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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: Family History:
Unknown
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ADMISSION EXAM:
98.2 134/82 72 20 98%RA
Overweight elderly F, sleeping soundly but easily awoken,
appears well, comfortable
EOMI, no scleral icterus
CTAB no w/c/r/r
RRR without m/g
Obese NT ND, benign
No BLE edema, cyanasis, mottling,
CN ___ grossly intact, speech normal, moving all extremities
DISCHARGE EXAM:
97.2 121/51 79 16 99%
Overweight elderly F, sleeping soundly but easily awoken,
appears well, comfortable
EOMI, no scleral icterus
CTAB no w/c/r/r
RRR without m/g
Obese NT ND, benign
No BLE edema, cyanasis, mottling,
CN ___ grossly intact, speech normal, moving all extremities
###RESPONSE: RA {Breathing room air}, Overweight {Overweight}, sleeping {Asleep}, comfortable {Comfortable appearance}, EOMI {Normal ocular motility}, scleral icterus {Scleral icterus}, CTAB {Normal breath sounds}, w {Wheezing}, c {Respiratory crackles}, RRR {Normal heart rate}, m {Heart murmur}, g {Gallop rhythm}, Obese {Obese}, NT {Abdominal tenderness}, ND {Swollen abdomen}, BLE {Edema of bilateral lower legs}, edema {Edema}, cyanasis {Cyanosis}, mottling {Mottling}, CN {Cranial nerve structure}, grossly intact {Normal nervous system function}, speech {Speech finding}, normal {No abnormality detected}, all extremities {All extremities}, Overweight {Overweight}, sleeping {Asleep}, comfortable {Comfortable appearance}, EOMI {Normal ocular motility}, scleral icterus {Scleral icterus}, CTAB {Normal breath sounds}, w {Wheezing}, c {Respiratory crackles}, RRR {Normal heart rate}, m {Heart murmur}, g {Gallop rhythm}, Obese {Obese}, BLE {Edema of bilateral lower legs}, edema {Edema}, cyanasis {Cyanosis}, mottling {Mottling}, CN {Cranial nerve structure}, grossly intact {Normal nervous system function}, speech {Speech finding}, normal {No abnormality detected}, moving all extremities {Does move all four limbs} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ 09:48PM WBC-8.7 RBC-3.95* HGB-11.4* HCT-33.9* MCV-86
MCH-28.9 MCHC-33.6 RDW-14.5
___ 09:48PM NEUTS-68.2 ___ MONOS-5.3 EOS-4.6*
BASOS-1.2
___ 09:48PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:48PM GLUCOSE-100 UREA N-26* CREAT-1.0 SODIUM-132*
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-24 ANION GAP-15
###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} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
PATIENT: ___ yo F history of dementia, HTN, DM2 who presents with
failure to thrive, admitted for ~1 months awaiting guardianship
papers and nursing home placement.
.
ACUTE ISSUES:
# Failure to thrive - Initially brought to the ED for question
of suicidal ideation. Family members reported she tried to jump
out the window. Further evaluation by psychiatry revealed
worsening dementia and a lack of caregivers in the home.
Patient's husband had recently moved back to ___, and
she was unable to care for herself at home. Patient's son
___ was contacted and agree to guardianship. Paperwork was
filed with the courts and with approval of guardianship she was
discharged to nursing home.
.
CHRONIC ISSUES:
# Dementia - continued on home memantine in the hospital.
Consistently alert but not oriented. Spent most of her time
walking around the unit. Easily re-directable. Not agitated.
There was a question of whether she was taking exelon at home,
this was not given during her hospitalization.
.
# Diabetes type II - It was confirmed through her pharmacy that
she was taking metformin 1000mg BID. This was held during her
hospital stay and instead she was maintained on an insulin
sliding scale. At discharge, her metformin will be restarted.
.
# Hypertension - We continued on home regimen of amlopidine,
HTCZ, and lisinopril. Atenolol was held given good BP control.
###RESPONSE: dementia {Dementia}, HTN {Hypertensive disorder, systemic arterial}, DM2 {Diabetes mellitus type 2}, failure to thrive {Failure to thrive}, Failure to thrive {Failure to thrive}, suicidal ideation {Suicidal thoughts}, worsening {Patient's condition worsened}, dementia {Dementia}, Dementia {Dementia}, alert {Mentally alert}, agitated {Feeling agitated}, .
# Diabetes type II {Diabetes mellitus type 2}, insulin
sliding scale {Sliding scale insulin regime}, 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: Medications on Admission:
Confirmed with her pharmacy:
ferrous sulfate 325 daily
multivit
namenda 10 mg BID
HCTZ 25 mg daily
lisinopril 20 mg daily
lipitor 20 mg daily
metformin 1 gm BID
amlodipine 5 mg daily
atenolol 50 daily
Discharge Medications:
1. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metformin 500 mg Tablet Sig: Two (2) Tablet PO twice a day.
7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day as needed for constipation.
10. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
12. Tylenol ___ mg Tablet Sig: ___ Tablets PO four times a day
as needed for 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:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Dementia
SECONDARY DIAGNOSES:
- Diabetes (Type 2)
- Psoriasis
- Hypertension
- Depression
- Cholecystectomy
- Hysterectomy
- Breast cancer status post lumpectomy, radiation, and CMF
chemotherapy. This was stage I invasive mucinous carcinoma of
the right breast diagnosed in ___.
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Dementia {Dementia}, Diabetes (Type 2) {Diabetes mellitus type 2}, Psoriasis {Psoriasis}, Hypertension {Hypertensive disorder, systemic arterial}, Depression {Depressive disorder}, Cholecystectomy {Cholecystectomy}, Hysterectomy {Hysterectomy}, Breast cancer {Malignant neoplasm of breast}, status post {Postoperative state}, lumpectomy {Excision of mass}, radiation {Radiation oncology AND/OR radiotherapy}, chemotherapy {Chemotherapy}, mucinous carcinoma {Mucinous adenocarcinoma}, right breast {Right breast structure}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, 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:
It was a pleasure to participate in Ms. ___ care while she
was in the hospital. She was admitted to the hospital after her
family had some concerns about her behavior. According to her
family, she had been trying to jump out of a window. Our
psychiatry team evaluated Ms. ___ upon her presentation and
determined that she was not suicidal. It was thought that her
concerning behavior represented confusion due to her dementia.
Ms. ___ primary caretaker was her boyfriend, but he recently
moved back to ___. Ms. ___ is unable to care for
herself without the assistance of others. Prior to this
hospitalization, she did not have a guardian. Her son ___
agreed to be her guardian and paperwork for guardianship was
processed.
###RESPONSE: suicidal {Suicidal}, confusion {Clouded consciousness}, dementia {Dementia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None.
###RESPONSE: chest pain {Chest pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ with PMH of NIDDM, smoking,
CAD s/p MI (___), PCI in ___ at ___ who presents as transfer
from ___ with NSTEMI.
Pain started on ___ morning while at work as a ___
___.
Per pt, pain similar to chest pain from previous MI. Episodic
pain lasting ~15 mins. Per pt, not currently on sublingual
nitroglycerin. Pain epigastric, shartp, ___, and radiates
episodically to R or L chest. No diaphoresis, nausea, vomiting,
or chest pressure.
Went to ___ where he had trop elevated to 0.131. He AMA'd after
not feeling staff were addressing his needs.
At ___: s/p 4x ASA 81, 4,000U IV heparin @ ___ 140-160s systolic
Cr 1.4
Trop I 0.10
During initial eval, had brief episode of CP lasting a few
seconds that resolved. CP free currently. Denies headache,
dizziness, fever, chills, SOB, abdominal pain, nausea vomiting,
or dysuria.
In the ED initial vitals were: 98 82 184/99 14 100% RA
ED Exam:
Gen: NAD
HEENT: PERRLA, EOMI, MMM, oropharynx clear
Lungs: bibasilar crackles, otherwise CTAB
CV: RRR, no murmurs
Abd: soft NTND
Ext: WWP, no edema
EKG (___)- J point elevation in T2& V3 without reciprocal
changes.
Labs notable for:
1) CBC 10.4, Hb 16.5, plt 189
2) BNP 16
3) Trop-T <0.01 x2
4) BMP: Na 143, K 4.1, Cl 103, HCO3 21, BUN 17, Cr 1.3, AG 19
5) Coags: INR 1.2, PTT 150
6) U/A: negative bacteria/nitr, 2 WBC, 0 RBC
Patient was given:
___ 17:13 IV Heparin 900 units/hr
___ 19:14 IV Heparin Stopped As Directed
___ 20:20 IV Heparin Restarted 500 units/hr
Vitals on transfer: ___ pain 97.6 72 173/94 23 98% RA
On the floor:
He reports he presented initially to ___, and from there went to
___.
He reports his chest pain started after he had gone to see his
sister. He reports he was sitting in his car, and all of a
sudden
he felt like his heart was beating fast with some pressure. He
reports this pain radiated upward.
He reports that he did nothing for the pain at that time, and
drove to ___. He reports the pain came and went a few more
times.
He reports he was given some medications.
He reports that this pain lasts about 20 minutes and then goes
away.
He reports that he is not currently having any pain or pressure
for at least a few hours.
Denies dizziness, lightheadedness. Denies pain elsewhere except
for some pain in the back of his neck with extension which is
new. Denies blurry or double vision. Denies SOB.
Denies f/c, nausea, vomiting, diarrhea, constipation.
Denies recent infections. Denies DOE. Denies syncope.
He reports remote history of MI (___) and catheterization with
stent placement at ___.
REVIEW OF SYSTEMS:
Positive per HPI.
###RESPONSE: NIDDM {Diabetes mellitus type 2}, smoking {Smoker}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, PCI {Percutaneous coronary intervention}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, Pain {Pain}, pain {Pain}, chest pain {Chest pain}, MI {Myocardial infarction}, Episodic
pain {Intermittent pain}, Pain epigastric {Epigastric pain}, radiates
episodically to R or L chest {Radiating chest pain}, diaphoresis {Excessive sweating}, nausea, vomiting {Nausea and vomiting}, chest pressure {Tight chest}, trop elevated {Troponin I above reference range}, AMA'd {Patient self-discharge against medical advice}, IV {Intravenous therapy}, heparin {Heparin therapy}, 140-160s systolic {Increased systolic arterial pressure}, Trop {Troponin measurement}, CP {Chest pain}, resolved {Problem resolved}, CP {Chest pain}, headache {Headache}, dizziness {Dizziness}, fever {Fever}, chills {Chill}, SOB {Dyspnea}, abdominal pain {Abdominal pain}, nausea vomiting {Nausea and vomiting}, dysuria {Dysuria}, vitals {Vital signs finding}, RA {Breathing room air}, Exam {Physical examination procedure}, Gen {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, oropharynx {Oropharyngeal structure}, Lungs {Examination of respiratory system}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, CTAB {Normal breath sounds}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, murmurs {Murmur}, Abd {Examination of abdomen}, soft {Abdomen soft}, NTND {Abdominal tenderness}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, edema {Edema}, EKG {Electrocardiographic procedure}, elevation in T2& V3 {Electrocardiogram abnormal}, CBC {Complete blood count}, BNP {Brain natriuretic peptide measurement}, Trop {Troponin measurement}, BMP {Serum metabolic panel}, BUN {Blood urea nitrogen measurement}, INR {Calculation of international normalized ratio}, U/A {Urinalysis}, negative {No abnormality detected}, bacteria {Bacteriuria}, WBC {White blood cell count}, RBC {Red blood cell count}, IV {Intravenous therapy}, Heparin {Heparin therapy}, IV {Intravenous therapy}, Heparin {Heparin therapy}, IV {Intravenous therapy}, Heparin {Heparin therapy}, Restarted {Restart of medication}, Vitals {Vital signs finding}, pain {Pain}, RA {Breathing room air}, chest pain {Chest pain}, sitting {Sitting position}, heart was beating fast {Tachycardia}, pressure {Tight chest}, pain radiated {Radiating pain}, pain {Pain}, pain came and went a few more
times {Intermittent pain}, medications {Administration of drug or medicament}, pain {Pain}, pain {Pain}, pressure {Tight chest}, dizziness {Dizziness}, lightheadedness {Lightheadedness}, pain {Pain}, pain {Pain}, back of his neck {Cervical region back structure}, blurry {Blurring of visual image}, double vision {Diplopia}, SOB {Dyspnea}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, infections {Infectious disease}, DOE {Dyspnea on exertion}, syncope {Syncope}, MI {Myocardial infarction}, catheterization {Cardiac catheterization}, stent placement {Placement of stent in coronary artery}, REVIEW OF SYSTEMS {Review of systems} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
1. CARDIAC RISK FACTORS
- NIDDM
-Tobacco use
2. CARDIAC HISTORY
- CAD s/p MI (___)
- PCI in ___ at ___
3. OTHER PAST MEDICAL HISTORY
-None
Past surgical history:
cyst removal (unknown date)
###RESPONSE: CARDIAC RISK FACTORS {Assessment for risk of cardiovascular disease}, NIDDM {Diabetes mellitus type 2}, Tobacco use {Tobacco user}, CARDIAC {Heart disease}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, PCI {Percutaneous coronary intervention}, cyst {Cyst}, removal {Aneurysmectomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
###RESPONSE: MI {Myocardial infarction}, arrhythmia {Cardiac arrhythmia}, cardiomyopathies {Cardiomyopathy}, sudden cardiac death {Sudden cardiac death} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Admission
Vital Signs: 2345 98.2 PO 150 / 84 L Sitting 95 18 94 Ra
General: Patient is well appearing in no acute distress,
cooperative with exam. Laying flat in bed without difficulty.
Eyes: no conjunctival injection or scleral icterus.
Head, ears, nose, and throat: Normocephalic. Atraumatic.
Ears grossly normal bilaterally. Nose grossly normal. MMM
Neck: Supple with full ROM. Does experience pain with
hyperextension of neck, however full range of motion with no
stiffness. Some muscular tenderness in bilateral cervical
spine.
No bony deformities. JVP not elevated.
Respiratory/chest: No respiratory distress, speaks in full
sentences. Crackles noted in lung bases bilaterally, no wheezes
noted.
Cardiovascular: RRR no m/r/g, normal S1/S2
Gastrointestinal: Abdomen is soft. No distension. + bowel
sounds. No tenderness. No rebound.
Back: No tenderness. No CVAT
Musculoskeletal: Normal muscle tone, moving all extremities. No
calf tenderness. No lower extremity edema.
Skin: Warm and well perfused. No obvious rash. No obvious
erythema/ecchymosis.
Neurologic: Alert and oriented x 3, no focal deficits.
Discharge
Vital Signs: 97.4 PO 148 / 83 83 20 99 Ra
General: comfortable, lying in bed, flat, without difficulty
breathing
Neck: Supple w/ JVP not elevated.
Respiratory/chest: CTAB
Cardiovascular: RRR no m/r/g, normal S1/S2
Gastrointestinal: Abdomen is soft. NTND, +BS
Extremities: no ___, WWP
Neurologic: Alert and oriented x 3, moving all extremities with
purpose
###RESPONSE: Physical Exam {Physical examination procedure}, Vital Signs {Vital signs finding}, Sitting {Sitting position}, 4 Ra {Breathing room air}, General {General examination of patient}, well appearing {Well cared for appearance}, no acute {No abnormality detected}, distress {Distress}, cooperative {Cooperative mental state}, exam {Physical examination procedure}, Laying flat in bed {Lying in bed}, Eyes {Ophthalmic examination and evaluation}, conjunctival injection {Conjunctival hyperemia}, scleral icterus {Scleral icterus}, Head {Head structure}, ears {Ear structure}, nose {Nasal structure}, throat {Structure of anterior portion of neck}, Normocephalic {Normal head}, Atraumatic {No injuries apparent}, Ears grossly normal bilaterally {Ear normal}, Nose grossly normal {Nose normal}, MMM {Moist oral mucosa}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, full ROM {Normal range of cervical spine movement}, pain {Pain}, hyperextension {Hyperextension}, neck {Neck structure}, stiffness {Stiff neck}, tenderness {Tenderness}, bony deformities {Deformity of bone}, JVP not elevated {Normal jugular venous pressure}, Respiratory {Examination of respiratory system}, chest {Examination of respiratory system}, distress {Distress}, speaks {Does speak}, Crackles {Respiratory crackles}, bases {Structure of base of lung}, wheezes {Wheezing}, Cardiovascular {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, Gastrointestinal {Examination of digestive system}, soft {Abdomen soft}, distension {Swollen abdomen}, + bowel
sounds {Normal bowel sounds}, tenderness {Tenderness}, rebound {Rebound tenderness}, Back {Structure of back of trunk}, tenderness {Tenderness}, CV {Cardiovascular physical examination}, Musculoskeletal {Musculoskeletal system physical examination}, Normal muscle tone {Normal tone in skeletal muscle}, all extremities {All extremities}, tenderness {Tenderness}, edema {Edema}, Skin {Examination of skin}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, rash {Eruption of skin}, erythema {Erythema}, ecchymosis {Ecchymosis}, Neurologic {Neurological examination}, Alert {Mentally alert}, oriented {Orientated}, no focal deficits {Normal nervous system function}, Vital Signs {Vital signs finding}, Ra {Breathing room air}, General {General examination of patient}, comfortable {Comfortable appearance}, lying in bed {Lying in bed}, difficulty
breathing {Difficulty breathing}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, Respiratory {Examination of respiratory system}, chest {Examination of respiratory system}, CTAB {Normal breath sounds}, Cardiovascular {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, Gastrointestinal {Examination of digestive system}, soft {Abdomen soft}, ND {Swollen abdomen}, +BS {Normal bowel sounds}, Extremities {Examination of limb}, WWP {Normal tissue perfusion}, Neurologic {Neurological examination}, Alert {Mentally alert}, oriented {Orientated}, all extremities {All extremities} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Studies
Stress test ___
% MAX HRT RATE ACHIEVED: 89
IMPRESSION: Poor exercise tolerance with the test being
terminated
secondary to an exaggerated systolic blood pressure response
with
exercise. No anginal symptoms or ischemic ST segment changes.
Echo
report sent separately.
TTE ___
The patient exercised for 4 minutes and 30 seconds according to
a Modified ___ treadmill protocol ___ METS) reaching a peak
heart rate of 142 bpm and a peak blood pressure of 256/80 mmHg.
The test was stopped because of a hypertensive response. This
level of exercise represents a poor exercise tolerance for age
and gender. In response to stress, the ECG showed no ST-T wave
changes (see exercise report for details). with an abnormal
increase in blood pressure/hypertensive response and a normal
heart rate response to stress.
.
Resting images were acquired at a heart rate of 63 bpm and a
blood pressure of 170/96 mmHg. These demonstrated normal
regional and global left ventricular systolic function. Right
ventricular free wall motion is normal. There is no pericardial
effusion. Doppler demonstrated no aortic stenosis, aortic
regurgitation or significant mitral regurgitation or resting
LVOT gradient. .
Echo images were acquired within 46 seconds after peak stress
at heart rates of 131 - 108 bpm. These demonstrated appropriate
augmentation of all left ventricular segments with slight
decrease in cavity size. There was augmentation of right
ventricular free wall motion.
IMPRESSION: Test stopped because of hypertension. No ECG or 2D
echocardiographic evidence of inducible ischemia to achieved
workload. Marked hypertensive response to exercise.
Admission labs
___ 04:47PM BLOOD WBC-10.4* RBC-5.76 Hgb-16.5 Hct-49.5
MCV-86 MCH-28.6 MCHC-33.3 RDW-15.4 RDWSD-47.5* Plt ___
___ 04:47PM BLOOD Neuts-37 Bands-0 ___ Monos-8 Eos-1
Baso-0 Atyps-3* ___ Myelos-0 AbsNeut-3.85 AbsLymp-5.62*
AbsMono-0.83* AbsEos-0.10 AbsBaso-0.00*
___ 05:06PM BLOOD ___ PTT-150* ___
___ 04:47PM BLOOD Glucose-154* UreaN-17 Creat-1.3* Na-143
K-4.1 Cl-103 HCO3-21* AnGap-19*
___ 05:57AM BLOOD ALT-20 AST-22 LD(LDH)-216 AlkPhos-77
TotBili-0.5
___ 04:47PM BLOOD cTropnT-<0.01 proBNP-16
___ 05:06PM BLOOD proBNP-16
___ 05:06PM BLOOD cTropnT-<0.01
___ 12:10AM BLOOD cTropnT-<0.01 proBNP-19
___ 04:47PM BLOOD Calcium-9.3 Phos-2.9 Mg-2.2
Discharge
___ 06:40AM BLOOD ___ PTT-35.1 ___
___ 06:40AM BLOOD Glucose-129* UreaN-20 Creat-1.2 Na-143
K-4.3 Cl-103 HCO3-23 AnGap-17
___ 06:40AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.___ with PMH of NIDDM, smoking, CAD s/p MI (___), PCI in ___
who presents as transfer from ___ with NSTEMI.
ACUTE ISSUES:
=============
#NSTEMI
#CAD s/p PCI in ___
The patien's presentation in the setting of his significant
coronary artery disease, status post PCI, and similarity of
chest pain to prior episodes when he was diagnosed with MI, was
consistent with an ischemic process underlying his chest pain.
Elevated troponin at OSH prior to arrival was consistent with
NSTEMI. Troponins at ___ were negative and EKGs after transfer
negative for changes suggesting active ischemia. Given these
negative findings, IV heparin was discontinued and the patient
underwent a stress test for further risk stratification which
was negative for anginal symptoms or ischemic ST segment changes
in the setting of appropiate heart rate response to exercise.
Given the stress test results, the decision was made to defer
cardiac catheterization at this point. Aspirin and high dose
atorvastatin were continued. In addition, the patient was
started on metoprolol to optimize anti-anginal treatment and
lisinopril for blood pressure management.
___
Cr 1.3 on admission, baseline unknown; improved to 1.2 in ED.
Creatinine on discharge stable at 1.2. Potassium stable at 4.3.
Please obtain BMP on follow up with one to two weeks to monitor
renal function and potassium
CHRONIC ISSUES:
===============
#Hypertension
The patient had been on lisinopril as an outpatient in the past
(but wasn't taking any his medications for several months prior
to admission). No anti-hypertensives were given on admission in
setting of initial ___ and potential catheterization. Systolic
blood pressures were subsequently between 150-160 and the
patient was started on Lisinopril 10mg dialy.
- Follow-up as an outpatient with uptitration of
anti-hypertensives as tolerated is recommended.
#Non-insulin dependent diabetes
A1c 6.7% on labs ___ at ___. Patient does not report any
medications to treat this issue at this time. Not started on
Metformin as he was newly started on Lisinopril with possible
worsening of his renal function
- Metformin should be started as an outpatient if his renal
function allows
TRANSITIONAL ISSUES
===================
[] Discharge Creatinine 1.2; potassium on discharge 4.3 (both
stable) [] Please repeat BMP within two weeks of discharge to
ensure resolution ___ and to monitor potassium (newly started
on Lisinopril)
[] Newly started on Lisinopril 20mg daily - follow-up blood
pressure, consider uptitration of lisinopril as tolerated by
renal function and electrolytes
[] Patient also started on Metoprolol succinate 25mg, aspirin
81mg daily and atorvastatin 80mg daily during this admission;
please continue this medications in the outpatient setting
[] Follow-up on blood sugar and HBA1c, consider initiating
metformin going forward pending renal function
#CODE STATUS: FULL, confirmed
#CONTACT: Silnola (sister) ___
###RESPONSE: Stress test {Electrocardiogram with exercise test}, HRT RATE {Finding of heart rate}, Poor exercise tolerance {Impaired exercise tolerance}, exaggerated systolic blood pressure {Increased systolic arterial pressure}, exercise {Exercises}, anginal symptoms {Angina}, ischemic {Ischemia}, ST segment changes {Electrocardiographic ST segment changes}, Echo {Echocardiography}, TTE {Transthoracic echocardiography}, exercised {Exercises}, heart rate {Finding of heart rate}, peak blood pressure {Increased systolic arterial pressure}, hypertensive {Increased systolic arterial pressure}, exercise {Exercises}, poor exercise tolerance {Impaired exercise tolerance}, stress {Electrocardiogram with exercise test}, ECG {Electrocardiographic procedure}, no ST-T wave
changes {Electrocardiogram normal}, exercise {Electrocardiogram with exercise test}, increase in blood pressure {Increased systolic arterial pressure}, hypertensive {Increased systolic arterial pressure}, normal
heart rate {Normal heart rate}, stress {Electrocardiogram with exercise test}, heart rate {Finding of heart rate}, blood pressure {Blood pressure finding}, normal
regional and global left ventricular systolic function {Echocardiogram shows normal left ventricular function}, Right
ventricular {Right cardiac ventricular structure}, free wall motion is normal {Normal ventricular wall motion}, pericardial
effusion {Pericardial effusion}, Doppler {Doppler ultrasound}, aortic stenosis {Aortic valve stenosis}, aortic
regurgitation {Aortic valve regurgitation}, mitral regurgitation {Mitral valve regurgitation}, Echo {Echocardiography}, stress {Physical stress}, heart rates {Finding of heart rate}, left ventricular segments {Structure of segment of left cardiac ventricle}, decrease {Decreased size}, cavity {Structure of cavity of left cardiac ventricle}, right
ventricular {Right cardiac ventricular structure}, free wall motion {Normal ventricular wall motion}, hypertension {Hypertensive disorder, systemic arterial}, ECG {Electrocardiographic procedure}, echocardiographic {Echocardiography}, ischemia {Ischemia}, hypertensive {Hypertensive disorder, systemic arterial}, exercise {Exercises}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Serum total lactate dehydrogenase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, cTropnT {Troponin T cardiac measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, NIDDM {Diabetes mellitus type 2}, smoking {Smoker}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, PCI {Percutaneous coronary intervention}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, CAD {Coronary arteriosclerosis}, PCI {Percutaneous coronary intervention}, disease {Disease}, status post {Postoperative state}, PCI {Percutaneous coronary intervention}, chest pain {Chest pain}, MI {Myocardial infarction}, ischemic {Ischemia}, chest pain {Chest pain}, Elevated troponin {Troponin I above reference range}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, Troponins {Troponin measurement}, negative {No abnormality detected}, EKGs {Electrocardiographic procedure}, negative {No abnormality detected}, ischemia {Ischemia}, negative {No abnormality detected}, IV {Intravenous therapy}, heparin {Heparin therapy}, discontinued {Recommendation to stop drug treatment}, stress test {Electrocardiogram with exercise test}, negative {No abnormality detected}, anginal symptoms {Angina}, ST segment changes {Finding of electrocardiogram ST segment}, heart rate {Finding of heart rate}, exercise {Electrocardiogram with exercise test}, stress test {Electrocardiogram with exercise test}, cardiac catheterization {Cardiac catheterization}, Aspirin {Administration of aspirin}, anginal {Angina}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, blood pressure management {Angiotensin converting enzyme inhibitor therapy}, Cr {Creatinine measurement}, baseline {Baseline state}, improved {Patient's condition improved}, Creatinine {Creatinine measurement}, stable {Patient's condition stable}, Potassium {Potassium measurement}, stable {Patient's condition stable}, BMP {Serum metabolic panel}, monitor
renal function {Renal function monitoring}, potassium {Potassium measurement}, Hypertension {Hypertensive disorder, systemic arterial}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, wasn't taking any his medications {Does not take medication}, anti-hypertensives {On treatment for hypertension}, catheterization {Cardiac catheterization}, Systolic
blood pressures were subsequently between 150-160 {Increased systolic arterial pressure}, Lisinopril {Angiotensin converting enzyme inhibitor therapy}, uptitration {Increasing dosage of medication}, anti-hypertensives {On treatment for hypertension}, Non-insulin dependent diabetes {Diabetes mellitus type 2}, does not report any
medications to treat {Does not take medication}, Lisinopril {Angiotensin converting enzyme inhibitor therapy}, worsening of his renal function {Decreased renal function}, if his renal
function allows {Renal function monitoring}, Creatinine {Creatinine measurement}, potassium {Potassium measurement}, stable {Patient's condition stable}, BMP {Serum metabolic panel}, Lisinopril {Angiotensin converting enzyme inhibitor therapy}, Lisinopril {Angiotensin converting enzyme inhibitor therapy}, blood
pressure {Blood pressure monitoring}, r uptitration {Increasing dosage of medication}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, renal function {Renal function monitoring}, electrolytes {Electrolyte monitoring}, aspirin {Administration of aspirin}, continue this medications {Recommendation to continue with drug treatment}, blood sugar {Blood sugar management}, pending renal function {Renal function monitoring} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
None
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
3. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
#Unstable angina
#CAD s/p PCI in ___
___
Secondary diagnoses:
#Hypertension
#Non-insulin dependent diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Unstable angina {Preinfarction syndrome}, CAD {Coronary arteriosclerosis}, PCI {Percutaneous coronary intervention}, Hypertension {Hypertensive disorder, systemic arterial}, Non-insulin dependent diabetes mellitus {Diabetes mellitus type 2}, 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 Mr ___,
It was a pleasure taking care of you at ___!
Why was I admitted to the hospital?
- you had two episodes of chest pain that were similar in
character to the pain you had in the past when you had a heart
attack
- the current episodes were likely caused by a minor heart
attack. You underwent a test that showed you were able to
exercise appropriately. Therefore, you did not require any
intervention at this point.
- You were started on medications to help prevent future
episodes of chest pain
What should I do after discharge?
- Please take all the medications as prescribed (your were newly
started on aspirin, metoprolol, lisinopril, and atorvastatin)
- Please follow up with your new PCP as below for further
management of your blood pressure
- Please see an MD or go to the emergency department in case of
recurrent or new symptoms
All the best,
Your ___ care team
###RESPONSE: chest pain {Chest pain}, pain {Pain}, heart
attack {Myocardial infarction}, heart
attack {Myocardial infarction}, exercise {Exercises}, medications {Administration of drug or medicament}, chest pain {Chest pain}, medications {Patient medication education}, aspirin {Administration of aspirin}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, PCP {Primary care management}, management of your blood pressure {Blood pressure monitoring} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Metastatic Renal Cell Cancer
Major Surgical or Invasive Procedure:
Central Line placmeent and removal
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Metastatic Renal Cell Cancer {Metastatic renal cell carcinoma}, Central Line placmeent {Insertion of peripherally inserted central catheter}, removal {Removal of central venous line} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Mr. ___ is a ___ year old man with a history of T2 renal cell
carcinoma, s/p left nephrectomy on ___, who was recently
found to have pulmonary metastases.
In ___, he noted left back pain, which he thought was
activity-related after working out. A CT scan showed a 7 cm
left
kidney mass. Additional imaging showed no evidence of metastatic
disease at the time and a nephrectomy was done on ___ which
revealed clear cell renal cell carcinoma. A follow-up CT scan
done in ___ showed right-sided pulmonary nodules, the largest
of
which was 1 cm in size. Repeat CT scan down ___ revealed 5
masses in the right lung, the largest of which was > 3 cm in
size. A PET scan done ___ showed these pulmonary masses as
well as a mass in the right tonsillar tissue measuring 1.8 cm in
size with an SVU of 6.2 and nonspecific uptake in the left
parotid. He was seen by ENT on ___, who recommended
observation and follow-up in 1 month. A CT-guided biopsy of the
right lung mass was obtained on ___ and showed metastatic
renal cell carcinoma. He passed all screenign tests and is here
to begin cycle 1 week 1 of HD Il-2. He feels excellent and ROS
negative.
###RESPONSE: renal cell
carcinoma {Renal cell carcinoma}, left nephrectomy {Excision of left kidney}, pulmonary metastases {Metastatic malignant neoplasm to lung}, back pain {Backache}, CT scan {Computed tomography}, left {Left kidney structure}, kidney mass {Renal mass}, imaging {Imaging}, no evidence {No abnormality detected}, metastatic
disease {Metastatic malignant neoplasm}, nephrectomy {Total excision of left kidney}, clear cell renal cell carcinoma {Clear cell renal cell carcinoma}, CT scan {Computed tomography}, right-sided {Right lung structure}, pulmonary nodules {Nodule of lung}, CT scan {Computed tomography}, masses {Lung mass}, right lung {Right lung structure}, PET scan {Positron emission tomography}, pulmonary masses {Nodule of lung}, mass {Mass of body structure}, right tonsillar tissue {Right faucial tonsil structure}, left
parotid {Structure of left parotid gland}, CT-guided biopsy {Computed tomography guided biopsy}, right {Right lung structure}, metastatic
renal cell carcinoma {Metastatic renal cell carcinoma}, HD {Hemodialysis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
alcohol abuse, in AA
anxiety and depression
###RESPONSE: alcohol abuse {Alcohol abuse}, anxiety {Anxiety}, depression {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: 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:
He reports a mother with pancreatic cancer. His father had
diabetes and hypertension. He has 1 brother and 1 sister who
are
healthy.
###RESPONSE: pancreatic cancer {Malignant tumor of pancreas}, diabetes {Diabetes mellitus}, 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:
GEN: Well appearing gentleman in no acute distress.
Ht: 67 inches Wt: 168.3 lbs
VS: ___ O2 sat 99%RA
HEENT: clear, atraumatic, anicteric.
CV: RRR without MGR
RESP: CTA, no wheezes or rhonchi
ABD: Soft, nontender BS positive
M/S: ROM intact
Lymph: No lympadenopathy in the bilateral axillary,
supraclavicular, ingunal, cervical nodes.
Neuro: No focal deficit on exam
###RESPONSE: GEN {General examination of patient}, Well appearing {Well cared for appearance}, distress {Distress}, VS {Vital signs finding}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, HEENT {Physical examination procedure}, clear {Normal breath sounds}, atraumatic {No injuries apparent}, anicteric {White sclera}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, RESP {Examination of respiratory system}, CTA {Normal breath sounds}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABD {Examination of abdomen}, Soft {Abdomen soft}, nontender {Abdominal tenderness}, BS {Normal bowel sounds}, ROM {Range of motion activity}, intact {Normal sensation}, Lymph {Lymphatic system physical examination}, lympadenopathy {Lymphadenopathy}, axillary {Axillary lymph node structure}, supraclavicular {Structure of supraclavicular lymph node}, ingunal {Inguinal lymph node structure}, cervical nodes {Cervical lymph node structure}, Neuro {Neurological examination}, No focal deficit {Normal nervous system function} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 11:55AM GLUCOSE-93 UREA N-12 CREAT-1.1 SODIUM-139
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-31 ANION GAP-9
___ 11:55AM estGFR-Using this
___ 11:55AM ALT(SGPT)-13 AST(SGOT)-16 CK(CPK)-147 TOT
BILI-0.3
___ 11:55AM ALBUMIN-4.1 CALCIUM-9.3 PHOSPHATE-3.4
MAGNESIUM-1.8
___ 11:55AM WBC-6.4 RBC-4.06* HGB-12.6* HCT-37.8* MCV-93
MCH-31.0 MCHC-33.3 RDW-12.8
___ 11:55AM PLT COUNT-206
___ 11:55AM ___ PTT-29.7 ___
___ 04:00AM BLOOD WBC-4.3 RBC-4.14* Hgb-12.5* Hct-36.8*
MCV-89 MCH-30.3 MCHC-34.1 RDW-12.7 Plt Ct-98*
___ 04:00AM BLOOD Plt Ct-98*
___ 04:00AM BLOOD Glucose-119* UreaN-15 Creat-1.2 Na-137
K-4.5 Cl-106 HCO3-19* AnGap-17
___ 04:00AM BLOOD ALT-50* AST-44* CK(CPK)-40* TotBili-1.7*
___ 04:00AM BLOOD Albumin-2.8* Calcium-7.7* Phos-2.7
Mg-1.5*
___ 04:03AM BLOOD WBC-7.6# RBC-3.88* Hgb-12.0* Hct-34.2*
MCV-88 MCH-30.9 MCHC-35.0 RDW-12.7 Plt Ct-91*
___ 04:03AM BLOOD Glucose-104* UreaN-16 Creat-1.2 Na-135
K-4.3 Cl-104 HCO3-24 AnGap-11
___ 12:00PM BLOOD CK(CPK)-38*
___ 04:03AM BLOOD ALT-61* AST-46* CK(CPK)-47 TotBili-1.6*
___ 04:03AM BLOOD Albumin-2.5* Calcium-7.9* Phos-2.6*
Mg-1.9
###RESPONSE: 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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, TOT
BILI {Bilirubin, total measurement}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium 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}, PTT {Partial thromboplastin time, activated}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, 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}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, 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}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Mr. ___ was admitted for HD IL-2 cycle 1 week 1.
Upon arrival to ___, informed consent was obtained for HD
IL-2. He then underwent central line placement with chest X-ray
confirmation of placement.
He received HD IL-2, 45.7 Million Units IV Q8H. He recieved
total of ___ doses this week. His course was complicated by
chills, rigors, fever, diarrhea, and pruritus. Of all, chills
and rigors were difficult to control given he refused all
controlled medications such as lorazepam and demerol due to his
past medical history of ETOH ause and being in AA. He also had
thrombocytopenia of PLT 98k. On day 5, with increased fatigue,
malaise, rigors after each dose, he refused fruther doses and
this was agreed by our team as well.
His central line was removed on day 6 and was discharged to home
in stable condition on ___.
###RESPONSE: HD {Hemodialysis}, informed consent {Informed consent for procedure}, HD {Hemodialysis}, central line placement {Insertion of peripherally inserted central catheter}, chest X-ray {Plain chest X-ray}, placement {Implantation procedure}, HD {Hemodialysis}, IV {Administration of drug or medicament via intravenous route}, chills {Chill}, rigors {Rigor}, fever {Fever}, diarrhea {Diarrhea}, pruritus {Itching of skin}, chills {Chill}, rigors {Rigor}, ETOH ause {Alcohol abuse}, thrombocytopenia {Thrombocytopenic disorder}, fatigue {Fatigue}, malaise {Malaise}, rigors {Rigor}, central line was removed {Removal of central venous line}, stable condition {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:
fluoxetin 40 mg 2 tabs a day
Discharge Medications:
1. diphenhydramine HCl 25 mg Capsule Sig: ___ Capsules PO Q6H
(every 6 hours) as needed for pruritis.
Disp:*30 Capsule(s)* Refills:*0*
2. cephalexin 500 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 5 days.
Disp:*10 Capsule(s)* Refills:*0*
3. oral wound care products Gel in Packet Sig: Fifteen (15)
ML Mucous membrane TID (3 times a day) as needed for mucositis.
Disp:*500 ML(s)* Refills:*0*
4. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours.
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2*
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritus.
Disp:*1 bottle* Refills:*3*
###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:
Metastatic Renal Cell CA
Discharge Condition:
Mental Status: Clear and coherent.
###RESPONSE: Metastatic Renal Cell CA {Metastatic renal cell carcinoma}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Please call ___, RN for any issues after discharge.
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Lisinopril / alcohol
Attending: ___
Chief Complaint:
atrial fibrillation with RVR
Major Surgical or Invasive Procedure:
none
###RESPONSE: Lisinopril {Non-allergic hypersensitivity to lisinopril}, alcohol {Allergy to ethyl alcohol}, atrial fibrillation with RVR {Atrial fibrillation with rapid ventricular response} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ presents with tachycardia. Patient with recent admission for
atrial fibrillation with RVR at that time underwent
cardioversion and was started on low-dose
metoprolol. Now with returned for tachycardia to the 150s.
Patient was reportedly feeling weak at home and noted to be
orthostatic. She was additionally noted to have highly variable
heart rate with irregular heart rhythm. At time of evaluation
she denies any acute complaints however is noted to be
tachycardic from the 120s to 150s. Patient states she has been
taking her metoprolol as prescribed.
In the ED, initial vitals were 97.8 74 128/50 16 97% ra. Labs
significant for unremarkable CBC and CHem7 with the exception of
BUN 21, glucose 127, phos 2.0, Lactate: 1.9. UA unremarkable.
Urine and blood cultures sent. CXR showed cardiomegaly and small
bilateral effusions. No superimposed acute cardiopulmonary
process. Patient was evaluated by cardiology in the ED and
admitted for AF with RVR, for rate control with beta blocker
uptitration. VS prior to transfer include 98.8 113 122/78 20 98%
RA.
On the floor, patient is comfortable without any recent chest
pain, palpitations, shortness of breath, lightheadedness with
walking to the bathroom or peripheral edema. She states she
cannot feel that her heart rate is fast.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
###RESPONSE: tachycardia {Tachycardia}, atrial fibrillation with RVR {Atrial fibrillation with rapid ventricular response}, cardioversion {Cardioversion}, tachycardia {Tachycardia}, feeling weak {Asthenia}, orthostatic {Orthostatic body position}, variable
heart rate {Alteration in heart rate}, irregular heart rhythm {Irregular heart beat}, evaluation {Evaluation procedure}, tachycardic {Tachycardia}, vitals {Vital signs finding}, ra {Breathing room air}, unremarkable {No abnormality detected}, CBC {Complete blood count}, BUN {Blood urea nitrogen measurement}, Lactate {Lactic acid measurement}, UA unremarkable {Urinalysis = no abnormality}, Urine {Urine culture}, blood cultures {Blood culture}, CXR {Plain chest X-ray}, cardiomegaly {Cardiomegaly}, small {Symptom mild}, bilateral effusions {Bilateral pleural effusion}, cardiology {Cardiology service}, AF with RVR {Atrial fibrillation with rapid ventricular response}, uptitration {Increasing dosage of medication}, VS {Vital signs finding}, RA {Breathing room air}, chest
pain {Chest pain}, palpitations {Palpitations}, shortness of breath {Dyspnea}, lightheadedness {Lightheadedness}, walking {Does walk}, peripheral edema {Peripheral edema}, heart rate is fast {Tachycardia}, review of systems {Review of systems}, stroke {Cerebrovascular accident}, TIA {Transient ischemic attack}, deep venous thrombosis {Deep venous thrombosis}, pulmonary embolism {Pulmonary embolism}, bleeding {Bleeding}, surgery {Surgical procedure}, myalgias {Muscle pain}, joint pains {Joint pain}, cough {Cough}, hemoptysis {Hemoptysis}, black
stools {Dark stools}, red stools {Red stools}, fevers {Fever}, chills {Chill}, rigors {Rigor}, buttock {Pain in buttock}, calf pain {Pain in calf}, review of systems {Review of systems}, negative {No abnormality detected}, Cardiac {Cardiovascular physical examination}, review of systems {Review of systems}, chest pain {Chest pain}, dyspnea on exertion {Dyspnea on exertion}, paroxysmal nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, ankle edema {Ankle edema}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
1. CARDIAC RISK FACTORS: + Hypertension
2. CARDIAC HISTORY: afib
3. OTHER PAST MEDICAL HISTORY:
CATARACT
DEGENERATIVE JOINT DISEASE
OSTEOPOROSIS
PELVIC FRACTURE
TINNITUS
RETINAL VASCULAR OCCLUSION
H/O COLLES' FRACTURE
H/O HEMATURIA S/P CYSTOSCOPY
H/O PROLAPSE VAGINAL WALL W/O UTERINE PROLAPSE
H/O SYNCOPE
###RESPONSE: CARDIAC RISK FACTORS {Assessment for risk of cardiovascular disease}, Hypertension {Hypertensive disorder, systemic arterial}, CARDIAC {Heart structure}, afib {Atrial fibrillation}, CATARACT {Cataract}, DEGENERATIVE JOINT DISEASE {Osteoarthritis}, OSTEOPOROSIS {Osteoporosis}, PELVIC FRACTURE {Fracture of pelvis}, TINNITUS {Tinnitus}, RETINAL VASCULAR OCCLUSION {Retinal vascular occlusion}, COLLES' FRACTURE {Colles' fracture}, HEMATURIA {Blood in urine}, CYSTOSCOPY {Transurethral cystoscopy}, PROLAPSE VAGINAL WALL {Vaginal wall prolapse}, UTERINE PROLAPSE {Uterine prolapse}, SYNCOPE {Syncope} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
non-contributory to this admission
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
On Admission:
VS: 98.1 123/71 120s-140s 16 93%RA wt 38kg (discharged at
36.4kg)
GENERAL: awake and alert, in NAD, pleasant
HEENT: AT/NC, + cataracts, anicteric sclera, good dentition
NECK: JVP not elevated
CARDIAC: irreg irreg, no Murmurs appreciated
LUNG: bibasilar crackles
ABDOMEN: soft, non-tender, non-distended
EXT: warm and well-perfused, no edema
NEURO: alert, neuro exam grossly non-focal
On Discharge:
Vitals: 97.5 104/76(80-123/46-73) 97(68-136) 16 92%RA
weight: 38.1kg from 38kg at admission (last discharge at 36.4kg)
GENERAL: awake and alert, in NAD
HEENT: AT/NC, HOH, anicteric sclera, good dentition
NECK: JVP of 6
CARDIAC: RRR, no Murmurs appreciated
LUNG: bibasilar crackles, no wheezing
ABDOMEN: soft, non-tender, non-distended
EXT: warm and well-perfused, no edema.
NEURO: alert, neuro exam grossly non-focal
###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, wt {Weight finding}, GENERAL {General examination of patient}, awake {Awake}, alert {Mentally alert}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, cataracts {Cataract}, anicteric sclera {White sclera}, good dentition {Normal dentition}, NECK {Physical examination procedure}, JVP not elevated {Normal jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, irreg irreg {Pulse irregularly irregular}, Murmurs {Heart murmur}, LUNG {Examination of respiratory system}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, ABDOMEN {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, EXT {Examination of limb}, warm {Warm skin}, well-perfused {Normal tissue perfusion}, edema {Edema}, NEURO {Neurological examination}, alert {Mentally alert}, neuro exam {Neurological examination}, Vitals {Vital signs finding}, RA {Breathing room air}, weight {Weight finding}, GENERAL {General examination of patient}, awake {Awake}, alert {Mentally alert}, NAD {No abnormality detected}, HOH {Hearing loss}, anicteric sclera {White sclera}, good dentition {Normal dentition}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, Murmurs {Heart murmur}, LUNG {Examination of respiratory system}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, wheezing {Wheezing}, ABDOMEN {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, EXT {Examination of limb}, warm {Warm skin}, well-perfused {Normal tissue perfusion}, edema {Edema}, NEURO {Neurological examination}, alert {Mentally alert}, neuro exam {Neurological examination} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
On Admission:
___ 01:49PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:49PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
___ 01:49PM URINE RBC-30* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-6
___ 01:49PM URINE MUCOUS-FEW
___ 01:33PM LACTATE-1.9
___ 01:15PM GLUCOSE-127* UREA N-21* CREAT-0.6 SODIUM-138
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
___ 01:15PM CALCIUM-8.6 PHOSPHATE-2.0*# MAGNESIUM-2.2
___ 01:15PM WBC-5.9 RBC-4.02* HGB-11.5* HCT-36.6 MCV-91
MCH-28.7 MCHC-31.5 RDW-15.7*
___ 01:15PM NEUTS-64.9 ___ MONOS-10.6 EOS-1.2
BASOS-1.4
___ 01:15PM PLT COUNT-324
Other Pertinent Labs:
___ 06:10AM BLOOD ___ PTT-36.7* ___
___ 06:10AM BLOOD ALT-37 AST-20 AlkPhos-72 TotBili-0.4
On Dishcarge:
___ 06:20AM BLOOD WBC-3.9* RBC-3.64* Hgb-10.7* Hct-34.0*
MCV-93 MCH-29.5 MCHC-31.6 RDW-15.6* Plt ___
___ 06:20AM BLOOD Glucose-79 UreaN-20 Creat-0.6 Na-136
K-4.7 Cl-103 HCO3-28 AnGap-10
___ 06:20AM BLOOD Mg-2.1
Imaging:
CXR ___:
Cardiomegaly and small bilateral effusions. No superimposed
acute cardiopulmonary process.
EKG: ___:
afib with RVR, rate 127, normal axis, nonspecific ST changes
laterally and Q waves w/TWI in III, aVF similar to last
admission
###RESPONSE: URINE {Evaluation of urine specimen}, COLOR {Color finding}, Clear {Urine looks clear}, 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}, RBC {Red blood cell count}, WBC {White blood cell count}, AST {Aspartate aminotransferase measurement}, URINE {Evaluation of urine specimen}, 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}, CALCIUM {Blood calcium 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}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, PTT {Partial thromboplastin time, activated}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Mg {Blood magnesium measurement}, CXR {Plain chest X-ray}, Cardiomegaly {Cardiomegaly}, bilateral effusions {Bilateral pleural effusion}, afib with RVR {Atrial fibrillation with rapid ventricular response}, normal {No abnormality detected}, axis {Electrocardiographic axis finding}, ST changes {Electrocardiographic ST segment changes}, TWI {Inverted T wave}, III {Lead III}, aVF {Finding present on electrocardiogram} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ with history of hypertension, presented with recurrent
atrial fibrillation with RVR s/p cardioversion on ___.
# Atrial fibrillation with rapid ventricular response: CHADS2=3
(HTN, CHF, Age). Underwent workup for etiology of new atrial
fibrillation at last admission. She returned with rapid atrial
fibrillation but no signs of systolic heart failure
exacerbation. Rate control strategy was favored given paroxysmal
nature of her atrial fibrillation despite being euvolemic as
volume overload was initially felt to be a contributing factor.
She was rate controlled on increased dose of metoprolol and her
symptoms of fatigue resolved. She also continued Rivaroxaban for
stroke prevention.
# Chronic Systolic Congestive Heart Failure Exacerbation: Has
dilated cardiomyopathy. Appears euvolemic on exam with flat JVP.
She has crackles but no dyspnea or other signs of volume
overload on exam. She was discharged on low dose of lasix to
take outpatient to prevent volume overload as her JVP had
increased slightly over the course of the hospitalization
(although remains <10) and her weight was increased from her
prior discharge weight. She is now lacking her atrial kick to
aid with forward flow. She was instructed to monitor her weights
outpatient.
# Leg Pain: Felt to be from trochanteric bursitis outpatient. No
acute fracture was seen on imaging. DVT was ruled out with
ultrasound last admission. Continued Tylenol for pain control
and physical therapy was consulted.
# Hypertension: Her home olmesartan and Felodipine continued to
be held from last admission. Metoprolol was given per above. She
should restart her ___ outpatient as she has systolic heart
failure if her blood pressure permits.
HOSPITAL ISSUES:
- Code: Full Code
- should have BP check at follow up outpatient visit and restart
___ if BP allows
- CTA last hospitalization showed incidental finding of
narrowing of the left
mainstem bronchus with soft tissue fullness posteriorly and
distal esophageal thickening. This can be further worked up if
clinically indicated.
###RESPONSE: hypertension {Hypertensive disorder, systemic arterial}, recurrent {Recurrent disease}, atrial fibrillation with RVR {Atrial fibrillation with rapid ventricular response}, cardioversion {Cardioversion}, Atrial fibrillation with rapid ventricular response {Atrial fibrillation with rapid ventricular response}, HTN {Hypertensive disorder, systemic arterial}, CHF {Congestive heart failure}, workup {Evaluation procedure}, atrial
fibrillation {Atrial fibrillation}, rapid atrial
fibrillation {Rapid atrial fibrillation}, signs {Sign}, systolic heart failure {Systolic heart failure}, atrial fibrillation {Atrial fibrillation}, euvolemic {Normal blood volume}, volume overload {Hypervolemia}, fatigue {Fatigue}, resolved {Problem resolved}, Rivaroxaban {Administration of prophylactic anticoagulant}, stroke prevention {Stroke prevention}, Chronic {Chronic congestive heart failure}, Systolic Congestive Heart Failure {Congestive heart failure due to left ventricular systolic dysfunction}, dilated cardiomyopathy {Congestive cardiomyopathy}, euvolemic {Normal blood volume}, exam {Physical examination procedure}, flat JVP {Normal jugular venous pressure}, crackles {Respiratory crackles}, dyspnea {Dyspnea}, signs {Sign}, volume
overload {Hypervolemia}, exam {Physical examination procedure}, lasix {Diuretic therapy}, volume overload {Hypervolemia}, JVP had
increased {Raised jugular venous pressure}, weight was increased {Weight increased}, weight {Weight finding}, atrial {Atrial structure}, monitor her weights {Weight monitoring}, Leg Pain {Pain in lower limb}, trochanteric bursitis {Greater trochanteric pain syndrome}, No
acute {No abnormality detected}, fracture {Fracture}, imaging {Imaging}, DVT {Deep venous thrombosis}, ultrasound {Ultrasonography}, Tylenol {Administration of analgesic}, pain control {Pain control}, physical therapy {Physical therapy procedure}, Hypertension {Hypertensive disorder, systemic arterial}, restart {Restart of medication}, systolic heart
failure {Systolic heart failure}, blood pressure {Blood pressure monitoring}, BP check {Blood pressure monitoring}, restart {Restart of medication}, CTA {Computed tomography angiography with contrast}, narrowing {Narrowing}, left {Structure of left bronchus}, bronchus {Bronchial structure}, soft tissue {Structure of soft tissue}, distal esophageal {Structure of lower third of esophagus}, thickening {Increased thickness}, worked up {Evaluation procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1250 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Rivaroxaban 15 mg PO DAILY
4. alendronate 70 mg oral weekly
5. Estrogens Conjugated 1 gm VG PRN daily
Discharge Medications:
1. Calcium Carbonate 1250 mg PO DAILY
2. Metoprolol Succinate XL 75 mg PO BID
RX *metoprolol succinate 25 mg 3 tablet extended release 24
hr(s) by mouth twice a day Disp #*180 Tablet Refills:*0
3. Rivaroxaban 15 mg PO DAILY
4. alendronate 70 mg oral weekly
5. Estrogens Conjugated 1 gm VG PRN daily
6. Furosemide 10 mg PO DAILY
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth once a
day Disp #*20 Tablet Refills:*0
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
atrial fibrillation with rapid ventricular response
chronic systolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Home {Home health aide service management}, With Service {Home health aide service management}, atrial fibrillation with rapid ventricular response {Atrial fibrillation with rapid ventricular response}, chronic systolic heart failure {Chronic systolic heart failure}, 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 Ms. ___,
It was a pleasure seeing you again during your recent
hospitalization at ___. You were admitted to the hospital
again because your heart rhythm returned into atrial
fibrillation and was beating very fast. We increased your dose
of metoprolol and now your heart rate is better controlled.
Please take your medications as prescribed and go to your clinic
appointments shown below. Remember to weigh yourself every
morning and call your doctor if your weight goes up more than 3
lbs.
###RESPONSE: heart rhythm {Finding of heart rhythm}, atrial
fibrillation {Atrial fibrillation}, beating very fast {Tachycardia}, heart rate {Finding of heart rate}, better controlled {Disease condition determination, well controlled}, take your medications as prescribed {Patient medication education}, clinic {Outpatient care management}, weigh yourself every
morning {Weight monitoring}, weight goes up {Weight increased} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 / Ace Inhibitors / Aspirin / Rifaximin / Tramadol /
Plavix / morphine / Statins-Hmg-Coa Reductase Inhibitors /
Effexor XR
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
###RESPONSE: Penicillins {Allergy to penicillin}, Ace Inhibitors {Allergy to acetylcholinesterase inhibitor}, Aspirin {Allergy to aspirin}, Tramadol {Allergy to tramadol}, morphine {Allergy to morphine}, Statins-Hmg-Coa Reductase Inhibitors {Allergy to 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor}, Chest pain {Chest pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Patient is a ___ year old female, history of CAD (MI ___ s/p
PCIx2 to ramus intermedius, TTE ___, pAF (on Coumadin),
moderate AS, HTN, anemia, dementia, GERD, and hx breast cancer
(s/p R mastectomy with XRT) who presents with chest pain.
Patient
reports that symptoms began 2 or 3 days ago. She reports 8 out
of
10 substernal chest "pressure." Mild dyspnea with cough. No
hemoptysis. Denies fever, chills, nausea, vomiting, change in
bowel or bladder function, change in vision or hearing,
bruising,
adenopathy, new rash or lesion.
She is somewhat difficult to get a clear history from w/r/t her
pain. When it initially started about 48 hours ago, it awoke her
up out of her sleep. She doesn't recall anything that improved
or
made it worse, but since then it has been rather episodic
throughout the day. She has felt generally "low energy" and thus
has not been moving about all that much, but when she has
exerted
herself she does not think that brought about the pain or made
it
any worse. She does think that she has felt generally weaker
while exerting herself over the last week or so.
In the ED initial vitals were:
97.3 56 155/65 16 97% RA
Labs/studies notable for:
___: 35.8 PTT: 43.3 INR: 3.3
5.1 > 12.1/37.1 < 230
ALT: 36 AP: 85 Tbili: 0.4 Alb: 4.2
AST: 45
CK: 295 MB: 8 Trop-T: 0.02
135 97 29
-------------< 82
4.2 23 1.2
UA negative
Trop 0.02 --> 0.01
###RESPONSE: CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, PCI {Percutaneous coronary intervention}, ramus intermedius {Structure of coronary intermediate artery}, TTE {Transthoracic echocardiography}, pAF {Paroxysmal atrial fibrillation}, moderate AS {Moderate stenosis of aortic valve}, HTN {Hypertensive disorder, systemic arterial}, anemia {Anemia}, dementia {Dementia}, GERD {Gastroesophageal reflux disease}, breast cancer {Malignant neoplasm of breast}, R mastectomy {Mastectomy of right breast}, XRT {X-ray beam therapy}, chest pain {Chest pain}, substernal {Structure of substernal region}, chest "pressure {Tight chest}, dyspnea {Dyspnea}, cough {Cough}, hemoptysis {Hemoptysis}, fever {Fever}, chills {Chill}, nausea {Nausea}, vomiting {Vomiting}, change in
bowel {Altered bowel function}, bladder function {Altered bladder function}, bruising {Contusion}, adenopathy {Lymphadenopathy}, rash {Eruption of skin}, lesion {Lesion}, pain {Pain}, improved {Patient's condition improved}, 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: Past Medical History:
HYPONATREMIA
ATRIAL FIBRILLATION on Coumadin
BREAST CANCER TWICE IN RIGHT BREAST
lumpectomy and xrt s/p mastectomy ___
CORONARY ARTERY DISEASE
s/p ramus stent ___, negative exercise echo ___
CORONARY ARTERY DISEASE
___ cath 3-v disease with PCTA ramus of circ
DEPRESSION
GASTROESOPHAGEAL REFLUX
HYPERTENSION
OSTEOARTHRITIS
OSTEOPOROSIS
ANXIETY
MDD WITH PSYCHOTIC FEATURES
GAD
CATARACT
AORTIC SCLEROSIS
###RESPONSE: HYPONATREMIA {Hyponatremia}, ATRIAL FIBRILLATION {Atrial fibrillation}, BREAST CANCER {Malignant neoplasm of breast}, RIGHT BREAST {Right breast structure}, lumpectomy {Lumpectomy of breast}, xrt {X-ray beam therapy}, mastectomy {Excision of breast}, CORONARY ARTERY DISEASE {Coronary arteriosclerosis}, stent {Insertion of arterial stent}, exercise echo {Exercise stress echocardiography}, CORONARY ARTERY DISEASE {Coronary arteriosclerosis}, cath {Cardiac catheterization}, 3-v disease {Triple vessel disease of the heart}, PCTA {Percutaneous transluminal coronary angioplasty}, DEPRESSION {Depressive disorder}, GASTROESOPHAGEAL REFLUX {Gastroesophageal reflux disease}, HYPERTENSION {Hypertensive disorder, systemic arterial}, OSTEOARTHRITIS {Osteoarthritis}, OSTEOPOROSIS {Osteoporosis}, ANXIETY {Anxiety}, MDD WITH PSYCHOTIC FEATURES {Major depression with psychotic features}, GAD {Generalized anxiety disorder}, CATARACT {Cataract}, AORTIC SCLEROSIS {Aortic valve sclerosis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
FAMILY PSYCHIATRIC HISTORY: brother with ___ (in ___
Mother died of AD at age ___
Father died of MI age ___.
###RESPONSE: died {Dead}, died {Dead}, MI {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:
ADMISSION PHYSICAL EXAM
==========================
VS: ___ 0200 Temp: 98.0 PO BP: 150/63 L Lying HR: 58 RR:
18
O2 sat: 99% O2 delivery: Ra
GENERAL: Cachectic elderly woman, lying comfortably in bed, NAD
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: No JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. ___, late peaking cresc/decresc
murmur best heart at LUSB, radiating to carotids with delayed
carotid upstroke.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM
=====================================
Temp: 97.7 (Tm 98.8), BP: 159/72 (113-159/53-72), HR: 69
(52-69), RR: 18 (___), O2 sat: 97% (96-98), O2 delivery: Ra,
Wt: 92.15 lb/41.8 kg
GENERAL: Cachectic elderly woman, lying comfortably in bed, NAD
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: No JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. ___, late peaking cresc/decresc
murmur best heart at LUSB, radiating to carotids with delayed
carotid upstroke.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, GENERAL {General examination of patient}, Cachectic {Cachexia}, lying comfortably in bed {Lying in bed}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva {Conjunctival structure}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthelasma {Xanthelasma}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, intercostal space {Structure of intercostal space}, midclavicular
line {Midclavicular line}, Regular rate {Normal heart rate}, murmur {Murmur}, LUSB {Structure of upper parasternal region}, carotids {Carotid artery structure}, LUNGS {Examination of respiratory system}, chest wall deformities {Deformity of chest wall}, tenderness {Tenderness}, Respiration {Examination of respiratory system}, unlabored {Breathing easily}, accessory muscle {Accessory skeletal muscle}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, hepatomegaly {Large liver}, splenomegaly {Splenomegaly}, EXTREMITIES {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, SKIN {Examination of skin}, lesions {Lesion}, rashes {Eruption of skin}, pulses palpable {Peripheral pulse palpable}, PHYSICAL EXAM {Physical examination procedure}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, GENERAL {General examination of patient}, Cachectic {Cachexia}, lying comfortably in bed {Lying in bed}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva {Conjunctival structure}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthelasma {Xanthelasma}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, intercostal space {Structure of intercostal space}, midclavicular
line {Midclavicular line}, Regular rate {Normal heart rate}, murmur {Murmur}, LUSB {Structure of upper parasternal region}, carotids {Carotid artery structure}, LUNGS {Examination of respiratory system}, chest wall deformities {Deformity of chest wall}, tenderness {Tenderness}, Respiration {Examination of respiratory system}, unlabored {Breathing easily}, accessory muscle {Accessory skeletal muscle}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, hepatomegaly {Large liver}, splenomegaly {Splenomegaly}, EXTREMITIES {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, SKIN {Examination of skin}, lesions {Lesion}, rashes {Eruption of skin}, pulses palpable {Peripheral pulse palpable} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS
=====================
___ 02:10PM cTropnT-<0.01
___ 12:29PM URINE HOURS-RANDOM
___ 12:29PM URINE UHOLD-HOLD
___ 12:29PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:29PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 08:15AM GLUCOSE-82 UREA N-29* CREAT-1.2* SODIUM-135
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-23 ANION GAP-15
___ 08:15AM estGFR-Using this
___ 08:15AM ALT(SGPT)-36 AST(SGOT)-45* CK(CPK)-295* ALK
PHOS-85 TOT BILI-0.4
___ 08:15AM LIPASE-46
___ 08:15AM CK-MB-8 cTropnT-0.02*
___ 08:15AM ALBUMIN-4.2 CALCIUM-9.5 PHOSPHATE-3.0
MAGNESIUM-2.1
___ 08:15AM WBC-5.1 RBC-3.90 HGB-12.1 HCT-37.1 MCV-95
MCH-31.0 MCHC-32.6 RDW-14.0 RDWSD-49.2*
___ 08:15AM NEUTS-59.3 ___ MONOS-12.4 EOS-1.6
BASOS-1.2* IM ___ AbsNeut-3.02 AbsLymp-1.29 AbsMono-0.63
AbsEos-0.08 AbsBaso-0.06
___ 08:15AM PLT COUNT-230
___ 08:15AM PLT COUNT-230
PERTINENT STUDIES
========================
CARDIAC PERFUSION PHARM ___
Normal myocardial perfusion exam. The ejection fraction is 70%.
CXR ___
No acute cardiopulmonary abnormality.
TTE ___
Vigorous left ventricular systolic function. Severe aortic
stenosis with mild aortic regurgitation. Mild mitral and
tricuspid regurgitation. Borderline pulmonary hypertension.
STRESS TEST ___
Non-anginal type symptoms in the absence of significant ST
segment changes. Resting systolic hypertension with an
appropriate
hemodynamic response to vasodilator stress. Nuclear report sent
separately.
DISCHARGE LABS
========================
___ 08:40AM BLOOD WBC-5.1 RBC-3.58* Hgb-11.2 Hct-34.9
MCV-98 MCH-31.3 MCHC-32.1 RDW-14.2 RDWSD-51.8* Plt ___
___ 07:33PM BLOOD ___ PTT-40.6* ___
___ 08:40AM BLOOD Glucose-75 UreaN-28* Creat-1.1 Na-137
K-4.3 Cl-101 HCO3-23 AnGap-13
___ 08:40AM BLOOD CK(CPK)-191
___ 08:40AM BLOOD CRP-7.3*
###RESPONSE: cTropnT {Troponin T cardiac measurement}, COLOR {Color finding}, PROTEIN {Measurement of protein in urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, 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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, TOT BILI {Bilirubin, total measurement}, cTropnT {Troponin T cardiac measurement}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium 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}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, CXR {Plain chest X-ray}, TTE {Transthoracic echocardiography}, aortic
stenosis {Aortic valve stenosis}, mild aortic regurgitation {Mild aortic valve regurgitation}, Mild mitral {Mild mitral valve regurgitation}, tricuspid regurgitation {Tricuspid valve regurgitation}, pulmonary hypertension {Pulmonary hypertension}, ST
segment changes {Electrocardiographic ST segment changes}, systolic hypertension {Systolic hypertension}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, 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} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
====================
PATIENT SUMMARY:
====================
___ year old female, history of CAD (MI ___ s/p PCIx2 to ramus
intermedius, TTE ___, pAF (on Coumadin), moderate AS, HTN,
anemia, dementia, GERD, and hx breast cancer (s/p R mastectomy
with XRT) who presents with chest pain, possibly anginal vs.
symptomatic severe AS vs. non-cardiac.
CORONARIES: Diffuse 3VD
PUMP: Preserved EF (70%)
RHYTHM: pAF
====================
ACTIVE ISSUES
====================
#Chest pain
#CAD (MI ___ s/p PCIx2 to ramus intermedius, last cath ___
with 3VD, declining intervention)
Suspect that some of her chest pain is anginal in nature, though
not entirely clear from her history. Low concern for ACS given
very mild trop elevation which was downtrending and no ischemic
EKG changes. Pmibi was reassuring. Notably long acting nitrates
have resulted in HA in the past. Beta blocker not uptitrated due
to resting bradycardia. Also, she recently had two episodic
visits for diffuse muscle aches and fatigue, with labs showing
mildly elevated CK; statin was discontinued in this setting. ASA
was also held on her last admission due to concern for GIB. Her
symptoms were resolved on the day of discharge.
#pAF: On warfarin. INR on admission 3.3 so Warfarin held on
admission day but resumed on ___. Patient was in sinus this
admission. Continued Amiodarone but Carvedilol 3.125 BID held
due to resting bradycardia. INR on discharge was 2.3.
#Moderate-Severe AS: AS valve area of 1cm, with mean gradient
36.
This is slightly worsened in the past year with prior area
measured at 1.1cm with mean gradient in the low ___. Aortic
stenosis will be discussed further at outpatient visit with
___.
#Diffuse muscle aches: Given vague nature of symptoms, certainly
possible that her pain was related to neither AS nor ischemic
heart disease. Interestingly, her CK and AST were both elevated
on admission likely indicating some skeletal muscle breakdown.
Statin induced myopathy is certainly possible so continued to
hold her Atorvastatin, though other myopathies should be
considered. CRP mildly elevated and ESR pending on discharge.
TSH also checked which was normal.
#HTN: Holding carvedilol but continued amlodipine as above.
#Dementia
#Anxiety:
Continued home wellbutrin and mirtazapine.
#CKD: Appeared to be at baseline Cr from most recent checks. Cr
on discharge was 1.1.
#H/o breast CA s/p R mastectomy with XRT
====================
TRANSITIONAL ISSUES:
====================
- New Meds: None
- Stopped/Held Meds: Carvedilol 3.125mg BID
- Changed Meds: None
- Discharge weight: 41.8 kg (92.15 lb)
- Discharge creatinine: 1.1
[] Held carvedilol in the setting of resting bradycardia. Please
consider restarting if heart rates allow.
[] Warfarin held on ___ because patient was supratherapeutic
but resumed her home dose prior to discharge
# CONTACT: HCP: ___ (Nephew)
Phone number: ___
Cell phone: ___
###RESPONSE: CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, PCI {Electrocardiographic ST segment changes}, ramus
intermedius {Structure of coronary intermediate artery}, TTE {Transthoracic echocardiography}, pAF {Paroxysmal atrial fibrillation}, moderate AS {Moderate stenosis of aortic valve}, HTN {Hypertensive disorder, systemic arterial}, anemia {Anemia}, dementia {Dementia}, GERD {Gastroesophageal reflux disease}, breast cancer {Malignant neoplasm of breast}, R mastectomy {Mastectomy of right breast}, XRT {X-ray beam therapy}, chest pain {Chest pain}, 3VD {Triple vessel disease of the heart}, pAF {Paroxysmal atrial fibrillation}, Chest pain {Chest pain}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, PCI {Electrocardiographic ST segment changes}, ramus intermedius {Structure of coronary intermediate artery}, cath {Cardiac catheterization}, 3VD {Triple vessel disease of the heart}, chest pain {Chest pain}, ACS {Acute coronary syndrome}, ischemic
EKG changes {Electrocardiographic myocardial ischemia}, HA {Headache}, bradycardia {Bradycardia}, muscle aches {Muscle pain}, fatigue {Fatigue}, elevated CK {Creatine kinase level above reference range}, GIB {Gastrointestinal hemorrhage}, pAF {Paroxysmal atrial fibrillation}, On warfarin {Warfarin therapy}, sinus {Sinus rhythm}, bradycardia {Bradycardia}, AS {Aortic valve stenosis}, AS {Aortic valve stenosis}, Aortic
stenosis {Aortic valve stenosis}, muscle aches {Muscle pain}, pain {Muscle pain}, AS {Aortic valve stenosis}, ischemic
heart disease {Ischemic heart disease}, CK {Creatine kinase level above reference range}, AST were both elevated {Aspartate aminotransferase serum level above reference range}, skeletal muscle {Skeletal muscle structure}, myopathy {Disorder of skeletal AND/OR smooth muscle}, myopathies {Disorder of skeletal AND/OR smooth muscle}, CRP mildly elevated {C-reactive protein above reference range}, TSH also checked which was normal {Serum thyroid stimulating hormone level within reference range}, HTN {Hypertensive disorder, systemic arterial}, Dementia {Dementia}, CKD {Chronic kidney disease}, breast CA {Malignant neoplasm of breast}, R mastectomy {Mastectomy of right breast}, XRT {X-ray beam therapy}, bradycardia {Bradycardia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Amiodarone 100 mg PO DAILY
3. amLODIPine 2.5 mg PO DAILY
4. Carvedilol 3.125 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
7. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Second
Line
8. Mirtazapine 7.5 mg PO QHS
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 17.2 mg PO QHS
11. Warfarin 2 mg PO 4X/WEEK (___)
12. Warfarin 1.5 mg PO 3X/WEEK (___)
13. Azopt (brinzolamide) 1 % ophthalmic (eye) TID
14. BuPROPion 100 mg PO BID
15. Chlorpheniramine-Hydrocodone 5 mL PO Q6H:PRN cough
16. Citracal + D Petites (calcium citrate-vitamin D3) 200 mg
calcium -250 unit oral BID
17. Furosemide 20 mg PO DAILY
18. Mag-Al Plus (alum-mag hydroxide-simeth) 200-200-20 mg/5 mL
oral TID
19. melatonin 1 mg oral QHS
20. Sucralfate 0.5 gm PO TID:PRN stomach upset
21. trimethobenzamide 300 mg oral Q8H:PRN nausea
22. Vitamin D 1000 UNIT PO DAILY
23. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Warfarin 1.5 mg PO DAILY16
2. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
3. Amiodarone 100 mg PO DAILY
4. amLODIPine 2.5 mg PO DAILY
5. Azopt (brinzolamide) 1 % ophthalmic (eye) TID
6. BuPROPion 100 mg PO BID
7. Chlorpheniramine-Hydrocodone 5 mL PO Q6H:PRN cough
8. Citracal + D Petites (calcium citrate-vitamin D3) 200 mg
calcium -250 unit oral BID
9. Docusate Sodium 100 mg PO BID
10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
11. Furosemide 20 mg PO DAILY
12. Mag-Al Plus (alum-mag hydroxide-simeth) 200-200-20 mg/5 mL
oral TID
13. melatonin 1 mg oral QHS
14. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Second
Line
15. Mirtazapine 7.5 mg PO QHS
16. Pantoprazole 40 mg PO Q24H
17. Polyethylene Glycol 17 g PO DAILY
18. Senna 17.2 mg PO QHS
19. Sucralfate 0.5 gm PO TID:PRN stomach upset
20. trimethobenzamide 300 mg oral Q8H:PRN nausea
21. Vitamin D 1000 UNIT PO DAILY
22. Warfarin 2 mg PO 4X/WEEK (___)
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
non-coronary chest pain
SECONDARY DIAGNOSIS
====================
coronary artery disease
aortic stenosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: non-coronary chest pain {Non-cardiac chest pain}, coronary artery disease {Coronary arteriosclerosis}, aortic stenosis {Aortic valve stenosis}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, Alert {Mentally alert}, Ambulatory - requires assistance or aid {Finding of walking aid use} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for chest pain and fatigue
What was done for me while I was in the hospital?
- You underwent a stress test which was normal.
- Your medicines were changed to improve your symptoms.
What should I do when I leave the hospital?
- Please continue to take your medicines as prescribed and
follow up with your outpatient providers.
We wish you the best!
Sincerely,
Your ___ Care Team
###RESPONSE: chest pain {Chest pain}, fatigue {Fatigue}, stress test {Electrocardiogram with exercise test} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Latex
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
###RESPONSE: Latex {Allergy to Hevea brasiliensis latex protein}, Chest pain {Chest pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ with h/o liver transplant ___ (HBV) on prograf, IDDM, HLD
with chest pain. Briefly, pt developed severe
epigastric/substernal pain this morning. Pain was severe and
woke him up. He describes it as crampy, nonradiating. Pain was
constant and unremitting, lasting for approximately 3 hours. It
was associated with 3x episodes of vomiting with some relief of
pain. It was not affected by position. No
light-headedness/dizziness. No abdominal pain. Pt notes he had a
very large meal earlier that night. He has never had this type
of pain before. He has never had an esopohogram before and
denies any history of DES. No history of esophageal injury. No
recent dysphagia/odynophagia. No recent sick contacts/illnesses.
Mild SOB, which patient attributes to not being able to take a
deep breath from pain.
In the ambulance, pt received 2x nitro without improvement in
sx.
On admission to the ED, VS were: 96.4 100 97/62 20 97% 4L. Labs
significant for Cr 1.4, ALT/AST: ___, AP 86, TBili 0.5, Lipase
42. Trops negative x2. EKG grossly unchanged from prior. CTA
negative for PE, and CXR negative for any acute process. Pt was
given zofran, morphine x2, GI ocktail, donnatal with improvement
in symptoms. Pt desated to 92% on RA, and he was placed back on
nasal cannula and admitted for workup of chest pain an hypoxia.
On arrival, VS were: 99.5; 130/85; 80; 16; 97% 2LNC. Pt reported
feeling much better. He continues to have some mild chest pain
which is worse with deep breaths.
###RESPONSE: liver transplant {Transplanted liver present}, HBV {Viral hepatitis type B}, IDDM {Diabetes mellitus type 1}, HLD {Hyperlipidemia}, chest pain {Chest pain}, severe {Severe pain}, epigastric {Epigastric pain}, substernal {Retrosternal pain}, pain {Pain}, Pain was severe {Severe pain}, crampy {Cramping pain}, Pain {Pain}, constant {Constant pain}, vomiting {Vomiting}, pain {Pain}, light-headedness {Lightheadedness}, dizziness {Dizziness}, abdominal pain {Abdominal pain}, pain {Pain}, DES {Endovascular insertion of drug eluting stent}, esophageal injury {Injury of esophagus}, dysphagia {Dysphagia}, odynophagia {Swallowing painful}, illnesses {Illness}, Mild {Symptom mild}, SOB {Dyspnea}, deep breath {Deep breathing}, pain {Pain}, improvement {Patient's condition improved}, Labs {Laboratory test}, TBili {Bilirubin, total measurement}, Lipase {Serum lipase measurement}, Trops {Troponin measurement}, negative {No pathologic diagnosis}, EKG {Electrocardiographic procedure}, CTA {Computed tomography angiography with contrast}, negative {No pathologic diagnosis}, PE {Pulmonary embolism}, CXR negative {Standard chest X-ray normal}, improvement {Patient's condition improved}, desated {Oxygen saturation below reference range}, placed back on
nasal cannula {Oxygen administration by nasal cannula}, workup {Evaluation procedure}, chest pain {Chest pain}, hypoxia {Hypoxia}, 2LNC {Oxygen administration by nasal cannula}, mild {Symptom mild}, chest pain {Chest pain}, worse {Increased pain}, deep breaths {Deep breathing} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
HepB cirrhosis s/p OLT in ___
-On Prograf
Hepatitis B on ___ and HepaGam
IDDM
HLD
###RESPONSE: HepB cirrhosis {Cirrhosis of liver due to hepatitis B}, OLT {Orthotopic transplantation of whole liver}, Hepatitis B {Viral hepatitis type B}, IDDM {Diabetes mellitus type 1}, HLD {Hyperlipidemia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
DM, HTN, HLD
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
On Admission:
General: Pleasant, well-appearing NAD.
HEENT: NC/AT. MMM. EOMI.
LAD: No LAD appreciated
CV: RRR. No MRG.
Pulmonary: CTAB. No wheezes, rales, rhonchi
Abdomen: +BS. Soft, NTND. Long horizontal incision over
epigastric region well-healed. No HSM appreciated.
Extremities: WWP. 2+ DP pulese, equal bilaterally. No c/c/e
Neuro: CNII-XII grossly intact
On Discharge:
General: Pleasant, well-appearing NAD.
HEENT: NC/AT. MMM. EOMI.
LAD: No LAD appreciated
CV: RRR. No MRG.
Pulmonary: CTAB. No wheezes, rales, rhonchi
Abdomen: +BS. Soft, NTND. Long horizontal incision over
epigastric region well-healed. No HSM appreciated.
Extremities: WWP. 2+ DP pulese, equal bilaterally. No c/c/e
Neuro: CNII-XII grossly intact
###RESPONSE: General {General examination of patient}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, MMM {Moist oral mucosa}, EOMI {Normal ocular motility}, LAD {Lymphadenopathy}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, No MRG {Heart sounds normal}, Pulm {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, incision {Surgical incision wound}, epigastric region {Epigastric region structure}, well-healed {Wound healed}, HSM {Hepatosplenomegaly}, Extremities {Examination of limb}, WWP {Normal tissue perfusion}, 2+ DP {Dorsalis pulse present}, No c/c/e {No abnormality detected}, Neuro {Neurological examination}, grossly intact {Normal nervous system function}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC/AT {Normal head}, MMM {Moist oral mucosa}, EOMI {Normal ocular motility}, LAD {Examination of lymph nodes}, LAD {Lymphadenopathy}, RRR {Normal heart rate}, No MRG {Heart sounds normal}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Soft {Abdomen soft}, NTND {Abdominal tenderness}, incision {Surgical incision wound}, epigastric region {Epigastric region structure}, well-healed {Wound healed}, HSM {Hepatosplenomegaly}, WWP {Normal tissue perfusion}, 2+ DP {Dorsalis pulse present}, No c/c/e {No abnormality detected}, Neuro {Neurological examination}, CNII-XII grossly intact {Normal nervous system function} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
On Admission:
___ 05:30AM BLOOD WBC-10.5# RBC-4.63 Hgb-14.6 Hct-40.7
MCV-88 MCH-31.6 MCHC-36.0* RDW-14.8 Plt ___
___ 05:30AM BLOOD ___ PTT-23.1* ___
___ 05:30AM BLOOD Glucose-216* UreaN-22* Creat-1.4* Na-139
K-4.4 Cl-101 HCO3-27 AnGap-15
___ 05:30AM BLOOD ALT-23 AST-26 AlkPhos-86 TotBili-0.5
Troponins:
___ 05:30AM BLOOD cTropnT-<0.01
___ 11:36AM BLOOD cTropnT-<0.01
On Discharge:
___ 04:35AM BLOOD WBC-8.1 RBC-4.40* Hgb-13.8* Hct-39.1*
MCV-89 MCH-31.3 MCHC-35.3* RDW-14.3 Plt ___
___ 04:35AM BLOOD ___ PTT-28.4 ___
___ 04:35AM BLOOD Glucose-145* UreaN-23* Creat-1.4* Na-139
K-4.6 Cl-98 HCO3-30 AnGap-16
___ 04:35AM BLOOD ALT-19 AST-23 AlkPhos-79 TotBili-0.9
___ 04:35AM BLOOD Calcium-9.5 Phos-1.8* Mg-1.9
___ 04:35AM BLOOD tacroFK-3.1*
Microbiology:
None
Imaging:
___ CTA Chest
IMPRESSION:
1. No pulmonary embolism.
2. Small pericardial effusion.
3. Few pulmonary nodules measuring up to 4 mm. Followup in ___
year is
recommended there is high risk for lung malignancy.
4. Paraesophageal varices.
___ CXR:
IMPRESSION:
1. Mild vascular congestion.
2. Chronic small right pleural effusion versus pleural
thickening.
2. Left lower lobe atelectasis with elevation of left
hemidiaphragm.
___ ECG:
Sinus rhythm. Compared to the previous tracing of ___ there
are no
significant changes.
###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}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, cTropnT {Troponin T cardiac measurement}, 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}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, 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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, CTA Chest {Computed tomography angiography of chest with contrast}, pulmonary embolism {Pulmonary embolism}, pericardial effusion {Pericardial effusion}, pulmonary nodules {Nodule of lung}, Followup {Follow-up consultation}, lung malignancy {Metastatic malignant neoplasm to lung}, Paraesophageal varices {Esophageal varices}, Mild {Symptom mild}, vascular {Blood vessel structure}, congestion {Congestion}, Chronic {Chronic disease}, right {Right pleura structure}, pleural effusion {Pleural effusion}, pleural
thickening {Thickening of pleura}, Left lower lobe {Structure of lower lobe of left lung}, atelectasis {Atelectasis}, elevation {Elevated diaphragm}, left
hemidiaphragm {Structure of left hemidiaphragm}, ECG:
Sinus rhythm {Electrocardiogram: sinus rhythm} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ with pmhx of HBV cirrhosis (sp xplant in ___, IDDM, HLD,
CKD, h/o strongyloides, h/o fasciola who presented with SSCP
following a large meal.
#Chest pain: Felt to be esophageal spasm in the setting of GERD.
EKG unchanged from prior and tropopnins were negative. CTA
otherwise negative for PE. Pt was started on a PPI, and he had
only minor recurrence of chest pain after coming to the floor.
Pt was discharged with a PPT as well as a plan for follow up EGD
with possible barium swallow.
#Shortness of Breath: Pt's shortness of breath was felt to be
related to his inability to take a deep breath due to pain. His
desaturation in the ED may have been related to the pain
medications he was administered. Pt's oxygen was quickly weanes
off an admission, and his respiratory status remained stable
during this admission.
#Hepatitis B: Pt was continued on ___
#Cirrhosis s/p OLT: MELD score 10. Pt was continued on home
Prograf. Level was 3.1 on morning of discharge.
#Pulmonary nodules: Pt was incidentally found to have pulmonary
nodules on CTA, and it was recommended that they be followed up
in ___ year if pt felt to be high risk for malignancy.
Transitional:
[] Please consider up-titration of PPI
[] Pt will be scheduled for follow-up EGD +/- barium swallow -
manometry may be indicated in the future
[] Consider f/u of pulmonary nodules in ___ year
###RESPONSE: HBV cirrhosis {Cirrhosis of liver due to hepatitis B}, xplant {Transplanted liver present}, IDDM {Diabetes mellitus type 1}, HLD {Hyperlipidemia}, CKD {Chronic kidney disease}, strongyloides {Infection caused by Strongyloides}, fasciola {Infection caused by Fasciola}, Chest pain {Chest pain}, esophageal spasm {Diffuse spasm of esophagus}, GERD {Gastroesophageal reflux disease}, EKG {Electrocardiographic procedure}, tropopnins {Troponin measurement}, negative {No pathologic diagnosis}, CTA {Computed tomography angiography of chest with contrast}, negative {No pathologic diagnosis}, PE {Pulmonary embolism}, started {New medication added}, PPI {Proton pump inhibitor therapy}, chest pain {Chest pain}, follow up {Follow-up arranged}, EGD {Esophagogastroduodenoscopy}, barium swallow {Barium swallow}, Shortness of Breath {Dyspnea}, shortness of breath {Dyspnea}, inability to take a deep breath {Unable to take deep breaths}, pain {Pain}, desaturation {Oxygen saturation below reference range}, pain
medications {Administration of analgesic}, respiratory status {Monitoring of respiration}, stable {Patient's condition stable}, Hepatitis B {Viral hepatitis type B}, Cirrhosis {Cirrhosis of liver}, OLT {Orthotopic transplantation of whole liver}, Prograf. Level {Blood tacrolimus level}, Pulmonary nodules {Nodule of lung}, pulmonary
nodules {Nodule of lung}, CTA {Computed tomography angiography of chest with contrast}, risk for malignancy {At increased risk of malignancy}, PPI {Proton pump inhibitor therapy}, follow-up {Follow-up arranged}, EGD {Esophagogastroduodenoscopy}, barium swallow {Barium swallow}, manometry {Esophageal manometry}, pulmonary nodules {Nodule of lung} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 40 mg PO QPM
2. Phosphorus 250 mg PO TID W/MEALS
3. Amoxicillin ___ mg PO ONE HOUR PRIOR TO DENTAL SURGERY
4. Tacrolimus 0.5 mg PO Q12H
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Entecavir 1 mg PO DAILY
7. Escitalopram Oxalate 10 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. GlipiZIDE 7.5 mg PO QAM
10. GlipiZIDE 10 mg PO QPM
11. Calcitriol 0.25 mcg PO BID
12. Glargine 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Hepatitis B Immun Globulin (HepaGam B) 5000 UNIT IV Q4
MONTHS
Discharge Medications:
1. Calcitriol 0.25 mcg PO BID
2. Entecavir 1 mg PO DAILY
3. Escitalopram Oxalate 10 mg PO DAILY
4. Glargine 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Phosphorus 250 mg PO TID W/MEALS
7. Pravastatin 40 mg PO QPM
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Tacrolimus 0.5 mg PO Q12H
10. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
11. Amoxicillin ___ mg PO ONE HOUR PRIOR TO DENTAL SURGERY
___. GlipiZIDE 7.5 mg PO QAM
13. GlipiZIDE 10 mg PO QPM
14. Hepatitis B Immun Globulin (HepaGam B) 5000 UNIT IV Q4
MONTHS
###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:
Esophageal spasm
Gastroesophageal reflux disease
Chest pain
Secondary:
Diabetes
Chronic kidney disease
Hepatitis B
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Esophageal spasm {Diffuse spasm of esophagus}, Gastroesophageal reflux disease {Gastroesophageal reflux disease}, Chest pain {Chest pain}, Diabetes {Diabetes mellitus type 1}, Chronic kidney disease {Chronic kidney disease}, Hepatitis B {Viral hepatitis type B}, Hyperlipidemia {Hyperlipidemia}, Clear {Normal state of mind}, 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 Dr. ___,
___ was a pleasure to participate in your care. You were admitted
for chest pain. You were found to have no evidence of cardiac
ischemia or pulmonary embolism. Your symptoms improved with a
proton pump inhibitor. We believe that your symptoms may have
been due to gastric reflux or esophageal spasm. Please follow up
with your Gastroenterologist for outpatient endoscopy and barium
enema.
Best Regards,
Your ___ Medicine Team
###RESPONSE: chest pain {Chest pain}, no evidence {No abnormality detected}, cardiac
ischemia {Myocardial ischemia}, pulmonary embolism {Pulmonary embolism}, improved {Patient's condition improved}, proton pump inhibitor {Proton pump inhibitor therapy}, gastric reflux {Gastric reflux}, esophageal spasm {Diffuse spasm of esophagus}, follow up {Follow-up arranged}, endoscopy {Endoscopy}, barium
enema {Barium enema} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Penicillins / Amoxicillin
Attending: ___.
Chief Complaint:
Back and Left Leg Pain
Major Surgical or Invasive Procedure:
PROCEDURES: ___
1. Anterior lumbar interbody fusion, L4-L5, L5-S1.
2. Anterior interbody cage placement L4-L5, L5-S1.
PROCEDURES: ___
1. L5 laminectomy, L4 laminotomy
2. Posterior Spinal Instrumented Fusion L4-S1
###RESPONSE: Penicillins {Allergy to penicillin}, Amoxicillin {Allergy to amoxicillin}, Back {Structure of back of trunk}, Left Leg Pain {Pain in left lower limb}, Anterior lumbar interbody fusion {Interbody fusion of lumbar spine by anterior approach}, L4-L5 {Intervertebral disc structure of fourth lumbar vertebra}, L5-S1 {Structure of intervertebral disc of L5 and S1}, placement {Implantation procedure}, L4-L5 {Intervertebral disc structure of fourth lumbar vertebra}, L5-S1 {Structure of intervertebral disc of L5 and S1}, L5 {Structure of lamina of fifth lumbar vertebra}, laminectomy {Excision of lamina of vertebra}, L4 {Structure of lamina of fourth lumbar vertebra}, laminotomy {Laminotomy}, Posterior Spinal Instrumented {Posterior spinal instrumentation}, Fusion {Fusion procedure}, L4 {Bone structure of L4}, S1 {Structure of first sacral vertebra} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
This patient presented with persistent back and left-sided leg
pain. This goes down in an L5 distribution. It is approximately
60% back, 40% leg and it goes down the outside of his leg,
outside of his calf, top of his foot. He had
an injury approximately ___ years ago while wrestling and he wore
a back brace for two to three months due to spondylolisthesis.
He has been followed at ___. He has been good
for approximately five to ___ years, but the past six months
have
been significantly bothersome for him. He had a recent child;
he
is unable to pick the child up. He has had no injections
recently. He discontinued physical therapy secondary to pain.
It is ___ ___nd ___ with activity. His mom is with him
today. He has a history of anxiety and chest pain and he had a
workup for cardiac chest pain, which was negative and with a
diagnosis of stress. He is on Lamictal and Geodon for bipolar
depression. He is allergic to amoxicillin. He smokes
approximately half a pack a day, which is a decrease from the
two
packs.
His films were reviewed, which show a grade ___
spondylolisthesis
at L5-S1 with spondylolysis. An MRI was reviewed from
___
from ___ MRI, which shows a bilateral L5 spondylolysis and
L5-S1 spondylolisthesis that is grade 2. There is severe
foraminal stenosis bilaterally.
On physical examination, he is an alert and oriented male.
Affect is within normal limits. He has an antalgic gait. He
has
___ strength bilaterally with a ___ ___ and abductors. His
sensation is grossly intact to light touch. He has a positive
straight leg raise approximately 70 degrees. No pain with
internal rotation of hips. Distal pulses intact. Calves are
soft. No signs of atrophy.
This is a patient with a grade ___ spondylolisthesis, who by
report was a grade 1 and followed at ___. He
has
severe left back as well as left lower extremity radicular
symptoms. We talked about possible surgical intervention. This
would either be an anterior-posterior fusion with interbody
cages
from ___ versus a strut graft through the sacrum and L5 combined
with a posterolateral fusion. We discussed this at length as
well as risks and benefits using models as MRI. All questions
were answered. I would like to obtain a CT scan and see him
back
in followup. I gave him a surgical packet and asked him to look
at the animations and come back with any questions. Given his
x-rays and MRIs as well as clinical symptoms, I do recommend
surgical intervention.
###RESPONSE: back {Structure of back of trunk}, left-sided leg
pain {Pain in left lower limb}, L5 {Bone structure of L5}, back {Structure of back of trunk}, leg {Structure of left lower leg}, leg {Structure of left lower leg}, calf {Structure of calf of right lower leg}, foot {Structure of right foot}, injury {Traumatic or non-traumatic injury}, wore
a back brace {Application of back brace}, spondylolisthesis {Spondylolisthesis}, unable to pick the child up {Unable to pick up objects}, injections {Injection}, physical therapy {Physical therapy procedure}, pain {Abdominal pain}, anxiety {Anxiety}, chest pain {Chest pain}, cardiac chest pain {Cardiac chest pain}, stress {Stress}, bipolar {Bipolar disorder}, depression {Depressive disorder}, allergic to amoxicillin {Allergy to amoxicillin}, smokes {Smoker}, spondylolisthesis {Spondylolisthesis}, L5 {Bone structure of L5}, S1 {Structure of first sacral vertebra}, spondylolysis {Spondylolysis}, MRI {Magnetic resonance imaging}, MRI {Magnetic resonance imaging}, L5 {Bone structure of L5}, spondylolysis {Spondylolysis}, L5 {Bone structure of L5}, S1 {Structure of first sacral vertebra}, spondylolisthesis that is grade 2 {Spondylolisthesis, grade 2}, foraminal stenosis {Stenosis of lumbar vertebral foramen}, physical examination {Physical examination procedure}, alert {Mentally alert}, oriented {Orientated}, Affect {Mood finding}, antalgic gait {Antalgic gait}, sensation {Normal sensation}, intact to light touch {Light touch sensation present}, straight leg raise {Finding of straight leg raise}, pain {Abdominal pain}, internal rotation of hips {Structure of internal rotator of hip joint}, Calves {Structure of calf of leg}, atrophy {Atrophy}, spondylolisthesis {Spondylolisthesis}, grade 1 {Spondylolisthesis, grade 1}, t back {Structure of back of trunk}, left lower extremity {Structure of left lower limb}, radicular
symptoms {Radicular pain}, surgical intervention {Surgical procedure}, fusion {Fusion procedure}, sacrum {Structure of sacral vertebral column}, L5 {Bone structure of L5}, fusion {Fusion procedure}, MRI {Magnetic resonance imaging}, CT scan {Computed tomography of abdomen}, x-rays {Radiographic imaging procedure}, MRIs {Magnetic resonance imaging}, surgical intervention {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: Past Medical History:
see HPI
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
see HPI
###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:
see HPI
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 07:09AM BLOOD ALT-24 AST-18 LD(LDH)-148 AlkPhos-81
TotBili-1.6*
___ 05:00AM BLOOD Glucose-135* UreaN-10 Creat-0.7 Na-137
K-4.8 Cl-103 HCO3-28 AnGap-11
___ 05:00AM BLOOD WBC-12.2* RBC-3.43* Hgb-10.7* Hct-30.6*
MCV-89 MCH-31.2 MCHC-35.1* RDW-12.3 Plt ___
###RESPONSE: ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. The two
portions of the surgery were staged apart by four days. Refer
to the dictated operative notes for further details. The
surgeries were without complication and the patient was
transferred to the PACU in a stable condition each time.
TEDs/pnemoboots were used for postoperative DVT prophylaxis.
Intravenous antibiotics were continued for 24hrs postop per
standard protocol. Initial postop pain was controlled with a
PCA. Diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
Foley was removed on POD#1. Physical therapy was consulted for
mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
###RESPONSE: procedure {Surgical procedure}, surgery {Surgical procedure}, stable condition {Patient's condition stable}, TEDs {Application of antithromboembolic stockings}, postoperative {Postoperative state}, DVT prophylaxis {Prevention of deep vein thrombosis}, Intravenous antibiotics {Intravenous antibiotic therapy}, pain was controlled {Demonstrates adequate pain control}, PCA {Patient controlled analgesia}, Diet was advanced as tolerated {Advance diet as tolerated}, oral {Administration of drug or medicament via oral route}, pain medication {Administration of analgesic}, diet {Dietary finding}, Foley was removed {Removal of urinary bladder catheter}, mobilization {Mobilization}, ambulate {Ambulation training}, unremarkable {No abnormality detected}, afebrile {Fever}, stable vital signs {Normal vital signs}, oral {Administration of drug or medicament via oral route}, pain control {Pain control}, regular diet {Normal diet} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. ziprasidone HCl 20 mg Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)).
Discharge Medications:
1. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
once a day as needed for constipation for 3 doses.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. ziprasidone HCl 20 mg Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)).
5. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for constipation.
###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:
L5-S1 Anterior Spondylolisthesis
Discharge Condition:
A+Ox3
Ambulate as tolerated
###RESPONSE: 5-S1 {Structure of first sacral vertebra}, Spondylolisthesis {Spondylolisthesis}, Ox3 {Oriented to person, time and place} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You have undergone the following operation: Lumbar Decompression
With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
-Brace: You may have been given a brace. This brace is to be
worn when you are walking. You may take it off when sitting in a
chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
-You should resume taking your normal home medications.
-You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___ 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
###RESPONSE: operation {Surgical procedure}, Lumbar Decompression {Decompression of lumbar spine}, Fusion {Lumbar spinal fusion}, operation {Surgical procedure}, Activity {Functional activity education}, Rehabilitation/ Physical Therapy {Physical rehabilitation therapy procedure}, Diet {Dietary finding}, healthy diet {Healthy diet}, constipation {Constipation}, surgery {Surgical procedure}, medication {Administration of drug or medicament}, Brace {Application of back brace}, sitting {Sitting position}, lying in bed {Lying in bed}, Wound Care {Wound treatment education}, dressing {Application of dressing}, incision {Surgical incision wound}, draining {Wound discharge}, sterile dressing {Application of dressing, sterile}, incision {Surgical incision wound}, incision {Surgical incision wound}, operation {Surgical procedure}, soak {Soak}, incision {Surgical incision wound}, incision {Surgical incision wound}, draining {Wound discharge}, surgery {Surgical procedure}, incision {Surgical incision wound}, sterile
dressing {Application of dressing, sterile}, medications {Administration of drug or medicament}, pain {Pain}, prescriptions {Prescription}, prescriptions {Prescription}, pain medications {Administration of analgesic}, surgery {Surgical procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
NONE
###RESPONSE: Dyspnea {Dyspnea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ y/o ___ man with multiple medical problems
most notable for HTN, COPD, HFpEF, Afib on Coumadin who presents
with dyspnea. Of note, the patient was discharged on ___
following treatment for community acquired pneumonia. The
patient was found to have RML consolidation, initially treated
with IV CTX and Azithromycin and transitioned to Levofloxacin x7
day total course (last day ___.
Patient complained of increasing dyspnea. EMS called, patient
was not initially hypoxic but hypertensive SBP 210s, patient
given nitro spray x3 and started on BiPAP. Patient brought to
___ ED. In the ED, initial vitals: T 97.5 HR 89 BP 107/67 RR
19 SpO2 100% cpap. Exam notable for respiratory distress and
increased work of breathing. No evidence of JVD ___ edema.
Initial labs notable for lactate 1.3 and VBG pH 7.29 pCO2 66 pO2
36. The patient was given Albuterol/Ipratropium Nebs and
Methylpred 125 mg IV x1.
On arrival to the MICU, ___ y/o ___ man with
multiple medical problems most notable for HTN, COPD, HFpEF,
Afib on Coumadin who presents with dyspnea. Of note, the patient
was discharged on ___ following treatment for community
acquired pneumonia. The patient was found to have RML
consolidation, initially treated with IV CTX and Azithromycin
and transitioned to Levofloxacin x7 day total course (last day
___.
###RESPONSE: problems {Problem}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, HFpEF {Heart failure with normal ejection fraction}, Afib {Atrial fibrillation}, Coumadin {Anticoagulant therapy}, dyspnea {Dyspnea}, community acquired pneumonia {Community acquired pneumonia}, RML {Right middle zone pneumonia}, consolidation {Consolidation}, IV {Administration of drug or medicament via intravenous route}, dyspnea {Dyspnea}, hypoxic {Hypoxia}, hypertensive {Finding of increased blood pressure}, BiPAP {Bilevel positive airway pressure titration}, vitals {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, cpap {Continuous positive airway pressure ventilation treatment}, respiratory distress {Respiratory distress}, No evidence {No abnormality detected}, JVD {Jugular venous engorgement}, edema {Edema}, IV {Administration of drug or medicament via intravenous route}, problems {Problem}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, HFpEF {Heart failure with normal ejection fraction}, Afib {Atrial fibrillation}, Coumadin {Anticoagulant therapy}, dyspnea {Dyspnea}, community
acquired pneumonia {Community acquired pneumonia}, RML {Right middle zone pneumonia}, consolidation {Consolidation}, IV {Administration of drug or medicament via intravenous route} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
- Hyperlipidemia
- Hypertension
- COPD
- CHF
- Atrial fibrillation (CHADS=3)
- Gout
###RESPONSE: Hyperlipidemia {Hyperlipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, CHF {Congestive heart failure}, Atrial fibrillation {Atrial fibrillation}, Gout {Inflammatory disorder due to increased blood urate level} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
No cardiac disease, HTN, DM in family.
###RESPONSE: cardiac disease {Heart disease}, HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ON ADMISSION:
=============
Vitals- T 97.9 BP138/67 HR78 RR20 SaO2 98RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
ON DISCHARGE:
=============
Vitals- T 97.7 Tmax98.1 BP 126-148/64-87 HR ___ RR ___ 98%
RA
General- Alert, oriented, no acute distress, seated in chair at
bedside
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Minimal wheezes diffusely, decreased breath sounds at
bases
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Moving all 4 limbs without focal neuro deficits
###RESPONSE: Vitals {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, SaO2 {Finding of oxygen saturation}, RA {Breathing room air}, GENERAL {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, NECK {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, LUNGS {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, ABD {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, EXT {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, Alert {Mentally alert}, oriented {Oriented to person}, distress {Distress}, seated {Sitting position}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, Neck- supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, wheezes {Wheezing}, decreased breath sounds {Decreased breath sounds}, bases {Structure of base of lung}, Regular rate and rhythm {Normal heart rate}, normal S1 + S2 {Heart sounds normal}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen- soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound tenderness {Rebound tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Moving all 4 limbs {Does move all four limbs}, neuro deficits {Neurological deficit} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ON ADMISSION:
=============
___ 09:24PM BLOOD WBC-9.5 RBC-5.11 Hgb-10.9* Hct-35.7*
MCV-70* MCH-21.3* MCHC-30.5* RDW-17.9* RDWSD-42.6 Plt ___
___ 09:24PM BLOOD Neuts-55.6 ___ Monos-9.8 Eos-3.5
Baso-0.7 Im ___ AbsNeut-5.25 AbsLymp-2.85 AbsMono-0.93*
AbsEos-0.33 AbsBaso-0.07
___ 09:24PM BLOOD ___ PTT-37.6* ___
___ 09:24PM BLOOD Plt ___
___ 09:24PM BLOOD Glucose-138* UreaN-16 Creat-1.3* Na-137
K-3.9 Cl-96 HCO3-28 AnGap-17
___ 09:24PM BLOOD ALT-14 AST-24 AlkPhos-112 TotBili-0.3
___ 09:24PM BLOOD proBNP-1603*
___ 09:24PM BLOOD cTropnT-<0.01
___ 02:53PM BLOOD CK-MB-3 cTropnT-0.03*
___ 09:24PM BLOOD Albumin-4.1
___ 09:28PM BLOOD ___ pO2-36* pCO2-66* pH-7.29*
calTCO2-33* Base XS-2
___ 09:28PM BLOOD Lactate-1.3
STUDIES AND IMAGING
___ PORTABLE CXR
Resolved pneumonia. Limited evaluation of the lung apices. No
convincing
evidence for pneumonia or edema.
ON DISCHARGE:
=============
___ 06:45AM BLOOD WBC-10.0 RBC-4.89 Hgb-10.4* Hct-33.5*
MCV-69* MCH-21.3* MCHC-31.0* RDW-18.0* RDWSD-41.5 Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-116* UreaN-23* Creat-1.0 Na-136
K-3.8 Cl-95* HCO3-33* AnGap-12
___ 06:45AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.7
___ 07:45AM BLOOD Lactate-2.___ old ___ man, ___'s Witness, with dCHF, HTN,
COPD, AF on coumadin p/w dyspnea, without pain.
MICU COURSE:
============
# Hypercarbic respiratory failure. Pt admitted after course of
treatment for CAP with increased dyspnea. In the the MICU, put
on BiPAP, PEEP8 FiO2 50% on arrival, breathing comfortably.
Received ipratropium/albuterol nebs x3, methylprednisolone in
the ED. Given the findings of the chest X-ray showing
hyperinflated lungs, there was an initial concern is for COPD
exacerbation. Patient started on standing duonebs, prn
albuterol, azithromycin: 500mg x 1, 250mg x 4 days and
prednisone 40 mg daily for five day course. However, on ___
lactate noted to be uptrending from 3.4 to 5.5 despite fluids
and IV thiamine. CXR at this time showed RLL consolidation,
started Vanc/Cefepime for ___ vs aspiration PNA. Speech/swallow
eval was ordered but no frank aspiration noted at bedside. Of
note, he was going to be called out to the medical floor on
___ but lactate persistently elevated to 3's. Given no other
signs of hypoperfusion, ICU team attributed his elevated lactate
to frequent nebs.
FLOOR COURSE:
=============
#Acute COPD exacerbation: Continued treatment for ___ and COPD
exacerbation with 7 day course of Levofloxacin (first day ___,
last day ___ and 5 days of prednisone (first day ___, last
day ___. BNP was at his baseline at roughly 1600. Patient was
on standing duonebs and albuterol PRN.
#Leukocytosis: Initially elevated then improved to 10 on ___.
Likely secondary to prednisone.
#Acute Renal Failure: Creatinine initially 1.3 and held home
bumetanide. Creatinine down to 1.0 on ___.
CHRONIC ISSUES
#dCHF: Creatinine initially 1.3 and held home bumetanide.
Restarted home bumetanide 3.5mg daily, clinically appears
euvolemic on exam.
#HTN: Continued carvedilol, valsartan, diltiazem
#AF: Rate controlled, continued home diltiazem and carvedilol.
Warfarin held for INR 3.4 on ___.
#Gout: Continued allopurinol.
#Anemia: Microcytic anemia with low iron in ___ gave 1
dose ferric gluconate here. Can work up further as outpatient if
within patients goals of care.
***TRANSITIONAL ISSUES:***
- Continue Levofloxacin 750mg PO QDay until last day ___
- Warfarin held for supratherapeutic INR (INR 3.4 on ___, INR
needs to be monitored and Warfarin restarted accordingly
- Consider anemia work up as outpatient
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, 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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, Albumin {Albumin measurement}, pH {pH measurement}, CXR {Plain chest X-ray}, Resolved {Problem resolved}, pneumonia {Pneumonia}, evaluation {Evaluation procedure}, lung apices {Structure of apex of lung}, pneumonia {Pneumonia}, edema {Edema}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, 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}, dCHF {Chronic diastolic heart failure}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, AF {Atrial fibrillation}, coumadin {Anticoagulant therapy}, dyspnea {Dyspnea}, without pain {No present pain}, Hypercarbic respiratory failure {Hypercapnic respiratory failure}, CAP {Community acquired pneumonia}, dyspnea {Dyspnea}, BiPAP {Bilevel positive airway pressure titration}, breathing comfortably {Breathing easily}, chest X-ray {Plain chest X-ray}, hyperinflated {Chest over-expanded}, COPD
exacerbation {Acute exacerbation of chronic obstructive airways disease}, fluids {Administration of fluid therapy}, IV {Administration of drug or medicament via intravenous route}, CXR {Plain chest X-ray}, RLL {Structure of lower lobe of right lung}, consolidation {Consolidation}, aspiration PNA {Aspiration pneumonia}, Speech/swallow
eval {Evaluation of oral and pharyngeal swallowing function}, aspiration {Pulmonary aspiration}, signs {Sign}, Acute COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD
exacerbation {Acute exacerbation of chronic obstructive airways disease}, BNP {Brain natriuretic peptide measurement}, baseline {Baseline state}, Leukocytosis {Leukocytosis}, improved {Patient's condition improved}, Acute Renal Failure {Acute kidney injury}, Creatinine {Creatinine measurement}, Creatinine {Creatinine measurement}, CHRONIC ISSUES {Chronic disease}, dCHF {Chronic diastolic heart failure}, Creatinine {Creatinine measurement}, euvolemic {Normal blood volume}, exam {Physical examination procedure}, HTN {Hypertensive disorder, systemic arterial}, AF {Atrial fibrillation}, Gout {Inflammatory disorder due to increased blood urate level}, Anemia {Anemia}, Microcytic anemia {Microcytic anemia}, work up {Evaluation procedure}, anemia {Anemia}, work up {Evaluation procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. albuterol sulfate 2.5 /3 mL (0.083 %) INHALATION BID:PRN
shortness of breath
3. Allopurinol ___ mg PO DAILY
4. Benzonatate 100 mg PO TID
5. Bumetanide 3.5 mg PO DAILY
6. Carvedilol 6.25 mg PO BID
7. Diltiazem Extended-Release 120 mg PO DAILY
8. Docusate Sodium 200 mg PO BID
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Ipratropium Bromide Neb 1 NEB IH BID
11. Senna 8.6 mg PO BID
12. Valsartan 40 mg PO BID
13. Warfarin 4 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. albuterol sulfate 2.5 /3 mL (0.083 %) INHALATION BID:PRN
shortness of breath
3. Allopurinol ___ mg PO DAILY
4. Benzonatate 100 mg PO TID
5. Bumetanide 3.5 mg PO DAILY
6. Carvedilol 6.25 mg PO BID
7. Diltiazem Extended-Release 120 mg PO DAILY
8. Docusate Sodium 200 mg PO BID
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Senna 8.6 mg PO BID
11. Valsartan 40 mg PO BID
12. Ipratropium Bromide Neb 1 NEB IH BID
13. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Hypercapnia Respiratory Failure
COPD exacerbation
___
Secondary:
___
HTN
Atrial fibrillation
Gout
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Home With Service {Home health aide service management}, Hypercapnia Respiratory Failure {Hypercapnic respiratory failure}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, HTN {Hypertensive disorder, systemic arterial}, Atrial fibrillation {Atrial fibrillation}, Gout {Inflammatory disorder due to increased blood urate level}, Anemia {Anemia}, Mental Status {Neurological mental status determination}, Alert {Mentally alert}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ on ___ because you were having
trouble breathing. We found that you were having a severe
exacerbation of your COPD as well as pneumonia. We treated you
with antibiotics and steroids and your breathing improved. You
were also found to have an acute injury of the kidneys, but we
gave you fluids and your kidneys recovered.
It was a pleasure taking care of you!
-Your BI___ team
###RESPONSE: trouble breathing {Difficulty breathing}, COPD {Chronic obstructive lung disease}, pneumonia {Pneumonia}, antibiotics {Antibiotic therapy}, steroids {Steroid therapy}, improved {Patient's condition improved}, injury {Traumatic or non-traumatic injury}, kidneys {Kidney structure}, fluids {Administration of fluid therapy}, kidneys recovered {Normal renal function} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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: SURGERY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right non-healing foot ulcer
Major Surgical or Invasive Procedure:
Right lower extremity Angiogram with stent placement to the
distal SFA/popliteal artery.
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, healing {Structure resulting from tissue repair process}, foot ulcer {Ulcer of foot}, Right lower extremity Angiogram {Angiography of artery of right lower limb}, stent placement {Placement of stent}, SFA {Structure of superficial femoral artery}, popliteal artery {Structure of popliteal 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:
Ms. ___ presents with chronic right
calcaneal ulcer. It has been present for approximately 6 months.
She also reports calf pain on ambulation to suggest
claudication. Her foot ulcer has been followed by podiatry. She
presents for a RLE angiogram for further evaluation and possible
intervention of RLE peripheral vascular disease.
###RESPONSE: chronic right
calcaneal ulcer {Chronic ulcer of right heel}, calf pain {Pain in calf}, ambulation {Pain aggravated by walking}, claudication {Intermittent claudication}, foot ulcer {Ulcer of foot}, RLE angiogram {Angiography of artery of right lower limb}, evaluation {Evaluation procedure}, RLE {Structure of right lower limb}, peripheral vascular disease {Peripheral vascular disease} |
Subsets and Splits