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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: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Mother, healthy.
Father, treated for colon cancer in the past.
No other malignancies in the family which he is aware.
###RESPONSE: colon cancer {Malignant neoplasm of colon}, malignancies {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:
EXAM ON ADMISSION
General: NAD
VITAL SIGNS: 98 132/70 85 18 98 ra
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly, colostomy
bag in palce with minimal formed brown stool, suprapubic
catheter in place, purulent material noted around site of entry
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities
EXAM ON DISCHARGE
###RESPONSE: General {General examination of patient}, NAD {No abnormality detected}, VITAL SIGNS {Vital signs finding}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, OP {Oropharyngeal structure}, lesions {Lesion}, cervical {Cervical lymphadenopathy}, supraclavicular {Supraclavicular lymphadenopathy}, axillary {Axillary lymph node structure}, adenopathy {Lymphadenopathy}, thyromegaly {Goiter}, CV {Cardiovascular physical examination}, RR {Finding of rate of respiration}, S2 {Normal second heart sound, S>2<}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, ABD {Examination of abdomen}, BS {Normal bowel sounds}, soft {Abdomen soft}, ND {Swollen abdomen}, masses {Abdominal mass}, hepatosplenomegaly {Hepatosplenomegaly}, colostomy {Colostomy}, stool {Stool finding}, suprapubic
catheter in place {Suprapubic urinary catheter in situ}, purulent {Purulent}, LIMBS {Examination of limb}, edema {Edema}, clubbing {Clubbing}, tremors {Tremor}, asterixis {Asterixis}, inguinal
adenopathy {Inguinal lymphadenopathy}, SKIN {Examination of skin}, rashes {Eruption of skin}, skin breakdown {Broken skin}, NEURO {Neurological examination}, Cranial nerves II {Optic nerve structure}, XII {Hypoglossal nerve structure}, visual acuity {Visual acuity finding}, nystagmus {Nystagmus}, upper {Upper limb structure}, lower extremities {Lower limb 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:
ADMISSION LABS
___ 09:20PM BLOOD WBC-10.3# RBC-4.14* Hgb-13.3* Hct-40.0
MCV-97 MCH-32.3* MCHC-33.4 RDW-20.1* Plt ___
___ 09:20PM BLOOD Neuts-86.4* Lymphs-6.7* Monos-6.4 Eos-0.3
Baso-0.1
___ 09:20PM BLOOD Glucose-136* UreaN-16 Creat-0.6 Na-131*
K-7.0* Cl-97 HCO3-25 AnGap-16
___ 09:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:00PM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 09:00PM URINE RBC-117* WBC-132* Bacteri-MOD Yeast-NONE
Epi-0
INTERVAL STUDIES
___ KUB
Nonobstructive bowel gas pattern
DISCHARGE LABS
###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}, 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}, URINE {Urinalysis}, Color {Color finding}, URINE Blood {Blood in urine}, Protein {Measurement of protein in 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}, KUB {Radiography of kidney-ureter-bladder}, Nonobstructive {Obstruction}, bowel gas pattern {Finding of gastrointestinal tract gas} |
###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:
___ is a ___ year old man with stage IV rectal cancer with
extensive pelvic nodal involvement, who is receiving palliative
CAPOX, admitted to ___ with UTI.
# Complicated UTI: patient presented with blocked suprapubic
catheter, which was exchanged and is now draining well. His pain
is better but found to have grossly positive UA consistent with
UTI. He was never febrile. No prior culture data at ___.
Creatinine stable at 0.5-0.6 range. Started on CTX, pending
culture data for tailored antibiotics. Urine culture was
polymicrobial, so he was switched to cefpodoxime to complete 10
days on discharge.
# Rectal Cancer: Patient stable on regimen of CAPOX. Currently
C6D8
- touch base with Dr. ___, as ___ need to continue
capecitabine 1500 mg PO Q12H until C6D14 (ordered by oncology
attending).
# CAD: stable - continued home ASA 81 mg.
###RESPONSE: stage IV {Clinical stage IV}, rectal cancer {Malignant tumor of rectum}, pelvic nodal {Pelvic lymphadenopathy}, CAPOX {Chemotherapy}, UTI {Urinary tract infectious disease}, UTI {Urinary tract infectious disease}, blocked suprapubic
catheter {Obstruction of suprapubic catheter}, exchanged {Change of cystostomy tube}, pain {Abdominal pain}, UA {Urinalysis}, UTI {Urinary tract infectious disease}, febrile {Fever}, culture {Microbial culture}, Creatinine {Creatinine measurement}, CTX {Contraction of uterus during labor}, culture {Microbial culture}, antibiotics {Antibiotic therapy}, Urine culture {Urine culture}, Rectal Cancer {Malignant tumor of rectum}, stable {Patient's condition stable}, regimen {Therapeutic regimen}, CAPOX {Chemotherapy}, CAD {Coronary arteriosclerosis}, stable {Patient's condition stable} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Capecitabine 1500 mg PO Q12
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 9 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*36 Tablet Refills:*0
4. Capecitabine 1500 mg PO Q12
###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 diagnoses: occluded suprapubic catheter, UTI
Secondary diagnoses: stage IV rectal cancer, hyperlipidemia,
cataracts, lymphadenopathy (supraclavicular, mediastinal, RP,
pelvic sidewall, iliac, cervical); pelvic lymphadenopathy
causing lower extremity swelling
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: occluded suprapubic catheter {Obstruction of suprapubic catheter}, UTI {Urinary tract infectious disease}, stage IV {Clinical stage IV}, rectal cancer {Malignant tumor of rectum}, hyperlipidemia {Hyperlipidemia}, cataracts {Cataract}, lymphadenopathy {Lymphadenopathy}, supraclavicular {Supraclavicular lymphadenopathy}, mediastinal {Mediastinal lymphadenopathy}, RP {Retroperitoneal lymphadenopathy}, pelvic {Pelvic lymphadenopathy}, iliac {Iliac lymphadenopathy}, cervical {Cervical lymphadenopathy}, pelvic lymphadenopathy {Pelvic lymphadenopathy}, lower extremity swelling {Swelling of lower limb}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for a clogged suprapubic
catheter and a urinary tract infection. Your catheter was
exchanged and you were treated for your urinary tract infection
with IV antibiotics while in house. Lab data returned and showed
which antibiotics your infection is susceptible to. We switched
you to oral antibiotics to complete at home.
We wish you a very speedy recovery! It was a pleasure caring for
you.
- Your team at ___
###RESPONSE: clogged suprapubic
catheter {Obstruction of suprapubic catheter}, urinary tract infection {Urinary tract infectious disease}, catheter was
exchanged {Change of cystostomy tube}, urinary tract infection {Urinary tract infectious disease}, IV antibiotics {Intravenous antibiotic therapy}, antibiotics {Antibiotic therapy}, infection {Infectious disease}, oral antibiotics {Oral antibiotic 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: NEUROSURGERY
###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:
pituitary adenoma
Major Surgical or Invasive Procedure:
___ Transphenoidal resection of tumor
###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, pituitary adenoma {Pituitary adenoma}, Transphenoidal resection of tumor {Transsphenoidal total excision of neoplasm of pituitary gland} |
###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 male with a hitory of a prior
transphenoidal resection on ___ at ___ by Dr. ___.
His cystic pituitary mass was originally found incidentally in
___, after he had imaging for a complaint of tinnitus. He now
presents for a re-resection of the pituitary lesion. The initial
pathology from ___ was adenoma.
###RESPONSE: transphenoidal resection {Transsphenoidal total excision of neoplasm of pituitary gland}, pituitary mass {Mass of pituitary}, tinnitus {Tinnitus}, resection of the pituitary lesion {Transsphenoidal total excision of neoplasm of pituitary gland}, pathology {Abnormal histology findings}, adenoma {Benign pituitary adenoma} |
###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:
transsphenoidal resection ___, polyp s/p lap,
and hypothyroidism
###RESPONSE: transsphenoidal resection {Transsphenoidal total excision of neoplasm of pituitary gland}, polyp {Polyp}, hypothyroidism {Hypothyroidism} |
###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:
Exam on Admission
Neural intact. Visual fields full.
On Discharge:
A&Ox3
PERRL
visual fields intact
No pronator drift
No leaking from nose when sitting up and leaning forward
Motor: ___ throughout
###RESPONSE: Neural {Neurological examination}, Visual fields full {Normal visual field}, Ox3 {Oriented to person, time and place}, PERRL {Pupils equal and reacting to light}, visual fields intact {Normal visual field}, pronator drift {Downward drift of outstretched supinated arm}, leaking {Discharge}, nose {Nasal structure}, sitting {Sitting position}, Motor {Motor testing} |
###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:
CT HEAD W/O CONTRAST ___
Status post transsphenoidal resection of pituitary lesion with
expected
postoperative changes. No evidence of pneumocephalus or
intracranial
hemorrhage.
###RESPONSE: AST {Aspartate aminotransferase measurement}, Status post {Postoperative state}, transsphenoidal resection of pituitary lesion {Transsphenoidal total excision of neoplasm of pituitary gland}, postoperative {Postoperative state}, No evidence {No abnormality detected}, pneumocephalus {Pneumocephalus}, intracranial
hemorrhage {Intracranial hemorrhage} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Mr. ___ was taken to the operating room on the day of
admission on ___ and underwent a transphenoidal resection of a
pituitary lesion. He tolerated the procedure well and was
extubated in the operating room. He was transferred to the Neuro
ICU post-operatively. Nasal packing was left in place
post-operatively and he was started on antibiotics for the
duration of the packing placement. He underwent a post-operative
non-contrast head CT which showed post-operative changes. His
diet as advanced as tolerated. His visual fields, as well as
urine and serum labs were routinely monitored.
On ___ Mr ___ remained in the PACU. He was completely
neurologically intact. Vitals remained stable and he was
ambulatory out of bed to chair. Transfer orders pending and
awaiting transfer to floor.
On ___, patient had two hours of increase urine output, urine
specific gravity and serum Na which were normal. Endocrine
evaluated the patient who recommended starting him on 40mg QAM
and 20mg QPM hydrocortisone today and decreasing to 20mg QAM and
10mg QPM tomorrow. They were not concerned with his output and
recommended discharge home. On exam, no drainage from the nose
or salty taste at the back of the throat. He was ambulating and
eating appropriately. He was discharge home and will be contact
for further follow up with endocrinology.
###RESPONSE: transphenoidal resection of a
pituitary lesion {Transsphenoidal total excision of neoplasm of pituitary gland}, procedure {Surgical procedure}, extubated {Removal of endotracheal tube}, Neuro {Neurology service}, ICU {Patient transfer to intensive care unit}, post-operatively {Postoperative state}, Nasal packing {Packing of nasal cavity and nasopharynx}, post-operatively {Postoperative state}, antibiotics {Antibiotic therapy}, packing {Packing of wound}, post-operative {Postoperative state}, non-contrast head CT {Computed tomography of head without contrast}, post-operative {Postoperative state}, diet {Dietary finding}, visual fields {Visual field study}, urine {Evaluation of urine specimen}, serum labs {Blood test}, monitored {Monitoring procedure}, PACU {Postanesthesia care}, neurologically intact {Normal nervous system function}, Vitals remained stable {Normal vital signs}, increase urine output {Increased urine output}, urine
specific gravity {Urine specific gravity within reference range}, serum Na which were normal {Serum sodium level within reference range}, drainage from the nose {Nasal discharge}, throat {Structure of anterior portion of neck}, ambulating {Fully mobile}, follow up {Follow-up arranged} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
c
abergoline,fluocinonide,levothyroxine,simvastatin,Cialis,aspirin
81, VITAMIN D2,multivitamin tablet
Discharge Medications:
1. Hydrocortisone 20 mg PO REFER TO OTHER INSTRUCTIONS
please take 40mg QAM on ___ and 20mg QPM on ___, then 20mg QAM
and 10mg QPM until follow up.
RX *hydrocortisone 20 mg 1 tablet(s) by mouth refer to other
instructions Disp #*60 Tablet Refills:*1
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth DAILY Disp #*60
Capsule Refills:*1
4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*50 Tablet Refills:*0
5. Simvastatin 10 mg PO QPM
6. Vitamin D 1400 UNIT PO DAILY
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*1
###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:
pituitary adenoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: pituitary adenoma {Pituitary adenoma}, Mental Status {Neurological mental status determination}, Clear {No abnormality detected}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
¨Take your pain medicine as prescribed.
¨Exercise should be limited to walking; no lifting, straining,
or excessive bending.
¨Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
¨Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
¨Clearance to drive and return to work will be addressed at
your post-operative office visit.
¨Continue Sinus Precautions for an additional two weeks. This
means, no use of straws, forceful blowing of your nose, or use
of your incentive spirometer.
¨If you have been discharged on Prednisone, take it daily as
prescribed.
¨If you are required to take Prednisone, an oral steroid, make
sure you are taking a medication to protect your stomach
(Prilosec, Protonix, or Pepcid), as this medication can cause
stomach irritation. Prednisone should also be taken with a
glass of milk or with a meal.
CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
¨New onset of tremors or seizures.
¨Any confusion or change in mental status.
¨Any numbness, tingling, weakness in your extremities.
¨Pain or headache that is continually increasing, or not
relieved by pain medication.
¨Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
¨It is normal for feel nasal fullness for a few days after
surgery, but if you begin to experience drainage or salty taste
at the back of your throat, that resembles a dripping
sensation, or persistent, clear fluid that drains from your nose
that was not present when you were sent home, please call.
¨Fever greater than or equal to 101° F.
¨If you notice your urine output to be increasing, and/or
excessive, and you are unable to quench your thirst, please call
your endocrinologist.
###RESPONSE: Discharge Instructions {Final inpatient visit with instructions at discharge}, Take your pain medicine {Administration of analgesic}, Exercise {Exercises}, walking {Does walk}, Increase your intake of fluids {Fluid intake encouragement}, narcotic pain
medicine can cause {Narcotics education}, constipation {Constipation}, stool softener {Administration of laxative}, while taking narcotic pain medication {Narcotics education}, Aspirin {Administration of aspirin}, post-operative office visit {Postoperative follow-up visit}, Sinus {Nasal sinus structure}, Precautions {Safety precautions}, nose {Nasal structure}, oral {Administration of drug or medicament via oral route}, steroid {Steroid therapy}, medication {Prescription of drug}, stomach {Stomach structure}, s medication can cause {Medication education}, stomach {Stomach structure}, tremors {Tremor}, seizures {Seizure}, confusion {Clouded consciousness}, mental status {Mental state finding}, numbness, tingling {Numbness and tingling sensation of skin}, weakness {Asthenia}, extremities {All extremities}, Pain {Pain}, headache {Headache}, pain medication {Administration of analgesic}, signs of infection {Monitoring for signs and symptoms of infection}, wound {Wound}, redness {Redness of skin over lesion}, swelling {Swelling}, tenderness {Tenderness}, drainage {Discharge}, nasal {Nasal structure}, after
surgery {Postoperative state}, drainage {Nasal discharge}, throat {Structure of anterior portion of neck}, clear fluid that drains from your nose {Leakage of cerebrospinal fluid from nose following surgical procedure}, Fever {Fever}, urine output to be increasing {Increased urine output} |
###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:
Urinary Tract Infection
Major Surgical or Invasive Procedure:
None
###RESPONSE: Urinary Tract Infection {Urinary tract infectious 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:
___ male with quadriplegia, recurrent prior UTIs, neurogenic
bladder, and sacral decubitus presents with abd and back pain
and persistent UTI symtpoms. In ___ had E. Coli UTI
treated to ___ with Cefpodoxime. Was again admitted
___ again for UTI symptoms without indication of
infection. A CT showed a decompressed bladder, bladder wall
thickening and enhancement of unclear significance for which
urology follow-up was recommended. He received Ceftriaxone then
36hr Cefpodoxime. UCx (+) Enterococcus and another gram positive
bacteria so treated with Bactrim. He was given a 7 day course.
On ___ he was empirically started on Ampicillin for another
presumed UTI (had fevers). Oxycodone ws increased and pyridium
started ___ for complaints of bladder spasms, but this worsened
with pain in back and over all body and abd. He was given 1mg
Ativan and then sent in.
On ___ he was seen by Dr. ___ in Urology, where a KUB was
done showing no renal calculi, though pneumatosis could not be
ruled out. Prior CT mentioned, "There are scattered foci of air
and soft tissue thickening in the anterior abdominal wall."
There has been concern that some of his behavior is
stress/coping related, and I understand that the patient had a
psych consult completed last week, after which Seroquel and
Valium were increased and Wellbutrin was started.
###RESPONSE: quadriplegia {Quadriplegia}, recurrent prior UTIs {Recurrent urinary tract infection}, neurogenic
bladder {Neurogenic bladder}, sacral decubitus {Chronic skin ulcer of sacrum}, abd {Abdominal pain}, back pain {Backache}, UTI {Urinary tract infectious disease}, E. Coli UTI {Urinary tract infection caused by Escherichia coli}, UTI {Urinary tract infectious disease}, infection {Infectious disease}, CT {Computed tomography}, bladder {Urinary bladder structure}, bladder wall {Structure of wall of urinary bladder}, thickening {Increased thickness}, UCx (+) Enterococcus and another gram positive {Urine culture - mixed growth}, Bactrim {Antibiotic therapy}, UTI {Urinary tract infectious disease}, fevers {Fever}, bladder spasms {Spasm of bladder}, worsened {Increased pain}, pain in back {Backache}, abd {Abdominal pain}, KUB {Radiography of kidney-ureter-bladder}, renal calculi {Kidney stone}, pneumatosis {Gas retention}, CT {Computed tomography}, soft tissue {Structure of soft tissue}, thickening {Increased thickness}, anterior abdominal wall {Anterior abdominal wall structure}, behavior {Behavior finding}, stress {Stress}, psych consult {Psychiatric procedure, interview AND/OR consultation} |
###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:
- fall injury c/b cervical spine and rib fracture in ___, s/p
multiple spine surgeries (c1-c4, c5-c7, L3-L5)
- complete quadriplegia s/p baclofen pump placement on ___
at ___
- neurogenic bladder s/p suprapubic indrwelling catheter
(catheter placed in ___ ___
- multiple UTIs
- neurogenic bowel
- lower back stage II coccyx pressure ulcer
- muscle spasms
- type II diabetes
- anxiety (pyschiatrist ___. Worc. MA ___
- depression (pyschiatrist ___. Worc. MA ___
- hypercholesterolemia
- GERD
- h/o DVT/PE s/p IVC filter placement
- history of gastrostomy
- history of tracheostomy
- history of alcohol abuse
- history of drug (marijuana and cocaine) abuse
###RESPONSE: fall injury {Falling injury}, cervical spine {Structure of cervical vertebral column}, rib fracture {Fracture of rib}, spine surgeries {Operative procedure on spinal structure}, quadriplegia {Quadriplegia}, placement {Implantation procedure}, neurogenic bladder {Neurogenic bladder}, suprapubic indrwelling catheter {Suprapubic urinary catheter in situ}, placed {Implantation procedure}, UTIs {Recurrent urinary tract infection}, neurogenic bowel {Neurogenic bowel}, lower back {Lower back structure}, stage II coccyx pressure ulcer {Pressure injury of coccygeal region of back stage II}, muscle spasms {Spasm}, type II diabetes {Diabetes mellitus type 2}, anxiety {Anxiety}, depression {Depressive disorder}, hypercholesterolemia {Hypercholesterolemia}, GERD {Gastroesophageal reflux disease}, DVT {Deep venous thrombosis}, PE {Pulmonary embolism}, IVC filter placement {Insertion of inferior vena caval filter}, gastrostomy {Gastrostomy}, tracheostomy {Exteriorization of trachea}, alcohol abuse {Alcohol abuse}, drug {Drug abuse}, cocaine) abuse {Cocaine abuse} |
###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:
Noncontributory
###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:
T 99.5, BP 111/66, HR 20, RR 20, SpO2 97%
In NAD.
OP clear, poor dentition, no lesions, no ___, neck supple
No JVD, no bruits
___ - none
LUNGS CTA bilat w/o rhonchi, rubs, wheezes
COR - RRR no MRG nl S2, S2. Normal PMI
ABD - mild distended, nl active bowel signs, non-tender, LLQ
mass under scar consistent with history of baclofen pump placed
there. No rebound/guarding
EXT - no clubbing, cyanosis, edema
SKIN - Stage II decubiti bilat upper medial gluteal area with
surrounding StageI erythema, Stage II midline skin breakdown
coccygeal
NERUO - Minimal proximal LUEx strength, more strength and
sensation RUEXt. Is paraplegic LExt.
###RESPONSE: BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, NAD {No abnormality detected}, OP clear {Pharynx normal}, dentition {Structure of dentition}, lesions {Lesion}, supple {Normal movement of neck}, JVD {Jugular venous engorgement}, bruits {Bruit}, LUNGS {Examination of respiratory system}, CTA {Normal breath sounds}, rhonchi {Wheeze - rhonchi}, rubs {Pericardial friction rub}, wheezes {Wheezing}, COR {Cardiovascular physical examination}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, S2 {Normal second heart sound, S>2<}, S2 {Normal second heart sound, S>2<}, Normal {No abnormality detected}, ABD {Examination of abdomen}, mild {Symptom mild}, distended {Swollen abdomen}, bowel {Intestinal structure}, non-tender {Abdominal tenderness}, LLQ
mass {Mass of left lower quadrant of abdomen}, scar {Scar}, placed {Implantation procedure}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXT {Examination of limb}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, SKIN {Examination of skin}, Stage II decubiti {Pressure injury of sacral region of back stage II}, gluteal area {Buttock structure}, erythema {Erythema}, skin breakdown {Broken skin}, NERUO {Neurological examination}, LUEx {Structure of left upper limb}, sensation {Normal sensation}, RUEXt {Structure of right upper limb}, paraplegic {Paraplegia} |
###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:
___ 12:55PM WBC-7.8 RBC-4.05* HGB-11.9* HCT-36.6* MCV-90
MCH-29.4 MCHC-32.6 RDW-14.9
___ 12:55PM NEUTS-52.8 ___ MONOS-4.1 EOS-4.1*
BASOS-1.1
___ 12:22PM LACTATE-3.6* K+-3.9
___ 12:10PM GLUCOSE-249* UREA N-12 CREAT-0.4* SODIUM-138
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-19
___ 12:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-25
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
___ 12:10PM URINE ___ BACTERIA-FEW
YEAST-MOD ___
___ 12:00 am URINE Site: CATHETER
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- 32 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
___ 2:00 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
___. ___ (___) REQUESTED SUSCEPTIBILITY TEST FOR
CEFPODOXIME ON
___.
Cefpodoxime = SENSITIVE, sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- =>64 R
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
CXR ___
AP CHEST 6:33 P.M. ___
HISTORY: Quadriplegic fever. Question pneumonia.
IMPRESSION: AP chest compared to ___.
A roughly crescentic opacity in the right lower lung, beneath
the downward
displaced minor fissure is probably scarring or atelectasis
unchanged since at
least ___. Lungs otherwise clear. Heart size normal. No
pleural
effusion or evidence of central adenopathy.
The study and the report were reviewed by the staff radiologist.
Time Taken Not Noted Log-In Date/Time: ___ 2:05 pm
URINE Site: NOT SPECIFIED
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, PROTEIN {Measurement of protein in urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, URINE {Evaluation of urine specimen}, AST {Aspartate aminotransferase measurement}, URINE {Evaluation of urine specimen}, URINE CULTURE {Urine culture}, SENSITIVITIES {Antimicrobial susceptibility test}, URINE {Evaluation of urine specimen}, URINE CULTURE {Urine culture}, Culture {Microbial culture}, workup {Evaluation procedure}, sensitivity {Antimicrobial susceptibility test}, SENSITIVITIES {Antimicrobial susceptibility test}, CXR {Plain chest X-ray}, AP CHEST {Plain x-ray of chest anteroposterior view}, Quadriplegic {Quadriplegia}, fever {Fever}, pneumonia {Pneumonia}, AP chest {Plain x-ray of chest anteroposterior view}, opacity {Abnormally opaque structure}, right lower lung {Structure of base of right lung}, fissure {Fissure}, scarring {Scar}, atelectasis {Atelectasis}, Lungs {Lung structure}, clear {Normal breath sounds}, Heart {Heart structure}, normal {No abnormality detected}, pleural
effusion {Pleural effusion}, adenopathy {Lymphadenopathy}, URINE CULTURE {Urine culture}, AST {Aspartate aminotransferase 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:
___ quadriplegic with recurrent UTIs, now with worsening
dysuria while on Ampicillin which was started ___ for fevers
for presumed UTI. His UA is still positive nitrites and
leukocyte esterase.
.
# Presumed UTI: Given Vancomycin to cover enterococcus which he
received in the ED. He did not get anything for gram negative
coverage. Ceftriaxone 2gm daily added to based on prior
sensitivities. UCX came back negative for bacteria, and showed
___ of yeast, likely contaminant -- this was not treated
here. Will defer to PCP if he wants to treat this. A CXR was
negative for obvious pneumonia.
.
# Suprapubic/Abdominal Pain: DDx includes bladder spasm, but
given recent KUB and Abd/pelvic CT reads referenced above, I
reviewed recent radiology films with radiology ___ on
call radiologist who indicated the CT showed mild enhancement of
bladder which could be consistent with UTI, and non-specific air
around stool in the bowel with constipation. Valium was recently
increased prior to admission, and he was started on Pyridium
(which he states never helps him). The latter is discontinue on
discharge. Pt given Oxycodone prn for improved pain control and
continued on a bowel regimen as ordered. His pain is LLQ and
vague. I discussed with his PCP about having him see the
surgeons at ___ who put in his Baclofen pump at some point in
near future.
.
# Sacral Decubitus Ulcer: Stage II - present on admission.
___ wound RN to assess. Continue treatments.
.
# DM2: Normally on metformin, was continued.
.
#Depression/Anxiety: continue Seroquel, Wellbutrin, Citalopram
and valium.
.
CODE: FULL per patient
.
CONTACT: HCP = ___ ___
###RESPONSE: quadriplegic {Quadriplegia}, recurrent UTIs {Recurrent urinary tract infection}, dysuria {Dysuria}, Ampicillin {Antibiotic therapy}, fevers {Fever}, UTI {Urinary tract infectious disease}, UA {Urinalysis}, positive nitrites {Nitrite detected in urine}, UTI {Urinary tract infectious disease}, Vancomycin {Antibiotic therapy}, sensitivities {Antimicrobial susceptibility test}, UCX came back negative for bacteria {Urine culture - no growth}, PCP {Primary care management}, CXR {Plain chest X-ray}, negative {No abnormality detected}, pneumonia {Pneumonia}, Suprapubic {Suprapubic pain}, Abdominal Pain {Abdominal pain}, bladder spasm {Spasm of bladder}, KUB {Radiography of kidney-ureter-bladder}, Abd/pelvic CT {Computed tomography of abdomen and pelvis}, CT {Computed tomography}, bladder {Urinary bladder structure}, UTI {Urinary tract infectious disease}, bowel {Intestinal structure}, constipation {Constipation}, improved {Patient's condition improved}, pain control {Pain control}, bowel {Intestinal structure}, regimen {Therapeutic regimen}, pain {Pain}, LLQ {Structure of left lower quadrant of abdomen}, PCP {Primary care management}, Sacral Decubitus Ulcer: Stage II {Pressure injury of sacral region of back stage II}, wound {Wound}, DM2 {Diabetes mellitus type 2}, Depression {Depressive disorder}, Anxiety {Anxiety} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, PO EVERY OTHER DAY
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Ascorbic Acid ___ mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO BID
10. Baclofen 10 mg Tablet Sig: 2.5 Tablets PO TID
11. Zofran 4 mg Tablet Sig: One (1) Tablet PO once a day as
needed for nausea.
12. Baclofen Intrathecal
13. Metamucil Powder Sig: One (1) dose PO once a day as
needed for constipation.
14. Fragmin 5,000 unit/0.2 mL Syringe Sig: One (1) syringe
Subcutaneous once a day.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn
constipation.
16. Miralax 17 gram/dose Powder Sig: One (1) dose PO once a day
as needed for constipation.
17. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H prn
fever, pain.
18. Oxycodone 5 mg Tablet Sig: Five (5) Tablet PO q8h:PRN pain
19. Buspirone 10 mg Tablet Sig: One (1) Tablet PO TID
20. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
21. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS
22. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H prn spasms.
23. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS
24. Sodium Chloride 0.65 % Aerosol, Spray Sig: ___ Sprays Nasal
BID
25. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID prn
bladder pain
26. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
27. MagOx 400 mg Tablet Sig: One (1) Tablet PO twice a day.
28. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for pain.
29. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO q8h:PRN as needed
for anxiety.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for fever.
2. Senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day).
3. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
5. Baclofen 10 mg Tablet Sig: 2.5 Tablets PO TID (3 times a
day).
6. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily) as needed for nausea.
7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every
___.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Buspirone 10 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
16. Diazepam 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
17. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
18. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
19. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
20. Fragmin 5,000 unit/0.2 mL Syringe Sig: One (1) dose
Subcutaneous once a day.
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Abdominal Pain
Stage II sacral debuitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
###RESPONSE: Abdominal Pain {Abdominal pain}, Stage II sacral debuitus {Pressure injury of sacral region of back stage II}, Mental Status {Neurological mental status determination}, Clear {No abnormality detected}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Bedbound {Bed-ridden} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were admitted with complaints of abdominal pain. You were
empirically given antibiotics for possible urinary tract
infection but do not have a urinary tract infection by culture.
You have discomfort in your lower left abdomen, you are
tolerating all of your medications and a normal diet. I
recommend you follow-up with your PCP and discuss ___ possible
visit with the surgeons who put in the baclofen pump (in the
left abdomen). Please exercise patience with your current
condition and work with your facility's staff to help you as
best as possible.
###RESPONSE: abdominal pain {Abdominal pain}, antibiotics {Antibiotic therapy}, urinary tract
infection {Urinary tract infectious disease}, urinary tract infection {Urinary tract infectious disease}, culture {Microbial culture}, discomfort {Discomfort}, lower left abdomen {Structure of left lower quadrant of abdomen}, medications {Patient medication education}, normal diet {Normal diet}, follow-up {Follow-up status}, PCP {Primary care management}, left abdomen {Structure of left side 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: 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
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Imaging-guided LP - ___
###RESPONSE: Penicillins {Allergy to penicillin}, Headache {Headache}, Imaging {Imaging}, LP {Lumbar puncture} |
###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 ___ female with PMH of hypertension,
spinal stenosis, recent diagnosis of shingles, who presents with
severe headache.
Patient reports that the day of admission she woke up from sleep
around 3AM with a headache, which she describes as "intense" and
"all over". She states that this pain worsened throughout the
day. It was associated with nausea and vomiting -reports
vomiting several times throughout the day, not able to keep
anything down. She states that bright lights made somewhat
worse, but also that she does not normally like bright lights.
No phonophobia, though she does note continued ear pain.
Reports
no fevers or chills. Did have some shooting pains at the back
of
her neck, but no neck soreness or stiffness. No dizziness or
lightheadedness, but not associated with falls.
On review of records, patient first presented to her PCPs office
on ___ with a rash on her face and neck. She was diagnosed
at that time with shingles, and started on a 10-day course of
acyclovir. She returned to urgent care on ___ with
weakness on the left side of her face. She was diagnosed with
Bell's palsy secondary to her herpes zoster infection. Was
started on prednisone 60 mg daily for a week. Of note, patient
states that she was taking 60 mg 3 times a day rather than daily
(3 tabs, 3 times a day). She return to clinic on ___, the
day of admission, with her headache as described above. At this
time she was sent to the emergency department.
In the ED:
Initial vital signs were notable for: T 36.5, HR 63, BP 157/95,
RR 16, 98% RA
Exam notable for:
Constitutional: Comfortable.
Head/eyes: NCAT, PERRLA, EOMI.
ENT/neck: neck supple, no rigidity or pain
Neuro: Slowed speech, but fluent, left sided facial droop that
has been ongoing for a week due to bell's palsy resulting from
shingles. strength and sensation intact in bl UE and ___. ftn in
tact. CN ___ otherwise intact with exception of CN VII on left
side.
Labs were notable for:
- CBC: WBC 11.7, hgb 13.0, plt 288
- Lytes:
140 / 98 / 20 AGap=16
-------------- 91
3.4 \ 26 \ 0.8
- LFTs: AST: 20 ALT: 19 AP: 81 Tbili: 0.5 Alb: 4.1
- lipase 24
- lactate 1.8
Studies performed include:
- NCHCT with no evidence of acute intracranial hemorrhage.
- LP was attempted, but unable to obtain CSF sample
Consults: ___ was consulted for an LP, which was not done at time
of admission
Patient was given:
___ 17:21 IVF NS 1000 mL
___ 17:28 IV Metoclopramide 10 mg
___ 17:28 IV DiphenhydrAMINE 25 mg
___ 17:29 IV Acyclovir 600 mg
___ 20:16 IV Morphine Sulfate 4 mg
Vitals on transfer: T 98.5, HR 58, BP 158/82, RR 16, 96% RA
Upon arrival to the floor, patient recounts history as above.
She states that overall her headache is slightly better than it
was initially.
###RESPONSE: hypertension {Hypertensive disorder, systemic arterial}, spinal stenosis {Spinal stenosis}, shingles {Herpes zoster}, severe {Symptom severe}, headache {Headache}, headache {Headache}, pain {Pain}, nausea and vomiting {Nausea and vomiting}, vomiting {Vomiting}, worse {Increased pain}, phonophobia {Phonophobia}, ear pain {Pain of ear}, fevers {Fever}, chills {Chill}, shooting pains {Shooting pain}, back
of
her neck {Cervical region back structure}, neck {Cervical region back structure}, soreness {Soreness}, stiffness {Stiffness}, dizziness {Dizziness}, lightheadedness {Lightheadedness}, falls {Falls}, rash {Eruption of skin}, face {Face structure}, neck {Neck structure}, shingles {Herpes zoster}, weakness {Weakness of face muscles}, left side of her face {Structure of left half of face}, Bell's palsy {Bell's palsy}, herpes zoster infection {Herpes zoster}, headache {Headache}, emergency {Emergency treatment management}, vital signs {Vital signs finding}, RA {Breathing room air}, Comfortable {Comfortable appearance}, Head/eyes {Physical examination procedure}, NCAT {Normal head}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, ENT/neck {Physical examination procedure}, neck supple {Normal movement of neck}, rigidity {Nuchal rigidity}, pain {Pain}, Neuro {Neurological examination}, Slowed speech {Bradylalia}, fluent {Does speak fluently}, left sided facial {Structure of left half of face}, bell's palsy {Bell's palsy}, shingles {Herpes zoster}, sensation intact {Normal sensation}, UE {Upper limb structure}, CN {Cranial nerve structure}, CN VII on left
side {Structure of left facial nerve}, CBC {Complete blood count}, WBC {White blood cell count}, LFTs {Hepatic function panel}, AST {Aspartate aminotransferase measurement}, ALT {Alanine aminotransferase measurement}, AP {Alkaline phosphatase measurement}, Tbili {Bilirubin, total measurement}, Alb {Albumin measurement}, lipase {Serum lipase measurement}, lactate {Lactic acid measurement}, NCHCT {Computed tomography of head without contrast}, no evidence {No abnormality detected}, intracranial hemorrhage {Intracranial hemorrhage}, LP {Lumbar puncture}, CSF {Cerebrospinal fluid collection}, LP {Lumbar puncture}, IVF {Administration of intravenous fluids}, Vitals {Vital signs finding}, RA {Breathing room air}, headache {Headache} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
- hypertension
- melanoma
- hyperlipidemia
- Gastric ulcer
- Asthma
- Spinal stenosis, lumbar region, with neurogenic claudication
###RESPONSE: hypertension {Hypertensive disorder, systemic arterial}, melanoma {Malignant melanoma of skin}, hyperlipidemia {Hyperlipidemia}, Gastric ulcer {Gastric ulcer}, Asthma {Asthma}, Spinal stenosis, lumbar region {Spinal stenosis of lumbar region}, neurogenic claudication {Neurogenic claudication} |
###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:
Brother ___
Father ___
Mother ___ CAD/PVD - Early (___); Gout; Hypertension
###RESPONSE: CAD {Coronary arteriosclerosis}, PVD {Peripheral vascular disease}, Gout {Inflammatory disorder due to increased blood urate level}, Hypertension {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: Physical Exam:
VITALS: T 98.4, HR 66, BP 171/90, RR 18, 93% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Neck supple with negative brudzinski's and kernig's signs.
Crusted over lesions on left side of face, including pinna of
ear
and external canal. Very tender to light palpation
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Lesions over left side of face as noted above
NEURO: Alert, oriented x3, PEERL, EOMI. Left-sided facial droop
with decreased sensation to forehead and nearly no sensation in
V2 and V3 distribution. Hearing grossly intact bilaterally.
Palate raises symmetrically, shoulder shrug normal, tongue
midline, strength ___ in upper and lower distal and proximal
muscle groups.
PSYCH: pleasant, appropriate affect
###RESPONSE: VITALS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, RA {Breathing room air}, GENERAL {General examination of patient}, Alert {Mentally alert}, distress {Distress}, EYES {Ophthalmic examination and evaluation}, Anicteric {White sclera}, pupils equally round {Pupil size and shape normal}, ENT {Abdominal tenderness}, supple {Normal movement of neck}, negative {No abnormality detected}, brudzinski's {Brudzinski's sign}, kernig's signs {Kernig's sign}, lesions {Lesion}, left side of face {Structure of left half of face}, pinna of
ear {Pinna structure}, external canal {External auditory canal structure}, tender {Abdominal tenderness}, palpation {Palpation}, CV {Cardiovascular physical examination}, Heart {Cardiovascular physical examination}, murmur {Murmur}, no S3 {Third heart sound, S>3<, inaudible}, no S4 {Fourth heart sound, S>4<, inaudible}, JVD {Jugular venous engorgement}, RESP {Examination of respiratory system}, Lungs {Examination of respiratory system}, good air movement {Breath normal}, Breathing {Examination of respiratory system}, labored {Labored breathing}, GI {Examination of digestive system}, soft {Abdomen soft}, non-distended {Normal abdominal contour}, non-tender {Abdominal tenderness}, palpation {Palpation}, Bowel
sounds present {Normal bowel sounds}, HSM {Hepatosplenomegaly}, GU {Examination of genitourinary system}, suprapubic {Hypogastric region structure}, tenderness {Tenderness}, palpation {Palpation}, MSK {Musculoskeletal system physical examination}, supple {Normal movement of neck}, all extremities {All extremities}, symmetric bilaterally in all limbs {Normal bilateral upper limbs and bilateral lower limbs}, SKIN {Examination of skin}, Lesions {Skin lesion}, left side of face {Structure of left half of face}, NEURO {Neurological examination}, Alert {Mentally alert}, oriented {Orientated}, PEERL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Left-sided facial {Structure of left half of face}, decreased sensation {Hypesthesia}, forehead {Forehead structure}, no sensation {Absence of sensation}, V2 {Entire maxilla}, V3 {Lower jaw region structure}, grossly intact {Normal nervous system function}, Palate {Palatal structure}, shoulder {Structure of right shoulder region}, normal {No abnormality detected}, tongue {Tongue structure}, upper and lower distal {Structure of distal palatal tooth surfaces}, muscle {Skeletal and/or smooth muscle structure}, PSYCH {Psychiatry procedure or service}, affect {Mood finding} |
###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:
___ 03:15PM BLOOD WBC-11.7* RBC-4.54 Hgb-13.0 Hct-41.5
MCV-91 MCH-28.6 MCHC-31.3* RDW-12.6 RDWSD-41.7 Plt ___
___ 03:15PM BLOOD Glucose-91 UreaN-20 Creat-0.8 Na-140
K-3.4* Cl-98 HCO3-26 AnGap-16
___ 07:18AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.9
LP RESULTS:
Tube 1: ___ 03:15PM CEREBROSPINAL FLUID (CSF) TNC-19*
RBC-700* Polys-7 Bands-1 ___ Monos-4
Tube 4: ___ 03:15PM CEREBROSPINAL FLUID (CSF) TNC-22*
RBC-174* Polys-6 Bands-3 ___ ___ 03:15PM CEREBROSPINAL FLUID (CSF) TotProt-36 Glucose-57
RELEVANT IMAGING:
___ NCHCT:
There is no evidence of acute, large territorial infarction,
fracture,
hemorrhage,edema,or mass effect. There is mild prominence of
the ventricles and sulci suggestive of involutional changes.
Periventricular white-matter hypodensities are nonspecific,
likely sequela of chronic ischemic small vessel disease.
Hyperostosis frontalis interna is noted. Partial opacification
of the
posterior ethmoid air cells. Layering fluid within the
bilateral sphenoid
sinuses, left greater than right, with aerosolized component
within the left sphenoid sinus. The mastoid air cells are
clear. The visualized portion of the orbits are normal.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Paranasal sinus disease.
___ CTA head/neck:
FINDINGS:
CT head shows no evidence of hemorrhage, or loss of gray-white
matter
differentiation. No midline shift or hydrocephalus seen.
Aerosolized
secretions and fluid level are seen in the sphenoid sinus.
CT angiography of the neck shows normal appearance of the
carotid and
vertebral arteries without stenosis or occlusion or dissection.
CT angiography of the head shows normal appearance of the
arteries of the
anterior and posterior circulation without stenosis or occlusion
or aneurysm
greater than 3 mm in size.
IMPRESSION:
No significant abnormalities on CT of the head without contrast.
No
significant abnormalities on CT angiography of the head and
neck. Sphenoid sinus soft tissue changes.
DISCHARGE RESULTS:
___ 06:50AM BLOOD WBC-7.4 RBC-3.83* Hgb-11.2 Hct-36.5
MCV-95 MCH-29.2 MCHC-30.7* RDW-12.4 RDWSD-42.9 Plt ___
___ 07:00AM BLOOD Glucose-98 UreaN-13 Creat-1.0 Na-141
K-4.4 Cl-103 HCO3-28 AnGap-10
___ 07:00AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.___ woman with PMH of hypertension, spinal stenosis,
recent diagnosis of shingles with suspected Ramsay Hunt
syndrome, who presented with severe headache. CT head and CTA
head/neck showed no acute process. She underwent LP which showed
22 WBCs, primarily lymphs, without xanthochromia. ID was
consulted who felt this finding may represent VZV meningitis vs
meningeal irritation from VZV, and recommended 10-day course of
anti-viral therapy. She was treated initially with IV acyclovir,
transitioned to valacyclovir to complete course, last day ___.
She was also seen by neurology, who recommended initiation of
amitriptyline for headache management, and treatment of
neuropathic pain. Gabapentin was also uptitrated to 400mg TID.
Lisinopril was uptitrated to 20mg from 10mg daily.
TRANSITIONAL ISSUES:
-Valtrex to finish ___
-Patient should receive shingles vaccine ___ weeks after
resolution of symptoms
-Amitriptyline started for neuropathic pain and headache
-Gabapentin increased to 400mg TID for neuropathic pain
-Patient complaining of headaches brought on by chewing, thought
to be related to shingles. If no improvement at f/u, would check
ESR/CRP to evaluate for GCA
-Please refer to ___ neurology for f/u, per patient preference
-Lisinopril increased from 10mg to 20mg daily
###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}, 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}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, RBC {Red blood cell count}, Monos {Monocyte count}, RBC {Red blood cell count}, Glucose {Glucose measurement, blood}, NCHCT {Computed tomography of head without contrast}, no evidence {No abnormality detected}, infarction {Infarct}, fracture {Fracture}, hemorrhage {Hemorrhage}, edema {Edema}, mass {Mass}, ventricles {Brain ventricle structure}, sulci {Structure of sulcus of brain}, involutional changes {Involution}, Periventricular white-matter {Structure of periventricular white matter}, chronic ischemic {Chronic cerebral ischemia}, small vessel {Structure of small blood vessel (organ)}, Hyperostosis frontalis interna {Hyperostosis interna frontalis}, opacification {Abnormally opaque structure}, posterior ethmoid air cells {Structure of posterior cells of ethmoid sinus}, fluid {Accumulation of fluid}, sphenoid
sinuses {Sphenoid sinus structure}, left {Left sphenoid sinus structure}, right {Right sphenoid sinus structure}, left sphenoid sinus {Left sphenoid sinus structure}, mastoid air cells {Structure of mastoid cell}, are
clear {No abnormality detected}, orbits {Structure of orbit proper}, normal {No abnormality detected}, No evidence {No abnormality detected}, intracranial hemorrhage {Intracranial hemorrhage}, Paranasal sinus disease {Disorder of nasal sinus}, CT head {Computed tomography of head}, no evidence {No abnormality detected}, hemorrhage {Hemorrhage}, midline shift {Midline shift of brain}, hydrocephalus {Hydrocephalus}, fluid {Accumulation of fluid}, sphenoid sinus {Sphenoid sinus structure}, CT angiography of the neck {Computed tomography angiography of vascular structure of neck with contrast}, normal appearance {Normal appearance}, carotid {Carotid artery structure}, vertebral arteries {Structure of vertebral artery}, stenosis {Stenosis}, occlusion {Complete obstruction}, dissection {Dissection of artery}, CT angiography of the head {Computed tomography angiography of head with contrast}, normal appearance {Normal appearance}, arteries {Arterial structure}, circulation {Structure of cardiovascular system}, stenosis {Stenosis}, occlusion {Complete obstruction}, aneurysm {Aneurysm}, No significant abnormalities {No abnormality detected}, CT of the head without contrast {Computed tomography of head without contrast}, No
significant abnormalities {No abnormality detected}, CT angiography of the head and
neck {Computed tomography angiography of head and neck with contrast}, Sphenoid sinus {Sphenoid sinus structure}, soft tissue {Structure of soft tissue}, 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}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, hypertension {Hypertensive disorder, systemic arterial}, spinal stenosis {Spinal stenosis}, shingles {Herpes zoster}, Ramsay Hunt
syndrome {Herpes zoster auricularis}, severe {Symptom severe}, headache {Headache}, CT head {Computed tomography of head}, CTA
head/neck {Computed tomography angiography of head and neck with contrast}, no acute {No abnormality detected}, LP {Lumbar puncture}, lymphs {Lymphocyte count}, VZV meningitis {Herpes zoster with meningitis}, meningeal irritation {Meningeal irritation}, anti-viral therapy {Antiviral therapy}, headache {Headache}, neuropathic pain {Neuropathic pain}, receive shingles vaccine {Administration of vaccine product containing only Human alphaherpesvirus 3 antigen for shingles}, neuropathic pain {Neuropathic pain}, headache {Headache}, neuropathic pain {Neuropathic pain}, headaches {Headache}, shingles {Herpes zoster}, no improvement {Patient condition unchanged}, ESR {Erythrocyte sedimentation rate measurement}, CRP {C-reactive protein measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Omeprazole 20 mg PO BID
3. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
4. Pravastatin 40 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. DICYCLOMine 20 mg PO TID
7. Polyethylene Glycol 17 g PO BID
8. TraZODone 50-100 mg PO QHS:PRN insomnia
9. Senna 17.2 mg PO QHS
10. Morphine SR (MS ___ 30 mg PO Q12H
11. Gabapentin 300 mg PO TID
Discharge Medications:
1. Amitriptyline 10 mg PO QHS
RX *amitriptyline 10 mg 1 tablet(s) by mouth at bedtime Disp
#*30 Tablet Refills:*0
2. Artificial Tears 2 DROP BOTH EYES QID
RX *dextran 70-hypromellose (PF) [Artificial Tears (PF)] 0.1
%-0.3 % ___ drops ___ four times a day Disp #*1 Bottle Refills:*2
3. Capsaicin 0.025% 1 Appl TP TID
RX *capsaicin 0.025 % Apply small amount to affected area three
times a day Refills:*1
4. HydrOXYzine 25 mg PO QHS:PRN itchiness
This medication will make you drowsy. Do not drive or operate
machinery while using this medication.
RX *hydroxyzine HCl 25 mg 1 tab by mouth at bedtime Disp #*20
Tablet Refills:*0
5. ValACYclovir 1000 mg PO TID Duration: 4 Days
RX *valacyclovir 1,000 mg 1 tab by mouth three times a day Disp
#*13 Tablet Refills:*0
6. Gabapentin 400 mg PO TID
RX *gabapentin 400 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
7. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. DICYCLOMine 20 mg PO TID
9. Morphine SR (MS ___ 30 mg PO Q12H
10. Omeprazole 20 mg PO BID
11. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
12. Polyethylene Glycol 17 g PO BID
13. Pravastatin 40 mg PO DAILY
14. Senna 17.2 mg PO QHS
15. TraZODone 50-100 mg PO QHS:PRN insomnia
16. Vitamin D ___ 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:
Home
Discharge Diagnosis:
Shingles with meningeal irritation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Shingles with meningeal irritation {Herpes zoster with meningitis}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Ms. ___,
You came to the hospital with a headache. While you were here,
you had a lumbar puncture which showed irritation due to
shingles. You were started on anti-viral medication, as well as
medications to help your headache. You should continue the
anti-viral medication (valacyclovir, also called Valtrex) until
___. You should also use artificial tears as needed for dry
eyes, and use your eye patch at night until your eye is closing
completely.
Please follow-up with your PCP as scheduled below. At this
visit, you may request a referral to neurology for further
follow-up.
It was a pleasure participating in your care.
Sincerely,
Your ___ Team
###RESPONSE: headache {Headache}, lumbar puncture {Lumbar puncture}, shingles {Herpes zoster}, anti-viral medication {Antiviral therapy}, medications {Patient medication education}, headache {Headache}, anti-viral medication {Antiviral therapy}, dry
eyes {Dry eyes}, eye {Structure of eye proper}, eye {Structure of eye proper} |
###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:
Syncope
Back pain
Major Surgical or Invasive Procedure:
Nil
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Syncope {Syncope}, Back pain {Backache} |
###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 female with history of HL, hypothyroidism, anxiety and
depression who presented after syncopal episode. She reports
being in her USOH until she was walking up to the store this
morning as per her routine. All of a sudden she felt her "eyes
went black". She reports fainting and losing consciousness. She
denies any other prior symptoms including dizziness, LH, visual
changes, nausea, CP, SOB, or palpitations. She denies any
urinary or fecal incontinence during the episode. She fell into
a seated position, as if she "plopped down" and broke her fall
with her right wrist. She then felt pain in both her right wrist
and her left hip, and it was this pain that "awoke her". She
denies hitting her head during the fall. No recent positional
change prior to the syncopal event. She has previously
experienced this same syncopal episode.
.
After her fall, she reports marked left hip pain. She denies any
urinary or fecal incontinence since the fall. She denies
numbness, tingling, weakness, or radiating pain in her legs
###RESPONSE: HL {Hyperlipidemia}, hypothyroidism {Hypothyroidism}, anxiety {Anxiety}, depression {Depressive disorder}, syncopal {Syncope}, yes
went black {Syncope}, fainting {Syncope}, losing consciousness {Decreased level of consciousness}, dizziness {Dizziness}, LH {Labile essential hypertension}, visual
changes {Sight deteriorating}, nausea {Nausea}, SOB {Dyspnea}, palpitations {Palpitations}, urinary {Urinary incontinence}, fecal incontinence {Incontinence of feces}, fell {Falls}, fall {Falls}, right wrist {Structure of right wrist region}, pain {Pain}, right wrist {Structure of right wrist region}, left hip {Left hip region structure}, pain {Pain}, fall {Falls}, syncopal {Syncope}, syncopal {Syncope}, fall {Falls}, left hip {Left hip region structure}, pain {Pain}, urinary {Urinary incontinence}, fecal incontinence {Incontinence of feces}, fall {Falls}, numbness, tingling {Numbness and tingling sensation of skin}, weakness {Asthenia}, radiating pain {Radiating pain}, legs {Lower limb 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: Past Medical History:
Osteopenia
Hypothyroidism
Depression
Anxiety
HLD
Cataracts s/p repair
###RESPONSE: Osteopenia {Osteopenia}, Hypothyroidism {Hypothyroidism}, Depression {Depressive disorder}, Anxiety {Anxiety}, HLD {Hyperlipidemia}, Cataracts {Cataract}, repair {Cataract surgery} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Mother:faint spells, breast Ca in ___
###RESPONSE: faint {Syncope}, breast Ca {Malignant neoplasm of breast} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS - 97.7 66 117/64 14 96% on RA 73.8kg
GENERAL - Alert, interactive, well-appearing elderly female in
pain, laying still in bed, unable to sit
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement
ABDOMEN - +BS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
BACK - tender over thoracic spine T4-T8, no paraspinal muscle
tenderness, no lumbosacral tenderness, pain over left SI joint
and into left groin
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
.
###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, Alert {Mentally alert}, interactive {Does communicate}, well-appearing {Well cared for appearance}, pain {Pain}, laying still in bed {Lying in bed}, unable to sit {Unable to sit}, HEENT {Physical examination procedure}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, sclerae anicteric {White sclera}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, JVD {Jugular venous engorgement}, HEART {Cardiovascular physical examination}, displaced {Apex beat displaced}, RRR {Normal heart rate}, nl S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, no MRG {Heart sounds normal}, LUNGS {Examination of respiratory system}, CTAB {Normal breath sounds}, ABDOMEN {Examination of abdomen}, +BS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, 2+ peripheral pulses {Peripheral pulses normal}, tender {Abdominal tenderness}, T4 {Bone structure of T4}, T8 {Bone structure of T8}, paraspinal {Structure of paravertebral region}, tenderness {Tenderness}, lumbosacral {Structure of lumbar and/or sacral region of back}, tenderness {Tenderness}, pain {Pain}, left SI joint {Structure of left sacroiliac joint}, left groin {Left inguinal region structure}, NEURO {Neurological examination}, awake {Awake}, Ox3 {Oriented to person, time and place}, grossly intact {Normal nervous system function}, muscle {Skeletal and/or smooth muscle structure}, sensation grossly intact {Normal sensation} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 07:30PM cTropnT-<0.01
___ 07:30PM WBC-14.9* RBC-4.80 HGB-13.0 HCT-41.2 MCV-86
MCH-27.2 MCHC-31.6 RDW-13.___ yo female with history of osteopenia, HL, and hypothyroidism
admitted for syncope.
.
# Syncope: Although patient has had previous syncopal episodes
in the past, she has always had prior warning of feeling hot and
sweatty and had managed to sit down and prevent herself from
passing out. This episode was different. She had no prior
warning symptoms as before making this episode an unlikely
vasovagal. There was no positional changes prior to fall making
orthostatic hypotension induced syncope unlikely. She is also
not on any current anti-hypertensives such as thiazides. She
was not exerting herself in terms of coughing/sneezing prior to
episode making effort syncope unlikely. However, she was walking
to the store and exerting herself minimally although she states
this walk has never troubled her before. No faecal/urinary
incontinence or confusion post syncope also rules out a seizure.
Although she denies any chest pain/palpitations/SOB/headache,
and unremarkable cardiovascular exam, her recent ECG shows new
atrial enlargement and slight intraventricular delay. This
warrants further cardiac workup to rule out transient arrhythmia
inducing syncopal episodes.
-ECG - no ST/T wave changes, troponin <0.01
-monitor on telemetry
-ECHO looking specifically at valvular function (evidence of
aortic stenosis) which came back normal
-As per Dr. ___, patient going home with event
recorder
-Out patient PCP and cardiology appointments
.
# Left hip pain: Xrays without evidence of fracture. Most likely
contusion of left hip/sacrum.
-tylenol standing
-patient has been taking ibuprofen PRN for back pain, so discuss
risks in terms of GI bleed and pre-renal failure
-small dose of oxycodone prn further pain
-___ consult
.
# Back pain: History of osteopenia on BMD in ___. Compression
fracture seen in lumbar spine L2 level but does not correlate to
current symptoms. Compression fracture in the thoracic spine
would not be an unreasonable explanation for her current
symptoms given the mechanism of her fall.
-thoracic spine films
-___ as outpatient
-Discuss commencement of Calcium and Vit D supplements as well
as bisphosphonates even though patient has declined these in the
past
.
# Leukocytosis: Most likely stress response. No signs or
symptoms of infection.
.
# Hypothyroidism: continue levothyroxine
.
# HL: continue simvastatin
.
# Anxiety/depression: continue sertraline
.
###RESPONSE: cTropnT {Troponin T cardiac 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}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, osteopenia {Osteopenia}, HL {Hyperlipidemia}, hypothyroidism {Hypothyroidism}, syncope {Syncope}, Syncope {Syncope}, syncopal {Syncope}, hot and
sweatty {Feels hot and sweaty}, passing out {Syncope}, vasovagal {Vasovagal syncope}, fall {Falls}, orthostatic hypotension {Orthostatic hypotension}, syncope {Syncope}, t anti-hypertensives {On treatment for hypertension}, coughing {Cough}, sneezing {Sneezing}, effort syncope {Effort syncope}, faecal {Incontinence of feces}, urinary
incontinence {Urinary incontinence}, confusion {Clouded consciousness}, syncope {Syncope}, seizure {Seizure}, chest pain {Chest pain}, palpitations {Palpitations}, SOB {Dyspnea}, headache {Headache}, unremarkable cardiovascular exam {Cardiovascular system normal}, ECG {Electrocardiographic procedure}, atrial {Atrial structure}, enlargement {Enlargement}, intraventricular delay {Non-specific intraventricular conduction delay}, r cardiac workup {Examination of heart}, arrhythmia {Cardiac arrhythmia}, syncopal {Syncope}, ECG {Electrocardiographic procedure}, no ST/T wave change {Electrocardiogram normal}, troponin {Troponin measurement}, telemetry {Electroencephalogram telemetry}, ECHO {Echocardiography}, valvular {Structure of heart valve tissue}, aortic stenosis {Aortic valve stenosis}, PCP {Primary care management}, cardiology appointments {Cardiac care management}, Left hip {Left hip region structure}, pain {Pain in scrotum}, fracture {Fracture}, contusion of left hip {Contusion of left hip region}, sacrum {Structure of sacral vertebral column}, back pain {Backache}, GI bleed {Gastrointestinal hemorrhage}, pre-renal failure {Pre-renal acute kidney injury}, pain {Pain}, Back pain {Backache}, osteopenia {Osteopenia}, Compression
fracture seen in lumbar spine L2 level {Compression fracture of second lumbar vertebra}, thoracic spine {Structure of thoracic vertebral column}, fall {Falls}, thoracic spine {Structure of thoracic vertebral column}, Leukocytosis {Leukocytosis}, stress {Stress}, signs {Sign}, infection {Infectious disease}, Hypothyroidism {Hypothyroidism}, HL {Hyperlipidemia}, Anxiety/depression {Mixed anxiety and depressive disorder} |
###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:
sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: ___ Tablets PO every six (6)
hours.
2. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
-Syncope
-Lumbar level 2 fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Syncope {Syncope}, Lumbar level 2 fracture {Fracture of second lumbar vertebra}, Mental Status {Neurological mental status determination}, Clear {No abnormality detected}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear ___,
___ were admitted to the ___ on the ___ after ___
experienced a black out and subsequent back pain. Hip x-rays
and back x-rays were done on ___. Hip x-rays showed no hip
fracture but back x-ray revealed a fracture at the L2 level of
your spine. Your previous diagnosis of osteopenia likely
contributed to this.
Your black out episode sounds like it could have been like your
previous episodes. However, in order to rule out a cardiac
cause, we took an image of your heart with an "echo" which was
normal. We will still send ___ home with an event recorder
which ___ will have for two weeks. The results of this can be
reviewed with Dr. ___ and with Dr. ___ as per your
appointments below.
Your medications will continue as per your home regimen:
Oxybutinin 5mg twice daily
Simvastatin 20mg Once daily
Levothyroxine 75mcg once daily
Sertraline 50mg once daily
As acetominophen helped your pain, ___ may take the 500mg
tablets ___ tablets upto 4 times per day, but don't take more
than 6 in a day
Please ensure ___ attend your follow up appointments as
described below.
It was a pleasure looking after ___ here at the ___.
###RESPONSE: black out {Syncope}, back pain {Backache}, Hip x-rays {Radiography of hip}, back {Structure of back of trunk}, x-rays {Radiographic imaging procedure}, Hip x-rays {Radiography of hip}, hip
fracture {Fracture of proximal end of femur}, back {Structure of back of trunk}, x-ray {Radiographic imaging procedure}, fracture at the L2 level of
your spine {Fracture of second lumbar vertebra}, osteopenia {Osteopenia}, black out {Syncope}, cardiac {Heart structure}, image of your heart {Imaging of heart}, echo {Echocardiography}, normal {No abnormality detected}, pain {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: 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:
Bactrim
Attending: ___.
Chief Complaint:
mouth pain, odynophagia, rash
Major Surgical or Invasive Procedure:
None
###RESPONSE: Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, mouth pain {Painful mouth}, odynophagia {Swallowing painful}, rash {Eruption of skin} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ year old male with history of recently diagnosed HIV/AIDS,
PCP pneumonia treated with 21 days of high dose bactrim, now
presenting with 4 days of diffuse maculopapular rash, mouth
pain, and fevers to 102.
.
Patient requested HIV test approximately one month ago after
learning that a prior partner was HIV positive. He then
developed shortness of breath and cough and presented to the
emergency department. CXR demonstrated multifocal infiltrates
and he was diagnosed with PCP pneumonia by bronchoscopy. At that
time his HIV antibody was positive, his CD4 count was 54
(___), and his HIV VL was 321,000. He was treated with
bactrim DS 2 tabs TID for 21 days, and with a prednisone taper.
.
Since this time, he has been started on atripla as an outpatient
on ___. Over the last week he noticed a rash on his chest
and arms that worsened. It was itchy but not painful. He also
noted steadily worsening oral pain and pain with swallowing. He
also had fevers to 102 with chills for the past two nights and
poor PO intake. He presented to outpatient clinic and was
treated with fluconazole for thrush, and with valtrex for oral
herpes.
.
He then presented to outpatient clinic, and was noted to have a
diffuse maculopapular rash and mucositis. he was referred to the
ED with concern for ___ syndrome.
###RESPONSE: HIV {Human immunodeficiency virus infection}, AIDS {Acquired immune deficiency syndrome}, PCP pneumonia {Pneumocystosis jirovecii pneumonia}, maculopapular rash {Maculopapular rash}, mouth
pain {Painful mouth}, fevers {Fever}, HIV {Human immunodeficiency virus infection}, HIV positive {Human immunodeficiency virus detected}, shortness of breath {Dyspnea}, cough {Cough}, CXR {Plain chest X-ray}, infiltrates {Infiltration}, PCP pneumonia {Pneumocystosis jirovecii pneumonia}, bronchoscopy {Bronchoscopy}, HIV antibody {Human immunodeficiency virus antibody test}, CD4 count {Absolute CD4 count procedure}, HIV VL {Human immunodeficiency virus viral load}, started {New medication added}, rash {Eruption of skin}, chest {Skin structure of chest}, arms {Upper limb structure}, itchy {Itching}, painful {Pain}, worsening {Increased pain}, oral pain {Painful mouth}, pain with swallowing {Swallowing painful}, fevers {Fever}, chills {Chill}, poor PO intake {Decrease in appetite}, thrush {Candidiasis}, oral
herpes {Oral herpes simplex infection}, maculopapular rash {Maculopapular rash}, mucositis {Inflammatory disease of mucous membrane}, referred to the
ED {Referral to accident and emergency service}, syndrome {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: Past Medical History:
Esophageal candidiasis
HIV/AIDS
Pneumocystis pneumonia
Hypertension
Vitamin D Deficiency
Tinea Barbae
Alcohol Abuse
###RESPONSE: Esophageal candidiasis {Candidiasis of the esophagus}, HIV {Human immunodeficiency virus infection}, AIDS {Acquired immune deficiency syndrome}, Pneumocystis pneumonia {Pneumocystosis jirovecii pneumonia}, Hypertension {Hypertensive disorder, systemic arterial}, Vitamin D Deficiency {Vitamin D deficiency}, Tinea Barbae {Tinea barbae}, Alcohol Abuse {Alcohol abuse} |
###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:
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History: Mother with DM, HTN, father with DM, HTN and
pacemaker.
###RESPONSE: DM {Diabetes mellitus}, HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, HTN {Hypertensive disorder, systemic arterial}, pacemaker {Implantation of cardiac pacemaker} |
###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:
PHYSICAL EXAM:
Vitals - T: 98.6 BP: 140/90 HR: 120 RR: 18 02 sat:98/RA
GENERAL: Pleasant, well appearing in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. Desquamation of mouth, lips,
oozing blood on lips, ginigivitis.
SKIN: Diffuse maculopapular rash, with red papules over chest,
arms, face, scrotum and legs.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or gallops.
LUNGS: CTAB, no wheezes, rales, rhonchi, good air movement
biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. ___ reflexes,
equal ___. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, 02 sat {Oxygen saturation measurement}, RA {Breathing room air}, GENERAL {General examination of patient}, well appearing {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, conjunctival pallor {Pale conjunctiva}, scleral icterus {Scleral icterus}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, Desquamation {Peeling of skin}, mouth {Mouth region structure}, lips {Lip structure}, oozing {Wound discharge}, ginigivitis {Gingivitis}, SKIN {Examination of skin}, rash {Eruption of skin}, papules {Papular eruption of chin}, over chest {Skin structure of chest}, arms {Upper limb structure}, face {Face structure}, scrotum {Scrotal structure}, legs {Lower limb structure}, CARDIAC {Cardiovascular physical examination}, Regular rhythm {Normal sinus rhythm}, normal rate {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, LUNGS {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, good air movement {Breath normal}, ABDOMEN {Examination of abdomen}, NABS {Normal bowel sounds}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, edema {Edema}, pain {Pain}, 2+ dorsalis pedis {Dorsalis pulse present}, posterior
tibial pulses {Posterior tibial pulse present}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, ecchymoses {Ecchymosis}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, Appropriate {Appropriate affect}, grossly intact {Normal nervous system function}, Preserved
sensation {Normal sensation}, reflexes {Normal reflex}, Normal coordination {Normal coordination}, Gait assessment {Gait evaluation}, PSYCH {Psychological assessment} |
###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:
___ 11:50AM BLOOD WBC-5.7 RBC-3.94* Hgb-11.7* Hct-34.1*
MCV-87 MCH-29.7 MCHC-34.4 RDW-16.3* Plt ___
___ 11:50AM BLOOD Neuts-63 Bands-2 Lymphs-12* Monos-19*
Eos-3 Baso-1 ___ Myelos-0
___ 11:50AM BLOOD ___ PTT-29.7 ___
___ 11:50AM BLOOD Glucose-107* UreaN-14 Creat-1.8* Na-126*
K-4.8 Cl-95* HCO3-20* AnGap-16
___ 11:50AM BLOOD ALT-34 AST-32 LD(LDH)-273* AlkPhos-50
TotBili-0.3
___ 05:56AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9
___ 11:45AM BLOOD Lactate-1.2 K-5.1
###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}, Lymphs {Lymphocyte count}, Monos {Monocyte 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}, LDH {Serum total lactate dehydrogenase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Lactate {Lactic acid measurement}, K {Blood potassium 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:
# ___: Bactrim was considered the most
likely causal agent was held. Dermatology was consulted on
admission. Skin biopsies were taken and he was started on
prednisone 80mg PO daily, with a planned taper over 4 weeks.
His bactrim, fluconazole and valtrex were stopped. Opthomology
was consulted and found no ocular involvement. His muscositis
pain was managed with lidocaine mouthwash, dexamthasone
mouthwash and PO vicodin. His rash and mucositis improved,
though he still had substantial painful desquamation of the
scrotuim on discharge.
.
# HIV/AIDS: Patient had recently been started on atripla. This
medication was initially held due to concern for low serum
bicarbonate, but was restarted once this resolved. He was
treated with inhaled pentamindine once for PCP ___. CXR
demonstrated no evidence of pneumonia.
.
# Hypertension/Tachycardia: On admission, patient was
tachycardic and hypertensive. He was intially restarted on his
home amlodipine and given IVF as there was concern that he was
hypovolemic. His amlodipine was stopped, and he was started on
metoprolol. His dose was titrated up to 50mg PO bid.
.
# Hyponatremia/ ARF: On admission, serum sodium was 126 and
creatine was 1.8. With aggresive fluid resusciation with normal
saline, these values returned the the normal range.
###RESPONSE: held {Recommendation to stop drug treatment}, Skin biopsies {Biopsy of skin}, started {New medication added}, stopped {Recommendation to stop drug treatment}, pain {Pain}, rash {Eruption of skin}, mucositis {Inflammatory disease of mucous membrane}, improved {Patient's condition improved}, painful {Pain}, desquamation {Peeling of skin}, scrotuim {Scrotal structure}, HIV {Human immunodeficiency virus infection}, AIDS {Acquired immune deficiency syndrome}, started {New medication added}, held {Recommendation to stop drug treatment}, restarted {Restart of medication}, resolved {Problem resolved}, PCP {Pneumocystosis jirovecii pneumonia}, CXR {Plain chest X-ray}, no evidence {No abnormality detected}, pneumonia {Pneumonia}, Hypertension {Hypertensive disorder, systemic arterial}, Tachycardia {Tachycardia}, tachycardic {Tachycardia}, hypertensive {Finding of increased blood pressure}, restarted {Restart of medication}, IVF {Administration of intravenous fluids}, hypovolemic {Hypovolemia}, stopped {Recommendation to stop drug treatment}, started {New medication added}, Hyponatremia {Hyponatremia}, ARF {Acute kidney injury}, serum sodium {Sodium measurement, serum}, creatine {Creatine measurement}, fluid resusciation {Resuscitation using intravenous fluid} |
###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 D 50,000 units q weekly
Nizoral 2% shampoo
Azithromycin 1000 mg po weekly
Atripla 1 po daily
Norvasc 10 mg po daily
Fluconazole 200 mg po daily x 10 days ___ day 1)
Ambien ___ mg po qhs prn insonia
Valtrex 1 gm po BID x 10 days for initial HSV outbreak ___ day
1)
Ibuprofen 600 mg po QID with meals prn pain, fever
Ammonium Lactate one application for dry skin
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic TID (3 times a day).
2. Hydrocodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*qs Tablet(s)* Refills:*2*
4. Zolpidem 5 mg Tablet Sig: ___ Tablets PO HS (at bedtime) as
needed for insomnia.
5. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain/fever.
6. Lidocaine HCl 2 % Solution Sig: Ten (10) ML Mucous membrane
QID (4 times a day) as needed for mouth pain.
Disp:*qs 100 ml* Refills:*5*
7. Prednisone 10 mg Tablet Sig: Please see below Tablet PO once
a day: 60mg daily (6 pills) for ___
then switch to 40 mg (4 pills) for 5 days, 20mg (2 pills) for 5
days, 10 mg (1 pills) for 5 days then stop.
Disp:*60 Tablet(s)* Refills:*0*
8. ATRIPLA ___ mg Tablet Sig: One (1) Tablet PO once a
day.
9. Dexamethasone 0.5 mg/5 mL Elixir Sig: ___ MLs PO BID (2
times a day).
Disp:*qs ML(s)* Refills:*2*
10. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO once a
week: As directed by Dr. ___.
11. Pentamidine 300 mg Recon Soln Sig: One (1) inhaler
Inhalation once a month: As directed by Dr. ___.
12. Maalox/Viscous Lidocaine 2%
1 part maalox (aluminum hydroxide/magnesium hydroxide), 1 part
viscous lidocaine 2%. Swish and swallow, four times daily as
needed for oral pain.
###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:
___
HIV/AIDS
Hypertension
Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: HIV {Human immunodeficiency virus infection}, AIDS {Acquired immune deficiency syndrome}, Hypertension {Hypertensive disorder, systemic arterial}, Tachycardia {Tachycardia}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were admitted with ___ syndrome, a condition
which affects the skin and mucous membranes. We think this was
caused by the antibiotic bactrim. You were treated with
steroids and pain medications. You will continue to take
steroids (prednisone) for several weeks as we taper the dose
down from 80mg to zero. You will take 60mg for 5 days, 40mg for
5 days, 20 mg for 5 days, 10 mg for 5 days, and then stop taking
it all together.
You should not take bactrim in the future. You can continue
taking atripla for your HIV infection, and will continue taking
weekly azithromax and monthly pentamidine to prevent you from
getting opportunistic infections, until your CD4 count raises or
your primary HIV doctor decides that you no longer need them.
These drugs should be safe and will not cause recurrence of your
___.
While you were here, you also showed signs of elevated heart
rate and blood pressure. We saw that Dr. ___
Cardiologist, had suggested you change from amlodipine (Norvasc)
to Metoprolol (Toprol), which will help keep your heart from
beating too fast and also help lower your blood pressure. We are
sending you home on a dose of 50mg Metoprolol twice daily, and
you should follow up with Dr. ___ to see if this is
appropriately controlling your heart rate and blood pressure.
The last thing you were followed for while here was your
shortness of breath. Given your history of PCP, we performed two
xrays to make sure you didn't have ongoing pneumonia. Your lungs
are currently clear, but you should ensure that you continue
taking your monthly pentamadine.
Please stop taking valtex and fluconazole. Discuss all
medication changes with your primary care doctor, ___.
###RESPONSE: syndrome {Disease}, skin {Skin structure}, mucous membranes {Mucous membrane structure}, antibiotic {Antibiotic therapy}, steroids {Steroid therapy}, pain medications {Administration of analgesic}, steroids {Steroid therapy}, stop taking {Recommendation to stop treatment}, continue
taking {Recommendation to continue with drug treatment}, HIV infection {Human immunodeficiency virus infection}, continue taking {Recommendation to continue with drug treatment}, prevent {Preventive procedure}, infections {Infectious disease}, CD4 count {Absolute CD4 count procedure}, HIV {Human immunodeficiency virus infection}, recurrence {Recurrent disease}, signs {Sign}, elevated heart
rate {Tachycardia}, blood pressure {Finding of increased blood pressure}, heart {Heart structure}, blood pressure {Finding of increased blood pressure}, heart rate {Cardiotachometry}, blood pressure {Blood pressure monitoring}, shortness of breath {Dyspnea}, PCP {Pneumocystosis jirovecii pneumonia}, pneumonia {Pneumonia}, lungs {Lung structure}, continue
taking {Recommendation to continue with drug treatment}, stop taking {Recommendation to stop treatment}, medication changes {Change of medication}, primary care {Primary care management} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness and worsening right sided weakness
Major Surgical or Invasive Procedure:
none
###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, dizziness {Dizziness}, right sided weakness {Right hemiparesis} |
###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:
___ Stroke Scale Score: 9
NIHSS performed within 6 hours of presentation at: ___ at
2325
NIHSS Total: 9
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 2 (residual)
5a. Motor arm, left: 0
5b. Motor arm, right: 2 (residual)
6a. Motor leg, left: 0
6b. Motor leg, right: 1 (residual)
7. Limb Ataxia: 0
8. Sensory: 1 (residual?)
9. Language: 1 (residual?)
10. Dysarthria: 1 (residual?)
11. Extinction and Neglect: 1 (residual?)
REASON FOR CONSULTATION: dizziness, intermittent right lower
extremity weakness throughout day
HPI:
___ is a ___ year old woman with history of
hypertension, hyperlipidemia, prior stroke with residual right
hemiparesis, localization-related epilepsy on Keppra and
lamotrigine, hypothyroidism, and glaucoma who presented to ED
from nursing home after new-onset dizziness this morning with
subsequent acute-on-chronic right lower extremity weakness.
History obtained by patient and as per chart review.
The patient reports that she was she had seen Dr. ___
yesterday in clinic to establish new neurology clinic follow-up.
No outside records were available for evaluation at that time
but
her baseline exam prior to new symptom onset was documented.
After her clinic appointment, she returned to her nursing home
in
usual state of health. She woke up this morning and felt well.
At
around 11AM, while urinating, she suddenly felt room-spinning
dizziness that resolved but was followed by an atypical
sensation
in her right lower extremity, described as heaviness and
weakness. She notes that she has lived with her residual stroke
deficits for ___ years and never felt anything like this in her
right leg. She tried to get up from the commode but did not have
the strength and as such called for help. Throughout the rest of
the day, she notes that her right sided weakness and heaviness
was intermittent. Her dizziness has since resolved. This
evening,
she noted that she was again feeling weaker in her right lower
extremity, requiring assistance to mobilize which is atypical
for
her. She thus requested ED evaluation and was brought to ___.
Since arrival at ___ (~ 15 minutes prior to my evaluation) she
notes her symptoms have started to improve again. She now thinks
she may be back at baseline, or close to it.
Per Dr. ___ initial clinic note on ___:
" Based on history, the patient suffered a stroke ___ years ago
and was left with right hemiparesis. Since the stroke she has
been on ASA 81 mg and had no recurrent events. She also suffers
from seizures with mouth foaming, shaking and urinary
incontinence, but no generalization. She is on Keppra for
her seizures and she has not had a seizure for a long time." His
exam at the time was notable for "mild aphasia and dysarthria
with right facial droop and right hemiparesis." He had no
outside
records at that time and as primary reason for visit was to
establish neurological care, he continued her on home dose of
atorvastatin 60mg, aspirin 81 mg per his note, Keppra, and
lamictal (for mood? is what is questioned in Dr. ___.
ROS:
Notable for above findings, otherwise noncontributory
PMH:
====
HYPERTENSION
HYPERLIPIDEMIA
HYPOTHYROIDISM
STROKE
SEIZURE DISORDER
GLAUCOMA
Surgical History (Last Verified ___ by ___,
MD):
Surgical History updated, no known surgical history.
Medications:
===========
***NEEDS MEDICATION RECONCILLIATION***
Keppra 500mg BID
lamotrigine 200mg BID (for mood)
Aspirin (either 81 or 325, unclear per chart review/med review
in
OMR)
metoprolol succinate 25mg ER qday
levothyroxine 50ucg qday
furosemide 20mg qday
baclofen 10mg PRN muscle spasm (BID)
atorvastin 60mg qPM
###RESPONSE: Stroke {Cerebrovascular accident}, NIHSS performed {Assessment using National Institutes of Health stroke scale}, Level of Consciousness {Assessment of consciousness level}, Visual fields {Visual field study}, Facial palsy {Facial palsy}, Motor {Motor testing}, arm, left {Structure of left upper limb}, Motor {Motor testing}, arm, right {Structure of right upper limb}, Motor {Motor testing}, leg, left {Structure of left lower limb}, Motor {Motor testing}, leg, right {Structure of right lower limb}, Limb {All extremities}, Ataxia {Ataxia}, Sensory {Sensory testing}, Dysarthria {Dysarthria}, dizziness {Dizziness}, lower
extremity weakness {Paresis of lower extremity}, hypertension {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, stroke {Cerebrovascular accident}, right
hemiparesis {Right hemiparesis}, localization-related epilepsy {Focal epilepsy}, hypothyroidism {Hypothyroidism}, glaucoma {Glaucoma}, dizziness {Dizziness}, chronic {Chronic disease}, right lower extremity weakness {Paresis of right lower limb}, chart review {Chart evaluation by healthcare professional}, evaluation {Evaluation procedure}, baseline {Baseline state}, exam {Physical examination procedure}, dizziness {Dizziness}, resolved {Problem resolved}, atypical
sensation {Abnormal sensation}, right lower extremity {Structure of right lower limb}, heaviness {Sensation of heaviness in limbs}, weakness {Asthenia}, stroke {Cerebrovascular accident}, deficits {Neurological deficit}, right leg {Structure of right lower leg}, right sided weakness {Right hemiparesis}, heaviness {Sensation of heaviness in limbs}, dizziness {Dizziness}, resolved {Problem resolved}, feeling weaker {Asthenia}, right lower
extremity {Structure of right lower limb}, assistance to mobilize {Difficulty mobilizing}, evaluation {Evaluation procedure}, evaluation {Evaluation procedure}, baseline {Baseline state}, stroke {Cerebrovascular accident}, right hemiparesis {Right hemiparesis}, stroke {Cerebrovascular accident}, seizures {Seizure}, mouth {Mouth region structure}, shaking {Tremor}, urinary
incontinence {Urinary incontinence}, seizures {Seizure}, seizure {Seizure}, exam {Physical examination procedure}, mild {Symptom mild}, aphasia {Aphasia}, dysarthria {Dysarthria}, right facial droop {Weakness of right facial muscle}, right hemiparesis {Right hemiparesis}, neurological care {Care of neurological patient}, mood {Mood management}, HYPERTENSION {Hypertensive disorder, systemic arterial}, HYPERLIPIDEMIA {Hyperlipidemia}, HYPOTHYROIDISM {Hypothyroidism}, STROKE {Cerebrovascular accident}, SEIZURE DISORDER {Seizure disorder}, GLAUCOMA {Glaucoma}, surgical {Surgical procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
=========
no known drug allergies
SOCIAL HISTORY:
Social History (Last Verified ___ by ___,
MD):
Lives with: Group setting
Tobacco use: Never smoker
Alcohol use: Denies
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
- Modified Rankin Scale:
[] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[x] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
FAMILY HISTORY:
notable for stroke and hypertension
PHYSICAL EXAMINATION:
Vitals:
T96.9, HR70-80s, RR16-24, BP140-180/70s 95 SaO2
Orthostatics:
137/81 supine with HR 78 --> standing HR 95; BP 161/92
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: trace pedal edema.
Neurologic:
-Mental Status: Alert and interactive with examiner. Oriented to
self and to situation. Able to follow midline and appendicular
commands. Has difficulty with two-step commands. Able to name
high and low frequency objects with exception of wristwatch
clasp
(refers to as band). Difficulty with ___ backwards and ___
backwards, after multiple attempts with either task says
___ Repetition intact.
No neglect.
-Cranial Nerves: PERRL 3>2. No nystagmus. Right eye does not
fully bury sclera on lateral gaze. Visual fields full to finger
counting. ? prior left bells palsy?. Right NLFF with delayed
activation. Facial musculature symmetric. Hearing intact to
conversation. Tongue midline. Slight dysarthria with guttural
sounds.
-Motor: Right hemibody is with increased tone and spasticity at
baseline. No adventitious movements.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 3 ___ 0 0 0 3 4 4 4 4 0
Per Dr. ___ ___
"R 2 ___ 0 0 0 2 -___ 4 2"
-Sensory: Diminished sensation to pinprick on right lower
extremity compared to left. Extinguishes to light touch with DSS
on right. Temperature, proprioception intact.
-Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 3 2 3 3
Plantar response was ? extensor on right, flexor on left.
-Coordination: No intention tremor. No dysmetria on FNF on left
and no decreased augmentation of movements with heel tapping on
right or left lower extremity.
-Gait: Deferred in setting of acute illness, without baseline
walker on hand
LABORATORY DATA:
___ 12:00AM BLOOD WBC: 4.4 RBC: 4.24 Hgb: 11.7 Hct: 38.5
MCV: 91 MCH: 27.6 MCHC: 30.4* RDW: 15.2 RDWSD: 50.4* Plt Ct: 244
___ 12:10AM BLOOD ___: 11.8 PTT: 28.3 ___: 1.1
___ 12:00AM BLOOD Glucose: 82 UreaN: 9 Creat: 0.8 Na: 142
K:
4.0 Cl: 104 HCO3: 28 AnGap: 10
___ 12:00AM BLOOD ALT: 18 AST: 28 AlkPhos: 90 TotBili: 0.5
___ 12:00AM BLOOD cTropnT: <0.01
___ 12:00AM BLOOD Albumin: 4.3 Calcium: 10.0 Phos: 2.7 Mg:
2.1
___ 12:00AM BLOOD ASA: NEG Ethanol: NEG Acetmnp: 8*
Tricycl:
NEG
___ 12:06AM BLOOD Glucose: 82 Lactate: 1.5 Creat: 0.7 Na:
139 K: 4.7 Cl: 108 calHCO3: 29
___ 12:06AM BLOOD Hgb: 12.5 calcHCT: 38
___ 02:36AM URINE Blood: NEG Nitrite: NEG Protein: NEG
Glucose: NEG Ketone: NEG Bilirub: NEG Urobiln: NEG pH: 6.5
Leuks:
NEG
___ 02:36AM URINE bnzodzp: NEG barbitr: NEG opiates: NEG
cocaine: NEG amphetm: NEG oxycodn: NEG mthdone: NEG
EKG: NSR
IMAGING:
NCHCT: multiple areas of encephalomalacia, including left
frontoparietal, left occipital, right frontal and right parietal
lobe suggestive of chronic incarcts. Prominent ventricles. ?
periventricular white matter hypodensity.
CTA head and neck: no large vessel occlusion, no significant
intracranial disease.
ASSESSMENT:
THis is a ___ year old woman with HTN, hyperlipidemia, prior
stroke with right hemiparesis, recently seen in stroke neurology
clinic, who presents today for new onset dizziness and
intermittent stuttering right lower extremity
weakness/heaviness.
Exam is notable for mild aphasia, which I suspect is at her
baseline as per Dr. ___ on ___. She is
slightly
inattentive to ___, which his mental exam also suggests was the
case two days prior. However, I do not some slightly more
profound right hemibody weakness as compared to his exam, with 0
in ___ (previously documented as 2). The patient also endorses
loss of pinprick sensation in right lower extremity and
extinguishes on the right with DSS.
The underlying etiology for her new symptoms remains unclear. I
am reassured by the resolution since arrival to the ED but am
concerned about the possibility of a stuttering lacune given the
intermittent right lower extremity weakness vs flow-dependent
perfusion states vs subclinical seizures vs stroke
recrudescence.
No obvious infectious triggers on routine lab work in ED. Given
new onset of waxing/waning symptoms with significant stroke risk
factors, admission is warranted for expedited management.
PLAN:
- Admit to stroke neurology service under attending Dr. ___.
# Neuro:
- MRI head
- Check risk factors: fasting lipid panel and HBA1c
- Consider increasing/transitioning aspirin
- Allow BP to autoregulate as below
- ___ consults
# CV:
- R/o MI with cardiac enzymes
- Monitor cardiac telemetry
- Allow BP to autoregulate with goal SBP<180 (goal 140-180s)
- Hydralazine 10 mg IV q6h prn SBP > 180
- Hold home antihypertensives / halve dose of beta-blocker
- Trans-thoracic echo
# Pulmonary:
- Monitor oximetry
- Screening CXR
# GI/Nutrition:
- NPO until passes water swallowing screen
- Cardiac heart healthy diet once passess
- Bowel regimen with Senna, Colace
# Renal:
- Baseline Cr: 0.7
- Continue to trend
- mIVF @ 70cc/hr for 1L pending PO eval
# Endocrine:
- TSH, A1c
- Finger sticks QID
- Insulin sliding scale
# Toxic/Metabolic:
- Check LFTs
- Check urine and serum toxin screens
# ID:
- Check UA
- Check CXR
# Heme:
- Baseline Hgb: 11.7
# Psychiatric/Behavioral:
- No active issues
# Hospital Issues:
- DVT PPx: Pneumoboots, SQ heparin
- Precautions: Fall, Aspiration
- Restraints: none
- Health Care Proxy: unknown
- Code Status: full
###RESPONSE: drug allergies {Allergy to drug}, Never smoker {Never smoked tobacco}, disability {Disability}, able to carry out all usual
activities {Able to carry out daily routine}, disability {Disability}, disability {Disability}, able to walk {Able to walk}, disability {Disability}, unable to walk {Unable to walk}, disability {Disability}, requires constant nursing care {Nursing assistance required}, Dead {Dead}, stroke {Cerebrovascular accident}, hypertension {Hypertensive disorder, systemic arterial}, standing {Orthostatic body position}, Awake {Awake}, cooperative {Cooperative mental state}, scleral icterus {Scleral icterus}, MMM {Moist oral mucosa}, lesions noted in
oropharynx {Lesion of oropharynx}, Supple {Normal movement of neck}, nuchal rigidity {Nuchal rigidity}, RRR {Normal heart rate}, warm {Warm skin}, well-perfused {Normal tissue perfusion}, Soft {Abdomen soft}, non-distended {Normal abdominal contour}, pedal edema {Edema of foot}, Mental Status {Neurological mental status determination}, Alert {Mentally alert}, interactive {Does communicate}, Oriented {Oriented to person}, Repetition {Verbal repetition}, PERRL {Pupils equal and reacting to light}, nystagmus {Nystagmus}, Right eye {Right eye structure}, sclera {Scleral structure}, Visual fields {Visual field study}, full to finger
counting {Full to finger counting}, bells palsy {Bell's palsy}, Facial musculature symmetric {Facial symmetry}, Hearing intact {Hearing normal}, Tongue {Tongue structure}, dysarthria {Dysarthria}, increased tone {Increased muscle tone}, spasticity {Spasticity}, baseline {Baseline state}, adventitious movements {Involuntary movement}, Delt {Structure of deltoid muscle}, Bic {Biceps brachii muscle structure}, Tri {Triceps brachii muscle structure}, WrE {Structure of extensor of wrist joint}, FFl {Structure of flexor of interphalangeal joint of finger}, FE {Structure of extensor muscle of forearm}, IO {Structure of intrinsic muscle of hand}, IP {Structure of iliopsoas muscle}, Quad {Structure of quadriceps femoris muscle}, Ham {Posterior muscle of thigh structure}, TA {Tibialis anterior muscle structure}, Diminished sensation {Hypesthesia}, pinprick {Finding of pin prick discrimination}, right lower
extremity {Structure of right lower limb}, left {Structure of left lower limb}, light touch {Light touch sensation present}, right {Structure of right lower limb}, proprioception intact {Normal joint position sense}, Plantar response was ? extensor on right {Extensor plantar response right}, flexor on left {Plantar response-L=flexor}, intention tremor {Intention tremor}, dysmetria {Dysmetria}, FNF {Finger-to-nose test}, heel {Heel structure}, right {Structure of right lower limb}, left lower extremity {Structure of left lower limb}, baseline {Baseline state}, walker {Uses zimmer frame}, NSR {Normal sinus rhythm}, NCHCT {Computed tomography of head without contrast}, encephalomalacia {Encephalomalacia}, left
frontoparietal {Left frontal and parietal lobes (combined site)}, left occipital {Left occipital lobe structure}, right frontal {Right frontal lobe structure}, right parietal
lobe {Right parietal lobe structure}, chronic {Chronic disease}, incarcts {Infarct}, ventricles {Brain ventricle structure}, periventricular white matter {Structure of periventricular white matter}, CTA head and neck {Computed tomography angiography of head and neck with contrast}, large vessel {Large blood vessel structure}, occlusion {Complete obstruction}, intracranial {Intracranial structure}, disease {Disease}, HTN {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, stroke {Cerebrovascular accident}, right hemiparesis {Right hemiparesis}, stroke {Cerebrovascular accident}, dizziness {Dizziness}, lower extremity
weakness {Paresis of lower extremity}, heaviness {Sensation of heaviness in limbs}, Exam {Physical examination procedure}, mild {Symptom mild}, aphasia {Aphasia}, baseline {Baseline state}, right hemibody weakness {Right hemiparesis}, exam {Physical examination procedure}, pinprick {Finding of pin prick discrimination}, sensation {Abnormal sensation}, right lower extremity {Structure of right lower limb}, lacune {Lacunar infarction}, right lower extremity weakness {Paresis of right lower limb}, perfusion {Perfusion}, seizures {Seizure}, stroke {Cerebrovascular accident}, infectious {Infectious disease}, significant stroke risk {At increased risk of cerebrovascular accident}, neurology service {Neurology service}, Neuro {Neurological examination}, MRI head {Magnetic resonance imaging of head}, fasting {Fasting}, lipid panel {Lipid panel}, MI {Myocardial infarction}, cardiac enzymes {Cardiac enzymes/isoenzymes measurement}, cardiac telemetry {Cardiac telemetry}, IV {Administration of drug or medicament via intravenous route}, Trans-thoracic echo {Transthoracic echocardiography}, oximetry {Oximetry}, CXR {Plain chest X-ray}, NPO {Nil by mouth}, healthy diet {Healthy diet}, regimen {Therapeutic regimen}, Baseline {Baseline state}, TSH {Thyroid stimulating hormone measurement}, Finger sticks {Finger-prick sampling}, Insulin sliding scale {Sliding scale insulin regime}, LFTs {Hepatic function panel}, urine {Urinalysis}, UA {Urinalysis}, CXR {Plain chest X-ray}, Baseline {Baseline state}, Hgb {Measurement of total hemoglobin concentration}, DVT {Deep venous thrombosis}, PPx {Preventive procedure}, Precautions {Safety precautions}, Fall {Falls}, Aspiration {Pulmonary aspiration} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
HYPERTENSION
HYPERLIPIDEMIA
HYPOTHYROIDISM
STROKE
SEIZURE DISORDER
GLAUCOMA
###RESPONSE: HYPERTENSION {Hypertensive disorder, systemic arterial}, HYPERLIPIDEMIA {Hyperlipidemia}, HYPOTHYROIDISM {Hypothyroidism}, STROKE {Cerebrovascular accident}, SEIZURE DISORDER {Seizure disorder}, GLAUCOMA {Glaucoma} |
###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:
notable for stroke and hypertension
###RESPONSE: stroke {Cerebrovascular accident}, hypertension {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: Physical Exam:
24 HR Data (last updated ___ @ 423)
Temp: 98.3 (Tm 98.4), BP: 113/71 (113-145/71-84), HR: 72
(65-94), RR: 16 (___), O2 sat: 96% (96-98), O2 delivery: Ra
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Extremities: trace pedal edema.
Neurologic:
-Mental Status: Alert and interactive with examiner. Oriented to
self and to situation. Able to follow midline and appendicular
commands. Has difficulty with two-step commands. Repetition
intact.
-Cranial Nerves: PERRL 3>2. No nystagmus. Right eye does not
fully bury sclera on lateral gaze. Visual fields full to finger
counting. Right NLFF with delayed activation. Facial musculature
symmetric. Hearing intact to conversation. Tongue midline.
Slight
dysarthria with guttural sounds.
-Motor: Right hemibody is with increased tone and spasticity at
baseline. No adventitious movements.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 3 4 4- 0 0 0 0 3 4 4 4- 4 0
Per Dr. ___ ___
"R 2 ___ 0 0 0 2 -___ 4 2"
-Sensory: deferred
-Reflexes: deferred
Plantar response was extensor on right, flexor on left.
-Coordination: No intention tremor. No dysmetria on FNF on left
and no decreased augmentation of movements with heel tapping on
right or left lower extremity.
-Gait: Deferred
###RESPONSE: O2 sat {Oxygen saturation measurement}, General {General examination of patient}, Awake {Awake}, cooperative {Cooperative mental state}, HEENT {Physical examination procedure}, scleral icterus {Scleral icterus}, MMM {Moist oral mucosa}, lesions noted in
oropharynx {Lesion of oropharynx}, Supple {Normal movement of neck}, nuchal rigidity {Nuchal rigidity}, Pulmonary {Examination of respiratory system}, Cardiac {Cardiovascular physical examination}, RRR {Normal heart rate}, warm {Warm skin}, well-perfused {Normal tissue perfusion}, Extremities {Examination of limb}, pedal edema {Edema of foot}, Neurologic {Neurological examination}, Mental Status {Neurological mental status determination}, Alert {Mentally alert}, interactive {Does communicate}, Oriented {Oriented to person}, Repetition {Verbal repetition}, Cranial Nerves {Examination of cranial nerve}, PERRL {Pupils equal and reacting to light}, nystagmus {Nystagmus}, Right eye {Right eye structure}, sclera {Scleral structure}, Visual fields {Visual field study}, full to finger
counting {Full to finger counting}, Facial musculature
symmetric {Facial symmetry}, Hearing intact {Hearing normal}, Tongue {Tongue structure}, dysarthria {Dysarthria}, Motor {Motor testing}, increased tone {Increased muscle tone}, spasticity {Spasticity}, baseline {Baseline state}, adventitious movements {Involuntary movement}, Delt {Structure of deltoid muscle}, Bic {Biceps brachii muscle structure}, Tri {Triceps brachii muscle structure}, WrE {Structure of extensor of wrist joint}, FFl {Structure of flexor of interphalangeal joint of finger}, FE {Structure of extensor muscle of forearm}, IO {Structure of intrinsic muscle of hand}, IP {Structure of iliopsoas muscle}, Quad {Structure of quadriceps femoris muscle}, Ham {Posterior muscle of thigh structure}, TA {Tibialis anterior muscle structure}, Sensory {Sensory testing}, Reflexes {Reflex studies}, Plantar response was extensor on right {Extensor plantar response right}, flexor on left {Plantar response-L=flexor}, intention tremor {Intention tremor}, dysmetria {Dysmetria}, FNF {Finger-to-nose test}, heel {Heel structure}, right {Structure of right lower limb}, left lower extremity {Structure of left lower limb}, Gait {Examination of gait} |
###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:
___ 06:00AM ALT(SGPT)-16 AST(SGOT)-22 LD(LDH)-236
CK(CPK)-134 ALK PHOS-83 TOT BILI-0.4
___ 06:00AM CK-MB-3 cTropnT-<0.01
___ 06:00AM ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-2.6*
MAGNESIUM-2.1 CHOLEST-154
___ 06:00AM %HbA1c-5.3 eAG-105
___ 06:00AM TRIGLYCER-40 HDL CHOL-76 CHOL/HDL-2.0
LDL(CALC)-70
___ 06:00AM TSH-7.9*
___ 06:00AM T4-8.1
___ 06:00AM WBC-4.7 RBC-4.00 HGB-11.0* HCT-36.4 MCV-91
MCH-27.5 MCHC-30.2* RDW-15.2 RDWSD-50.2*
___ 06:00AM ___ PTT-28.2 ___
___ 02:36AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 12:10AM ___ PTT-28.3 ___
___ 12:06AM GLUCOSE-82 LACTATE-1.5 CREAT-0.7 NA+-139
K+-4.7 CL--108 TCO2-29
___ 12:06AM HGB-12.5 calcHCT-38
___ 12:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-8*
tricyclic-NEG
CT Head/ neck:
1. Multifocal areas of encephalomalacia as described above,
largest in the
left frontoparietal lobe. This limits sensitivity for acute
territorial
infarction. Consider further evaluation with MRI.
2. Small chronic infarct left thalamus.
3. No evidence of acute intracranial hemorrhage.
4. Patent head and neck vasculature with no evidence of focal
stenosis,
occlusion, or aneurysm.
5. Right thyroid lobe nodule measuring 1.9 cm.
MR brain:
1. Study is moderately degraded by motion.
2. Multiple bilateral supratentorial chronic infarcts, largest
in the left MCA territory, with evidence of probable chronic
blood products within right parieto-occipital infarct.
3. No acute infarct or extra-axial collection.
###RESPONSE: ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, PHOS {Phosphate, total measurement}, TOT BILI {Bilirubin, total measurement}, cTropnT {Troponin T cardiac measurement}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium measurement}, CHOLEST {Cholesterol measurement}, eAG {Glucose measurement estimated from glycated hemoglobin}, TSH {Thyroid stimulating hormone 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}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, CL {Chloride measurement, blood}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, encephalomalacia {Encephalomalacia}, left frontoparietal lobe {Left frontal and parietal lobes (combined site)}, infarction {Cerebral infarction}, evaluation {Evaluation procedure}, MRI {Magnetic resonance imaging of head}, infarct left thalamus {Thalamic infarction}, No evidence {No abnormality detected}, intracranial hemorrhage {Intracranial hemorrhage}, no evidence {No abnormality detected}, stenosis {Stenosis of artery}, occlusion {Occlusion of artery}, aneurysm {Arterial aneurysm}, thyroid lobe nodule {Thyroid nodule}, supratentorial {Supratentorial brain structure}, infarcts {Cerebral infarction}, left MCA {Structure of left middle cerebral artery}, right parieto-occipital {Right parietal and occipital lobes (combined site)}, infarct {Right sided cerebral infarction}, acute infarct {Cerebral infarction} |
###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:
Hospital Course:
___ is a ___ year old woman with history of
hypertension, hyperlipidemia, prior stroke with residual right
hemiparesis, localization-related epilepsy on Keppra and
lamotrigine, hypothyroidism, and glaucoma who presented to ED
from nursing home after new-onset dizziness with subsequent
acute-on-chronic right lower extremity weakness. Dizziness
resolved but reported right sided "heaviness" persisted more so
than her baseline deficit and thus was admitted to the stroke
service. Upon admission to stroke service, underlying etiology
for her new symptoms remained unclear. Cardiac origin ruled out
with EKG and telemetry. There was resolution since arrival to
the ED but concerning with possibility of a stuttering lacune
given the intermittent right lower extremity weakness vs
flow-dependent perfusion states vs subclinical seizures vs
stroke recrudescence. No obvious infectious triggers on routine
lab work in ED. Ultimately determined to have no stroke on MRI
but given risk factors and past stroke burden, diagnosis of
nonspecific sequela of cerebral infarction.
#Nonspecific Sequela of infarction: patient reportedly had
intermittent weakness and dizziness while at her facility. Upon
assessment in the ED, her symptoms had significantly improved
and she reported basically being back to baseline. NCHCT was
ordered and read as showing multiple areas of encephalomalacia,
including left frontoparietal, left occipital, right frontal and
right parietal lobe suggestive of chronic infarcts. Prominent
ventricles and periventricular white matter hypodensity. CTA
head and neck showed no large vessel occlusion, no significant
and no intracranial disease. She was admitted to the stroke
service and an MRI brain was ordered. MR brain read as: Multiple
bilateral supratentorial chronic infarcts, largest in the left
MCA territory, with evidence of probable chronic blood products
within right parieto-occipital infarct. No acute infarct or
extra-axial collection. Stroke risk factor labs sent. TTE was
done and found to have EF of 60, no cardiac origin of emboli
observed and no PFO. ___ recommended ___ rehab. She was
kept on ASA 325 mg. Atorvastatin 60mg kept on.
#HYPERTENSION
She was initially taken off of her home BP meds and given BP
chance to autoregulate given concern for stroke. Once new
infarct ruled out on imaging, home BP meds added back.
Metoprolol 25mg PO daily
#HYPERLIPIDEMIA
She will be sent home on atorvastatin 60mg.
#HYPOTHYROIDISM
Her TSH was found to be elevated at 7.9 and her home
levothyroxine was increased from 50 to 62mg qday. Her PCP ___
need to continue trending TSH while outpatient.
#SEIZURE DISORDER
Initial concern that her symptoms potentially were related to
seizure however no further concern and home medications were not
changed. She arrived on lamotrigine 200mg BID and keppra 500 BID
which she remained on.
#GLAUCOMA
No issues while inpatient.
Transitional Issues:
[ ] PCP: trend TSH. Levothyroxine increased from 50 to 62.5mcg
daily given TSH 7.9.
Core Measures:
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL =70 ) - () No
5. Intensive statin therapy administered? atorvastatin 60mg LDL
> 70) (x) Yes - () No
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
10. Discharged on antithrombotic therapy? ASA 325
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - If no, why not (I.e.
bleeding risk, etc.)
###RESPONSE: hypertension {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, stroke {Cerebrovascular accident}, right
hemiparesis {Right hemiparesis}, localization-related epilepsy {Focal epilepsy}, hypothyroidism {Hypothyroidism}, glaucoma {Glaucoma}, dizziness {Dizziness}, right lower extremity weakness {Paresis of right lower limb}, Dizziness {Dizziness}, resolved {Problem resolved}, right sided {Structure of right half of body}, heaviness {Sensation of heaviness in limbs}, baseline {Baseline state}, deficit {Neurological deficit}, Cardiac {Heart disease}, EKG {Electrocardiographic procedure}, telemetry {Cardiac telemetry}, lacune {Lacunar infarction}, right lower extremity weakness {Paresis of right lower limb}, perfusion {Perfusion}, seizures {Seizure}, stroke {Cerebrovascular accident}, infectious {Infectious disease}, stroke {Cerebrovascular accident}, MRI {Magnetic resonance imaging of head}, risk factors and past stroke burden {At increased risk of cerebrovascular accident}, cerebral infarction {Cerebral infarction}, infarction {Cerebral infarction}, weakness {Asthenia}, dizziness {Dizziness}, assessment {Evaluation procedure}, improved {Patient's condition improved}, baseline {Baseline state}, NCHCT {Computed tomography of head without contrast}, encephalomalacia {Encephalomalacia}, left frontoparietal {Left frontal and parietal lobes (combined site)}, left occipital {Left occipital lobe structure}, right frontal {Right frontal lobe structure}, right parietal lobe {Right parietal lobe structure}, infarcts {Cerebral infarction}, ventricles {Brain ventricle structure}, periventricular white matter {Structure of periventricular white matter}, CTA
head and neck {Computed tomography angiography of head and neck with contrast}, large vessel {Large blood vessel structure}, occlusion {Occlusion of cerebral artery}, intracranial {Intracranial structure}, disease {Disease}, MRI brain {Magnetic resonance imaging of brain}, MR brain {Magnetic resonance imaging of brain}, supratentorial {Supratentorial brain structure}, infarcts {Cerebral infarction}, left
MCA {Structure of left middle cerebral artery}, right parieto-occipital {Right parietal and occipital lobes (combined site)}, infarct {Cerebral infarction}, acute infarct {Acute infarct}, Stroke {Cerebrovascular accident}, TTE {Transthoracic echocardiography}, cardiac {Heart structure}, emboli {Embolus}, HYPERTENSION {Hypertensive disorder, systemic arterial}, stroke {Cerebrovascular accident}, infarct {Cerebral infarction}, imaging {Imaging}, HYPERLIPIDEMIA {Hyperlipidemia}, HYPOTHYROIDISM {Hypothyroidism}, TSH was found to be elevated {Thyroid stimulating hormone level above reference range}, PCP {Primary care management}, SEIZURE DISORDER {Seizure disorder}, seizure {Seizure}, GLAUCOMA {Glaucoma}, PCP {Primary care management}, Ischemic Stroke {Ischemic stroke}, Transient Ischemic
Attack {Transient ischemic attack}, Dysphagia screening {Screening for dysphagia}, DVT Prophylaxis {Prevention of deep vein thrombosis}, bleeding risk {At increased risk of hemorrhage}, hemorrhage {Bleeding}, Antithrombotic therapy {Continuous infusion of antithrombotic}, bleeding risk {At increased risk of hemorrhage}, hemorrhage {Bleeding}, LDL {Low density lipoprotein cholesterol measurement}, statin therapy {Administration of prophylactic statin}, Smoking cessation counseling {Smoking cessation education}, non-smoker {Non-smoker}, Stroke education {Education about cerebrovascular accident}, stroke {Cerebrovascular accident}, stroke {Cerebrovascular accident}, warning signs and symptoms {Discussion about clinical red flag warning sign}, Assessment for rehabilitation {Assessment for rehabilitation}, baseline {Baseline state}, statin therapy {Administration of prophylactic statin}, oral {Administration of drug or medicament via oral route}, anticoagulation {Anticoagulant therapy}, atrial
fibrillation {Atrial fibrillation}, flutter {Atrial flutter}, bleeding risk {At increased risk of hemorrhage} |
###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. Levothyroxine Sodium 50 mcg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Vitamin D ___ UNIT PO MONTHLY
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. LevETIRAcetam 500 mg PO BID
7. LamoTRIgine 200 mg PO BID
8. Furosemide 20 mg PO DAILY
9. Baclofen 15 mg PO QPM
10. Atorvastatin 60 mg PO QPM
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 60 mg PO QPM
3. Baclofen 15 mg PO QPM
4. Furosemide 20 mg PO DAILY
5. LamoTRIgine 200 mg PO BID
6. LevETIRAcetam 500 mg PO BID
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Vitamin D ___ UNIT PO MONTHLY
###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:
Nonspecific Sequela of Infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: Infarction {Cerebral infarction}, 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:
Dear Ms. ___,
You were hospitalized due to symptoms of dizziness and right
sided weakness resulting from what we believe to be nonspecific
sequela of cerebral infarction. You were not found to have a new
stroke on MRI, however you have a history of residual problems
from past stroke and your new symptoms seemed consistent with
stroke. We believe that your new symptoms are likely secondary
to your stroke risk factors and related to old stroke. We would
like you to continue your current home meds and to continue
following closely with outpatient neurology in order to best
prevent further strokes. A stroke is a condition where a blood
vessel providing oxygen and nutrients to the brain is blocked by
a clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are: high blood pressure, high
cholesterol.
We are not changing your home medications.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
###RESPONSE: dizziness {Dizziness}, right
sided weakness {Right hemiparesis}, cerebral infarction {Cerebral infarction}, stroke {Cerebrovascular accident}, MRI {Magnetic resonance imaging of head}, problems {Problem}, stroke {Cerebrovascular accident}, stroke {Cerebrovascular accident}, stroke {Cerebrovascular accident}, stroke {Cerebrovascular accident}, strokes {Cerebrovascular accident}, stroke {Cerebrovascular accident}, blood
vessel {Blood vessel structure}, brain {Brain structure}, clot {Blood clot}, brain {Brain structure}, damage {Damage}, brain {Brain structure}, Stroke {Cerebrovascular accident}, stroke {Cerebrovascular accident}, strokes {Cerebrovascular accident}, high blood pressure {Hypertensive disorder, systemic arterial}, high
cholesterol {Hypercholesterolemia}, follow up with Neurology {Follow-up neurological assessment}, stroke {Cerebrovascular accident}, loss of vision {Functional visual loss}, loss of the ability to speak {Follow-up neurological assessment}, mouth {Mouth region structure}, loss of the ability to understand {Abnormal ability to understand}, weakness of one side of the body {Hemiparesis}, drooping of one side of the face {Facial hemiparesis}, loss of sensation {Numbness} |
###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: CARDIOTHORACIC
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Codeine / adhesive tape / Percocet
Attending: ___.
Chief Complaint:
Recurrent chest pain, fatigue
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Grafting x 2 (left internal mammary
artery to the left anterior descending coronary artery;
saphenous vein graft to the obtuse marginal branch)
###RESPONSE: Codeine {Allergy to codeine}, adhesive tape {Allergy to adhesive agent}, chest pain {Chest pain}, fatigue {Fatigue}, Coronary Artery Bypass Grafting x 2 {Coronary artery bypass grafts x 2}, left internal mammary
artery {Structure of left internal thoracic artery}, left anterior descending coronary artery {Structure of anterior descending branch of left coronary artery}, saphenous vein graft {Aortocoronary artery bypass of one coronary artery with saphenous vein graft}, obtuse marginal {Structure of obtuse marginal branch of circumflex branch of left coronary artery} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Mrs. ___ is a ___ year old female with multiple cardiac risk
factors who
presented with recurrent chest pain concerning for angina.
Stress test was notable for mild anteroseptal ischemia.
Subsequent cardiac catheterization showed 60% left main lesion.
Of note, she has history of SVT. She reported
occasional episodes of palpitations and diaphoresis sometimes
associated with chest pain. These episodes occurred several
times per week. Based upon the above findings, she was referred
to Dr. ___ surgical revascularization.
###RESPONSE: cardiac risk
factors {Assessment for risk of cardiovascular disease}, chest pain {Chest pain}, angina {Angina}, Stress test {Electrocardiogram with exercise test}, anteroseptal ischemia {Ischemia of myocardium of anteroseptal region}, cardiac catheterization {Cardiac catheterization}, left main {Left coronary artery structure}, lesion {Lesion}, SVT {Supraventricular tachycardia}, palpitations {Palpitations}, diaphoresis {Excessive sweating}, chest pain {Chest pain}, surgical {Surgical procedure}, revascularization {Heart revascularization} |
###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. Hypertension
2. Dyslipidemia
3. Type II Diabetes Mellitus
4. History of SVT
5. Abdominal Aortic Aneurysm - incidental finding on cath
Past Surgical History:
1. s/p Open Cholecystectomy
2. s/p Appendectomy
###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, Dyslipidemia {Dyslipidemia}, Type II Diabetes Mellitus {Diabetes mellitus type 2}, SVT {Supraventricular tachycardia}, Abdominal Aortic Aneurysm {Abdominal aortic aneurysm}, cath {Cardiac catheterization}, Cholecystectomy {Cholecystectomy}, Appendectomy {Excision of appendix} |
###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 myocardial infarction in his ___
###RESPONSE: died {Dead}, myocardial infarction {Myocardial infarction} |
###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:
HR: 77 BP: 133/77 RR: 16 O2 sat: 99% RA
Height: 61 inches Weight: 145 lbs
General: Well-developed female in no acute distress
Skin: Warm [X] Dry [X] Intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X] JVD []
Chest: Lungs clear bilaterally [X]
Heart: RRR [X], No murmur/rub/Gallop
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema -, Slight rash on
bilateral forearms.
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
___ Right: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Discharge Exam:
Carotid Bruit Right: - Left: -
Discharge Exam:
VS: T: 98.3 HR: 80-90's SR BP: 98-111/60 Sats: 96% RA
WT: 65 Kg preop 65.7 Kg
General: ___ year-old female in no apparent distress
HEENT: normocephalic
Card: RRR normal S1,S2 no murmur
Resp: clear breath sounds throughout
GI: benign
Extr: warm no edema
Wound: sternal and RLE clean dry intact no erythema. sternum
stable
Neuro: awake, alert oriented. ambulating in halls
###RESPONSE: HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, Height {Height / growth finding}, Weight {Weight finding}, General {General examination of patient}, distress {Distress}, Skin {Examination of skin}, Warm {Warm skin}, Intact {Intact skin}, HEENT {Physical examination procedure}, NC {Normal head}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Full ROM {Normal range of cervical spine movement}, JVD {Jugular venous engorgement}, Chest {Examination of respiratory system}, Lungs {Examination of respiratory system}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, murmur {Murmur}, rub {Pleural friction rub}, Gallop {Gallop rhythm}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-distended {Normal abdominal contour}, non-tender {Abdominal tenderness}, bowel sounds {Normal bowel sounds}, Extremities {Examination of limb}, Warm {Warm skin}, well-perfused {Normal tissue perfusion}, Edema {Edema}, rash {Eruption of skin}, forearms {Forearm structure}, Varicosities {Venous varices}, Neuro {Neurological examination}, Grossly intact {Normal nervous system function}, Femoral {Structure of femoral artery}, Right: 2+ {Pulse present in right femoral artery}, Left: 2+ {Pulse present in left femoral artery}, DP {Structure of dorsalis pedis artery}, Right: 2 {Pulse present in right dorsalis pedis artery}, Left: 2+ {Pulse present in left dorsalis pedis artery}, Right: 2 {Normal pulse in right dorsalis pedis artery}, Left: 2 {Pulse present in left femoral artery}, Radial {Structure of radial artery}, Right {Structure of right radial artery}, Left {Structure of left radial artery}, Carotid Bruit {Carotid bruit}, Right {Structure of right carotid artery}, Left {Structure of left carotid artery}, VS {Vital signs finding}, RA {Breathing room air}, preop {Preoperative state}, General {General examination of patient}, distress {Distress}, HEENT {Physical examination procedure}, normocephalic {Normal head}, Card {Structure of cardiovascular system}, RRR {Normal heart rate}, normal S1,S2 {Heart sounds normal}, murmur {Murmur}, Resp {Examination of respiratory system}, clear breath sounds {Normal breath sounds}, GI {Examination of digestive system}, Extr {Examination of limb}, warm {Warm skin}, edema {Edema}, sternal {Sternal skin structure}, RLE {Skin structure of right lower limb}, clean dry intact {Wound healing well}, erythema {Erythema}, sternum {Sternal skin structure}, Neuro {Neurological examination}, awake {Awake}, alert {Mentally alert}, oriented {Orientated}, ambulating {Fully mobile} |
###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:
Cardiac Catheterization
Right dominant system. Left main coronary artery with ostial
60% stenosis. Left anterior descending and left circumflex
arteries had no aniographically apparent coronary artery
disease. The right coronary artery had proximal 30% lesion.
Estimated LVEF was 60%. Abdominal aortogram showed distal
aneurysm.
Labs:
___ WBC-7.1 RBC-3.11* Hgb-9.5* Hct-27.8* MCV-90 MCH-30.5
MCHC-34.0 RDW-12.8 Plt ___
___ WBC-7.6# RBC-3.29*# Hgb-10.2*# Hct-28.6*# MCV-87
MCH-30.9 MCHC-35.5* RDW-12.8 Plt ___
___ Glucose-158* UreaN-12 Creat-0.6 Na-129* K-4.2 Cl-91*
HCO3-34
___ Glucose-128* UreaN-11 Creat-0.5 Na-127* K-4.1 Cl-90*
HCO3-33
___ Glucose-148* UreaN-10 Creat-0.6 Na-130* K-4.1 Cl-92*
HCO3-29
___ UreaN-9 Creat-0.4 Na-137 K-3.3 Cl-108 HCO3-23
___ Mg-1.9
___ Hgb-8.7* calcHCT-26
___ MRSA SCREEN (Final ___: No MRSA isolated.
Chest X-Ray ___: There is evidence of bilateral basal
atelectasis, left more than right. In addition, a minimal left
pleural
effusion cannot be excluded. The sternal wires and the
postoperative clips are in unchanged position. No overt
pulmonary edema. No pneumothorax.
###RESPONSE: Cardiac Catheterization {Cardiac catheterization}, Right dominant system {Right dominant coronary system}, Left main coronary artery {Structure of left coronary artery main stem}, stenosis {Stenosis}, Left anterior descending {Structure of anterior descending branch of left coronary artery}, left circumflex
arteries {Structure of circumflex branch of left coronary artery}, disease {Disease}, right coronary artery had proximal {Structure of proximal portion of right coronary artery}, lesion {Lesion}, Abdominal aortogram {Abdominal aortogram}, aneurysm {Aneurysm}, 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}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, 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}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, Mg {Blood magnesium measurement}, Hgb {Measurement of total hemoglobin concentration}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, MRSA {Methicillin resistant Staphylococcus aureus infection}, Chest X-Ray {Plain chest X-ray}, atelectasis {Atelectasis}, left {Left lung structure}, right {Right lung structure}, left {Structure of left pleural cavity}, pleural
effusion {Pleural effusion}, sternal {Structure of sternal region}, pulmonary edema {Pulmonary edema}, pneumothorax {Pneumothorax} |
###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:
She was admitted to ___ on ___ and was taken to the
operating room. She underwent Coronary Artery Bypass Grafting x
2 (left internal mammary artery to the left anterior descending
coronary artery; saphenous vein graft to the obtuse marginal
branch). She tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and invasive monitoring.
She weaned from sedation, awoke neurologically intact and was
extubated on POD 1. She was weaned from inotropic and
vasopressor support. She remained hemodynamically stable and was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
Respiratory: aggressive pulmonary toilet and nebs she titrated
off oxygen.
Cardiac: Beta-blockers were titrated for rate control Lopressor
50 mg tid. She remained in sinus rhythm without ectopy. Blood
pressure was initially high 130-140's her losartan 50 mg was
restarted but required titration down to 25 mg daily for SBP
98-111. Aspirin and Statin were resumed.
GI: benign PPI and bowel regime continued
Renal: renal function within normal limits. She was gently
diuresed to her preop weight of 65.7 Kg.
Hyponatremia: Na+ 12. With free water restriction it slowly
trend ed up. Discharge Na 129. She was asymptomatic.
Endocrine: IV insulin and sliding scale for good blood sugar
control. Once taken PO medication her metformin and Glyburide
were resumed.
Disposition: She was evaluated by the physical therapy service
for assistance with strength and mobility. By the time of
discharge on POD 4 she was ambulating freely, the wound was
healing, and pain was controlled with oral analgesics. She was
discharged home with ___ in good condition with appropriate
follow up instructions.
###RESPONSE: Coronary Artery Bypass Grafting x
2 {Coronary artery bypass grafts x 2}, left internal mammary artery {Structure of left internal thoracic artery}, left anterior descending
coronary artery {Structure of anterior descending branch of left coronary artery}, saphenous vein graft {Aortocoronary artery bypass of one coronary artery with saphenous vein graft}, obtuse marginal {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, procedure {Surgical procedure}, post-operatively {Postoperative state}, stable condition {Patient's condition stable}, monitoring {Monitoring procedure}, sedation {Administration of sedative}, neurologically intact {Normal nervous system function}, extubated {Removal of endotracheal tube}, vasopressor support {Vasopressor therapy}, hemodynamically stable {Hemodynamically stable}, telemetry {Cardiac telemetry}, Chest
tubes {Insertion of pleural tube drain}, pulmonary toilet {Airway toilet}, sinus rhythm {Sinus rhythm}, Blood
pressure {Blood pressure finding}, restarted {Restart of medication}, Aspirin {Administration of aspirin}, bowel {Intestinal structure}, renal function {Renal function monitoring}, diuresed {Diuretic therapy}, preop {Preoperative state}, weight {Weight finding}, Hyponatremia {Hyponatremia}, asymptomatic {Asymptomatic}, sliding scale {Sliding scale insulin regime}, blood sugar {Blood sugar management}, evaluated {Evaluation procedure}, physical therapy {Physical therapy assessment}, ambulating {Fully mobile}, wound was
healing {Wound healing well}, pain was controlled with oral analgesics {Demonstrates adequate pain control}, good {Patient's condition satisfactory}, instructions {Recommendation to} |
###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. Atenolol 50 mg PO DAILY
2. GlyBURIDE 5 mg PO BID
3. Hydrochlorothiazide 50 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. MetFORMIN (Glucophage) 850 mg PO BID
6. Aspirin 162 mg PO DAILY
7. Calcium Carbonate 500 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID:PRN indigestion
3. GlyBURIDE 5 mg PO BID
4. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Fish Oil (Omega 3) 1000 mg PO BID
6. MetFORMIN (Glucophage) 850 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN pain, fever
9. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every six (6) hours
Disp #*50 Tablet Refills:*0
10. Lovastatin *NF* 40 mg Oral daily Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
11. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*90 Tablet Refills:*5
12. Senna 2 TAB PO DAILY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Type II Diabetes Mellitus
History of SVT
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
###RESPONSE: Home With Service {Home health aide service management}, Coronary Artery Disease {Coronary arteriosclerosis}, Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, Type II Diabetes Mellitus {Diabetes mellitus type 2}, SVT {Supraventricular tachycardia}, Alert {Mentally alert}, oriented x3 {Oriented to person, time and place}, Ambulating {Fully mobile}, gait steady {Gait normal}, Sternal pain {Pain of sternum}, oral analgesics {Administration of analgesic}, Sternal Incision {Wound of structure of sternal region}, healing well {Wound healing well}, erythema {Erythema}, drainage {Wound 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: Discharge Instructions:
1. Please shower daily including washing incisions gently with
mild soap, no baths or swimming, and look at your incisions
2). Please NO lotions, cream, powder, or ointments to incisions
3). Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4). No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
5). No lifting more than 10 pounds for 10 weeks
6). Please wear a bra to reduce pulling on the sternal incision
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
###RESPONSE: shower {Functional activity education}, incisions {Surgical incision wound}, incisions {Surgical incision wound}, incisions {Surgical incision wound}, temperature {Body temperature finding}, while taking
narcotics {Narcotherapy}, No lifting {Functional activity education}, sternal incision {Wound of structure of sternal region} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
Subsets and Splits