {No abnormality detected}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - requires assistance or aid {Finding of walking aid use}, LLE {Structure of left lower limb}, Incision {Surgical incision wound}, well approximated {Wound healing well}, Dressing {Application of dressing}, SILT {Light touch sensation present}, Toes {Structure of all toes}, 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: Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated in left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
PAIN MEDICATIONS INSTRUCTIONS:
1) Take Tylenol ___ every 6 hours around the clock.
2) Add your prescribed narcotics as needed for increased pain.
Start weaning the narcotic medication once you get home.
This is an example on how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
ANTICOAGULATION:
- Please continue taking your home Eliquis
WOUND CARE:
- Your incision is covered with a dry dressing. Please change
the dressing daily. If there is no drainage, you may leave your
incision open to the air. If you are continuing to have
drainage, you may place a dry dressing over the incision as
needed.
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Call your surgeon's office with any questions.
###RESPONSE: INSTRUCTIONS {Education}, SURGERY {Surgical procedure}, surgery {Surgical procedure}, tired {Tired}, washed out {Exhaustion}, after surgery {Postoperative state}, weight bearing {Weight-bearing}, precautions {Safety precautions}, Weight bearing {Weight-bearing}, left lower extremity {Structure of left lower limb}, Do not drink alcohol {Education about alcohol consumption}, pain relievers {Administration of analgesic}, pain relievers {Administration of analgesic}, constipation {Constipation}, take a stool softener {Administration of laxative}, Add your prescribed narcotics as needed {Narcotics education}, increased pain {Increased pain}, Start weaning the narcotic medication once you get home {Narcotics education}, pain {Pain}, Do not stop the Tylenol until you are off of the narcotic
medication {Narcotics education}, incision {Surgical incision wound}, dressing {Application of dressing}, change
the dressing {Change of dressing}, drainage {Discharge}, incision {Surgical incision wound}, drainage {Discharge}, dressing {Application of dressing}, incision {Surgical incision wound}, Activity as tolerated {Education about increasing activity tolerance}, Right lower extremity {Structure of right lower limb}, Full weight bearing {Full weight-bearing gait training}, Left lower extremity {Structure of left lower limb}, Full weight bearing {Full weight-bearing gait training}, cough and deep breathe {Deep breathing and coughing exercises}, awake {Awake}, Incision {Surgical incision wound}, draining {Wound discharge}, draining {Wound discharge}, apply a gauze dressing {Application of dressing}, 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: 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: 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:
Penicillins / Amoxicillin
Attending: ___.
Chief Complaint:
COPD exacerbation
Major Surgical or Invasive Procedure:
None
###RESPONSE: Penicillins {Allergy to penicillin}, Amoxicillin {Allergy to amoxicillin}, COPD exacerbation {Acute exacerbation of chronic obstructive airways 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: History of Present Illness:
___ w/ COPD p/w shortness of breath. Her symptoms started ___
when she felt congested and had a little cough and bad chills.
Then with progressive SOB, cough, yellow sputum, subjective
fever. She reports being febrile to 99 at home. Today at ___ O2
sat 92% and was sent in after 2 nebs. Feels as though a
bronchial infection is occurring, but not pneumonia (she has had
both in the past). This is similar to her prior COPD
exacerbations, of which she has ___ per year, however this is
her first hospitalization for COPD exacerbation. No sick
contacts.
In the ED, initial VS were 98.3 102 114/71 20 94%. Labs were
remarkable for UA with 45 WBCs/few bacteria, K 3.6, Cr 0.6, mWBC
8.4, HCT 41. CXR showed evidence of COPD and L apical nodule.
Received albuterol/ipratropium nebs, 50mg prednisone, 500mg
azithromycin and was transferred to medicine for further
management. Transfer VS were 99.0 95 ___ 94% RA.
On arrival to the floor, patient reports that she is no longer
experiencing fever and chills. Not currently SOB although she
feels some chest tightness. She has a slight sore throat
although this is improved from this AM. Patient is very
friendly, speaking in full sentences, not on supplemental
oxygen.
###RESPONSE: COPD {Chronic obstructive lung disease}, shortness of breath {Dyspnea}, cough {Cough}, chills {Chill}, SOB {Dyspnea}, cough {Cough}, yellow sputum {Yellow sputum}, fever {Fever}, febrile {Fever}, O2
sat {Oxygen saturation measurement}, bronchial infection {Infectious disorder of bronchus}, pneumonia {Pneumonia}, COPD
exacerbations {Acute exacerbation of chronic obstructive airways disease}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, VS {Vital signs finding}, UA {Urinalysis}, CXR {Plain chest X-ray}, COPD {Chronic obstructive lung disease}, L apical {Structure of apex of left lung}, nodule {Nodule of lung}, VS {Vital signs finding}, RA {Breathing room air}, fever {Fever}, chills {Chill}, SOB {Dyspnea}, chest tightness {Tight chest}, sore throat {Sore throat}, improved {Patient's condition improved} |
###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:
COPD
MI
Positive PPD
Hyperlipidemia
Arthritis in bilateral hands
Coronary artery disease s/p angioplasty with stent
Bronchiectasis
###RESPONSE: COPD {Chronic obstructive lung disease}, MI {Myocardial infarction}, Positive PPD {Mantoux: positive}, Hyperlipidemia {Hyperlipidemia}, Arthritis in bilateral hands {Arthritis of finger of bilateral hand}, Coronary artery disease {Coronary arteriosclerosis}, angioplasty {Angioplasty of blood vessel}, stent {Insertion of arterial stent}, Bronchiectasis {Bronchiectasis} |
###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:
Father: Cancer
___ Grandmother: ___ - Type II
###RESPONSE: Cancer {Malignant neoplasm} |
###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 - 98.5 119/66 97 22 92% RA
General: Patient is sitting comfortably in bed, friendly and
alert, no acute distress
HEENT: MMM
Neck: Supple, non-tender, no lymphadenopathy appreciated
CV: Clear s1 and s2, irregular rhythm, no murmurs
Lungs: Lungs with decreased breath sounds bilaterally, regular
respiratory rate and effort
Abdomen: Soft, non distended, nontender, bowel sounds present
GU: Deferred
Ext: Warn and well perfused, no edema
Neuro: Patient with tremor of hands and head
Skin: No rashes
DISCHARGE PHYSICAL EXAM
VS - 97.9 118/79 91 18 98% RA
General: Patient is sitting comfortably in bed, friendly and
alert, no acute distress
HEENT: MMM
Neck: Supple, non-tender, no lymphadenopathy appreciated
CV: Regular rate and rhythm, clear s1 and s2, no murmurs
Lungs: Lungs with decreased breath sounds bilaterally, regular
respiratory rate and effort, prolonged expiratory phase
Abdomen: Soft, non distended, nontender, bowel sounds present
GU: Deferred
Ext: Warn and well perfused, no edema
Neuro: Patient with tremor of b/l hands and head
Skin: No rashes
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, sitting {Sitting position}, alert {Mentally alert}, distress {Distress}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, non-tender {Abdominal tenderness}, lymphadenopathy {Lymphadenopathy}, CV {Cardiovascular physical examination}, Clear {Normal breath sounds}, s1 and s2 {Heart sounds normal}, irregular rhythm {Irregular heart beat}, murmurs {Murmur}, Lungs {Examination of respiratory system}, Lungs {Examination of respiratory system}, decreased breath sounds {Decreased breath sounds}, regular
respiratory rate {Respiratory rate normal}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, distended {Swollen abdomen}, nontender {Abdominal tenderness}, bowel sounds present {Normal bowel sounds}, GU {Examination of genitourinary system}, Ext {Examination of limb}, well perfused {Normal tissue perfusion}, edema {Edema}, Neuro {Neurological examination}, tremor {Tremor}, hands {Hand structure}, head {Head structure}, Skin {Examination of skin}, rashes {Eruption of skin}, PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, sitting {Sitting position}, alert {Mentally alert}, distress {Distress}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, non-tender {Abdominal tenderness}, lymphadenopathy {Lymphadenopathy}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, s1 and s2 {Heart sounds normal}, murmurs {Murmur}, Lungs {Examination of respiratory system}, Lungs {Examination of respiratory system}, decreased breath sounds {Decreased breath sounds}, regular
respiratory rate {Respiratory rate normal}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, distended {Swollen abdomen}, nontender {Abdominal tenderness}, bowel sounds present {Normal bowel sounds}, GU {Examination of genitourinary system}, Ext {Examination of limb}, well perfused {Normal tissue perfusion}, edema {Edema}, Neuro {Neurological examination}, tremor {Tremor}, hands {Hand structure}, head {Head structure}, Skin {Examination of skin}, rashes {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:
ADMISSION LABS:
___ 02:36PM BLOOD WBC-8.4 RBC-4.53 Hgb-13.9 Hct-41.0 MCV-91
MCH-30.7 MCHC-33.9 RDW-12.2 Plt ___
___ 02:36PM BLOOD Neuts-79.1* Lymphs-11.3* Monos-7.5
Eos-1.4 Baso-0.7
___ 02:36PM BLOOD Plt ___
___ 02:36PM BLOOD Glucose-159* UreaN-17 Creat-0.6 Na-142
K-3.6 Cl-100 HCO3-32 AnGap-14
IMAGING:
CXR ___
PA and lateral views of the chest. The lungs are hyperinflated.
There is asymmetric left apical pulmonary opacity worrisome for
underlying nodule. Surgical chain sutures seen in the right mid
lung. There is also subtle increased opacity projecting over
the right breast shadow, anteriorly on the lateral view. The
cardiomediastinal silhouette is within normal limits. No acute
osseous abnormality is identified.
IMPRESSION:
Findings compatible with COPD. Subtle asymmetric right basilar
opacity potentially in the middle lobe which could represent
atelectasis or scarring however infection cannot be totally
excluded.
Findings worrisome for left apical pulmonary nodule for which
dedicated nonurgent chest CT is suggested.
DISCHARGE LABS:
___ 07:55AM BLOOD WBC-8.2 RBC-4.80 Hgb-14.7 Hct-43.1 MCV-90
MCH-30.6 MCHC-34.1 RDW-12.2 Plt ___
___ 07:55AM BLOOD Plt ___
___ 07:55AM BLOOD Glucose-113* UreaN-14 Creat-0.6 Na-144
K-4.0 Cl-101 HCO3-30 AnGap-17
MICROBIOLOGY:
___ URINE CULTURES: no growth (final)
___ BLOOD CULTURES: no growth (final)
###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}, 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}, CXR {Plain chest X-ray}, lungs {Lung structure}, hyperinflated {Chest over-expanded}, left apical pulmonary {Structure of apex of left lung}, opacity {Abnormally opaque structure}, nodule {Nodule}, lung {Lung structure}, opacity {Abnormally opaque structure}, right breast {Right breast structure}, shadow {Shadow}, lateral {Diagnostic radiography of chest, lateral}, osseous {Bone structure}, COPD {Chronic obstructive lung disease}, right basilar {Structure of base of right lung}, opacity {Abnormally opaque structure}, middle lobe {Structure of middle lobe of right lung}, atelectasis {Atelectasis}, scarring {Healing scar}, infection {Infectious disease}, left apical {Structure of apex of left lung}, pulmonary nodule {Nodule of lung}, chest CT {Computed tomography of chest}, 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}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap 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:
___ year old woman with a history of COPD, bronchiectasis, CAD
s/p MI with stent, among other medical issues who presented with
shortness of breath and increased cough and sputum production
consistent with her prior COPD flares.
ACTIVE DIAGNOSES:
# COPD exacerbation: Patient presented with symptoms similar to
her prior COPD exacerbations. Cannot exclude infectious etiology
however white count non-elevated, CXR consistent w/COPD.
Throughout the admission the patient has not needed supplemental
O2. She was treated with steroids, azithromycin, and PRN nebs.
Azithromycin was transitioned to doxycycline prior to discharge.
She remained stable with no worsening of symptoms. At time of
discharge, she is able to ambulate safely with a O2 sat in mid
90's. As her symptoms were not progressing and she was
saturating well on room air, we discharged her to follow-up with
PCP for further care. Of note, she asked us to provide her with
home nebulizer machine. We did not feel that was necessary. We
provided her with prescription for MDI plus spacer and urged her
to speak with her PCP if she believes she would benefit from
home nebulizer machine.
# Nausea: Patient complained of some morning nausea, with no
clear etiology. She noted that she would feel better after
eating or having her morning coffee. She received IV zofran PRN
for the nausea. No emesis on this admission. It had resolved by
time of discharge.
CHRONIC DIAGNOSES:
# CAD: Her home medications of metoprolol succinate and aspirin
162 daily were continued continued on this stay. She did not
have any chest pain or symptoms suggestive of cardiac origin for
her shortness of breath or nausea.
# Lung nodule: Patient has known lung nodules which have been
documented on prior CT scan. Nodule found incidentally on CXR,
and per report of location seems that it may be consistent with
location of previously known nodules. We recommended that this
be followed up on an outpatient basis. Radiology recommended a
non-urgent CT, however they may not have been aware that pt
already has known lung lesions being followed by serial CTs. As
above, patient has a significant smoking history.
# Tremor: Pt with resting tremor in b/l hands and head, she has
not noticed it before. Husband has noticed and says it is not
new. Patient was surprised when it was brought up, however it
may be exacerbated by nebs and not as prominent at baseline.
Most likely essential tremor, however we recommend outpatient
follow-up by PCP for further evaluation.
TRANSITIONAL ISSUES:
# We recommend continued outpatient follow-up of lung lesions
# Tremor is likely benign, however may need to be evaluated
further
###RESPONSE: COPD {Chronic obstructive lung disease}, bronchiectasis {Bronchiectasis}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, stent {Insertion of arterial stent}, shortness of breath {Dyspnea}, cough {Cough}, sputum production {Productive cough}, COPD {Chronic obstructive lung disease}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD exacerbations {Acute exacerbation of chronic obstructive airways disease}, infectious {Infectious disease}, CXR {Plain chest X-ray}, COPD {Chronic obstructive lung disease}, stable {Patient's condition stable}, able to ambulate {Able to walk}, O2 sat {Oxygen saturation measurement}, on room air {Breathing room air}, nebulizer {Nebulizer therapy}, nebulizer {Nebulizer therapy}, Nausea {Nausea}, IV {Administration of drug or medicament via intravenous route}, nausea {Nausea}, emesis {Vomiting}, CAD {Coronary arteriosclerosis}, medications {Prescription of drug}, chest pain {Chest pain}, cardiac {Heart structure}, shortness of breath {Dyspnea}, nausea {Nausea}, Lung nodule {Nodule of lung}, lung nodules {Nodule of lung}, CT scan {Computed tomography}, Nodule {Nodule}, CXR {Plain chest X-ray}, nodules {Nodule}, followed up on an outpatient basis {Outpatient care management}, CT {Computed tomography}, lung lesions {Lesion of lung}, CTs {Computed tomography}, smoking {Smoker}, Tremor {Tremor}, resting tremor {Resting tremor}, hands {Hand structure}, head {Head structure}, essential tremor {Essential tremor}, outpatient
follow-up {Outpatient care management}, evaluation {Evaluation procedure}, outpatient follow-up {Outpatient care management}, lung lesions {Lesion of lung}, Tremor {Tremor} |
###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. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
2. Lorazepam 1 mg PO HS:PRN Insomnia
3. ipratropium-albuterol ___ mcg/actuation Inhalation 4 times
daily PRN SOB/wheezing
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation 2 puffs twice daily
7. Aspirin 162 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Medications:
1. PredniSONE 40 mg PO DAILY Duration: 3 Days
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
2. Aspirin 162 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
5. Lorazepam 1 mg PO HS:PRN Insomnia
6. Metoprolol Succinate XL 25 mg PO DAILY
7. ipratropium-albuterol ___ mcg/actuation Inhalation 4 times
daily PRN SOB/wheezing
8. Nitroglycerin SL 0.3 mg SL PRN chest pain
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation 2 puffs twice daily
10. Doxycycline Hyclate 100 mg PO Q12H Duration: 3 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*6 Capsule 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:
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, 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:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
to the hospital for evaluation and management of your COPD
exacerbation, after you presented to your Primary Care Physician
with increased shortness of breath and productive cough. While
here, you were given antibiotics, steroids, and nebulizer
treatments and monitored overnight. You have not needed any
supplemental oxygen, and are walking around without significant
shortness of breath.
As your oxygen levels have been adequate and your symptoms have
not worsened, you are being discharged to continue your recovery
at home. We are discharging you with 3 days of antibiotics and
steroids to continue at home.
Thank you for allowing us to participate in your care.
###RESPONSE: COPD
exacerbation {Acute exacerbation of chronic obstructive airways disease}, shortness of breath {Dyspnea}, productive cough {Productive cough}, antibiotics {Antibiotic therapy}, steroids {Steroid therapy}, nebulizer
treatments {Nebulizer therapy}, shortness of breath {Dyspnea}, antibiotics {Antibiotic therapy}, steroids {Steroid therapy} |
###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:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, 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:
___ h/o HCV cirrhosis s/p OLT ___ who presents with chest
discomfort and ___. Patient states that yesterday (___) he
developed sharp pleuritic type chest pain that was worse with
deep inspiration. He has never had pain like this before. Pain
did not travel. It persisted for at least one day and prompted
him to present to outside hospital. There an EKG was negative
for acute ischemia and initial troponin was reported as
indeterminate near his baseline. Due to elevated creatinine,
patient was unable to undergo CTA and was transferred here.
Patient with history of liver transplant ___ years ago and
infected hardware in the left knee that has been removed several
months ago while he waits for a new knee repair. Currently
anticoagulated with Coumadin for history of PE and atrial
fibrillation. Patient states he does not remember what his prior
PE felt like. In the ED his CP resolved. On arrival to the floor
he complained only of right Knee pain for which he receives high
doses of narcotics at his rehab. He reports pain is ___
currently compared to ___ yesterday, but he will not beable to
sleep with this level of pain.
In the ED, initial vitals were:
98.2 67 123/68 19 99% 2L Nasal Cannula
- Labs were significant for
CBC
5.5 9.7 199
28.6
N:70.5 L:22.1 M:7.1 E:0 Bas:0.___.0 PTT: 37.1 INR: 3.4
Trop-T: 0.13
Chem 7
131 94 72
------------<125
4.4 26 2.2
ALT: 25 AP: 129 Tbili: 0.8 Alb: 3.0
AST: 12
- Imaging revealed
OSH CXR was without consolidation
ECG was Afib with RBBB stable from ___
-The patient was given
0.5 mg IV dilaudid x 1
Vitals prior to transfer were:
97.8 66 136/68 18 98% RA
Upon arrival to the floor,
T 97.8 BP 92/50 p 61 R 18 98% On RA
REVIEW OF SYSTEMS:
(+) Per HPI Of not he has not urinated in 12 hours
(-) Chest paint resolved in ED Denies fever, chills, night
sweats, recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel habits. No dysuria.
###RESPONSE: HCV cirrhosis {Cirrhosis of liver due to chronic hepatitis C}, OLT {Orthotopic transplantation of whole liver}, chest
discomfort {Chest discomfort}, sharp {Sharp pain}, pleuritic {Pleuritic pain}, chest pain {Chest pain}, worse {Increased pain}, pain {Pain}, Pain
did not travel {Radiating chest pain}, EKG {Electrocardiographic procedure}, acute ischemia {Acute myocardial ischemia}, troponin {Troponin measurement}, baseline {Baseline state}, elevated creatinine {Serum creatinine above reference range}, CTA {Computed tomography angiography with contrast}, liver transplant {Transplantation of liver}, left knee {Structure of left knee region}, removed {Removal}, knee repair {Arthroplasty of knee}, anticoagulated with Coumadin {Anticoagulant therapy}, PE {Pulmonary embolism}, atrial
fibrillation {Atrial fibrillation}, PE {Pulmonary embolism}, resolved {Problem resolved}, right Knee {Structure of right knee region}, narcotics {Narcotherapy}, pain {Pain}, pain {Pain}, vitals {Vital signs finding}, Nasal Cannula {Oxygen administration by nasal cannula}, Labs {Laboratory test}, CBC {Complete blood count}, INR {Calculation of international normalized ratio}, Trop {Troponin measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, Imaging {Imaging}, CXR {Plain chest X-ray}, consolidation {Consolidation}, ECG {Electrocardiographic procedure}, Afib {Atrial fibrillation}, RBBB {Electrocardiographic right bundle branch block}, stable {Patient's condition stable}, IV {Intravenous therapy}, RA {Breathing room air}, RA {Breathing room air}, REVIEW OF SYSTEMS {Review of systems}, urinated {Micturition finding}, Chest paint {Chest pain}, resolved {Problem resolved}, fever {Fever}, chills {Chill}, night
sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, headache {Headache}, sinus
tenderness {Tenderness over frontal sinus}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, Denies cough {Does not cough}, shortness of
breath {Dyspnea}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, change in bowel habits {Altered bowel function}, dysuria {Dysuria} |
###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:
1. Hep C Cirrhosis s/p transplant at ___ on ___
-- Discharged from ___, presented to ___ 8 weeks post op for
prolonged hosp stay complicated by encephalopathy (due to
cyclosporine and tacrolimus), transient ischemic attack,
neutropenia, thrombocytopenia, mild acute rejection, acute
kidney injury, hypertension (cyclosporine related), recurrent c.
difficile infection, and lower extremity edema
-- ___: portal vein thrombus with found incidental PE. U/S
of ___ negative for DVT. No anticoag at that time d/t bleeding
risk.
-- ___: Pt admitted to OSH with left ___ DV (fem-pop).
Preceded by episode of imobility from hospitalization for
pneumonia. Pt started on coumadin since this time with INR goal
___.
-- ___: left DVT in the setting of seemingly on
therapeutic anticoagulation with coumadin
-- BM suppression posttransplant: ___ BM Aspirate dyspoiesis
with myeloid and erythroid lineages along with megakaryocytic
hyperplasia
-- Posttransplant skin cancer: scalp lesion/squamous cell
carcinoma, R distal dorsal arm/squamous cell carcinoma, L
chest/basal cell carcinoma (s/p MOHs)
-- pseudogout, knee aspiration, s/p steroid injection
-- ___ edema, started lasix ___
2. H/O Esophageal varices, PVT prior to transplant: Most recent
BI records with ___ EGD without varicies
3. AVNRT s/p ablation in ___
4. Atrial fibrillation: failed CV immed post-tx, on coumadin
5. Melanoma status post excision in 1980s
6. Septic meningitis in ___
7. Osteoarthritis in the knees status post arthroscopy and left
knee replacement c/b septic joint on abx in ___.
8. Aphthous stomatitis
9. Asthma
10. GERD
11. High tibial osteotomy
12. s/p bilaterally cataract extraction
13. s/p Appendectomy
14. C. diff several times (4x) in ___ prior to transplant
15. History of CMV viremia.
16. History of acute rejection of a liver transplant.
###RESPONSE: Hep C Cirrhosis {Cirrhosis of liver due to chronic hepatitis C}, transplant {Transplantation of liver}, post op {Postoperative state}, encephalopathy {Disorder of brain}, transient ischemic attack {Transient ischemic attack}, neutropenia {Neutropenia}, thrombocytopenia {Thrombocytopenic disorder}, mild acute rejection {Acute rejection of liver transplant}, acute
kidney injury {Acute kidney injury}, hypertension {Hypertensive disorder, systemic arterial}, recurrent c.
difficile infection {Recurrent infection caused by Clostridioides difficile}, lower extremity edema {Edema of lower extremity}, portal vein thrombus {Portal vein thrombosis}, PE {Pulmonary embolism}, S {Ultrasonography}, negative {No pathologic diagnosis}, DVT {Deep venous thrombosis}, bleeding
risk {At increased risk of hemorrhage}, imobility {Musculoskeletal immobility}, pneumonia {Pneumonia}, INR {Calculation of international normalized ratio}, DVT {Deep venous thrombosis}, anticoagulation {Anticoagulant therapy}, BM suppression {Myelosuppression}, BM Aspirate {Bone marrow aspiration procedure}, dyspoiesis {Dyserythropoiesis}, megakaryocytic
hyperplasia {Megakaryocytic hyperplasia of bone marrow}, skin cancer {Malignant neoplasm of skin}, scalp lesion {Lesion of scalp}, squamous cell
carcinoma {Squamous cell carcinoma}, R {Right upper arm structure}, dorsal arm {Structure of posterior surface of upper arm}, squamous cell carcinoma {Squamous cell carcinoma of skin}, L
chest {Structure of left half of chest wall}, basal cell carcinoma {Basal cell carcinoma}, MOHs {Mohs surgery}, pseudogout {Chondrocalcinosis due to pyrophosphate crystals}, knee aspiration {Aspiration of knee joint}, steroid injection {Injection of steroid}, edema {Edema}, lasix {Diuretic therapy}, Esophageal varices {Esophageal varices}, PVT {Portal vein thrombosis}, transplant {Transplantation}, EGD {Esophagogastroduodenoscopy}, varicies {Venous varices}, AVNRT {Re-entrant atrioventricular node tachycardia}, ablation {Destructive procedure}, Atrial fibrillation {Atrial fibrillation}, failed CV {Heart failure}, Melanoma {Malignant melanoma of skin}, excision {Excision of melanoma}, Septic meningitis {Infective meningitis}, Osteoarthritis in the knees {Osteoarthritis of knee}, arthroscopy {Arthroscopy of knee joint}, left
knee replacement {Total replacement of left knee joint}, septic joint {Arthritis of knee}, Aphthous stomatitis {Aphthous ulcer of mouth}, Asthma {Asthma}, GERD {Gastroesophageal reflux disease}, tibial osteotomy {Osteotomy of tibia}, bilaterally cataract extraction {Extraction of cataract of bilateral eyes}, Appendectomy {Excision of appendix}, transplant {Transplant of kidney}, CMV viremia {Cytomegalovirus viremia}, acute rejection of a liver transplant {Acute rejection of liver transplant} |
###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:
The patient's father had bilateral lower extremity amputations
but had no clots prior to the surgery. There is no history of
VTE in the family. There is no history of miscarriages in the
family either.
###RESPONSE: bilateral lower extremity amputations {Amputation of bilateral lower limbs}, clots {Blood clot}, surgery {Surgical procedure}, VTE {Thromboembolism of vein}, miscarriages {Miscarriage} |
###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 EXAM:
================
Vitals: T 97.8 BP 92/50 p 61 R 18 98% On RA
General: Alert, oriented, mildly distraught regarding right knee
pain
HEENT: Sclera anicteric, dry oropharynx, EOMI
Neck: Supple
CV: Regular rate and rhythm, ___ SEM at apex
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: obese, soft,
Ext: Cool, pitting edema to sacrum bilaterally, R knee non ttp
but tender to flexion/extension and varous/valgus stress
Neuro: A+Ox3 ___ motor exam limited ___ pain
DISCHARGE EXAM:
================
Vitals: T 97.5, HR 81, BP 179/95, RR 22, SaO2 99% RA
General: Alert, oriented, NAD, chronically ill-appearing
HEENT: Sclera anicteric, oropharynx wnl, MMM, EOMI
Neck: Supple, no JVD
CV: Irregular rhythm, normal rate, no murmurs
Lungs: Limited exam, clear to auscultation anteriorly
Abdomen: +BS, obese, soft, nontender, nondistended
Ext: WWP, ___ pitting edema bilaterally, compression dressings
in place. L knee in brace.
Neuro: Oriented to self, place, and year (not day or month), no
asterixis, ___ motor exam limited ___ pain, sensation to light
touch intact
###RESPONSE: Vitals {Vital signs finding}, BP {Blood pressure finding}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, right knee {Structure of right knee region}, pain {Pain}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, oropharynx {Oropharyngeal structure}, EOMI {Normal ocular motility}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, SEM {Ejection murmur}, apex {Structure of apex of heart}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Abdomen {Examination of abdomen}, obese {Obese abdomen}, soft {Abdomen soft}, Ext {Examination of limb}, Cool {Cool skin}, edema {Edema}, sacrum {Structure of sacral vertebral column}, R knee {Structure of right knee region}, ttp {Tenderness}, tender {Abdominal tenderness}, flexion {Flexion test}, extension {Abnormal extension}, varous/valgus stress {Adduction test of knee}, Neuro {Neurological examination}, Ox3 {Oriented to person, time and place}, motor exam {Motor testing}, pain {Pain}, Vitals {Vital signs finding}, SaO2 {Finding of oxygen saturation}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, NAD {No abnormality detected}, ill-appearing {Looks ill}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, oropharynx {Oropharyngeal structure}, MMM {Moist oral mucosa}, EOMI {Normal ocular motility}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVD {Jugular venous engorgement}, CV {Cardiovascular physical examination}, Irregular rhythm {Irregular heart beat}, normal rate {Normal heart rate}, murmurs {Heart murmur}, Lungs {Examination of respiratory system}, exam {Lung finding}, clear to auscultation {Normal breath sounds}, Abdomen {Examination of abdomen}, +BS {Normal bowel sounds}, obese {Obese abdomen}, soft {Abdomen soft}, nontender {Abdominal tenderness}, nondistended {Normal abdominal contour}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, pitting edema {Pitting edema}, L knee {Structure of left knee region}, Neuro {Neurological examination}, Oriented to self, place, and year {Oriented to person, time and place}, asterixis {Asterixis}, motor exam {Motor testing}, pain {Pain}, sensation to light
touch intact {Light touch sensation present} |
###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:
================
___ 12:20AM BLOOD WBC-5.5 RBC-3.23* Hgb-9.7* Hct-28.6*
MCV-89 MCH-30.2 MCHC-34.1 RDW-16.3* Plt ___
___ 12:20AM BLOOD Neuts-70.5* ___ Monos-7.1 Eos-0
Baso-0.2
___ 12:20AM BLOOD ___ PTT-37.1* ___
___ 12:20AM BLOOD Plt ___
___ 12:20AM BLOOD Glucose-125* UreaN-72* Creat-2.2* Na-131*
K-4.4 Cl-94* HCO3-26 AnGap-15
___ 12:20AM BLOOD ALT-25 AST-12 AlkPhos-129 TotBili-0.8
___ 12:20AM BLOOD CK-MB-1 cTropnT-0.13*
___ 05:40AM BLOOD CK-MB-1 cTropnT-0.14*
___ 09:45AM BLOOD CK-MB-2 cTropnT-0.15*
___ 12:20AM BLOOD Albumin-3.0*
___ 05:40AM BLOOD Albumin-3.0* Calcium-9.1 Phos-4.1 Mg-1.6
___ 05:40AM BLOOD Osmolal-300
___ 05:40AM BLOOD Cyclspr-80*
___ 02:46PM URINE Color-LtAmb Appear-SlHazy Sp ___
___ 02:46PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 02:46PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 02:46PM URINE CastHy-8*
___ 02:46PM URINE Mucous-OCC
___ 02:46PM URINE Hours-RANDOM Creat-139 Na-15 K-63 Cl-<10
___ 02:46PM URINE Osmolal-369
OTHER PERTINENT LABS:
======================
___ 05:45AM BLOOD Cyclspr-157
___ 08:00AM BLOOD Cyclspr-114
___ 05:35AM BLOOD Cyclspr-140
___ 08:55AM BLOOD Cyclspr-339
___ 04:47AM BLOOD Cyclspr-77*
___ 05:40AM BLOOD Cyclspr-86*
___ 05:24AM BLOOD Cyclspr-81*
___ 06:40AM BLOOD Cyclspr-82*
DISCHARGE LABS:
================
___ 05:40AM BLOOD WBC-4.5 RBC-3.08* Hgb-9.1* Hct-27.4*
MCV-89 MCH-29.5 MCHC-33.1 RDW-15.6* Plt ___
___ 05:40AM BLOOD ___ PTT-36.1 ___
___ 05:40AM BLOOD Glucose-121* UreaN-57* Creat-2.1* Na-130*
K-4.3 Cl-91* HCO3-33* AnGap-10
___ 05:40AM BLOOD ALT-12 AST-9 AlkPhos-133* TotBili-0.8
___ 05:40AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.7
MICROBIOLOGY:
==============
___ 11:48 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ 2:46 pm URINE Source: Catheter.
URINE CULTURE (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
=========
TTE (___):
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
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. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___,
the degree of MR seen has decreased. AS is not appreciated.
CXR (___):
There is a right-sided PICC line terminating in the mid SVC.
Patient rotation contributes to exaggeration of the cardiac
size, which is likely normal. Segmental atelectasis is noted,
particular in the right lung, although there does appear to be
new pulmonary edema superimposed on this. There may be small
tiny effusions. There is no pneumothorax.
Renal U/S (___):
IMPRESSION:
1. No evidence of hydronephrosis.
2. Extremely limited Doppler evaluation due to technically
limited study,
demonstrating both kidneys to be vascularized. No further
Dopp;er analysis could be obtained.
###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}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, 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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, Albumin {Albumin measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Nitrite {Nitrite measurement}, Protein {Measurement of protein in urine}, Glucose {Glucose measurement, urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, URINE {Urinalysis}, RBC {Red blood cell count}, WBC {White blood cell count}, Bacteri {Bacteriuria}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, URINE {Urinalysis}, 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}, 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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, URINE {Urine culture}, URINE CULTURE {Urine culture}, SENSITIVITIES {Antimicrobial susceptibility test}, URINE {Urine culture}, URINE CULTURE {Urine culture}, Blood Culture {Blood culture}, left atrium is elongated {Left atrial enlargement}, right atrium is moderately
dilated {Right atrial dilatation}, atrial septal defect {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, normal
cavity {Normal size cardiac chamber}, regional/global systolic function {Normal left ventricular systolic function and wall motion}, ventricular septal defect {Ventricular septal defect}, Right ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Normal ventricular wall motion}, aorta at
the sinus {Structure of sinus of Valsalva}, ascending {Ascending aorta structure}, arch {Aortic arch structure}, normal {Normal appearance}, aortic
valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, Mild (1+) aortic regurgitation {Mild mitral valve regurgitation}, mitral
valve leaflets are mildly thickened {Thickened mitral leaflet}, Mild (1+) mitral
regurgitation {Mild mitral valve regurgitation}, tricuspid valve leaflets {Structure of leaflet of tricuspid valve}, pulmonary artery systolic hypertension {Pulmonary hypertensive arterial disease}, pericardial effusion {Pericardial effusion}, echocardiographic {Echocardiography}, signs {Sign}, tamponade {Cardiac tamponade}, MR {Mitral valve regurgitation}, PICC line {Peripherally inserted central venous catheter in situ}, SVC {Superior vena cava structure}, cardiac {Heart structure}, normal {Normal appearance}, atelectasis {Atelectasis}, right lung {Right lung structure}, pulmonary edema {Pulmonary edema}, effusions {Pleural effusion}, pneumothorax {Pneumothorax}, No evidence {No abnormality detected}, hydronephrosis {Hydronephrosis}, evaluation {Evaluation procedure}, both kidneys {Both kidneys} |
###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 ___ gentleman with HCV cirrhosis ___ years
s/p OLD and h/o DVT and PE (on Coumadin) who was transferred
from an OSH with chest pain, which resolved on admission, but
found to have supratherapeutic INR and ___.
# Acute on chronic kidney disease: Cr up to 2.2 on admission
from baseline of 1.4-1.5. Cr rose to 2.7 after albumin/IVF
boluses. Muddy brown casts were seen on urine sediment. Per
renal, multiple hypotensive episodes and bradycardia likely
resulted in ATN. Patient's creatinine slowly improved after
starting diuretics. Cr on discharge was 2.1. Kidney function
is expected to recover with time.
# Anasarca: Patient was grossly anasarcic after being volume
resuscitated with albumin for hypotension. TTE was largely
unchanged. Patient was diuresed with 40-80 mg IV Lasix/day and
his edema improved. He was discharged on torsemide 40 mg po
daily.
# Hepatitis C cirrhosis s/p OLT: Transplanted in ___, on
cyclosporine 75 mg q12h. MMF was stopped in clinic in
___ and LFTs remained normal. HCV VL 342,000 IU/mL on
___. Last biopsy was performed at previous admission
revealed Grade ___ inflammation, no acute cellular rejection, no
steatosis or ballooning, and stage ___ fibrosis. Atovaquone
was continued for prophylaxis. Cyclosporine was decreased to 50
mg q12h and levels were monitored.
# Supratherapeutic INR: Patient's Coumadin was held on
admission for supratherapeutic INR. He received vitamin K for
INR 5.2 and INR then became subtherapeutic. Warfarin was
restarted with a heparin gtt until INR became therapeutic. INR
became supratherapeutic again and Coumadin dose was adjusted.
INR on discharge was 3.6. He was discharged on Coumadin 1 mg
daily.
# Hypertension: Patient was initially hypotensive and losartan
and diuretics were held. He received an albumin bolus with
improvement in his blood pressure. He then became hypertensive
during the latter part of his hospitalization (SBP up to
170/180s). Losartan continued to be held given ___. Patient
was started on amlodipine 5 mg daily, which can be uptitrated as
needed.
# Prior left knee infection s/p hardware removal in ___:
Patient has chronic pain related to his previous knee
infection/hardware removal. He also has shallow venous stasis
ulcers on bilateral lower extremities. Patient's orthopedic
surgeon plans to replace his knee hardware once his ulcers have
healed and his leg swelling has resolved. Patient's pain was
well-controlled on home Oxycontin and po Dilaudid. He became
confused after receiving IV Dilaudid, so this was avoided.
# Catheter-associated UTI: Initial urine culture was negative.
Repeat urine culture after catheter was placed grew >100,000
Klebsiella sensitive to ceftriaxone. Foley was exchanged and
patient completed a 7 day course of ceftriaxone. Foley was
removed prior to discharge.
# Chest Pain: Patient had chest pain at OSH, which resolved on
admission here. No ischemic changes on EKG and three sets of
cardiac enzymes were negative. Considered PE, especially given
h/o prior PE, but patient had been therapeutic on Coumadin. CTA
was deferred given ___.
# Atrial fibrillation/pauses: Not on agents for rate or rhythm
control. During last admission (___), patient was
bradycardic at night with ___ second pauses seen on telemetry.
Patient continued to have pauses with HR ___, though rates
improved to ___ without intervention. It is unclear if these
pauses are contributing to hypotensive episodes. Patient is
followed by Dr. ___ have further outpatient EP
evaluation if warranted.
# Hyponatremia: Na persistently low (as low as 130s), which is
chronic per review of prior discharge summaries. Hyponatremia
neither responded to nor worsened with albumin or diuretics.
TRANSITIONAL ISSUES:
=====================
[ ] Please check labs (CBC, CMP, LFTs, cyclosporine level, INR,
and PTT) on ___. Send labs to the ___ at ___
___.
[ ] INR 3.6 on discharge. Please hold Coumadin on ___.
Restart Coumadin at 1 mg daily on ___. Recheck INR on
___. Goal INR 2.0-3.0
[ ] Patient was started on torsemide 40 mg daily for leg edema.
This should be decreased/discontinued if kidney function
worsens.
[ ] Losartan held given ___. Amlodipine 5 mg daily started for
hypertension. Uptitrate to 10 mg daily as needed for blood
pressure.
[ ] Cyclosporine dose decreased from 75 mg q12h to 50 mg q12h.
[ ] Patient is followed by Dr. ___. Consider further
evaluation of bradycardia/pauses if indicated (note: bradycardia
improved, pauses persisted)
[ ] Patient will have follow-up scheduled with orthopedics and
neurology (for pre-op clearance, per ortho). Ortho plans to
replace his left knee after venous stasis ulcers have healed and
after lower extremity swelling has resolved.
[ ] PICC kept in place given need for frequent lab draws.
# Code: Full (confirmed)
# Emergency contact/HCP: ___ (wife) ___
###RESPONSE: HCV cirrhosis {Cirrhosis of liver due to chronic hepatitis C}, OLD {Orthotopic liver transplant}, DVT {Deep venous thrombosis}, PE {Pulmonary embolism}, chest pain {Chest pain}, resolved {Problem resolved}, INR {Calculation of international normalized ratio}, Acute on chronic kidney disease {Acute-on-chronic renal failure}, Cr {Finding of creatinine level}, baseline {Baseline state}, Cr {Finding of creatinine level}, albumin {Administration of albumin}, IVF {Administration of intravenous fluids}, casts {Cast}, hypotensive episodes {Hypotensive episode}, bradycardia {Bradycardia}, ATN {Acute tubular necrosis}, creatinine {Creatinine measurement}, improved {Patient's condition improved}, diuretics {Diuretic therapy}, Cr {Finding of creatinine level}, Kidney function {Renal function monitoring}, Anasarca {Anasarca}, anasarcic {Anasarca}, resuscitated {Resuscitation}, albumin {Administration of albumin}, hypotension {Low blood pressure}, TTE {Transthoracic echocardiography}, diuresed {Diuretic therapy}, edema {Edema}, improved {Patient's condition improved}, Hepatitis C cirrhosis {Cirrhosis of liver due to chronic hepatitis C}, OLT {Orthotopic transplantation of whole liver}, Transplanted {Transplantation of liver}, LFTs {Hepatic function panel}, HCV {Viral hepatitis type C}, VL {Viral load}, biopsy {Biopsy}, inflammation {Inflammatory disorder}, acute cellular rejection {Acute cellular graft rejection}, steatosis {Steatosis}, fibrosis {Fibrosis}, prophylaxis {Preventive procedure}, monitored {Monitoring procedure}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, Warfarin {Warfarin therapy}, restarted {Restart of medication}, heparin {Heparin therapy}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, Hypertension {Hypertensive disorder, systemic arterial}, hypotensive {Low blood pressure}, diuretics {Diuretic therapy}, albumin {Administration of albumin}, improvement {Patient's condition improved}, blood pressure {Blood pressure finding}, hypertensive {Hypertensive disorder, systemic arterial}, SBP {Increased systolic arterial pressure}, left knee {Structure of left knee region}, infection {Infectious disease}, hardware removal {Removal of device}, chronic pain {Chronic pain}, knee {Structure of left knee region}, infection {Infectious disease}, hardware removal {Removal of device}, venous stasis
ulcers on bilateral lower extremities {Venous ulcer of lower limb}, knee {Structure of left knee region}, ulcers {Ulcer}, leg swelling {Leg swelling symptom}, resolved {Problem resolved}, pain was
well-controlled {Demonstrates adequate pain control}, confused {Clouded consciousness}, IV {Intravenous therapy}, Catheter-associated UTI {Urinary tract infection associated with catheter}, urine culture was negative {Urine culture - no growth}, urine culture {Urine culture}, catheter was placed {Catheterization}, Foley {Catheterization of urinary bladder}, exchanged {Replacement procedure}, Foley was
removed {Removal of urinary bladder catheter}, Chest Pain {Chest pain}, chest pain {Chest pain}, resolved {Problem resolved}, No ischemic changes {Electrocardiogram: no myocardial ischemia}, EKG {Electrocardiographic procedure}, cardiac enzymes were negative {Cardiac enzymes within reference range}, PE {Pulmonary embolism}, PE {Pulmonary embolism}, CTA {Computed tomography angiography with contrast}, Atrial fibrillation {Atrial fibrillation}, rate {Finding of heart rate}, rhythm {Normal sinus rhythm}, bradycardic {Bradycardia}, pauses {Heart block}, telemetry {Cardiac telemetry}, pauses {Heart block}, HR {Finding of heart rate}, rates {Finding of heart rate}, improved {Patient's condition improved}, hypotensive episodes {Hypotensive episode}, EP {Cardiac electrophysiology}, evaluation {Evaluation procedure}, Hyponatremia {Hyponatremia}, chronic {Chronic disease}, Hyponatremia {Hyponatremia}, worsened {Patient's condition worsened}, albumin {Administration of albumin}, diuretics {Diuretic therapy}, CBC {Complete blood count}, LFTs {Hepatic function panel}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, hold {Recommendation to stop drug treatment}, Restart {Restart of medication}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, leg edema {Edema of lower leg}, discontinued {Recommendation to stop drug treatment}, kidney function
worsens {Decreased renal function}, hypertension {Hypertensive disorder, systemic arterial}, evaluation {Evaluation procedure}, bradycardia {Bradycardia}, pauses {Heart block}, bradycardia {Bradycardia}, improved {Patient's condition improved}, pauses {Heart block}, follow-up {Follow-up arranged}, left knee {Structure of left knee region}, venous stasis ulcers {Venous ulcer of lower limb}, lower extremity swelling {Swelling of lower limb}, resolved {Problem resolved}, PICC {Peripherally inserted central venous catheter in situ} |
###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. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atovaquone Suspension 1500 mg PO DAILY
3. Bisacodyl ___AILY:PRN constipation
4. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
5. Fluoxetine 20 mg PO DAILY
6. Gabapentin 200 mg PO TID
7. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain
8. Losartan Potassium 25 mg PO DAILY
9. Omeprazole 40 mg PO BID
10. Ranitidine 75 mg PO BID:PRN heartburn
11. Senna 17.2 mg PO QHS
12. Vitamin D ___ UNIT PO DAILY
13. Warfarin 2.5 mg PO DAILY16
14. Lactulose 30 mL PO TID
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
BID
17. Ferrous Sulfate 325 mg PO DAILY
18. Polyethylene Glycol 17 g PO EVERY OTHER DAY
19. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
20. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atovaquone Suspension 1500 mg PO DAILY
3. Bisacodyl ___AILY:PRN constipation
4. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluoxetine 20 mg PO DAILY
7. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain
RX *hydromorphone 4 mg 1 tablet(s) by mouth q6h prn Disp #*10
Tablet Refills:*0
8. Lactulose 30 mL PO QID
9. Omeprazole 40 mg PO BID
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Polyethylene Glycol 17 g PO EVERY OTHER DAY
12. Ranitidine 75 mg PO BID:PRN heartburn
13. Senna 17.2 mg PO QHS
14. Vitamin D ___ UNIT PO DAILY
15. Warfarin 1 mg PO DAILY16
16. Amlodipine 5 mg PO DAILY
17. Torsemide 40 mg PO DAILY
18. Lidocaine 5% Patch 1 PTCH TD QAM
19. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
BID
20. OxyCONTIN (oxyCODONE) 10 mg oral Q12H
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*10 Tablet 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:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
Acute on chronic kidney disease
SECONDARY DIAGNOSES:
=====================
Hypertension
Catheter-associated urinary tract infection
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: Acute on chronic kidney disease {Acute-on-chronic renal failure}, Hypertension {Hypertensive disorder, systemic arterial}, Catheter-associated urinary tract infection {Urinary tract infection associated with catheter}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, 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. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted because your kidney function was abnormal. This
was likely due to damage to your kidneys from intermittently
having low blood pressure. Your kidney function slowly
recovered and will hopefully continue to improve. You were
given medications to remove fluid from your legs. After your
leg swelling resolves and your leg ulcers heal, the orthopedic
surgeons will replace your knee. Your blood pressure became
high, so you were started on a new medication to help with this.
It is very important that you continue to take your medications
as prescribed and keep your follow-up appointments.
We wish you good health!
Sincerely,
Your ___ Team
###RESPONSE: kidney function {Renal function monitoring}, damage {Damage}, kidneys {Kidney structure}, low blood pressure {Low blood pressure}, kidney function {Renal function monitoring}, medications {Patient medication education}, legs {Lower limb structure}, leg swelling {Leg swelling symptom}, resolves {Problem resolved}, leg ulcers {Ulcer of lower extremity}, replace your knee {Arthroplasty of knee}, blood pressure became
high {Hypertensive disorder, systemic arterial}, new medication {New medication commenced}, take your medications
as prescribed {Patient medication education} |
###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: 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:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
needs heparin bridge
Major Surgical or Invasive Procedure:
___ right premolar extraction
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, right {Structure of right half of lower jaw region}, premolar {Structure of premolar tooth}, extraction {Tooth extraction} |
###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:
Ms. ___ is a ___ ___ lady with AFib, MV
stenosis s/p mechanical MV replacement ___ on Warfarin (INR
goal 2.5-3.5), severe tricuspid regurgitation, chronic
right-sided heart failure (EF 50%), with congestive hepatopathy
and ascites, severe pulmonary hypertension, and CAD s/p CABG
___ who has had ongoing tooth pain and requires a dental
procedure so she is admitted for Heparin bridge in anticipation
of the procedure.
She has been having tooth pain for weeks. Pain is located in
right pre-molar. She denies fevers and has not been on any
antibiotics. She went to the dentist as an outpatient who
stated that she will need dental extraction (right pre-molar
tooth) but was unable to perform this in the setting of
mechanical valve. She told this with her HCA PCP ___
___ who discussed with her Cardiologist (___) who
recommended IV heparin bridging prior to dental procedure. She
is a direct admit to the Medicine floor.
On arrival to the floor, she feels at her baseline with pain of
right pre-molar tooth.
Review of sytems:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
###RESPONSE: AFib {Atrial fibrillation}, MV
stenosis {Mitral valve stenosis}, mechanical MV replacement {Mechanical prosthetic mitral valve replacement}, severe tricuspid regurgitation {Severe tricuspid valve regurgitation}, chronic
right-sided heart failure {Chronic right-sided heart failure}, hepatopathy {Disorder of liver}, ascites {Ascites}, severe pulmonary hypertension {Severe pulmonary hypertension}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, tooth pain {Toothache}, dental
procedure {Dental surgical procedure}, procedure {Procedure}, tooth {Structure of dentition}, pain {Pain}, Pain {Pain}, right {Structure of right half of lower jaw region}, pre-molar {Structure of premolar tooth}, fevers {Fever}, antibiotics {Antibiotic therapy}, dental extraction {Tooth extraction}, right {Structure of right half of lower jaw region}, pre-molar
tooth {Structure of premolar tooth}, dental procedure {Dental surgical procedure}, pain {Pain}, right {Structure of right half of lower jaw region}, pre-molar tooth {Structure of premolar tooth}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, headache {Headache}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, sore throat {Sore throat}, cough {Cough}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, BRBPR {Hematochezia}, melena {Melena}, hematochezia {Hematochezia}, dysuria {Dysuria}, hematuria {Blood in urine} |
###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:
1. CARDIAC RISK FACTORS:
Diabetes
2. CARDIAC HISTORY:
1.) Severe right heart failure: As of ___,
well-compensated NYHA ___, secondary to rheumatic fever as a
child. Complicated by congestive hepatopathy and cirrhosis.
2.) Severe pulmonary hypertension
3.) "Wide open," severe tricuspid regurgitation since MVR
___.
Status post-mitral valve
4.) Mechanical mitral valve repair ___ (and ___ per Pt) for
mitral stenosis (from rheumatic fever), on warfarin chronically
5.) Preserved EF
6.) CAD s/p CABG ___
7.) Atrial fibrillation, on warfarin. Bilaterally enlarged
atria.
-CABG: ___
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
OTHER PAST MEDICAL HISTORY:
1. Crystal-proven gout.
2. Osteoarthritis of the knees.
3. Osteoarthritis of the hands.
4. Right rotator tendinopathy, resolved.
5. Cirrhosis, secondary to chronic passive liver congestion:
with ascites
6. Diabetes mellitus: Insulin-dependent, type II, complicated
by neuropathy
7. Anxiety
8. Varicose veins (extensive).
9. GERD
###RESPONSE: CARDIAC RISK FACTORS {Assessment for risk of cardiovascular disease}, Diabetes {Diabetes mellitus}, CARDIAC {Heart structure}, right heart failure {Right ventricular failure}, rheumatic fever {Rheumatic fever}, hepatopathy {Disorder of liver}, cirrhosis {Cirrhosis of liver}, Severe pulmonary hypertension {Severe pulmonary hypertension}, severe tricuspid regurgitation {Severe tricuspid valve regurgitation}, MVR {Replacement of mitral valve}, mitral valve {Mitral valve structure}, Mechanical mitral valve repair {Mechanical prosthetic mitral valve replacement}, mitral stenosis {Mitral valve stenosis}, rheumatic fever {Rheumatic fever}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, Atrial fibrillation {Atrial fibrillation}, Bilaterally enlarged
atria {Bilateral enlargement of atria}, CABG {Coronary artery bypass grafting}, PERCUTANEOUS CORONARY INTERVENTIONS {Percutaneous coronary intervention}, gout {Inflammatory disorder due to increased blood urate level}, Osteoarthritis of the knees {Osteoarthritis of knee}, Osteoarthritis of the hands {Degenerative joint disease of hand}, Right rotator tendinopathy {Tendinitis of right rotator cuff}, Cirrhosis {Cirrhosis of liver}, liver congestion {Cardiac cirrhosis}, ascites {Ascites}, Diabetes mellitus {Diabetes mellitus type 2}, neuropathy {Neuropathy}, Anxiety {Anxiety}, Varicose veins {Venous varices}, 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 |
###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:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
###RESPONSE: MI {Myocardial infarction}, arrhythmia {Cardiac arrhythmia}, cardiomyopathies {Cardiomyopathy}, sudden cardiac death {Sudden cardiac death} |
###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 EXAM
Vitals - 98.2, 135/77, 68, 98%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, dentures of lower teeth on, pain of
right pre-molar, no erythema/exudate appreciated
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Irregular, diastolic murmur RUSB
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
___- significant vericose veins b/l ___, 2+ pulses, no clubbing,
cyanosis or edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM
Vitals - 97.___.2 129/54(120s-130s/50s), 70, 98%RA
GEN - Alert, oriented, no acute distress
HEENT - Right lower pre molar extracted, sutures observed, no
active signs of bleeding. Pain well controlled. No
erythema/exudate appreciated, no jaw pain, no difficulty
opening/closing mouth
NECK - supple, JVP elevated 5cm, no LAD
LUNGS - Clear to auscultation bilaterally, no wheezes, or
crackles
CV - Irregular, diastolic murmur RUSB/LSB
ABD - unchanged. soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- no foley
___ - unchanged. significant vericose veins b/l ___, 2+ pulses,
no clubbing, cyanosis or edema
Neuro- CNs2-12 intact, motor function grossly normal. lucid.
ambulating on own.
###RESPONSE: Vitals {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, teeth {Structure of dentition}, pain {Pain}, right {Structure of right half of lower jaw region}, pre-molar {Structure of premolar tooth}, erythema {Erythema}, exudate {Exudate}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, ronchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, Irregular {Irregular heart beat}, murmur {Murmur}, Abdomen- soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, vericose veins {Venous varices}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, CNs2-12 intact {Normal nervous system function}, motor function grossly normal {Normal motor response to command}, Vitals {Vital signs finding}, RA {Breathing room air}, GEN {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Right lower {Structure of right half of lower jaw region}, signs {Sign}, bleeding {Bleeding}, Pain well controlled {Demonstrates adequate pain control}, erythema {Erythema}, exudate {Exudate}, pain {Pain}, closing mouth {Difficulty closing mouth}, supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, LAD {Lymphadenopathy}, LUNGS {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, crackles {Respiratory crackles}, CV {Cardiovascular physical examination}, Irregular {Irregular heart beat}, murmur {Murmur}, ABD {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds
present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, vericose veins {Venous varices}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, CNs2-12 intact {Normal nervous system function}, motor function grossly normal {Normal motor response to command}, lucid {Lucid} |
###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
___ 10:02PM BLOOD WBC-7.0 RBC-3.57* Hgb-11.4* Hct-33.4*
MCV-94# MCH-31.9 MCHC-34.0 RDW-14.8 Plt ___
___ 11:47AM BLOOD ___
___ 06:00AM BLOOD Glucose-153* UreaN-50* Creat-1.5* Na-133
K-4.2 Cl-91* HCO3-33* AnGap-13
___ 06:00AM BLOOD Calcium-9.7 Phos-3.4 Mg-2.3
DISCHARGE LABS
___ 07:15AM BLOOD WBC-6.7 RBC-3.78* Hgb-12.0 Hct-34.8*
MCV-92 MCH-31.7 MCHC-34.4 RDW-14.6 Plt ___
___ 07:15AM BLOOD ___ PTT-91.1* ___
___ 06:48AM BLOOD Glucose-138* UreaN-46* Creat-1.4* Na-132*
K-4.4 Cl-88* HCO3-32 AnGap-16
___ 06:48AM BLOOD Calcium-9.8 Phos-4.2 Mg-2.4
INR TREND
___ 11:47AM BLOOD ___
___ 06:00AM BLOOD ___ PTT-150* ___
___ 07:00AM BLOOD ___ PTT-61.8* ___
___ 06:00AM BLOOD ___ PTT-58.5* ___
___ 12:43AM BLOOD ___ PTT-77.4* ___
___ 06:48AM BLOOD ___ PTT-90.5* ___
___ 07:15AM BLOOD ___ PTT-91.1* ___
___ (PANOREX FOR DENTAL) - unread
Pathology ReportTissue: Tooth # 28.Procedure Date of ___
Report not finalized.
Assigned Pathologist ___.
Please contact the pathology department, ___ ___
PATHOLOGY # ___
Tooth # 28.
###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}, 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}, 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}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, Tooth {Structure of dentition}, Tooth {Structure of dentition} |
###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:
Sra. ___ is a ___ ___ lady with AFib, MV
stenosis s/p mechanical MV replacement ___ on Warfarin (INR
goal 2.5-3.5), severe tricuspid regurgitation, chronic
right-sided heart failure (EF 50%), with congestive hepatopathy
and ascites, severe pulmonary hypertension, and CAD s/p CABG
___ who had ongoing tooth pain as an outpatient. She was
directly admitted to Medicine for Heparin bridge while her INR
was allowed to drift downwards in order to undergo tooth
extraction. She underwent uncomplicated single extraction of
tooth #28 on ___ and then remained in house on a Heparin drip
until her INR was therapeutic again, and then she was discharged
home.
## DENTAL INFECTION & PAIN: resolved s/p extraction.
No signs or symptoms of severe infection. OMFS performed
uncomplicated single extraction of tooth #28 on ___, with
pre-operative Unasyn. No bleeding complications. The procedure
was done in the OR but only under local anesthesia. Sutures
will dissolve. She will follow up with her dentist or OMFS, as
she prefers.
## MECHANICAL MV REPLACEMENT: on Warfarin, goal INR 2.5-3.5.
As soon as she was directly admitted to the Medicine floor, she
was placed on Heparin gtt and her Warfarin was held. She was
therapeutic for the duration of her admission, except for
stopping the drip 6 hrs pre-procedure. It was able to be
re-started immediately post-operatively, and she was restarted
on her Warfarin post-operatively as well. Heparin gtt was
stopped and she was discharged when her INR was >2.5. Home
Warfarin dose was not changed; she will f/u tomorrow at ___
___ clinic for INR check.
- 5mg given ___ mg given ___ (INR in am = 1.9)
- 7.5 mg give ___ (INR in am = 2.3)
- Discharged ___ (INR in am = 3.0), please take 5 mg at home
## CHF: stable issue, euvolemic.
Her tricuspid regurgitation is severe and moderate pulmonary
hypertension; she was euvolemic on exam. She was continued on
her home meds (torsemide, metoprolol, hctz, spironolactone).
## HYPONa: asymptomatic, stable.
Na 133 on admission. Euvolemic on exam. Baseline Na appears to
be 133-140. She remains on HCTZ, Torsemide, Spironolactone
which could be contributing. Na was stable at 132 on the day of
discharge.
## DM 2: stable.
She was continued on her home Lantus 60mg QHS. She initially
declined the proposed sliding scale (she felt that she would
drop too low since she was NPO for the procedure) and was
subsequently hyperglycemic in the 200's-300's. When her family
brought in her home sliding scale, it was entered and she
complied, with much better blood glucose control. She did not
have any hypoglycemia during this admission.
## GOUT/OA: stable.
She was continued on Febuxostat and low-dose Prednisone.
## TRANSITIONAL ISSUES
Emergency Contact: ______
Studies/labs pending at discharge:
--Panorex was viewed/interpreted by ___ so no Radiology read
pending
--Extracted tooth pathology
###RESPONSE: AFib {Atrial fibrillation}, MV
stenosis {Mitral valve stenosis}, mechanical MV replacement {Mechanical prosthetic mitral valve replacement}, severe tricuspid regurgitation {Severe tricuspid valve regurgitation}, chronic
right-sided heart failure {Chronic right-sided heart failure}, congestive hepatopathy {Cardiac cirrhosis}, ascites {Ascites}, severe pulmonary hypertension {Severe pulmonary hypertension}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, tooth pain {Toothache}, tooth
extraction {Tooth extraction}, single extraction of
tooth {Extraction of single tooth}, DENTAL INFECTION {Infection of tooth}, PAIN {Pain}, extraction {Tooth extraction}, signs {Sign}, infection {Infectious disease}, single extraction of tooth {Extraction of single tooth}, bleeding {Bleeding}, procedure {Procedure}, under local anesthesia {Under local anesthesia}, MECHANICAL MV REPLACEMENT {Mechanical prosthetic mitral valve replacement}, CHF {Congestive heart failure}, stable {Patient's condition stable}, tricuspid regurgitation {Tricuspid valve regurgitation}, moderate pulmonary
hypertension {Moderate pulmonary hypertension}, HYPONa {Hyponatremia}, asymptomatic {Asymptomatic}, Baseline {Baseline state}, DM 2 {Diabetes mellitus type 2}, stable {Patient's condition stable}, procedure {Procedure}, blood glucose {Glucose measurement, blood}, hypoglycemia {Hypoglycemia}, GOUT {Inflammatory disorder due to increased blood urate level}, OA {Osteoarthritis}, stable {Patient's condition stable}, Extracted tooth {Tooth extraction} |
###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:
1. Febuxostat 80 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Potassium Chloride 10 mEq PO BID
6. PredniSONE 5 mg PO DAILY
7. Spironolactone 50 mg PO DAILY
8. Torsemide 150 mg PO DAILY
9. Warfarin ___ mg PO DAILY (AS DIRECTED BY ___
___ CLINIC)
10. Glargine 60 Units Bedtime
Insulin SC Sliding Scale using HUMALOG Insulin
Discharge Medications:
1. Febuxostat 80 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Potassium Chloride 10 mEq PO BID
6. PredniSONE 5 mg PO DAILY
7. Spironolactone 50 mg PO DAILY
8. Torsemide 150 mg PO DAILY
9. Warfarin ___ mg PO DAILY (AS DIRECTED BY ___
___ CLINIC)
10. Glargine 60 Units Bedtime
Insulin SC Sliding Scale using HUMALOG Insulin
###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:
- Tooth extraction
- INR maintenance and Heparin Bridge
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Tooth extraction {Tooth extraction}, 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:
Dear. Ms. ___,
Thank you for choosing ___. You were
admitted for extraction of your right premolar tooth and
management of your Warfarin/INR during this procedure. Your
Home INR(International Normalized Ratio) goal is 2.5 - 3.5 given
your mechanical mitral valve. Your Warfarin was stopped the day
before the procedure, and Heparin was started to maintain
anticoagulation. The oral and maxillofacial surgeons (___)
performed the extraction in an operating room while Heparin was
off. The operation was successful and there was minimal
bleeding. Sutures were left in the location of the former
tooth, and these sutures will dissolve on their own. The ___
team suggests you follow up with them, or your home Dentist.
The ___ phone number is ___ if you wish to follow up
with them.
After the procedure your Heparin was continued and Warfarin was
restarted to reach your INR goal of 2.5. On the day of
discharge your INR = 3.0.
POST PROCEDURE RECOMMENDATIONS:
- Pain control with Tylenol
- Soft diet
- Maintain meticulous oral hygiene
- Rinse your mouth with Over the counter product called
"Peridex" twice/day
- No straws, vigorous rinsing, spitting
MEDICATIONS:
WARFARIN:
- 5mg given ___ mg given ___ (INR in am = 1.9)
- 7.5 mg give ___ (INR in am = 2.3)
- Discharged ___ (INR in am = 3.0), please take 5 mg at home
Continue other medications normally
###RESPONSE: extraction {Extraction}, premolar tooth {Structure of premolar tooth}, procedure {Procedure}, mechanical mitral valve {Metal mitral valve prosthesis in situ}, procedure {Procedure}, anticoagulation {Anticoagulant therapy}, extraction {Extraction}, bleeding {Bleeding}, tooth {Structure of dentition}, procedure {Procedure}, Pain control {Pain control}, Soft diet {Soft diet}, oral hygiene {Mouth care} |
###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:
Change in mental status and fever
Major Surgical or Invasive Procedure:
None
###RESPONSE: Change in mental status {Altered mental status}, fever {Fever} |
###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:
___ yo M with recent diagnosis of gastric CA s/p total
gastrectomy of the Roux-en-Y reconstruction and feeding
jejunostomy with known anastamosis site ulcer and h/o aspiration
admitted with change in mental status and fever. Patient has
been feeling poorly since he was discharged home from the
hospital about 3 weeks ago. The patient has been following up
closely with his PCP who added ___ fentanyl patch and zofran to
help with pain and nausea. The patient went home and had 2 very
good days. On the third day he was a bit out of it but stable
and then on the fourth day he fell out of his chair and was
disoriented. He presented to the ED ___ and was treated for a
change in MS felt likely ___ oversedation with opiates. A CXR
was sent which showed atelectasis but no infiltrate. He was
taken off the oxycodone and fentanyl patch and sent home.
On the day of admission his wife noted his temp to be 102 and
thought his MS had not improved very much so she called his pcp.
In office temp was 96, patient was noted to have increased cough
and sputum. His PCP sent him here for workup of mental status
change and fever.
On presentation he did not complain of pain just a diffuse
malaise. He reports a cough and wretching with nausea that is
responsive to zofran. He does not report SOB, chest pain,
abdominal pain, or calf pain. He reports feeling hot off and on
at homebut normally temp runs ___ except for the one at ___
yesterday. He reports feeling a bit dehydrated but not dizzy or
light-headed. N one at home is sick and he has not traveled
anywhere recently.
###RESPONSE: gastric CA {Malignant tumor of stomach}, total
gastrectomy {Total gastrectomy}, Roux-en-Y reconstruction {Total gastrectomy and anastomosis of esophagus to transposed jejunum}, feeding
jejunostomy {Feeding enterostomy of jejunum}, anastamosis site ulcer {Ulcer of anastomosis}, aspiration {Pulmonary aspiration}, change in mental status {Altered mental status}, fever {Fever}, pain {Pain}, nausea {Nausea}, stable {Patient's condition stable}, disoriented {Disorientated}, MS {Altered mental status}, CXR {Plain chest X-ray}, atelectasis {Atelectasis}, infiltrate {Infiltration}, temp {Body temperature finding}, MS {Altered mental status}, improved {Patient's condition improved}, temp {Body temperature finding}, cough {Cough}, sputum {Sputum finding}, workup {Evaluation procedure}, mental status {Neurological mental status determination}, fever {Fever}, pain {Pain}, malaise {Malaise}, cough {Cough}, nausea {Nausea}, SOB {Dyspnea}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, calf pain {Pain in calf}, temp {Body temperature finding}, dehydrated {Dehydration}, dizzy {Dizziness} |
###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:
Per OMR:
HTN
Osteoarthritis of L knee and R shoulder - s/p TKR ___
Tonsillectomy
Appendectomy
Bilateral cataract excision.
###RESPONSE: Osteoarthritis of L knee {Osteoarthritis of left knee joint}, R shoulder {Osteoarthritis of joint of right shoulder region}, TKR {Total knee replacement}, Tonsillectomy {Tonsillectomy}, Appendectomy {Excision of appendix}, Bilateral cataract excision {Extraction of cataract of bilateral eyes} |
###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 notable for a son who died of lung cancer.
###RESPONSE: died {Dead}, lung cancer {Malignant tumor of lung} |
###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: t 95.6 BP 141/61 HR 80 RR 16 O2sat 95% RA
GEN: Cachectic elderly M in NAD
HEENT: NC/AT No scleral icterus. MMM
NECK: No JVD. No LAD
LUNGS: Crackles ___ way up
HEART: RRR S1/S2 No M/R/G
ABD: Incision site without erythema, dehiscence, or discharge.
Well-healed. Feeding tube in place with dressing
clean/dry/intact and just replaced today by PCP. +BS. NT/ND. NO
HSM
EXTREM: No cyanosis, clubbing, edema
NEURO: Alert. Oriented X 3. CN ___ in tact.
###RESPONSE: VITALS {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2sat {Oxygen saturation measurement}, RA {Breathing room air}, GEN {General examination of patient}, Cachectic {Cachexia}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, scleral icterus {Scleral icterus}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, LUNGS {Examination of respiratory system}, Crackles {Respiratory crackles}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, No M/R/G {Heart sounds normal}, ABD {Examination of abdomen}, Incision site {Surgical incision wound}, erythema {Erythema}, dehiscence {Dehiscence}, Well-healed {Wound healed}, +BS {Normal bowel sounds}, NT {Abdominal tenderness}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, EXTREM {Examination of limb}, cyanosis {Cyanosis}, clubbing {Clubbing}, edema {Edema}, NEURO {Neurological examination}, Alert {Mentally alert}, Oriented X 3 {Oriented to person, time and place}, CN {Cranial nerve 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:
___ 12:30PM WBC-13.0* RBC-3.72* HGB-11.2* HCT-33.8*
MCV-91 MCH-30.2 MCHC-33.2 RDW-15.5
___ 12:30PM NEUTS-87.0* LYMPHS-6.2* MONOS-6.5 EOS-0.3
BASOS-0.1
___ 12:30PM PLT COUNT-268
___ 12:30PM UREA N-17 CREAT-0.7 SODIUM-135 POTASSIUM-4.4
CHLORIDE-93* TOTAL CO2-33* ANION GAP-13
___ 03:35PM ___ PTT-32.4 ___
___ 03:35PM ALBUMIN-3.4 CALCIUM-9.0 PHOSPHATE-3.2
MAGNESIUM-1.9
___ 03:35PM ALT(SGPT)-18 AST(SGOT)-19 LD(LDH)-166 ALK
PHOS-71 TOT BILI-0.___XR: Pneumonia in the superior segment of the left lower lobe.
Results
communicated with Dr. ___ at 2:20 p.m.
CT HEAD: No acute intracranial abnormality.
Assessment/Plan:
___ yo M with recent diagnosis of gastric CA s/p total
gastrectomy of the Roux-en-Y reconstruction and feeding
jejunostomy admitted with fever and inc cough productive of
yellow sputum ___ PNA.
.
#. PNA: Patient with likely aspiration PNA. Clindmycin 300mg Q8H
and then switched to levofloxacin which would cover both the PNA
and the UTI. Blood cultures were pending at time of discharge
and will be followed up by Dr. ___.
.
#. UTI: Urine culture showed E.Coli. Sensitivities are pending
at time of discharge. He will be treated with Levofloxacin for 5
days with your last dose on ___.
.
#. Aspiration: Speech and swallow saw him and said nectar thick
liquids and pureed foods are ok but no medications PO. Refused
video swallow to eval for silent aspiration as cause of PNA.
Will go home on nectar thick liquids and pureed foods and have
repeat swallow exam as outpatient when can tolerate barium.
.
#. Pain: Controlled with tylenol standing, fentanyl patch, and
dilaudid PRN for pain while in house.
.
#.Nausea: Exacerbated by constipation and increased rate of tube
feedings. Responds well to Zofran and compazine. Will go home
with scripts for this. Tube feeding goal rate was decreased to
70mL/hour to help him tolerate this and still get sufficient
caloric intake daily.
.
#. Anemia: Patient was noted to have a low hematocrit. Iron
studies suggest anemia of chronic disease. Patient will follow
up with his pcp regarding treatment and monitoring of this.
.
#. HTN: Patient had HTN while admitted. Started on previous dose
of metoprolol 12.5mg BID with good effect. Will continue as
outpatient.
.
#. FEN:Nutrtion recommened replete with fiber at 70mL/hour for
24hours daily. He will follow up for further recommendations
with the nutrition clinic at ___ as an outpatient.
.
#. Prophylaxis: SC Heparin and PNeumoboots
.
#. Communication: With patient and dtr
.
#. Dispo: Full Code .
###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}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, PTT {Partial thromboplastin time, activated}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, TOT BILI {Bilirubin, total measurement}, Pneumonia {Pneumonia}, left lower lobe {Structure of lower lobe of left lung}, intracranial {Intracranial structure}, abnormality {No abnormality detected}, gastric CA {Malignant tumor of stomach}, total
gastrectomy {Total gastrectomy}, Roux-en-Y reconstruction {Total gastrectomy and anastomosis of esophagus to transposed jejunum}, feeding
jejunostomy {Feeding enterostomy of jejunum}, fever {Fever}, cough productive of
yellow sputum {Productive cough-yellow sputum}, PNA {Pneumonia}, PNA {Pneumonia}, aspiration PNA {Aspiration pneumonia}, PNA {Pneumonia}, UTI {Urinary tract infectious disease}, Blood cultures {Blood culture}, UTI {Urinary tract infectious disease}, Urine culture {Urine culture}, E.Coli {Infection caused by Escherichia coli}, Sensitivities {Antimicrobial susceptibility test}, Aspiration {Aspiration}, nectar thick
liquids {Dietary liquid consistency - nectar thick liquid}, video swallow {Videofluoroscopy swallow}, aspiration {Pulmonary aspiration}, PNA {Pneumonia}, nectar thick liquids {Dietary liquid consistency - nectar thick liquid}, swallow exam {Fiberoptic endoscopic evaluation of swallowing}, Pain {Pain}, pain {Pain}, Nausea {Nausea}, constipation {Constipation}, tube
feedings {Tube feeding of patient}, Tube feeding {Tube feeding of patient}, Anemia {Anemia}, low hematocrit {Hematocrit below reference range}, anemia of chronic disease {Anemia of chronic disorder}, HTN {Hypertensive disorder, systemic arterial}, HTN {Hypertensive disorder, systemic arterial}, FEN {Nutrition management}, Prophylaxis {Preventive 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:
Alternagel 1 tsp QID
Dilaudid-5 1 mg Q6H PRN
Atenolol 25mg PGT daily
Zofran 4mg Q6H
Lorazepam 0.5mg Per NG BID
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Please take through the feeding tube.
Disp:*30 Tablet(s)* Refills:*2*
2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: Please take through the feeding tube.
Disp:*30 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours): Please take through the feeding tube.
4. Lidocaine HCl 4 % Solution Sig: ___ MLs Mucous membrane Q6H
(every 6 hours).
Disp:*500 mL* Refills:*2*
5. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*5 Patch 72 hr(s)* Refills:*2*
6. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q4H
(every 4 hours): Please do not take if you are having diarrhea.
___ mL* Refills:*2*
7. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) g
PO DAILY (Daily) as needed: Please do not take if you are having
diarrhea.
Disp:*500 grams* Refills:*0*
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for for sleep.
9. Prochlorperazine Edisylate 5 mg/5 mL Syrup Sig: Ten (10) mg
PO every six (6) hours as needed for nausea.
Disp:*60 ml* Refills:*1*
10. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
12. Jevity Plus Liquid Sig: Seventy (70) ml/hr PO once a
day: Please increase tube feedings to 70mL/hour continuously for
24hours daily.
Disp:*30 cans* Refills:*2*
13. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): Last dose on ___.
Disp:*5 Tablet(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 With Service
Facility:
___
Discharge Diagnosis:
Aspiration PNA
Constipation
Discharge Condition:
The patient was afebrile, normotensive, not tachycaric, and
having normal bowel movements when he was discharged.
###RESPONSE: Aspiration PNA {Aspiration pneumonia}, Constipation {Constipation}, afebrile {Fever}, normotensive {Normal blood pressure}, tachycaric {Tachycardia} |
###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 have been admitted with pneumonia. you have been treated
with antibiotics for this infection. You should continue the
antibiotics at home as outlined below.
You have also had constipation leading to nausea while you were
here. You should go home on stool softeners and laxatives as
outlined below. For the nausea you should take the anti-nausea
medicines you have at home.
You were also started on a low dose patch for your pain. You
should continue this patch and take dilaudid for breakthrough
pain only.
You have been given a swallowing evaluation that shows that you
are stil having a little bit of difficult swallowing. You should
only eat nectar thick liquids and soft solids. Pills should be
taken through your feeding tube.
You had high blood pressures while you were hospitalized. You
were re-started on your metoprolol and your blood pressures were
more controlled. You should continue this as an outpatient.
Medication changes:
CHANGE Fentanyl Patch 25mg every 72 hours to Fentanyl Patch
12.5mg every 72 hours
START: Clindamycin 300mg through feeding tube every 6 hours.
Last dose on ___
START: Compazine 5mg through feeding tube every 6 hours as
needed for nausea
START: Lactulose 60mL through feeding tube four times daily
START: Polyethylene glycol 17g through feeding tube daily.
START: Benzonatate 100mg through feeding tube every 8 hours as
needed for cough.
START: Metoprolol 12.5mg via the feeding tube 2 times daily.
You should call your PCP or come back to the ED if you have
fevers, shortness of breath, chest pain, severe abdominal pain,
severe nausea/vomiting, bright red blood in your stools or
tarry-looking stools.
###RESPONSE: pneumonia {Pneumonia}, treated
with antibiotics {Antibiotic therapy}, antibiotics {Antibiotic therapy}, constipation {Constipation}, nausea {Nausea}, stool softeners {Administration of laxative}, nausea {Nausea}, pain {Pain}, breakthrough
pain {Breakthrough pain}, nectar thick liquids {Dietary liquid consistency - nectar thick liquid}, high blood pressures {Hypertensive disorder, systemic arterial} |
###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:
Lipitor / Simvastatin / Megestrol
Attending: ___.
Chief Complaint:
abdominal distension
Major Surgical or Invasive Procedure:
Paracentesis
###RESPONSE: Lipitor {Allergy to atorvastatin}, Simvastatin {Allergy to simvastatin}, Megestrol {Allergy to megestrol}, abdominal distension {Swollen abdomen}, Paracentesis {Centesis} |
###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:
Mr. ___ is a ___ year old man with h/o gastric ca, s/p
gastrectomy in ___, s/p 4 cycles ECX, cycle 1 CapOx in ___,
now with diffuse omental caking and malignant ascites, who is
being admitted with worsening abdominal distension, with plan
for ___ guided paracentesis.
The patient had a therapeutic paracentesis last week with some
improvement in abdominal fullness. However, he has noted
increasing abdominal fullness over the past few days, associated
with abdominal pain typically in the evenings. He was seen in
the ED yesterday and discharged home with plan for ___
paracentesis today. Otherwise, the patient is feeling ok. His
wife notes that he has had increasing nausea, not relieved with
Zofran, but Ativan helped yesterday. He also has mild shortness
of breath with exertion, but is still able to make it up 3
flights of stairs to their apartment.
ROS: No fevers, chills, chest pain, cough, headache, dysuria. No
BM in a week, not taking in much PO; on TPN at home.
###RESPONSE: gastric ca {Malignant tumor of stomach}, gastrectomy {Excision of stomach structure}, omental {Omentum structure}, malignant ascites {Malignant ascites}, abdominal distension {Swollen abdomen}, paracentesis {Centesis}, paracentesis {Centesis}, abdominal fullness {Abdominal distension symptom}, abdominal fullness {Abdominal distension symptom}, abdominal pain {Abdominal pain}, paracentesis {Centesis}, nausea {Nausea}, mild {Symptom mild}, shortness
of breath with exertion {Dyspnea on exertion}, fevers {Fever}, chills {Chill}, chest pain {Chest pain}, cough {Cough}, headache {Headache}, dysuria {Dysuria}, on TPN {Total parenteral nutrition} |
###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:
- p/w dysphagia
- EGD demonstrated a mass in the cardia of the stomach and
biopsy was consistent with poorly differentiated adenocarcinoma
with focal signet ring features.
- by EUS, he was staged as T3 with no evidence of invasion into
the thoracic aorta pericardium or pleura
- PET CT scan demonstrated a focus of avidity in the region of a
gastroesophageal junction, likely corresponding to the known
carcinoma and no evidence of distant metastatic disease was
identified.
- ___, underwent total gastrectomy - Pathology from that
procedure revealed a 6 x 6 x 1.5cm adenocarcinoma, diffuse type,
poorly differentiated with invasion into the serosa/visceral
peritoneum.
- ___ lymph nodes were positive out of 18 examined lymph nodes.
The proximal margin was involved by invasive carcinoma and he
did have lymphatic invasion.
- diagnosed with stage IIIC gastric cancer.
- Started on ___ with adjuvant ECX - received 4 cycles -
last treatment given on ___.
- Metastatic disease noted in ___ and C1D1
Oxaliplatin/capecitabine started on ___
Other
###RESPONSE: dysphagia {Dysphagia}, EGD {Esophagogastroduodenoscopy}, mass {Mass}, cardia {Cardia structure}, stomach {Stomach structure}, biopsy {Biopsy}, adenocarcinoma {Adenocarcinoma}, no evidence of invasion {No tumor invasion}, thoracic aorta {Thoracic aorta structure}, pericardium {Pericardial structure}, pleura {Pleural membrane structure}, PET {Positron emission tomography}, CT scan {Computed tomography of abdomen}, gastroesophageal junction {Cardioesophageal junction structure}, carcinoma {Carcinoma}, metastatic disease {Metastatic malignant neoplasm}, total gastrectomy {Total gastrectomy}, procedure {Procedure}, adenocarcinoma, diffuse type {Carcinoma, diffuse type}, serosa {Serous membrane structure}, lymph nodes {Structure of lymph node}, lymph nodes {Structure of lymph node}, carcinoma {Carcinoma}, lymphatic {Structure of lymphatic vessel}, gastric cancer {Malignant tumor of stomach}, Metastatic disease {Metastatic malignant neoplasm} |
###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:
HLD
Chronic pruritis, unknown etiology
Tonsillectomy and Adenoidectomy
Hydrocele repair
Ex-lap ___
Open chole
Meniscus surgery in ___
Cataract surgery in ___
Removal of a large colonic polyp on ___
###RESPONSE: HLD {Hyperlipidemia}, Chronic {Chronic disease}, Tonsillectomy and Adenoidectomy {Tonsillectomy and adenoidectomy}, Hydrocele repair {Repair of hydrocele}, Meniscus surgery {Operation on meniscus of the knee}, Cataract surgery {Cataract surgery}, Removal {Removal}, colonic polyp {Polyp of colon} |
###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:
His mother died at age ___ from a brain hemorrhage and then had a
kidney removed. Father had high blood pressure and died at ___ of
a stroke. Sister had cancer and died at ___. A sister had a
stroke and died at ___. He has another sister with no medical
problems and a brother had early stage lung cancer who is alive
at age ___.
###RESPONSE: died {Dead}, brain {Brain structure}, hemorrhage {Hemorrhage}, kidney {Kidney structure}, high blood pressure {Hypertensive disorder, systemic arterial}, died {Dead}, stroke {Cerebrovascular accident}, cancer {Malignant neoplasm}, died {Dead}, stroke {Cerebrovascular accident}, died {Dead}, problems {Problem}, lung cancer {Malignant tumor of lung}, alive {Alive} |
###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 EXAM:
VS: T 96.5 BP 118/78 HR 95 RR 18 O2sat 97%RA
GEN: AOx3, NAD, cachectic appearing
HEENT: MMM. no LAD. no JVD. neck supple.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, diffusely tender in abdomen, mildly distended
with +fluid wave, no rebound/guarding, no HSM
Extremities: wwp, no edema. DPs, PTs 2+.
Neuro: AOx3, no focal deficits
DISCHARGE EXAM:
Less fullness on abdominal exam, otherwise unchanged
###RESPONSE: VS {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, GEN {General examination of patient}, AOx3 {Oriented to person, time and place}, NAD {No abnormality detected}, cachectic {Cachexia}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, supple {Normal movement of neck}, RR {Finding of rate of respiration}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, Pulm {Examination of respiratory system}, dullness to percussion {Dullness to percussion over Traube's space}, CTAB {Normal breath sounds}, crackles {Respiratory crackles}, wheezes {Wheezing}, Abd {Examination of abdomen}, BS+ {Normal bowel sounds}, soft {Abdomen soft}, tender {Abdominal tenderness}, distended {Swollen abdomen}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, HSM {Hepatosplenomegaly}, Extremities {Examination of limb}, wwp {Normal tissue perfusion}, edema {Edema}, Neuro {Neurological examination}, AOx3 {Oriented to person, time and place}, no focal deficits {Normal nervous system function}, abdominal exam {Examination of abdomen} |
###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:
___ 09:45AM BLOOD WBC-13.7* RBC-3.91* Hgb-11.6* Hct-33.1*
MCV-85 MCH-29.7 MCHC-35.1* RDW-15.2 Plt ___
___ 09:45AM BLOOD Neuts-82.3* Lymphs-9.7* Monos-6.0 Eos-1.8
Baso-0.3
___ 09:45AM BLOOD ___ PTT-25.7 ___
___ 09:45AM BLOOD Glucose-177* UreaN-30* Creat-0.7 Na-132*
K-5.7* Cl-100 HCO3-24 AnGap-14
___ 01:09PM BLOOD K-4.4
STUDIES:
___ U/S guided paracentesis:
1. Small volume ascites.
2. Given the patient's pressure symptoms, 1.1 liters of fluid
was drained via a right flank approach.
###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}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, 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}, K {Blood potassium measurement}, U/S guided paracentesis {Puncture and aspiration of abdomen using ultrasonographic guidance}, ascites {Ascites}, fluid
was drained {Drainage of abdomen}, flank {Flank 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: Brief Hospital Course:
Mr. ___ is a ___ year old man with h/o gastric ca, s/p
gastrectomy in ___, s/p 4 cycles ECX, cycle 1 CapOx in ___,
now with diffuse omental caking and malignant ascites, admitted
for U/S-guided therapeutic paracentesis for abdominal
distension.
#. Abdominal distension: Initially thought to be due to
increasing ascites. However, only 1L removed from paracentesis
with little improvement in symptoms. Abdominal fullness likely
also related to constipation, as the patient did not have a
bowel movement for almost 10 days prior to admission. He was
given a dose of Lactulose, as well as an enema, and had a
successful bowel movement prior to discharge. He was started on
Lactulose, Colace, and Senna.
###RESPONSE: gastric ca {Malignant tumor of stomach}, gastrectomy {Excision of stomach structure}, omental {Omentum structure}, malignant ascites {Malignant ascites}, U/S-guided therapeutic paracentesis {Puncture and aspiration of abdomen using ultrasonographic guidance}, abdominal
distension {Swollen abdomen}, Abdominal distension {Swollen abdomen}, ascites {Ascites}, paracentesis {Centesis}, Abdominal fullness {Abdominal distension symptom}, constipation {Constipation}, did not have a
bowel movement {Constipation}, enema {Giving patient an enema}, bowel movement {Does defecate} |
###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:
Vitamin B12 1000mcg IM qmonth
Lidocaine-Prilocaine cream for port access
Lorazepam 0.5mg PO q6h prn
Zofran 8mg PO q8h prn
Oxycontin 10mg PO BID
Oxycodone ___ PO q4-6h prn
Maalox ___ PO prn
Terbinafine 1% cream BID to rash
Lidoderm TD daily
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea, anxiety.
Disp:*30 Tablet(s)* Refills:*0*
2. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
three times a day as needed for constipation.
Disp:*500 mL* Refills:*0*
3. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
4. insulin regular human 100 unit/mL Solution Sig: sliding scale
Injection four times a day: ___ 151-200: 2units
___ 201-250: 4units
___ 251-300: 6units
___ 301-350: 8units
___ 351-400: 10units.
5. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
6. oxycodone 5 mg/5 mL Solution Sig: ___ mg PO Q6H (every 6
hours) as needed for pain.
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
Fifteen (15) ML PO QID (4 times a day) as needed for
indigestion.
8. terbinafine 1 % Cream Sig: One (1) Appl Topical BID (2 times
a day).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
Subsets and Splits