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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: 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:
Patient recorded as having No Known Allergies to Drugs
Attending: ___.
Chief Complaint:
Hypotension, Fatigue/anemia
Major Surgical or Invasive Procedure:
None
###RESPONSE: Hypotension {Low blood pressure}, Fatigue {Fatigue}, anemia {Anemia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
This is an ___ year old ___ female who presents with one
month of progressive fatigue/weakness. She has had significant
fatigue for the past 6 months, but this has become worse over
the last month, and she has been feeling dizzy everyday. Her
daughter also notes that she looks paler than usual. The
patient has mild DOE. She has a known history of chronic anemia
with baseline HCT of ___ (in ___ of unclear etiology.
Per PCP records, she was evaluated at ___ several years ago
but no formal records of the results of that eval are known,
although the patient's daughter reports that "no problem was
found". She presented to her PCP today for evaluation, where
immediate labs were sent and noted to have a Hct of 23.1 and
plts of 59 from a baseline of 134. She was hypotensive in the
office, documented at 78/60, heart rate 93. Her PCP called her
to come into the ___ ED due to the hypotension, as well as to
work up her anemia. The patient denies fevers, chills, HA,
cough, chest pain, abdominal pain, N/V/D, vaginal bleeding,
dysuria, increased frequency, or rash. She does note some
constipation, which has been a chronic issue, and her last bowel
movement was ___ years ago. She has not had any episodes of
hematemesis, bloody or tarry stools.
.
In the ED, initial VS were: T 100.4 HR 95 BP 119/63 RR 16 O2-sat
100% RA. The patient was given nothing in the ED. Vitals on
transfer were T 99 HR 85 BP 106/60 RR19 O2-sat 98% RA.
.
On the floor, feels well but continues to feel fatigued.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, or abdominal pain. No recent change
in bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
###RESPONSE: progressive {Patient's condition worsened}, fatigue {Fatigue}, weakness {Asthenia}, fatigue {Fatigue}, dizzy {Dizziness}, mild {Symptom mild}, DOE {Dyspnea on exertion}, chronic anemia {Chronic anemia}, baseline {Baseline state}, HCT {Hematocrit determination}, PCP {Primary care management}, evaluated {Evaluation procedure}, eval {Evaluation procedure}, problem {Problem}, PCP {Primary care management}, evaluation {Evaluation procedure}, labs {Laboratory test}, baseline {Baseline state}, hypotensive {Low blood pressure}, heart rate {Finding of heart rate}, PCP {Primary care management}, hypotension {Low blood pressure}, work up {Evaluation procedure}, anemia {Anemia}, fevers {Fever}, chills {Chill}, cough {Cough}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, N/V/D {Nausea, vomiting and diarrhea}, vaginal bleeding {Bleeding from vagina}, dysuria {Dysuria}, increased frequency {Increased frequency of urination}, rash {Eruption of skin}, constipation {Constipation}, chronic issue {Chronic disease}, hematemesis {Hematemesis}, bloody {Hematochezia}, tarry stools {Melena}, O2-sat {Oxygen saturation measurement}, Vitals {Vital signs finding}, O2-sat {Oxygen saturation measurement}, feels well {Well in self}, fatigued {Fatigue}, Review of systems {Review of systems}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, headache {Headache}, sinus
tenderness {Tenderness over frontal sinus}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, cough {Cough}, shortness of
breath {Dyspnea}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, abdominal pain {Abdominal pain}, change
in bowel {Altered bowel function}, bladder habits {Alteration in patterns of urinary elimination}, dysuria {Dysuria}, arthralgias {Joint pain}, myalgias {Muscle 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:
# chronic anemia of unclear etiology, previously eval at ___,
family does not recall any abnormalities
# chronic constipation
# stress urinary incontinence
# osteoporosis
# osteoarthritis
# heart murmur
# mild dementia
# hematuria
# macular degeneration
# depression not on medications
# hyperlipidemia
# varicose veins in legs
###RESPONSE: chronic anemia {Chronic anemia}, eval {Evaluation procedure}, chronic constipation {Chronic constipation}, stress urinary incontinence {Genuine stress incontinence}, osteoporosis {Osteoporosis}, osteoarthritis {Osteoarthritis}, heart murmur {Heart murmur}, dementia {Dementia}, hematuria {Blood in urine}, macular degeneration {Degenerative disorder of macula}, depression {Depressive disorder}, medications {Administration of drug or medicament}, hyperlipidemia {Hyperlipidemia}, varicose veins {Venous varices}, legs {Lower limb structure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
Patient's father died of stomach cancer prior to World War II.
###RESPONSE: died {Dead}, stomach cancer {Malignant tumor of stomach} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Vitals: T 98.2, BP 138/82, HR 78, RR 16, O2 97% RA
General: Alert, oriented, no acute distress, pale
HEENT: Sclera anicteric, MMM, oropharynx clear, pale conjunctiva
Neck: supple, JVP not elevated, no LAD
Lungs: Bibasilar crackles, L>R
CV: Regular rate and rhythm, normal S1 + S2, ___ SEM loudest at
base
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, guaiac
negative in ED
Pelvic: Performed in ED, per report, no uterus felt, no vaginal
bleeding seen
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact
###RESPONSE: Vitals {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, pale {Pale complexion}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, pale conjunctiva {Pale conjunctiva}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, Bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, 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<}, SEM {Ejection murmur}, Abdomen {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}, guaiac {Guaiac test for occult blood in feces specimen}, negative {No pathologic diagnosis}, Pelvic {Manual pelvic examination}, uterus {Uterine structure}, vaginal
bleeding {Bleeding from vagina}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, CN II-XII intact {Normal central nervous system} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ 09:50PM GLUCOSE-114* UREA N-26* CREAT-1.3* SODIUM-136
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13
___ 11:35AM GLUCOSE-100
___ 11:35AM UREA N-20 CREAT-1.2* SODIUM-139 POTASSIUM-4.0
CHLORIDE-100 TOTAL CO2-28 ANION GAP-15
___ 08:08AM BLOOD Glucose-93 UreaN-18 Creat-1.0 Na-136
K-4.0 Cl-102 HCO3-27 AnGap-11
___ 08:08AM BLOOD Albumin-3.5 Calcium-8.4 Phos-3.5 Mg-2.0
.
Hematology:
.
___ 09:50PM WBC-3.1* RBC-2.12* HGB-7.2* HCT-20.8* MCV-98
MCH-34.0* MCHC-34.7 RDW-16.7*
___ 09:50PM NEUTS-41* BANDS-1 LYMPHS-44* MONOS-12* EOS-0
BASOS-0 ATYPS-2* ___ MYELOS-0
___ 09:50PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-2+
___ 09:50PM PLT SMR-VERY LOW PLT COUNT-52*
___ 09:50PM ___ PTT-28.1 ___
___ 09:50PM RET AUT-0.9*
___ 10:49PM D-DIMER-321
___ 10:20PM ___
___ 11:35AM WBC-4.0 RBC-2.25*# HGB-8.0* HCT-23.1*
MCV-102*# MCH-35.6*# MCHC-34.8 RDW-16.0*
___ 11:35AM PLT SMR-VERY LOW PLT COUNT-59*#
___ 08:08AM BLOOD WBC-3.1* RBC-2.62* Hgb-8.7* Hct-24.3*
MCV-93 MCH-33.1* MCHC-35.7* RDW-17.4* Plt Ct-49*
___ 08:08AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Tear ___
___ 08:08AM BLOOD Plt Ct-49*
___ 08:08AM BLOOD ___ PTT-28.8 ___
.
LFTs -
.
___ 09:50PM LD(LDH)-158 CK(CPK)-34 TOT BILI-0.6 DIR
BILI-0.2 INDIR BIL-0.4
___ 11:35AM ALT(SGPT)-8 AST(SGOT)-15 ALK PHOS-69
___ 11:35AM TOT PROT-7.1 CALCIUM-8.9 CHOLEST-185
___ 11:35AM TRIGLYCER-69 HDL CHOL-76 CHOL/HDL-2.4
LDL(CALC)-95
___ 08:08AM BLOOD ALT-7 AST-13 LD(LDH)-155 AlkPhos-65
TotBili-2.8*
.
___ 09:50PM CK-MB-NotDone cTropnT-<0.01
___ 09:50PM TOT PROT-6.6 IRON-51
___ 09:50PM calTIBC-226* VIT ___ FOLATE-11.6
___ FERRITIN-447* TRF-174*
___ 11:35AM estGFR-Using this
___ 11:35AM TSH-1.3
.
ON DISCHARGE: ___ 09:10a
.
139 102 18
------------< 97 gap 13
3.9 28 1.0
.
Ca: 8.8 Mg: 2.1 P: 3.2
.
10.0
2.8 >--< 67 mcv 96
29.0
.
Urinalysis-
.
___ 05:40AM URINE Color-Straw Appear-Clear Sp ___
___ 05:40AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 05:40AM URINE ___ Bacteri-RARE Yeast-NONE
Epi-<1
___ 05:40AM URINE Eos-NEGATIVE
___ 05:40AM URINE Hours-RANDOM UreaN-563 Creat-69 Na-72
.
MICROBIOLOGY:
___: Blood Culture, Routine (Pending): x 2
___: URINE CULTURE - final - MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
.
IMAGING:
.
CXR (___):
Lung volumes are low resulting in vascular crowding. Minimally
increased interstitial markings, predominantly at the lung bases
may indicate an underlying interstitial abnormality. There is no
consolidation or pleural effusion. There is no pneumothorax. The
heart size is top normal. The aorta is tortuous and calcified.
There is no hilar or mediastinal enlargement. Pulmonary
vascularity is normal. Degenerative changes and ossification of
the anterior longitudinal ligament are noted in the spine.
IMPRESSIONS: No consolidation. No hilar enlargement.
.
EKG (___): Normal sinus rhythm, left axis deviation, Right
bundle branch block with ? left anterior fascicular block. No
obvious ischemic changes.
###RESPONSE: GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, 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}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PLT {Platelet count}, LOW {Platelet count below reference range}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}, D-DIMER {D-dimer assay}, 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}, PLT {Platelet count}, LOW {Platelet count below reference range}, PLT COUNT {Platelet count}, 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}, NORMAL {Normal size}, NORMAL {Normal size}, PTT {Partial thromboplastin time, activated}, LFTs {Hepatic function panel}, LDH {Lactate dehydrogenase measurement}, CK(CPK {Creatine kinase measurement}, TOT BILI {Bilirubin, total measurement}, BILI {Bilirubin measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, ALK PHOS {Alkaline phosphatase measurement}, CALCIUM {Blood calcium measurement}, CHOLEST {Cholesterol measurement}, HDL {High density lipoprotein measurement}, HDL {High density lipoprotein measurement}, LDL(CALC) {Calculated low density lipoprotein cholesterol level}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Lactate dehydrogenase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, FOLATE {Whole blood folate within reference range}, TSH {Thyroid stimulating hormone measurement}, Urinalysis {Urinalysis}, URINE Color-Straw {Normal urine color}, Appear-Clear {Urine looks clear}, URINE Blood {Urine blood test}, Nitrite-NEG {Nitrite not detected in urine}, Protein-NEG {Urine protein not detected}, Glucose-NEG {Urine glucose not detected}, Ketone-NEG {Urine ketones not detected}, NEG {No abnormality detected}, Urobiln-NEG {Urine urobilinogen not detected}, pH {pH measurement}, Leuks-NEG {Urine leukocytes not detected}, URINE {Evaluation of urine specimen}, Bacteri {Bacteriuria}, Yeast {Urine microscopy for yeasts}, URINE {Evaluation of urine specimen}, NEGATIVE {No pathologic diagnosis}, URINE {Evaluation of urine specimen}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Blood Culture {Blood culture}, URINE CULTURE {Urine culture}, BACTERIAL {Bacterial infectious disease}, SKIN AND/OR GENITAL
CONTAMINATION. {Sample contaminated}, CXR {Plain chest X-ray}, Lung volumes {Finding of respiratory volume}, vascular crowding {Pulmonary hypertension}, lung bases {Structure of base of lung}, abnormality {Imaging result abnormal}, consolidation {Consolidation}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, heart {Heart structure}, size {Normal size}, normal {Normal size}, aorta {Aortic structure}, tortuous {Tortuosity}, calcified {Pathologic calcification, calcified structure}, hilar {Structure of hilum of lung}, mediastinal {Mediastinal structure}, enlargement {Enlargement}, Pulmonary {Lung structure}, normal {Normal size}, Degenerative changes {Cervical spondylosis}, anterior longitudinal ligament {Anterior longitudinal ligament structure}, spine {Structure of vertebral column}, consolidation {Consolidation}, hilar {Hilar lymphadenopathy}, enlargement {Enlargement}, EKG {Electrocardiographic procedure}, Normal sinus rhythm {Electrocardiogram: normal sinus rhythm}, left axis deviation {Left axis deviation}, Right
bundle branch block with ? left anterior fascicular block {Right bundle branch block AND left anterior fascicular block}, ischemic changes {Ischemia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
This is an ___ year old female with chronic anemia who presents
with 1 month of fatigue and found to have worsening anemia,
thrombocytopenia, and ARF.
.
# Hypotension: Pt presented to PCP ___ ___ with BP 78/60, but
BP has been stable and within normal limits since admission to
___. Hypotension was potentially hypovolemic in nature,
although patient did not require fluids for resolution of low
BP. The patient's orthostatics were negative during this
admission; an outpatient workup for orthostatic hypotension may
be worth considering, although the patient does not have a
history of falls and is otherwise asymptomatic.
.
# Anemia - Multiple possible causes, including aplastic anemia,
myelodysplastic syndrome, anemia of chronic disease, plasma cell
dyscrasias, blood loss, or hemolytic process. Symptoms suggest
a relatively chronic process but HCT dropped from 23->21 in 12
hours on ___, suggesting a possibly accelerating process.
Possible slow GI bleed but less likely given guaiac negative and
constipation. Hemolysis labs reportedly negative overnight, but
re-sent because could not find in system. DIC very unlikely
given elevated fibrinogen, normal D-dimer, and normal coags.
Concern for TTP-HUS with anemia, thrombocytopenia, low grade
fever and ARF but no schistocytes seen on smear and again, no
evidence of hemolysis (elevated TBili on ___ likely
post-transfusional). All cell lines down so possible marrow
process affecting production, especially with slight lymphocytic
predominance and atypicals on smear. Previous Fe studies and
B12/folate normal. Previous renal function normal and anemia is
normocytic, so anemia of chronic disease less likely. SPEP
normal in ___, resent to r/o plasma cell dyscrasia. No
chemotherapy, radiation exposure, or medications suggestive of
aplastic anemia. MDS is ___ strong possibility given her age,
pancytopenia, low reticulocyte count.
.
Two peripheral IVs (18-gauge) were placed and 2 units PRBCs
given on ___, with an improvement in Hct to from
20.8->24.3->29.0 on ___. Reticulocyte count was found to be
low at 0.9. Iron studies did not suggest iron deficiency anemia
or B12/folate deficiency, although we will continue the
patient's outpatient iron supplementation regimen. A peripheral
smear and SPEP/UPEP were sent and were pending at discharge.
Hematology-oncology saw the patient, agrees with our
differential of myelodysplastic syndrome vs. myelofibrosis and
recommended follow up in clinic for possible consideration of BM
biopsy which could provide definitive diagnosis, though the
extent that this would change management in this ___ year old
woman is unclear.
.
# Thrombocytopenia: Similar concerns as above. DIC and TTP were
thought to be unlikely in the absence of evidence for hemolysis.
There is a possible production problem as noted above. Could be
ITP but that is a diagnosis of exclusion, and less likely given
the patient's pancytopenia.
.
# ARF: Pt had a mild elevation in creatinine to 1.3 (baseline
1.0) on admission, which resolved with transfusion and
hydration. Likely related to anemia and relative hypovolemia.
BUN/Cr<20, suggestive of mild prerenal process. Receiving 2
units of blood which should be a good volume challenge.
Creatinine improved with transfusion to 1.0 on ___.
.
# Fever: Low grade temp to 100.4 in triage. No clear localizing
source. Will hold on abx unless decompensates. CXR was negative
for consolidation, exam does show some dry crackles most likely
due to atalectasis. Urinalysis was negative in detail, and
urine and blood cultures remain pending.
.
# Osteoporosis: Reports not taking her fosamax due to concerns
about not being able to sit up long enough. Will hold for now.
.
###RESPONSE: chronic anemia {Chronic anemia}, fatigue {Fatigue}, worsening {Patient's condition worsened}, anemia {Anemia}, thrombocytopenia {Thrombocytopenic disorder}, ARF {Acute kidney injury}, Hypotension {Low blood pressure}, PCP {Primary care management}, stable {Stable blood pressure}, normal {Normal vital signs}, Hypotension {Low blood pressure}, hypovolemic {Hypovolemia}, fluids {Administration of fluid therapy}, resolution {Problem resolved}, low
BP {Low blood pressure}, orthostatics {Orthostatic hypotension}, negative {No pathologic diagnosis}, workup {Evaluation procedure}, orthostatic hypotension {Orthostatic hypotension}, falls {Falls}, asymptomatic {Asymptomatic}, Anemia {Anemia}, aplastic anemia {Aplastic anemia}, myelodysplastic syndrome {Myelodysplastic syndrome}, anemia of chronic disease {Anemia of chronic disorder}, plasma cell
dyscrasias {Plasma cell neoplasm}, blood loss {Hemorrhage}, chronic {Chronic disease}, HCT {Hematocrit determination}, GI bleed {Gastrointestinal hemorrhage}, guaiac {Guaiac test for occult blood in feces specimen}, negative {No pathologic diagnosis}, constipation {Constipation}, Hemolysis {Hemolysis}, labs {Laboratory test}, negative {No pathologic diagnosis}, DIC {Blood coagulation panel, disseminated intravascular coagulation}, elevated fibrinogen {Fibrinogen in blood above reference range}, normal coags {Coagulation/bleeding tests normal}, TTP {Thrombotic thrombocytopenic purpura}, HUS {Hemolytic uremic syndrome}, anemia {Anemia}, thrombocytopenia {Thrombocytopenic disorder}, low grade
fever {Low grade pyrexia}, ARF {Acute kidney injury}, no
evidence {No abnormality detected}, hemolysis {Hemolysis}, elevated TBili {Total bilirubin above reference range}, cell {Cell structure}, Fe studies {Iron kinetics study}, B12/folate {B12/folate level}, renal function normal {Normal renal function}, anemia is
normocytic {Normocytic anemia}, anemia of chronic disease {Anemia of chronic disorder}, SPEP
normal {Serum proteins within reference range}, plasma cell dyscrasia {Plasma cell neoplasm}, chemotherapy {Chemotherapy}, radiation {Radiation oncology AND/OR radiotherapy}, aplastic anemia {Aplastic anemia}, MDS {Myelodysplastic syndrome}, pancytopenia {Pancytopenia}, reticulocyte count {Reticulocyte count}, placed {Implantation procedure}, PRBCs
given {Transfusion of packed red blood cells}, improvement {Patient's condition improved}, Reticulocyte count {Reticulocyte count outside reference range}, studies {Evaluation procedure}, iron deficiency anemia {Iron deficiency anemia}, B12/folate deficiency {Combined B12 and folate deficiency anemia}, iron supplementation regimen {Iron supplement therapy}, SPEP {Serum protein electrophoresis}, UPEP {Urine protein electrophoresis}, myelodysplastic syndrome {Myelodysplastic syndrome}, myelofibrosis {Myelofibrosis}, BM
biopsy {Bone marrow sampling}, Thrombocytopenia {Thrombocytopenic disorder}, DIC {Disseminated intravascular coagulation}, TTP {Thrombotic thrombocytopenic purpura}, hemolysis {Hemolysis}, problem {Problem}, ITP {Chronic idiopathic thrombocytopenic purpura}, pancytopenia {Pancytopenia}, ARF {Acute kidney injury}, elevation in creatinine {Serum creatinine above reference range}, baseline {Baseline state}, resolved {Problem resolved}, transfusion {Transfusion}, hydration {Administration of fluid therapy}, anemia {Anemia}, relative hypovolemia {Relative hypovolemia}, BUN/Cr {Blood urea nitrogen/creatinine ratio}, mild {Symptom mild}, Creatinine {Creatinine measurement}, improved {Patient's condition improved}, transfusion {Transfusion}, Fever {Fever}, temp {Body temperature finding}, triage {Triage}, hold {Recommendation to stop drug treatment}, CXR {Plain chest X-ray}, negative {Standard chest X-ray normal}, consolidation {Consolidation}, exam {Evaluation procedure}, crackles {Respiratory crackles}, atalectasis {Atelectasis}, Urinalysis {Urinalysis}, negative {No pathologic diagnosis}, urine {Urine culture}, blood cultures {Blood culture}, Osteoporosis {Osteoporosis}, able to sit up {Able to sit up}, hold {Recommendation to stop drug treatment} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Ferrous Sulfate 352mg PO daily
Fosamax 70mg PO qwk
Trospium 20mg PO BID
Calc/Vit. D 1000U PO daily
Discharge Medications:
1. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
2. Trospium 20 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
4. Cholecalciferol (Vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day. Capsule(s)
5. Outpatient Lab Work
Please check a CBC on ___ and have the results faxed to Dr.
___ (FAX ___
###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:
Anemia
Pancytopenia
Acute renal insufficiency
Fever
Hypotension
Secondary:
Osteoporosis
Stress urinary incontinence
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
###RESPONSE: Anemia {Anemia}, Pancytopenia {Pancytopenia}, Acute renal insufficiency {Acute renal insufficiency}, Fever {Fever}, Hypotension {Low blood pressure}, Osteoporosis {Osteoporosis}, Stress urinary incontinence {Genuine stress incontinence}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were admitted for weakness and fatigue and were found to
have a low red blood cell count (anemia). You were given a
blood transfusion and your symptoms improved. You were found to
have low platelets (thrombocytopenia) and white blood cell count
(leukopenia). You were seen by the hematology-oncology team and
they felt the low cell lines may be due to a process of abnormal
blood cell proliferation or other cause of hindrance in the bone
marrow (myelodysplastic syndrome or myelofibrosis).
No changes were made to your medication regimen. Please take
all of your home medications as prescribed.
###RESPONSE: weakness {Asthenia}, fatigue {Fatigue}, red blood cell count {Red blood cell count}, anemia {Anemia}, blood transfusion {Transfusion of blood product}, improved {Patient's condition improved}, low platelets {Thrombocytopenic disorder}, thrombocytopenia {Thrombocytopenic disorder}, white blood cell count {White blood cell count}, leukopenia {Leukopenia}, abnormal
blood cell proliferation {Proliferation of hematopoietic cell type}, bone
marrow {Bone marrow structure}, myelodysplastic syndrome {Myelodysplastic syndrome}, myelofibrosis {Myelofibrosis}, changes were made to your medication {Change of medication}, regimen {Therapeutic regimen}, medications {Administration of drug or medicament} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Left Thoracentesis- yield 1300mL
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Shortness of breath {Dyspnea}, Thoracentesis {Thoracentesis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 carotid
artery stenosis, chronic renal insufficiency, coronary artery
disease, hyperlipidemia, and hypertension. He developed upper
back pain in ___ and presented to an outside hospital. An
EKG demonstrated nonspecific ST changes. Cardiac catheterization
demonstrated severe multivessel coronary artery disease. He was
transferred to ___ for surgical revascularization. He
underwent coronary artery bypass grafting x 5 on ___ with
Dr. ___. His postoperative course was complicated by acute blood
loss anemia requiring transfusion of PRBCs. He also had
intermitted atrial fibrillation and was started on Amiodarone
and Coumadin. He was discharged to rehab on postoperative day 5.
He has remained deconditioned at rehab. He has noted shortness
of breath and serosanguinous sternal drainage. WBC at rehab
yesterday was 15.8 and he was started on empiric Keflex. He
presented today for wound evaluation. Prior to his visit he
underwent a chest x-ray which demonstrated an increase in
moderate to large left pleural effusion with compressive
atelectasis. There was also a mildly enlarged cardiomediastinal
silhouette suspicious for pericardial effusion. Discussed his
case with Dr. ___ who is covering for Dr. ___. Plan to admit
for observation.
###RESPONSE: carotid
artery stenosis {Carotid artery stenosis}, chronic renal insufficiency {Chronic renal insufficiency}, coronary artery
disease {Coronary arteriosclerosis}, hyperlipidemia {Hyperlipidemia}, hypertension {Hypertensive disorder, systemic arterial}, upper
back pain {Thoracic back pain}, EKG {Electrocardiographic procedure}, ST changes {Electrocardiographic ST segment changes}, Cardiac catheterization {Cardiac catheterization}, coronary artery disease {Coronary arteriosclerosis}, surgical {Surgical procedure}, revascularization {Heart revascularization}, coronary artery bypass grafting x 5 {Coronary artery bypass grafts x 5}, postoperative course {Postoperative state}, acute blood
loss anemia {Acute posthemorrhagic anemia}, transfusion of PRBCs {Transfusion of packed red blood cells}, atrial fibrillation {Atrial fibrillation}, Coumadin {Anticoagulant therapy}, shortness
of breath {Dyspnea}, serosanguinous sternal drainage {Serosanguineous discharge from wound}, WBC {White blood cell count}, wound evaluation {Evaluation of wound healing progress}, chest x-ray {Plain chest X-ray}, pleural effusion {Pleural effusion}, compressive
atelectasis {Compression atelectasis}, enlarged {Enlargement}, pericardial effusion {Pericardial effusion} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Carotid Artery Stenosis
Chronic Renal Insufficiency (Cre 1.2-1.4)
Coronary Artery Disease
Hyperlipidemia
Hypertension
Macular Degeneration
Non-ST Elevation Myocardial Infarction, ___ w/RCA stent
Osteoarthritis
###RESPONSE: Carotid Artery Stenosis {Carotid artery stenosis}, Chronic Renal Insufficiency {Chronic renal insufficiency}, Coronary Artery Disease {Coronary arteriosclerosis}, Hyperlipidemia {Hyperlipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, Macular Degeneration {Degenerative disorder of macula}, Non-ST Elevation Myocardial Infarction {Acute non-ST segment elevation myocardial infarction}, RCA {Right coronary artery structure}, stent {Insertion of arterial stent}, Osteoarthritis {Osteoarthritis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
###RESPONSE: MI {Myocardial infarction}, arrhythmia {Cardiac arrhythmia}, cardiomyopathies {Cardiomyopathy}, sudden cardiac death {Sudden cardiac death} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
HR: 78 SR. BP: 137/80, right. RR: 18. O2 Sat: 97% RA
Height: 66" Weight: 172 lbs
General: Pleasant man, WDWN, lying in stretcher
Skin: Warm, dry, intact
HEENT: PERRLA, EOMI, teeth in good repair
Neck: Supple, Full ROM
Chest: Diminished at bilateral bases, no crackles
Heart: Regular rate and rhythm, no murmur appreciated
Abdomen: Normal BS, soft, non-tender, non-distended
Extremities: Warm, well-perfused
Edema: 1+ edema bilaterally
Incision: ABD pad removed with scant serosanguinous drainage.
Wound well approximated without erythema. No click.
###RESPONSE: HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, O2 Sat {Oxygen saturation measurement}, RA {Breathing room air}, Height {Height / growth finding}, Weight {Weight finding}, General {General examination of patient}, WDWN {Well nourished}, lying {Lying in bed}, Skin {Examination of skin}, Warm {Warm skin}, dry {Xeroderma}, intact {Intact skin}, HEENT {Physical examination procedure}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, teeth {Structure of dentition}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Full ROM {Normal range of cervical spine movement}, Chest {Examination of respiratory system}, bases {Structure of base of lung}, crackles {Respiratory crackles}, Heart {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, murmur {Murmur}, Abdomen {Examination of abdomen}, Normal BS {Normal bowel sounds}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, Extremities {Examination of limb}, Warm {Warm skin}, well-perfused {Normal tissue perfusion}, edema {Edema}, Incision {Surgical incision wound}, ABD {Examination of abdomen}, removed {Removal}, serosanguinous drainage {Serosanguineous discharge from wound}, Wound {Wound}, well approximated {Wound healing well}, erythema {Erythema} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Transthoracic Echocardiogram (focused) ___
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation.
Trivial mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Trivial pericardial effusion. Normal global
biventricular systolic function.
Chest CT ___
1. Large left pleural effusion with volume loss in the left
lower lobe,
lingula.
2. Mild partially hemorrhagic pericardial effusion.
.
___ 05:07AM BLOOD WBC-16.8* RBC-3.68* Hgb-10.8* Hct-33.9*
MCV-92 MCH-29.3 MCHC-31.9* RDW-15.1 RDWSD-50.4* Plt ___
___ 04:25AM BLOOD WBC-21.3* RBC-3.51* Hgb-10.1* Hct-32.3*
MCV-92 MCH-28.8 MCHC-31.3* RDW-15.3 RDWSD-51.4* Plt ___
___ 05:07AM BLOOD ___ PTT-31.8 ___
___ 04:25AM BLOOD ___
___ 04:35AM BLOOD ___
___ 05:01PM BLOOD ___ PTT-30.4 ___
___ 05:07AM BLOOD Glucose-99 UreaN-30* Creat-1.4* Na-138
K-4.4 Cl-96 HCO3-27 AnGap-19
___ 04:35AM BLOOD Glucose-95 UreaN-26* Creat-1.3* Na-137
K-3.9 Cl-98 HCO3-24 AnGap-19
___ 05:07AM BLOOD ALT-82* AST-125* AlkPhos-184*
Amylase-159* TotBili-3.0*
___ 04:25AM BLOOD ALT-77* AST-113* LD(LDH)-441*
AlkPhos-182* Amylase-140* TotBili-3.2*
___ 05:07AM BLOOD Phos-4.3 Mg-2.3
___ 04:35AM BLOOD Calcium-7.9* Phos-4.4 Mg-2.6
###RESPONSE: Transthoracic Echocardiogram {Transthoracic echocardiography}, focal wall motion
abnormality {Left ventricular wall motion abnormality}, left ventricular
systolic function {Normal left ventricular systolic function and wall motion}, Right ventricular
chamber {Right cardiac ventricular structure}, wall motion are normal {Normal ventricular wall motion}, aortic valve
leaflets {Structure of cardiac valve leaflet}, structurally normal {Aortic valve normal}, leaflet {Structure of cardiac valve leaflet}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral regurgitation {Mitral valve regurgitation}, pericardial effusion {Pericardial effusion}, pericardial effusion {Pericardial effusion}, biventricular {Cardiac ventricular structure}, systolic function {Normal cardiac function}, pleural effusion {Pleural effusion}, volume loss {Lung volume test abnormal}, left
lower lobe {Structure of lower lobe of left lung}, lingula {Structure of lingula of left lung}, pericardial effusion {Pericardial effusion}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, 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}, 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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Serum lactate dehydrogenase level above reference range}, TotBili {Bilirubin, total measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
He was admitted on ___ for further evaluation. A chest CT
demonstrated a large left pleural effusion. An echocardiogram
revealed a trivial pericardial effusion. Warfarin was held for
procedure. He underwent left sided thoracentesis on ___
for a yield of 1300cc of serosanguinous fluid. Overall, the
patient tolerated the procedure well. Warfarin was resumed for
post-op afib. LFTs noted to be elevated- labs will be repeated
as an outpatient. He is discharged home after clearing ___ on
hospital day 3. He will follow-up as directed.
###RESPONSE: evaluation {Evaluation procedure}, chest CT {Computed tomography of chest}, pleural effusion {Pleural effusion}, echocardiogram {Echocardiography}, pericardial effusion {Pericardial effusion}, procedure {Procedure}, thoracentesis {Thoracentesis}, fluid {Effusion}, procedure {Procedure}, post-op {Postoperative state}, afib {Atrial fibrillation}, LFTs {Hepatic function panel}, elevated {Finding of increased blood pressure}, follow-up {Follow-up arranged} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Amiodarone 400 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Furosemide 40 mg PO DAILY
___ MD to order daily dose PO DAILY16 afib
7. Metoprolol Tartrate 50 mg PO TID
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain:
moderate/severe
9. Polyethylene Glycol 17 g PO DAILY
10. Potassium Chloride 20 mEq PO DAILY
11. Ranitidine 150 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
2. Warfarin 2 mg PO DAILY16 afib
RX *warfarin 2 mg ___ tablet(s) by mouth daily Disp #*60 Tablet
Refills:*1
3. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-Low] 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
4. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*1
6. Furosemide 40 mg PO DAILY Duration: 10 Days
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*10 Tablet
Refills:*0
7. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain:
moderate/severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*10 Packet Refills:*0
10. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
11. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pleural Effusion
Carotid Artery Stenosis
Chronic Renal Insufficiency (Cre 1.2-1.4)
Coronary Artery Disease
Hyperlipidemia
Hypertension
Macular Degeneration
Non-ST Elevation Myocardial Infarction, ___ w/RCA stent
Osteoarthritis
Discharge Condition:
Alert and oriented x3 non-focal
Ambulating, deconditioned
Incisional pain managed with oxycodone
Incisions:
Sternal - healing well, no erythema or drainage
Leg/left- healing well, no erythema or drainage
Edema: trace bilateral pedal
###RESPONSE: Home With Service {Home health aide service management}, Pleural Effusion {Pleural effusion}, Carotid Artery Stenosis {Carotid artery stenosis}, Chronic Renal Insufficiency {Chronic renal insufficiency}, Coronary Artery Disease {Coronary arteriosclerosis}, Hyperlipidemia {Hyperlipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, Macular Degeneration {Degenerative disorder of macula}, Non-ST Elevation Myocardial Infarction {Acute non-ST segment elevation myocardial infarction}, RCA {Right coronary artery structure}, stent {Insertion of arterial stent}, Osteoarthritis {Osteoarthritis}, Alert {Mentally alert}, oriented x3 {Oriented to person, time and place}, Ambulating {Fully mobile}, Incisional {Surgical incision wound}, pain {Pain}, Incisions {Surgical incision wound}, Sternal {Structure of sternal region}, healing well {Wound healing well}, erythema {Erythema}, drainage {Discharge}, Leg/left {Structure of left lower leg}, healing well {Wound healing well}, erythema {Erythema}, drainage {Discharge}, Edema {Edema} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon-when you will
be able to drive
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
###RESPONSE: shower {Able to shower self}, incisions {Surgical incision wound}, incisions {Surgical incision wound}, redness {Redness of skin over lesion}, drainage {Discharge}, incisions {Surgical incision wound}, while taking narcotics {Narcotics education}, No lifting {Functional activity education} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
all seafood / ibuprofen / bees / acetaminophen
Attending: ___.
Chief Complaint:
Groin pain
Major Surgical or Invasive Procedure:
None
###RESPONSE: seafood {Allergy to seafood}, ibuprofen {Allergy to ibuprofen}, bees {Allergy to bee venom}, acetaminophen {Allergy to paracetamol}, Groin pain {Inguinal 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:
The patient is a ___ woman with a past medical history
significant for HTN, T2DM, seizure disorder, Hepatitis C, and
schizoaffective disorder who presents with 10 days of R groin
pain.
At baseline, she uses a walker to ambulate and takes Oxycodone
for diabetic neuropathy, which she describes a "burning"
sensation in her BLE. She was in her usual state of health until
2 weeks ago when she slipped on a banana peel and ended up in a
splits position. 2 days later, she noted R groin pain. On ___,
she was admitted to ___ with acute urinary retention likely
___ Oxycodone/Benadryl use and UTI and RLQ abdominal pain. Her
Benadryl was temporarily D/C'ed, and she was treated with a
course of Macrobid. In terms of her RLQ abdominal pain, acute
processes were ruled-out via CT and U/S. She reports that her
pain, which she clarifies was always R groin and not RLQ,
slightly improved on D/C, but has gradually worsened since then.
She describes this pain as non-radiating, pulsating pain that is
constant; exacerbated with movement; and accompanied by shooting
pains down her RLE. She endorses fevers (Tm 100.4) and chills,
but denies N/V, abdominal pain, changes in her bowel habits, or
urinary symptoms.
In the ED, her initial vitals were T 99.8 HR 96 BP 144/77 RR 18
SaO2 97% on RA. Her physical examination was notable for R
inguinal TTP. Her laboratory results were notable for Na 131;
ALT 51 AST 87 Alk Phos 199 Tbili 1.7 Alb 3.0; and WBC 8.1. She
underwent RUQ U/S which was unchanged. She received IV Morphine
17 MG for pain.
Currently, she continues to report R groin pain and is
requesting pain medications. Otherwise, she has no additional
complaints.
REVIEW OF SYSTEMS: Per HPI, otherwise negative in detail.
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, T2DM {Diabetes mellitus type 2}, seizure disorder {Seizure disorder}, Hepatitis C {Viral hepatitis type C}, schizoaffective disorder {Schizoaffective disorder}, R groin
pain {Right inguinal pain}, baseline {Baseline state}, uses a walker to ambulate {Does mobilize using walker}, diabetic neuropathy {Neuropathy due to diabetes mellitus}, burning"
sensation {Burning sensation}, BLE {Lower limb structure}, R groin pain {Right inguinal pain}, acute urinary retention {Acute retention of urine}, UTI {Urinary tract infectious disease}, RLQ abdominal pain {Right lower quadrant pain}, RLQ abdominal pain {Right lower quadrant pain}, CT {Computed tomography}, U/S {Ultrasonography of abdomen}, pain {Pain}, R groin {Right inguinal region structure}, RLQ {Structure of right lower quadrant of abdomen}, improved {Patient's condition improved}, D/C {Discharged from hospital}, worsened {Increased pain}, pain {Pain}, radiating {Radiating pain}, pulsating pain {Throbbing pain}, constant {Constant pain}, shooting
pains {Shooting pain}, RLE {Structure of right lower limb}, fevers {Fever}, chills {Chill}, N/V {Nausea and vomiting}, abdominal pain {Abdominal pain}, changes in her bowel habits {Altered bowel function}, urinary symptoms {Urinary symptom change}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, SaO2 {Finding of oxygen saturation}, RA {Breathing room air}, physical examination {Physical examination procedure}, R
inguinal {Right inguinal region structure}, TTP {Tenderness}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, WBC {White blood cell count}, RUQ {Structure of right upper quadrant of abdomen}, U/S {Ultrasonography of abdomen}, pain {Pain}, R groin pain {Right inguinal pain}, requesting pain medications {Analgesics requested}, negative {No abnormality detected} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
Hypertension
Diabetes c/b neuropathy
Seizure disorder
Hepatitis C
Cirrhosis
Schizoaffective d/o
Asthma
Migraine headaches
###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, Diabetes c/b neuropathy {Neuropathy due to diabetes mellitus}, Seizure disorder {Seizure disorder}, Hepatitis C
Cirrhosis {Cirrhosis of liver due to chronic hepatitis C}, Schizoaffective {Schizoaffective disorder}, Asthma {Asthma}, Migraine headaches {Migraine} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Mother: HTN, DM, asthma
Father: ___ disorder
Nephew, niece: ___
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, asthma {Asthma}, disorder {Disease} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
On Admission:
Vitals: T 98.9 BP 129/75 HR 90 RR 17 SaO2 100% on RA
General: Well-appearing, obese female lying comfortably in bed
HEENT: Sclera anicteric, PERRLA, MMM, oropharynx clear
Neck: Supple, no JVD, no LAD
Lungs: CTAB
Heart: RRR, normal s1/2, no m/r/g
Abdomen: BS+, soft, NT/ND, no organomegaly
Back: No TTP, no CVA tenderness
Ext: WWP, 2+ pulses, no edema
Neuro: A&Ox3, CN II-XII intact
R hip: TTP along inguinal region and lateral aspect, limited
passive and active ROM (compared to L), no erythema or warmth,
no masses
On Discharge:
VS: Tm 99.1 Tc 98.1 BP 125/59 (113-139/59-78) HR 108 (92-108) RR
18 SaO2 95% on RA
I/O (8hrs) 600(PO)/BRP, (24hrs) 570(PO)/BRP, BM x1
FSBG 107-201
General: Well-appearing, obese female lying comfortably in bed
HEENT: Sclera anicteric, PERRLA, MMM, oropharynx clear
Neck: Supple, no JVD, no LAD
Lungs: CTAB
Heart: RRR, normal s1/2, no m/r/g
Abdomen: BS+, soft, NT/ND, no organomegaly
Back: No TTP, no CVA tenderness
Ext: WWP, 2+ pulses, no edema
Neuro: A&Ox3, CN II-XII intact
R hip: TTP along inguinal region and lateral aspect, limited
passive and active ROM (compared to L), no erythema or warmth,
no masses
###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}, Well-appearing {Well cared for appearance}, obese {Obese}, lying comfortably in bed {Lying in bed}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, PERRLA {Pupils equal, react to light and accommodation}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, normal s1 {Normal first heart sound, S>1<}, no m/r/g {Heart sounds normal}, Abdomen {Examination of abdomen}, BS+ {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, organomegaly {Abdominal organomegaly}, TTP {Tenderness}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, WWP {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, edema {Edema}, Neuro {Neurological examination}, A {Mentally alert}, Ox3 {Oriented to person, time and place}, CN II-XII intact {Normal central nervous system}, R hip {Right hip region structure}, TTP {Tenderness}, inguinal region {Right inguinal region structure}, limited
passive and active ROM {Decreased range of hip movement}, erythema {Erythema}, warm {Warm skin}, masses {Mass}, VS {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}, BM {Does defecate}, FSBG {Finding of blood glucose level}, General {General examination of patient}, Well-appearing {Well cared for appearance}, obese {Obese}, lying comfortably in bed {Lying in bed}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, PERRLA {Pupils equal, react to light and accommodation}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, normal s1 {Normal first heart sound, S>1<}, no m/r/g {Heart sounds normal}, Abdomen {Examination of abdomen}, BS+ {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, organomegaly {Abdominal organomegaly}, TTP {Tenderness}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, edema {Edema}, Neuro {Neurological examination}, A {Mentally alert}, Ox3 {Oriented to person, time and place}, CN II-XII intact {Normal central nervous system}, R hip {Right hip region structure}, TTP {Tenderness}, inguinal region {Right inguinal region structure}, limited
passive and active ROM {Decreased range of hip movement}, erythema {Erythema}, warmth {Joint warm}, masses {Mass} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
On Admission:
___ 08:20AM BLOOD WBC-8.1 RBC-3.35* Hgb-10.2* Hct-31.1*
MCV-93 MCH-30.6 MCHC-33.0 RDW-15.7* Plt ___
___ 08:20AM BLOOD Neuts-73.3* ___ Monos-4.7 Eos-2.1
Baso-0.2
___ 08:20AM BLOOD Plt ___
___ 08:10AM BLOOD ___
___ 08:20AM BLOOD Glucose-219* UreaN-4* Creat-0.5 Na-131*
K-3.8 Cl-96 HCO3-31 AnGap-8
___ 08:20AM BLOOD ALT-51* AST-87* AlkPhos-199* TotBili-1.7*
___ 08:20AM BLOOD Albumin-3.0* Calcium-8.2* Phos-2.5*
Mg-1.5*
___ 08:36AM BLOOD Lactate-2.1*
___ CXR:
IMPRESSION: No acute intrathoracic process.
___ RUQ U/S:
IMPRESSION:
1. Nodular and coarsened liver compatible with cirrhosis without
focal lesions.
2. Splenomegaly.
3. No evidence of cholecystitis or choledocholithiasis.
___ Hip XR:
FINDINGS: Bony structures and joint spaces are essentially
within normal limits and symmetric bilaterally. No evidence of
fracture or dislocation. However, if there is strong clinical
concern for an occult fracture, cross-sectional imaging should
be obtained.
___ MR-L spine:
IMPRESSION:
Multilevel disc disease most notably at the L4-L5 level where
there is a right paracentral disc bulge with superimposed disc
extrusion extending superiorly into the right lateral recess.
This disc causes mass effect on the exiting right L4 nerve root
and traversing right L5 nerve root.
___ MR-Hip (Prelim):
IMPRESSION:
MR of the hip demonstrating extensive edema of multiple muscles
around the pelvic girdle, predominantly involving obturator
internus, externus, quadratus femoris and gluteus medius. This
is centered around the superior pubic ramus which demonstrates
mild bone edema but no fracture. Differentials for this
appearance include myositis, infection, lymphoma. Recommend
contrast enhanced MRI to further evaluate.
___ MR-Hip with contrast:
IMPRESSION:
The area of diffuse muscular and bone marrow edema enhances
avidly. The lack of any fluid collection or heterogenous
enhancement makes infection somewhat less likely, however
differential considerations also include tumor and
post-traumatic changes.
Additional history was provided confirming recent trauma. Given
this additional information, post-traumatic change is the most
likely of the provided differentials. Follow-up with repeat MRI
in ___ weeks to ensure improvement/resolution is recommended.
On Discharge:
___ 07:00AM BLOOD WBC-6.8 RBC-3.29* Hgb-10.2* Hct-30.5*
MCV-93 MCH-31.1 MCHC-33.5 RDW-15.7* Plt ___
___ 08:10AM BLOOD ESR-98*
___ 07:00AM BLOOD Glucose-175* UreaN-5* Creat-0.6 Na-130*
K-3.5 Cl-96 HCO3-29 AnGap-9
___ 08:10AM BLOOD ALT-47* AST-88* LD(LDH)-282* CK(CPK)-155
AlkPhos-200* TotBili-1.9*
___ 07:00AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.5*
___ 08:10AM BLOOD CRP-50.2*
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, No acute intrathoracic process {No abnormality detected}, liver {Liver structure}, cirrhosis {Cirrhosis of liver}, lesions {Lesion}, Splenomegaly {Splenomegaly}, No evidence {No abnormality detected}, cholecystitis {Cholecystitis}, choledocholithiasis {Common bile duct calculus}, Bony structures {Bone structure of hip joint region}, joint spaces {Structure of articular space}, normal {No abnormality detected}, No evidence {No abnormality detected}, fracture {Fracture}, dislocation {Dislocation}, fracture {Fracture}, imaging {Imaging}, disc disease {Disorder of lumbar disc}, right {Structure of right lumbar region of back}, disc {Intervertebral disc structure of fourth lumbar vertebra}, bulge {Swelling}, d disc
extrusion {Displacement of lumbar intervertebral disc}, right {Structure of right lumbar region of back}, lateral recess {Structure of transverse process of lumbar vertebra}, disc {Intervertebral disc structure of fourth lumbar vertebra}, L4 nerve root {Structure of spinal nerve root L4}, right {Structure of right lumbar region of back}, L5 nerve root {Structure of spinal nerve root L5}, MR of the hip {Magnetic resonance imaging of hip}, edema {Edema of skeletal muscle}, muscles
around the pelvic {Skeletal muscle structure of pelvis}, obturator
internus {Internal obturator muscle structure}, externus {External obturator muscle structure}, quadratus femoris {Structure of quadratus femoris muscle}, gluteus medius {Structure of gluteus medius muscle}, superior pubic ramus {Structure of superior ramus of pubis}, mild {Symptom mild}, bone edema {Edema of bone marrow}, fracture {Fracture}, appearance {Edema of skeletal muscle}, myositis {Myositis}, infection {Infectious disease}, lymphoma {Malignant lymphoma}, contrast enhanced MRI {Magnetic resonance imaging with contrast}, muscular {Edema of skeletal muscle}, bone marrow edema {Edema of bone marrow}, fluid collection {Accumulation of fluid}, infection {Infectious disease}, tumor {Neoplasm}, traumatic {Traumatic injury}, trauma {Traumatic injury}, traumatic {Traumatic injury}, MRI {Magnetic resonance imaging}, ensure {Evaluation procedure}, improvement {Patient's condition improved}, resolution {Problem resolved}, 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}, ESR {Finding of erythrocyte sedimentation rate}, 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}, LDH {Lactate dehydrogenase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
#R groin pain: The patient presented with R groin pain in the
setting of a fall. Her pain was likely ___ musculoskeletal
strain in the setting of trauma. However, given her low-grade
fevers and elevated inflammatory markers, septic joint was
considered. Her WBC was WNL, and her Hip-XR were unremarkable.
Her MR-Hip with and without contrast were consistent with
post-traumatic changes. Initially, there was concern for
lymphoma. However, her laboratory values were only notable for a
slightly elevated LDH (her baseline) and significantly elevated
ESR and CRP. She was given PO Oxycodone for pain in addition to
her home Sulindac, and she was discharged on a limited supply of
PO Oxycodone. ___ evaluated her and felt that she was safe to
return home with ___. Follow-up with repeat MRI in ___ weeks to
ensure improvement/resolution is recommended.
#UTI: During her last admission, she was started on Macrobid for
a complicated UTI. She complicated her course prior to D/C.
#HTN: Her home HCTZ was continued.
#T2DM: Her home Metformin and NPH were continued, and she was
placed on ISS. Her home Glipizide was held and restarted on D/C.
For neuropathy, her home Gabapentin was continued.
#Seizure disorder: Her home Phenytoin and Lamotrigine were
continued.
#Schizoaffective disorder: Her home Abilify and Prazosin were
continued.
#COPD: Her home Montelukast and nebs were continued.
#Hyponatremia: She was admitted with Na 131, which is her
baseline and is likely ___ hypervolemia in the setting of liver
disease.
#Chronic HCV/?Cirrhosis: She presented with ALT 51, AST 87, Alk
Phos 199, and Tbili 1.7, which is her baseline. Her U/S revealed
nodular liver and splenomegaly, unchanged from prior. Outpatient
follow-up with Liver Clinic was scheduled for ___.
#Hypoalbuminemia: She was admitted with Alb 3.0, which is her
baseline and likely ___ liver disease. Per Nutrition, her Ensure
TID was continued.
TRANSITIONAL ISSUES:
1. She was treated with PO Oxycodone PRN and discharged on a
limited supply of PO Oxycodone.
2. ___ evaluated her and felt that she was safe to return home
with ___.
3. Follow-up with repeat MRI in ___ weeks to ensure
improvement/resolution is recommended.
4. If her pain persists, please consider an outpatient Ortho
eval.
5. Her urine and blood cultures will need to be followed-up.
###RESPONSE: R groin pain {Right inguinal pain}, R groin pain {Right inguinal pain}, fall {Falls}, pain {Right inguinal pain}, musculoskeletal
strain {Muscle strain}, trauma {Traumatic injury}, low-grade
fevers {Low grade pyrexia}, elevated {Elevation}, inflammatory {Inflammatory disorder}, markers {Laboratory test}, septic joint {Bacterial arthritis}, WBC {White blood cell count}, WNL {No abnormality detected}, Hip-XR {Radiography of hip}, unremarkable {No abnormality detected}, MR-Hip with {Magnetic resonance imaging of hip with contrast}, d without contrast {Magnetic resonance imaging without contrast}, traumatic {Traumatic injury}, lymphoma {Malignant lymphoma}, elevated LDH {Serum lactate dehydrogenase level above reference range}, baseline {Baseline state}, elevated
ESR {Erythrocyte sedimentation rate above reference range}, CRP {C-reactive protein above reference range}, pain {Pain}, Follow-up {Follow-up arranged}, MRI {Magnetic resonance imaging}, ensure {Evaluation procedure}, improvement {Patient's condition improved}, resolution {Problem resolved}, UTI {Urinary tract infectious disease}, UTI {Urinary tract infectious disease}, HTN {Hypertensive disorder, systemic arterial}, T2DM {Diabetes mellitus type 2}, ISS {Sliding scale insulin regime}, restarted {Restart of medication}, neuropathy {Neuropathy}, Seizure disorder {Seizure disorder}, Schizoaffective disorder {Schizoaffective disorder}, COPD {Chronic obstructive lung disease}, Hyponatremia {Hyponatremia}, baseline {Baseline state}, hypervolemia {Hypervolemia}, liver
disease {Disorder of liver}, Chronic HCV/?Cirrhosis {Cirrhosis of liver due to chronic hepatitis C}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, baseline {Baseline state}, U/S {Ultrasonography of abdomen}, nodular liver {Nodule of liver}, splenomegaly {Splenomegaly}, Outpatient
follow-up {Follow-up arranged}, Clinic {Outpatient care management}, Hypoalbuminemia {Hypoalbuminemia}, baseline {Baseline state}, liver disease {Disorder of liver}, Nutrition {Under care of dietitian}, Ensure {Administration of nutritional supplement}, Follow-up {Follow-up arranged}, MRI {Magnetic resonance imaging}, ensure {Evaluation procedure}, improvement {Patient's condition improved}, resolution {Problem resolved}, pain {Right inguinal pain}, urine {Urine culture}, blood cultures {Blood culture} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADOL (Ultram) 50 mg PO Q6H
2. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
3. Zolpidem Tartrate 10 mg PO HS
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
5. Aripiprazole 30 mg PO DAILY
6. Gabapentin 800 mg PO TID
7. Hydrochlorothiazide 25 mg PO DAILY
8. NPH 25 Units Breakfast
NPH 20 Units Bedtime
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
10. Lidocaine Viscous 2% 20 mL PO QID:PRN thrush
11. Montelukast Sodium 10 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Phenytoin Sodium Extended 200 mg PO BID
15. Sumatriptan Succinate 50 mg PO ONCE MR1 migraine
16. Tiotropium Bromide 1 CAP IH DAILY
17. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
18. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
19. GlipiZIDE 5 mg PO BID
20. MetFORMIN (Glucophage) 1000 mg PO BID
21. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION 2 PUFFS BID
22. Prazosin 2 mg PO QAM
23. Prazosin 8 mg PO QPM
24. LaMOTrigine 100 mg PO QAM
25. LaMOTrigine 200 mg PO QHS
26. Sulindac 200 mg PO BID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Aripiprazole 30 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
5. Gabapentin 800 mg PO TID
6. Hydrochlorothiazide 25 mg PO DAILY
7. NPH 25 Units Breakfast
NPH 20 Units Bedtime
8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
9. LaMOTrigine 100 mg PO QAM
10. LaMOTrigine 200 mg PO QHS
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Montelukast Sodium 10 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Phenytoin Sodium Extended 200 mg PO BID
16. Prazosin 2 mg PO QAM
17. Prazosin 8 mg PO QPM
18. Sulindac 200 mg PO BID
19. Tiotropium Bromide 1 CAP IH DAILY
20. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
21. GlipiZIDE 5 mg PO BID
22. Lidocaine Viscous 2% 20 mL PO QID:PRN thrush
23. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION 2 PUFFS BID
24. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive while taking this medication
RX *oxycodone 5 mg 1 tablet(s) by mouth four times a day Disp
#*20 Tablet Refills:*0
25. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
26. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice 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:
Groin pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: With Service {Home health aide service management}, Groin pain {Inguinal pain}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - 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 care of you while you were hospitalized
at ___. You were admitted to the hospital with right groin
pain. Your pain was likely due to a muscle tear. You were
treated and discharged with oral pain medications. Physical
Therapy evaluated you and felt that you were safe to return home
with physical therapy.
Please take care to follow-up with your Primary Care physician.
###RESPONSE: right groin
pain {Right inguinal pain}, pain {Right inguinal pain}, muscle tear {Rupture of muscle}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, physical therapy {Physical therapy procedure}, Primary Care {Primary care management} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: 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:
Shellfish / Iodine / seasonal allergy / Dilaudid / novocaine
Attending: ___.
Chief Complaint:
chemo
Major Surgical or Invasive Procedure:
port placement
###RESPONSE: Shellfish {Allergy to shellfish}, Iodine {Allergy to iodine compound}, seasonal allergy {Seasonal allergy}, chemo {Chemotherapy}, port placement {Insertion of implantable venous access port} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Ms. ___ is a ___ female with a history of
marginal zone lymphoma in ___ with subsequent diagnosis of
aggressive B cell lymphoma in ___. She is s/p ISRT to her
palate in ___ and surgical resection of left supraclavicular
lymph node in ___ for marginal zone lymphoma. She was found to
have right leg edema with large mass in ___, and the biopsy
confirmed mantle cell lymphoma, blastic variant. She is s/p
R-CHOP x 6 cycles in ___ and autologous transplant in ___.
PET/CT on ___ showed a new enlarged right inguinal lymph
node
with FDG avidity compatible concerning for relapse. Core biopsy
of right inguinal lymph node on ___ was consistent with NHL;
intermediate grade non-Hodgkin B-cell lymphoma. She appeared to
have a single site of disease and it was reasonable to attempt
radiation salvage as her systemic options were limited. This was
completed on ___. Restaging in ___ consistent with
new
PET avid periaortic node; bx consistent with relapsed aggressive
B cell lymphoma. Patient presents for the second cycle of
___.
First cycle complicated by prolonged nausea, constipation and
fatigue.
###RESPONSE: marginal zone lymphoma {Marginal zone lymphoma}, B cell lymphoma {B-cell lymphoma}, p ISRT {Radiation therapy care}, palate {Palatal structure}, surgical {Surgical procedure}, left supraclavicular
lymph node {Structure of left supraclavicular lymph node}, marginal zone lymphoma {Marginal zone lymphoma}, right leg edema {Edema of right lower leg}, mass {Mass}, biopsy {Biopsy}, mantle cell lymphoma {Mantle cell lymphoma}, R-CHOP {Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone chemotherapy regimen}, autologous transplant {Autogenous transplantation}, PET/CT {Positron emission tomography}, enlarged {Localized enlarged lymph nodes}, inguinal lymph
node {Inguinal lymph node structure}, Core biopsy {Core needle biopsy}, inguinal lymph node {Inguinal lymph node structure}, NHL {Non-Hodgkin's lymphoma}, intermediate grade non-Hodgkin B-cell lymphoma {Intermediate grade B-cell lymphoma}, disease {Disease}, radiation {Radiation oncology AND/OR radiotherapy}, PET {Positron emission tomography}, periaortic node {Structure of aortic lymph node}, bx {Biopsy finding}, B cell lymphoma {B-cell lymphoma}, nausea {Nausea}, constipation {Constipation}, fatigue {Fatigue} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
PAST MEDICAL/SURGICAL HISTORY:
(1) HTN.
(2) Hyperlipidemia.
(3) ___ esophagus
(4) Partial thyroidectomy for multinodular hyperplasia.
(5) Colonic hyperplastic polyps.
(6) Meniere's disease.
(7) Degenerative disease of the lumbar spine.
(8) Heterozygous for FXI deficiency by report
(9) Atrial fibrillation, on oral anticoagulation with warfarin.
(10) Lymphoma, as below
DETAILED ONCOLOGIC HISTORY:
History of extranodal marginal zone lymphoma of the palate
managed with excision and radiation in ___. Nodal recurrence of
mardinal zone lymphoma ___ that was excised. ___ patient was noted to have right lower extremity edema and
right inguinal LAD. Excisional biopsy consistent with an
aggressive B cell lymphoma, blastoid mantle cell.
R-CHOP x 6 cycles in ___ and autologous transplant in ___.
PET/CT on ___ showed a new enlarged right inguinal lymph
node with FDG avidity compatible concerning for relapse. Core
biopsy of right inguinal lymph node on ___ was consistent
with NHL; intermediate grade non-Hodgkin B-cell lymphoma. She
appeared to have a single site of disease and it was reasonable
to attempt radiation salvage as her systemic options were
limited. This was completed on ___. Restaging in ___
consistent with new PET avid periaortic node; bx consistent with
relapsed aggresive B cell lymphoma.
C1 R-BAC ___
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, esophagus {Esophageal structure}, thyroidectomy {Thyroidectomy}, multinodular hyperplasia {Multinodular hyperplasia}, Colonic {Colon structure}, hyperplastic polyps {Hyperplastic polyp}, Meniere's disease {Ménière's disease}, Degenerative disease of the lumbar spine. {Lumbar spondylosis}, FXI deficiency {Factor XI deficiency}, Atrial fibrillation {Atrial fibrillation}, oral {Administration of drug or medicament via oral route}, anticoagulation {Anticoagulant therapy}, Lymphoma {Malignant lymphoma}, marginal zone lymphoma {Marginal zone lymphoma}, palate {Palatal structure}, excision {Excision}, radiation {Radiation oncology AND/OR radiotherapy}, mardinal zone lymphoma {Marginal zone lymphoma}, right lower extremity edema {Edema of right lower limb}, inguinal LAD {Inguinal lymphadenopathy}, Excisional biopsy {Excisional biopsy}, B cell lymphoma {B-cell lymphoma}, cell {Cell structure}, R-CHOP {Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone chemotherapy regimen}, autologous transplant {Autogenous transplantation}, PET/CT {Positron emission tomography}, enlarged {Localized enlarged lymph nodes}, inguinal lymph
node {Inguinal lymph node structure}, Core
biopsy {Core needle biopsy}, inguinal lymph node {Inguinal lymph node structure}, NHL {Non-Hodgkin's lymphoma}, intermediate grade non-Hodgkin B-cell lymphoma {Intermediate grade B-cell lymphoma}, radiation {Radiation oncology AND/OR radiotherapy}, PET {Positron emission tomography}, B cell lymphoma {B-cell lymphoma} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Her father apparently had homozygous FXI deficiency, which
prompted testing in her (performed elsewhere). A niece was
diagnosed with a "bad type of lymphoma."
###RESPONSE: FXI deficiency {Factor XI deficiency}, lymphoma {Malignant lymphoma} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS: T 98.8 max, now 98.3 BP 126/70 HR 62 RR 18 O2 100%
Gen: WDWN NAD A&O x4
HEENT: oropharynx moist, no lesions
nodes: no LAD
CV: RRR no m/r/g, not irregular
LS: CTA
Abd: soft NT -HSM +BS, no masses palpated
Extr: no edema
Skin: no rash
Neuro: nonfocal, PERRLA, EOMI, no nystagmus, rapid hand
movements
and truncal gait appropriate, unsteady at baseline on tandem
gait
Access: POC with ecchymosis, ozzing resolved
###RESPONSE: VS {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 {Oxygen saturation measurement}, Gen {General examination of patient}, WDWN {Well nourished}, NAD {No abnormality detected}, A {Mentally alert}, O {Orientated}, HEENT {Physical examination procedure}, oropharynx {Oropharyngeal structure}, lesions {Lesion}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, irregular {Irregular heart beat}, LS {Examination of respiratory system}, CTA {Normal breath sounds}, Abd {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, HSM {Hepatosplenomegaly}, +BS {Normal bowel sounds}, masses {Mass}, palpated {Palpation}, Extr {Examination of limb}, edema {Edema}, Skin {Examination of skin}, rash {Eruption of skin}, Neuro {Neurological examination}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, nystagmus {Nystagmus}, gait appropriate {Gait normal}, unsteady at baseline on tandem
gait {Tandem gait test - abnormal}, ecchymosis {Ecchymosis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 12:11AM BLOOD WBC-2.6* RBC-2.26* Hgb-7.5* Hct-21.5*
MCV-95 MCH-33.3* MCHC-35.0 RDW-19.2* Plt ___
___ 09:05AM BLOOD WBC-4.1 RBC-2.88* Hgb-9.0* Hct-27.3*
MCV-95 MCH-31.3 MCHC-33.0 RDW-18.2* Plt ___
___ 12:11AM BLOOD Neuts-91.9* Lymphs-1.5* Monos-0.9*
Eos-5.5* Baso-0.2
___ 09:05AM BLOOD Neuts-84* Bands-0 Lymphs-3* Monos-12*
Eos-0 Baso-1 ___ Myelos-0 NRBC-1*
___ 12:11AM BLOOD Glucose-95 UreaN-16 Creat-0.7 Na-139
K-3.0* Cl-104 HCO3-27 AnGap-11
___ 09:05AM BLOOD Glucose-103* UreaN-10 Creat-0.6 Na-140
K-3.9 Cl-105 HCO3-25 AnGap-14
___ 12:11AM BLOOD Albumin-3.3* Calcium-7.7* Phos-4.7*
Mg-1.8
___ 09:05AM BLOOD Albumin-4.0 Calcium-9.3 Phos-4.6* Mg-1.7
UricAcd-5.9*
###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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ year old female with multiply relapsed NHL
admitted for cycle 2 of R-bendamustine cytarabine.
# Lymphoma: -Rituxan 700mg IV (375mg/m2) D1
-Cytarabine 1540 IV (800mg/m2) D2-4
-Bendamustine 125mg IV (70mg/m2) D2-3
-Pred drops up until 48hrs after cytarabine completes
- IVF/antiemetics per protocol
- Neuro exams assessed prior to each dose of ara-c
#Dyspnea: Resolved. may be combination of reactive airway flare
vs fluid
overload vs URI. CXR shows some fluid, no signs of active
infection. strict I/Os, diurese prn. resp swab PND.
#Fever: non neutropenic, may be secondary to chemo vs URI. will
send resp swab. b and u culture NTD, (u culture contaminate).
tylenol prn for relief.
- fever resolved after 1 day
# Nausea: supportive meds with dex, zofran pre chemo. add emend
po D2-4. give script at d/c for zyprexa to prevent delayed n/v
from last cycle. remind her to continue bowel regimen at d/c.
# Prophylaxis: acyclovir. consider bactrim if will not be on
coumadin.
# Osteoarthritis: tramadol prn. tylenol prn for breakthrough.
does not tolerate oxycodone-nausea. ___ evaluate, lifeline at
home and stable on feet. okay for safe discharge home.
# Paroxysmal a fib: EKG overnight with fever on ___, rate
stable in
70's, 80's. converted back with HR in 60's prior to discharge.
continue ___ go home with xarelto per primary
oncologist.
# HTN: continue amlodipine with parameters
# GERD: omeprazole daily
# Hypothyroidism: continue synthroid daily
# Hypercholestermia: hold during chemotherapy
# DVT prophylaxis: restarted Lovenox after port placement, will
go home with xarelto
# F/E/N: replace electrolytes prn. IVF as ordered.
# Access: POC
# code status Full
# dispo: home, neulasta in clinic ___
###RESPONSE: NHL {Non-Hodgkin's lymphoma}, Lymphoma {Malignant lymphoma}, Neuro exams {Neurological examination}, Dyspnea {Dyspnea}, Resolved {Problem resolved}, reactive airway flare {Reactive airway disease}, fluid
overload {Hypervolemia}, URI {Upper respiratory infection}, CXR {Plain chest X-ray}, fluid {Effusion}, active
infection {Infectious disease}, diurese {Diuresis}, swab {Taking of swab}, Fever {Fever}, neutropenic {Neutropenia}, chemo {Chemotherapy}, URI {Upper respiratory infection}, swab {Taking of swab}, b {Blood culture}, u culture {Urine culture}, (u culture {Urine culture}, fever {Fever}, resolved {Problem resolved}, Nausea {Nausea}, chemo {Chemotherapy}, n/v {Nausea and vomiting}, bowel regimen {Bowel care}, Prophylaxis {Preventive procedure}, Osteoarthritis {Osteoarthritis}, nausea {Nausea}, feet {Foot structure}, Paroxysmal a fib {Paroxysmal atrial fibrillation}, EKG {Electrocardiographic procedure}, fever {Fever}, rate
stable {Pulse rate stable}, HTN {Hypertensive disorder, systemic arterial}, GERD {Gastroesophageal reflux disease}, Hypothyroidism {Hypothyroidism}, Hypercholestermia {Hypercholesterolemia}, chemotherapy {Chemotherapy}, DVT prophylaxis {Prevention of deep vein thrombosis}, restarted {Restart of medication}, port placement {Insertion of implantable venous access port}, IVF {Administration of intravenous fluids} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Acyclovir 400 mg PO Q8H
3. Amlodipine 2.5 mg PO DAILY
4. Fexofenadine 180 mg PO DAILY
5. Fluticasone Propionate NASAL ___ SPRY NU DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 300 mg PO HS
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Sotalol 160 mg PO BID
12. Warfarin 2.5-5 mg PO ASDIR
13. Docusate Sodium 100 mg PO BID
14. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety insomnia nausea
15. Polyethylene Glycol 17 g PO DAILY:PRN no bm in 24h
16. PrednisoLONE Acetate 1% Ophth. Susp. 2 DROP BOTH EYES QID
17. Senna 8.6 mg PO BID
18. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
19. Atorvastatin 20 mg PO QPM
20. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
21. Multivitamins 1 TAB PO DAILY
22. Vitamin D ___ UNIT PO DAILY
23. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Acyclovir 400 mg PO Q8H
3. Docusate Sodium 100 mg PO BID
4. Fexofenadine 180 mg PO DAILY
5. Fluticasone Propionate NASAL ___ SPRY NU DAILY
6. Gabapentin 300 mg PO HS
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety insomnia nausea
9. Omeprazole 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN no bm in 24h
11. PrednisoLONE Acetate 1% Ophth. Susp. 2 DROP BOTH EYES QID
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
13. Senna 8.6 mg PO BID
14. Sotalol 160 mg PO BID
15. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
16. Vitamin D ___ UNIT PO DAILY
17. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
18. FoLIC Acid 1 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. Ondansetron 8 mg PO Q8H:PRN nausea
21. Rivaroxaban 20 mg PO DAILY
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
22. OLANZapine 5 mg PO HS
RX *olanzapine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
23. Allopurinol ___ mg PO DAILY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
lymphoma
reactive airway disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: lymphoma {Malignant lymphoma}, reactive airway disease {Reactive airway disease}, 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:
Ms. ___,
You were admitted to receive chemotherapy. You tolerated this
well however developed worsening shortness of breath and cough
overnight on ___. We did a workup which was most consistent
with your history of asthma flare with an upper respiratory
infection and fluid overload. Your symptoms improved with
nebulizer treatment and lasix.
You will follow up tomorrow in clinic to receive your neulasta
injection and to follow up with your outpatient team. Please do
not hesitate to call in the meantime with any fevers, chills,
worsening cough, shortness of breath, or any other concerns.
###RESPONSE: chemotherapy {Chemotherapy}, shortness of breath {Dyspnea}, cough {Cough}, workup {Evaluation procedure}, asthma {Asthma}, upper respiratory
infection {Upper respiratory infection}, fluid overload {Hypervolemia}, improved {Patient's condition improved}, nebulizer treatment {Nebulizer therapy}, lasix {Diuretic therapy}, clinic {Outpatient care management}, injection {Injection}, fevers {Fever}, chills {Chill}, cough {Cough}, shortness of breath {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: 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:
Ketorolac
Attending: ___.
Chief Complaint:
Chest pain and shortness of breath
Major Surgical or Invasive Procedure:
none
###RESPONSE: Chest pain {Chest pain}, shortness of breath {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:
___ year-old woman from nursing facility presents with shortness
of breath with substernal chest pain since the morning of
admission. The patient had no relief from 3 sublingual
nitroglycerin tablets, but got relief after receiving morphine
in the emergency department. The chest pain was non-radiating
and ___. She currently only complains of mild discomfort of
the chest.
She denies fevers or chills, but did have a cough for the last 2
weeks productive of yellow phlegm. She is staying at the
nursing facility because she is very debilitated from lower
extremity weakness and poor balance. She can walk short
distances with a walker. Denies orthopnea or PND.
She denies headache, neck pain, abdominal pain, nausea,
vomiting, dysuria. She does have urinary incontinence, but no
stool incontinence. She complains of constipation. She
endorses arthritic joint pain everywhere. She does not have
confusion.
###RESPONSE: shortness
of breath {Dyspnea}, substernal chest pain {Retrosternal pain}, relief after receiving morphine {Pain relieved by analgesic}, chest pain {Chest pain}, discomfort of
the chest {Chest discomfort}, fevers {Fever}, chills {Chill}, cough for the last 2
weeks productive {Productive cough}, lower
extremity weakness {Paresis of lower extremity}, poor balance {Poor balance}, walk short
distances with a walker {Does mobilize using walker}, orthopnea {Orthopnea}, headache {Headache}, neck pain {Pain radiating to neck}, abdominal pain {Abdominal pain}, nausea,
vomiting {Nausea and vomiting}, dysuria {Dysuria}, urinary incontinence {Urinary incontinence}, stool incontinence {Incontinence of feces}, constipation {Constipation}, joint pain {Joint pain}, confusion {Clouded consciousness} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
1. CAD status post CABG in ___ with an EF of greater than 55%
2. Chronic Atrial fibrillation but recently in NSR, on
amiodarone but not on anti-coagulation
3. Hypertension
4. Diabetes mellitus type 2
5. Hypercholesterolemia
6. Superficial spreading melanoma
7. Hip fracture with ORIF in ___
8. Urinary tract infection
9. Thyroid disease
10. Urinary incontinence
11. Constipation
12. Melanoma, locally metastatic with chemo ___
13. Right humeral head fracture in ___
14. s/p multiple falls
###RESPONSE: CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, Chronic Atrial fibrillation {Chronic atrial fibrillation}, NSR {Normal sinus rhythm}, Hypertension {Hypertensive disorder, systemic arterial}, Diabetes mellitus type 2 {Diabetes mellitus type 2}, Hypercholesterolemia {Hypercholesterolemia}, Superficial spreading melanoma {Superficial spreading melanoma}, Hip fracture {Fracture of proximal end of femur}, ORIF {Open reduction of fracture with internal fixation}, Urinary tract infection {Urinary tract infectious disease}, Thyroid disease {Disorder of thyroid gland}, Urinary incontinence {Urinary incontinence}, Constipation {Constipation}, Melanoma {Malignant melanoma of skin}, metastatic {Metastatic malignant neoplasm}, chemo {Chemotherapy}, Right humeral head fracture {Closed fracture of capitellum of right humerus}, falls {Falls} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Non contributory
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS: 98.2 123/82 72 19 96% on 2L
GEN: NAD, comfortable in bed, awake and alert
HEENT: PERRL, EOMI, MMM, no oropharyngeal lesions
NECK: Supple, JVP 7-8cm
CHEST: CTAB
CV: RRR, normal s1 and s2
ABD: Soft, nontender, nondistended, bowel sounds present
EXT: No lower extremity edema
SKIN: No rash
NEURO: CN ___ intact x mild decrease in hearing on right ear,
sensory intact throughout, strength ___ BUE/BLE, did not
ambulate patient, fluent speech
PSYCH: Pleasant, calm
###RESPONSE: VS {Vital signs finding}, GEN {General examination of patient}, NAD {No abnormality detected}, awake {Awake}, alert {Mentally alert}, HEENT {Physical examination procedure}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, lesions {Lesion}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, CHEST {Examination of respiratory system}, CTAB {Normal breath sounds}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, normal s1 {Normal first heart sound, S>1<}, ABD {Examination of abdomen}, Soft {Abdomen soft}, nontender {Abdominal tenderness}, nondistended {Normal abdominal contour}, EXT {Examination of limb}, edema {Edema}, SKIN {Examination of skin}, rash {Eruption of skin}, NEURO {Neurological examination}, decrease in hearing on right ear, {Hearing test right abnormality}, fluent speech {Finding of fluency of speech}, PSYCH {Initial psychiatric assessment}, calm {Feeling calm} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___
WBC-8.9 Hgb-12.7 Hct-38.5 MCV-88 Plt ___
Neuts-72.2* ___ Monos-5.0 Eos-1.8 Baso-0.8
___ PTT-28.4 ___
Glucose-236* UreaN-36* Creat-1.1 Na-142 K-4.1 Cl-99 HCO3-32
AnGap-15
CK(CPK)-62 cTropnT-0.06* proBNP-2636*
URINE Color-Straw Appear-Clear Sp ___ Blood-NEG
Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.0 Leuks-NEG
CXR IMPRESSION:
Left lower lobe consolidation, possibly atelectasis but
infection
is not excluded. Small bilateral pleural effusions.
###RESPONSE: WBC {White blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, cTropnT {Troponin T cardiac measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, URINE Color-Straw {Normal urine color}, Protein {Measurement of protein in urine}, Glucose {Glucose measurement, blood}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, CXR {Plain chest X-ray}, Left lower lobe consolidation {Lung consolidation}, atelectasis {Atelectasis}, infection {Infectious disease}, pleural effusion {Pleural effusion} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ year-old woman admitted with chest pain and shortness of
breath with evidence of possible PNA on CXR. The patient
received Vancomycin and Levaquin in the ED for possible
pneumonia and Lasix 10mg IV for possible congestive heart
failure. During her hospital course, her presentation was less
consistent with congestive heart failure, furthermore she does
not have a history of heart failure. She was ruled out for
cardiac ischemia or arrythmia. Her symptoms are thought to be
related to mild pneumonia versus bronchitis. Throughout her stay
her vital signs were stable and she never required supplemental
oxygen. We increased her long acting Isosorbide mononitrate to
60 mg daily for better blood pressure control. She will need to
finish a 7 day course of Levofloxacin. She was seen by
cardiology in consultation, who felt that her chest pain may be
cardiac, but they recommended medical management at present (in
the absence of elevated cardiac enzymes and EKG changes) with
potential additional diagnostics (e.g. stress test) to be
pursued as an outpatient. She will need follow up with
cardiology, and a new echocardiogram. Both of these should be
scheduled by the rehab facility, as we could not make these
appointments over the weekend.
Her daytime blood sugars were high on multiple occasions. She
may benefit from oral anti-diabetic regiment, which could be
considered as outpatient. All her other chronic medical problems
were stable, and required no change in her treatment plan.
During this hospitalization she expressed the wish to be
DNR/DNI.
###RESPONSE: chest pain {Chest pain}, shortness of
breath {Dyspnea}, PNA {Pneumonia}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, congestive heart
failure {Congestive heart failure}, congestive heart failure {Congestive heart failure}, heart failure {Heart failure}, cardiac ischemia {Myocardial ischemia}, arrythmia {Cardiac arrhythmia}, pneumonia {Pneumonia}, bronchitis {Bronchitis}, vital signs were stable {Normal vital signs}, consultation {Consultation}, chest pain {Chest pain}, cardiac {Heart disease}, elevated cardiac enzymes {Finding of cardiac enzyme levels}, EKG changes {Electrocardiogram abnormal}, stress test {Electrocardiogram with exercise test}, follow up with
cardiology {Follow-up cardiac assessment}, echocardiogram {Echocardiography}, blood sugars {Glucose measurement, blood}, oral {Administration of drug or medicament via oral route}, regiment {Therapeutic regimen}, problems {Problem}, stable {Patient's condition stable} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Levothyroxine 50mcg daily
Aspirin 325mg daily
Cyanocobalamin 1000mcg injection qmonth
Senna 8.6mg 2 tabs daily
Plavix 75mg daily
Lisinopril 5mg daily
Digoxin 0.125mg daily
Metoprolol ER 100mg BID
Isosorbide mononitrate 30mg daily
Lidoderm 5% patch to knee 9am, remove at 9pm
Bumetanide 2mg qam, 1mg qpm
Glimepiride 2mg daily
Crestor 10mg daily
Sliding scale insulin
Albuterol/Atrovent nebs prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Nebulization Inhalation Q6H (every 6
hours) as needed for Bronchospasm.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Inhalation Q6H (every 6 hours) as needed for wheezing.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain: please give prior to ambulation for
left ankle pain.
9. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to one to right knee and one to left ankle at 9am, remove at 9pm
daily.
.
14. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Insulin Regular Human 100 unit/mL Solution Sig: as directed
per standard insulin sliding scale 1 to 12 Injection ASDIR (AS
DIRECTED).
16. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
17. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 4 days.
18. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
pack PO DAILY (Daily) as needed for constipation.
19. Guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6
hours) as needed for cough.
20. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 5 days.
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Pneumonia
Chest pain
Secondary:
Coronoray artery disease, Chronic Atrial fibrillation,
Hypertension, Diabetes mellitus type 2, Hypercholesterolemia,
Constipation
Discharge Condition:
Pain free, oxygen saturation 96% on RA
###RESPONSE: Pneumonia {Pneumonia}, Chest pain {Chest pain}, Coronoray artery disease {Coronary arteriosclerosis}, Chronic Atrial fibrillation {Chronic atrial fibrillation}, Hypertension {Hypertensive disorder, systemic arterial}, Diabetes mellitus type 2 {Diabetes mellitus type 2}, Hypercholesterolemia {Hypercholesterolemia}, Constipation {Constipation}, Pain free {No present 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: Discharge Instructions:
You were admitted with chest pain and cough. You are being
treated for mild lung infection and will need to continue taking
your antibiotic as prescribed. We evaluated you also for any
heart problem, however could not find any abnormality with your
heart. You will need a follow up appointment scheduled with your
cardiologist as an outaptient for ongoing managment of your
congestive heart failure.
We increased your Isosorbid mononitrate to 60 mg daily
you need to continue taking Levofloxacine for 4 more days (Q48H)
###RESPONSE: chest pain {Chest pain}, cough {Cough}, lung infection {Infectious disease of lung}, antibiotic {Antibiotic therapy}, heart {Heart structure}, abnormality {No abnormality detected}, heart {Heart structure}, congestive heart failure {Congestive heart failure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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: ___
###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:
fever, respiratory distress
Major Surgical or Invasive Procedure:
Intubation ___
Extubation ___
###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, fever {Fever}, respiratory distress {Respiratory distress}, Intubation {Insertion of endotracheal tube}, Extubation {Removal of endotracheal tube} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
This is a ___ male with history of Alzheimer's,
previously on hospice care (recently discharged), who presents
with respiratory distress. Patient is nonverbal at baseline and
significantly altered and unable to provide additional history.
Today wife felt that he was increasingly sleepy and brought him
here for evaluation. He had a fever last night. Seen by ___ visiting clinician on ___ for aspiration/pneumonia,
for
which he received 10 day course of levofloxacin. Wife states he
has not had a cough but he has been having noisy breathing. No
vomiting or diarrhea. As he is nonverbal he has not been able to
articulate any specific complaints.
In the ED, patient minimally responsive on initial evaluation
and
hypoxic to the mid ___ on room air. He had difficulty increasing
oxygenation with nonrebreather and patient was too altered to
tolerate BiPAP. Therefore he was intubated. Received 3L LR,
vancomycin and cefepime in the ED. Chest x-ray suggestive of
aspiration pneumonia. WBC elevated and Hct/Hgb suggested
significant hemoconcentration.
On my evaluation, patient was intubated and unable to
participate
in history. He has previously had MOLST form with DNR/DNI
completed ___. Per daughter, currently DNR/ok to intubate.
In the ED, initial vitals: T100.8 HR139 BP145/94 RR20 SpO2 90%
nrb
Exam:
General: Seated in bed, minimally responsive
Head/eyes: Normocephalic/atraumatic. Pupils equal round and
reactive to light.
ENT/neck: Dry mucous membranes
Chest/Resp: Tachypnea, poor air movement, rhonchorous
Cardiovascular: Tachycardic, regular
GI/abdominal: Soft, nondistended
Musc/Extr/Back: No peripheral edema.
Skin: Warm and dry
Psych: Poor mentation
Labs: Na 150 Cl 110 BUN34 Glu189 K4.0 Bicarb23 Cr1.2
AGap=17
Ca: 10.3 Mg: 2.7 P: 2.7
ALT: 21 AP: 87 Tbili: 0.7 Alb: 3.8
AST: 15 Lip: 13
WBC 27.9 Hgb17.7/Hct 54.8 Plt326
Flu negative
Imaging:
CXR ___: Lower lung opacities concerning for pneumonia versus
the sequelae of aspiration. Possible pulmonary vascular
congestion.
Consults: None
Interventions: Intubation
VS Prior to Transfer: T98.9 HR80 BP93/62 RR16 SpO296% Intubation
ROS: Positives as per HPI; otherwise negative.
###RESPONSE: Alzheimer {Alzheimer's disease}, hospice care {Hospice care}, discharged {Discharge from hospice}, respiratory distress {Respiratory distress}, nonverbal {Does not speak}, baseline {Baseline state}, sleepy {Drowsy}, evaluation {Evaluation procedure}, fever {Fever}, aspiration {Aspiration pneumonia}, pneumonia {Pneumonia}, levofloxacin {Antibiotic therapy}, cough {Cough}, noisy breathing {Noisy respiration}, vomiting {Vomiting}, diarrhea {Diarrhea}, nonverbal {Does not speak}, evaluation {Evaluation procedure}, hypoxic {Hypoxia}, on room air {Breathing room air}, oxygenation with nonrebreather {Oxygen administration by mask}, BiPAP {Bilevel positive airway pressure titration}, intubated {Insertion of endotracheal tube}, vancomycin {Antibiotic therapy}, Chest x-ray {Plain chest X-ray}, aspiration pneumonia {Aspiration pneumonia}, WBC elevated {White blood cell count outside reference range}, Hct {Hematocrit determination}, Hgb {Measurement of total hemoglobin concentration}, evaluation {Evaluation procedure}, intubated {Insertion of endotracheal tube}, DNR {Not for resuscitation}, DNR {Not for resuscitation}, vitals {Vital signs finding}, nrb {Oxygen administration by mask}, General {General examination of patient}, Seated {Sitting position}, Head/eyes {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, Pupils equal round and
reactive to light {Pupils equal and reacting to light}, ENT/neck {Physical examination procedure}, Dry mucous membranes {Mucous membrane dryness}, Chest {Thoracic structure}, Resp {Examination of respiratory system}, Tachypnea {Tachypnea}, rhonchorous {Wheeze - rhonchi}, Cardiovascular {Cardiovascular physical examination}, Tachycardic {Tachycardia}, regular {Normal heart rate}, GI {Examination of digestive system}, abdominal {Examination of abdomen}, Soft {Abdomen soft}, nondistended {Normal abdominal contour}, Musc {Examination of muscle power}, Extr {Examination of limb}, peripheral edema {Peripheral edema}, Skin {Examination of skin}, Warm {Warm skin}, dry {Xeroderma}, Psych {Neurological mental status determination}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, WBC {White blood cell count}, Hct {Hematocrit determination}, Flu {Influenza}, Imaging {Imaging}, CXR {Plain chest X-ray}, Lower lung {Structure of lower lobe of lung}, opacities {Abnormally opaque structure}, pneumonia {Pneumonia}, sequelae {Sequelae of disorders}, aspiration {Aspiration pneumonia}, pulmonary vascular {Structure of pulmonary blood vessel}, congestion {Congestion}, Intubation {Insertion of endotracheal tube}, VS {Vital signs finding}, Intubation {Insertion of endotracheal tube} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
Essential hypertension
Hypercholesteremia
Early onset Alzheimer's disease with behavioral disturbance
Aspiration pneumonia of both lower lobes
Slow transit constipation
###RESPONSE: Essential hypertension {Essential hypertension}, Hypercholesteremia {Hypercholesterolemia}, Early onset Alzheimer's disease with behavioral disturbance {Early onset Alzheimer's disease with behavioral disturbance}, Aspiration pneumonia {Aspiration pneumonia}, lower lobes {Structure of lower lobe of lung}, Slow transit constipation {Slow transit constipation} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Noncontributory
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: Reviewed in Metavision, HR 78 BP 93/64, SpO2 96%, RR 15
GEN: Intubated, sedated
EYES: Pupils equal and nonreactive
HENNT: Intubated, trachea midline
CV: RRR, no m/r/g
RESP: Mechanical breath sounds
GI: Bowel sounds present
MSK: No gross deformity, warm extremities
SKIN: No rashes or skin breakdown
NEURO: Intubated and sedated
PSYCH: Unable to assess
DISCHARGE PHYSICAL EXAM:
========================
Not examined fully as he is CMO; appeared comfortable, without
labored or rapid respirations. No response to voice or touch. No
grimacing, restlessness, or obvious signs of distress.
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, GEN {General examination of patient}, Intubated {Insertion of endotracheal tube}, sedated {Sedated}, EYES {Ophthalmic examination and evaluation}, Pupils equal {Pupils equal}, NT {Abdominal tenderness}, Intubated {Insertion of endotracheal tube}, trachea {Tracheal structure}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, RESP {Examination of respiratory system}, GI {Examination of digestive system}, Bowel sounds present {Normal bowel sounds}, MSK {Musculoskeletal system physical examination}, deformity {Deformity}, warm {Warm skin}, SKIN {Examination of skin}, rashes {Eruption of skin}, skin breakdown {Broken skin}, NEURO {Neurological examination}, Intubated {Insertion of endotracheal tube}, sedated {Sedated}, PSYCH {Neurological mental status determination}, appeared comfortable {Comfortable appearance}, labored {Labored breathing}, rapid respirations {Tachypnea}, response to voice {Responds to voice}, touch {Finding of sensation of touch}, grimacing {Facial grimacing}, restlessness {Restlessness}, signs {Sign}, distress {Distress} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
===============
___ 05:30PM BLOOD WBC-27.9* RBC-5.73 Hgb-17.7* Hct-54.8*
MCV-96 MCH-30.9 MCHC-32.3 RDW-13.5 RDWSD-47.8* Plt ___
___ 05:30PM BLOOD Neuts-90.4* Lymphs-3.2* Monos-4.2*
Eos-0.0* Baso-0.4 Im ___ AbsNeut-25.18* AbsLymp-0.89*
AbsMono-1.18* AbsEos-0.00* AbsBaso-0.12*
___ 05:59PM BLOOD ___ PTT-32.7 ___
___ 05:30PM BLOOD Glucose-189* UreaN-34* Creat-1.2 Na-150*
K-4.0 Cl-110* HCO3-23 AnGap-17
___ 05:30PM BLOOD ALT-21 AST-15 AlkPhos-87 TotBili-0.7
___ 05:30PM BLOOD Lipase-13
___ 05:30PM BLOOD Albumin-3.8 Calcium-10.3 Phos-2.7 Mg-2.7*
___ 10:15AM BLOOD Triglyc-156*
___ 06:37PM BLOOD Type-ART pO2-155* pCO2-29* pH-7.48*
calTCO2-22 Base XS-0
___ 05:34PM BLOOD Lactate-2.3*
LAST SET OF LABS BEFORE ___ MADE CMO (___):
==============================================
___ 11:53AM BLOOD WBC-8.7 RBC-3.71* Hgb-11.6* Hct-35.8*
MCV-97 MCH-31.3 MCHC-32.4 RDW-13.0 RDWSD-45.8 Plt ___
___ 04:03AM BLOOD Glucose-85 UreaN-11 Creat-0.5 Na-141
K-4.2 Cl-111* HCO3-21* AnGap-9*
___ 04:03AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.3
MICRO:
======
__________________________________________________________
___ 7:24 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
__________________________________________________________
___ 8:00 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 5:49 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 5:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
========
___ Imaging CHEST (PORTABLE AP)
1. ET tube terminates 5.7 cm above the carina. Consider slight
advancement for more optimal positioning. OG tube positioned
appropriately.
2. Lower lung opacities concerning for pneumonia versus the
sequelae of
aspiration. Possible pulmonary vascular congestion.
___ Imaging CHEST (PORTABLE AP)
Lungs are low volume with bibasilar atelectasis. Mild
interstitial edema is unchanged. Support lines and tubes are
stable. Cardiomediastinal silhouette is also unchanged. Small
bilateral effusions left greater than right are unchanged. No
pneumothorax is seen.
___-SPINE W/O CONTRAST
1. No evidence of acute fracture or malalignment.
2. Mild cervical spondylosis.
___ Imaging CT HEAD W/O CONTRAST
1. No evidence of an acute intracranial abnormality.
2. Severe parenchymal atrophy.
###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}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Administration of albumin}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Triglyc {Triglycerides measurement}, pH {pH 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}, 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}, GRAM STAIN {Gram stain method}, cells {Cell structure}, RESPIRATORY CULTURE {Respiratory microbial culture}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, Nasal {Nasal structure}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, Imaging {Imaging}, CHEST (PORTABLE AP {Plain x-ray of chest anteroposterior view}, carina {Structure of carina of trachea}, for more optimal positioning {Checking position of endotracheal tube}, OG tube positioned {Checking position of nasogastric tube using X-ray}, Lower lung {Structure of lower lobe of lung}, opacities {Abnormally opaque structure}, pneumonia {Pneumonia}, sequelae {Sequelae of disorders}, aspiration {Aspiration pneumonia}, pulmonary vascular {Structure of pulmonary blood vessel}, congestion {Congestion}, Imaging {Imaging}, CHEST (PORTABLE AP {Plain x-ray of chest anteroposterior view}, Lungs {Lung structure}, low volume {Decreased size}, bibasilar {Structure of base of lung}, atelectasis {Atelectasis}, Mild {Symptom mild}, interstitial edema {Edema}, Small {Symptom mild}, bilateral effusions {Bilateral pleural effusion}, left {Left pleura structure}, right {Right pleura structure}, pneumothorax {Pneumothorax}, SPINE {Computed tomography of spine}, W/O CONTRAST {Computed tomography without contrast}, No evidence {No abnormality detected}, fracture {Fracture}, malalignment {Misalignment}, Mild {Symptom mild}, cervical spondylosis {Cervical spondylosis}, Imaging {Imaging}, CT HEAD W/O CONTRAST {Computed tomography of head without contrast}, No evidence {No abnormality detected}, intracranial {Intracranial structure}, abnormality {No abnormality detected}, atrophy {Atrophy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Patient is ___ male with history of severe Alzheimer's,
previously on hospice who presented with respiratory failure
requiring urgent intubation. The patient's family was present
for goals of care discussion, and it was ultimately decided to
transition to comfort-focused care with hospice.
ACUTE PROBLEMS:
===============
# Hypoxemic respiratory failure
The patient was brought in from home with increasing somnolence,
cough, and labored breathing. He was hypoxemic to the ___ on
arrival to the emergency room. He was started on IV vancomycin
and cefepime. CXR suggested aspiration pneumonia. He was
intubated and transferred to the intensive care unit. The ICU
team discussed goals of care with the patient's family, who
decided that the patient would not want to be on a ventilator.
He was extubated and transferred to the general floor for
comfort care. Subsequent respiratory distress was management
with IV morphine gtt and then SL liquid morphine.
# Hypovolemic hypernatremia
Patient was given IV fluids with subsequent improvement.
# Myoclonus
# Encephalopathy
Patient has dementia and is non-verbal at baseline, with acutely
worsened mental status in setting of infection. He was found to
have clonus of the extremities. Head CT and CT-spine were
unremarkable. There was low concern for seizures per neurology.
# Goals of care
The patient was previously on hospice prior to this admission.
Due to respiratory failure, the family decided to change the
patient's code status to DNR/DNI, comfort care, with plan for
home hospice. The patient was maintained on oral morphine and
Ativan for comfort.
========================
TRANSITIONAL ISSUES
========================
[ ] Patient is discharged to home hospice with scripts for
morphine and Ativan as needed for comfort.
[x] The patient is safe to discharge today, and I spent [x]
<30min; [ ] >30min in discharge day management services.
___, MD
___
Pager ___
###RESPONSE: Alzheimer {Alzheimer's disease}, hospice {Hospice care}, respiratory failure {Respiratory failure}, intubation {Insertion of endotracheal tube}, discussion {Discussion}, hospice {Hospice care}, Hypoxemic respiratory failure {Hypoxemic respiratory failure}, somnolence {Drowsy}, cough {Cough}, labored breathing {Labored breathing}, hypoxemic {Hypoxemia}, IV {Administration of drug or medicament via intravenous route}, vancomycin {Antibiotic therapy}, CXR {Plain chest X-ray}, aspiration pneumonia {Aspiration pneumonia}, intubated {Insertion of endotracheal tube}, transferred to the intensive care unit {Patient transfer to intensive care unit}, extubated {Removal of endotracheal tube}, comfort care {Comfort measures}, respiratory distress {Respiratory distress}, IV {Administration of drug or medicament via intravenous route}, SL {Administration of substance via sublingual route}, liquid {Liquid}, Hypovolemic {Hypovolemia}, hypernatremia {Hypernatremia}, given IV fluids {Administration of intravenous fluids}, improvement {Patient's condition improved}, Myoclonus {Myoclonus}, Encephalopathy {Disorder of brain}, dementia {Dementia}, non-verbal {Does not speak}, baseline {Baseline state}, worsened mental status {Altered mental status}, infection {Infectious disease}, clonus {Clonus}, extremities {Limb structure}, Head CT {Computed tomography of head}, CT-spine {Computed tomography of spine}, unremarkable {No abnormality detected}, seizures {Seizure}, hospice {Hospice care}, respiratory failure {Respiratory failure}, DNR {Not for resuscitation}, comfort care {Comfort measures}, home hospice {Referral to hospice at home service}, oral {Administration of drug or medicament via oral route}, hospice {Referral to hospice at home service} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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. Torsemide 5 mg PO DAILY
2. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
3. Hyoscyamine 0.125 mg PO QID:PRN secretions
4. amLODIPine 10 mg PO DAILY
5. Pravastatin 20 mg PO QPM
6. Lisinopril 2.5 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Donepezil 10 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Atropine Sulfate 1% ___ DROP SL Q4H:PRN excess secretions
3. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions
4. LORazepam Oral Solution 0.5 mg PO Q6H:PRN agitation, anxiety
RX *lorazepam 2 mg/mL 0.25 ml by mouth Once every six hours
Refills:*0
5. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg SL Q2H:PRN respiratory distress, pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.75-1.0 ml by
mouth Once every two hours Refills:*0
6. Scopolamine Patch 1 PTCH TD Q72H
###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:
-Aspiration pneumonia
-Acute hypoxemic respiratory failure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
###RESPONSE: With Service {Referral to hospice at home service}, Aspiration pneumonia {Aspiration pneumonia}, Acute hypoxemic respiratory failure {Acute hypoxemic respiratory failure}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, Level of Consciousness {Assessment of consciousness level}, Lethargic {Lethargy}, Activity Status {Physical functional dependency}, Bedbound {Bed-ridden} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___ and ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for difficulty breathing.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You had a breathing tube placed and were connected to a
ventilator for your difficulty breathing.
- Your family decided to remove the breathing tube and focus on
making you comfortable.
- You were connected with hospice care and arrangements were
made for you to go home on hospice.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Enjoy spending time with your family and loved ones.
Sincerely,
Your ___ Team
###RESPONSE: difficulty breathing {Difficulty breathing}, breathing tube placed {Insertion of endotracheal tube}, ventilator {Ventilator care}, difficulty breathing {Difficulty breathing}, remove the breathing tube {Removal of endotracheal tube}, hospice care {Hospice care}, hospice {Referral to hospice at home service} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea, wheezing
Major Surgical or Invasive Procedure:
None
###RESPONSE: dyspnea {Dyspnea}, wheezing {Wheezing} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Ms. ___ is a ___ pMHx COPD, asthma, GERD, and metastatic
carcinoma to the brain of unknown origin s/p resection and WBRT
in ___ who presents with dyspnea/wheezing.
She states that she has had 2 weeks of progressive SOB which
began with 1 week of URI-type symptoms. She states that she has
had a new productive cough over the past week as well. She is
normally on 10 mg prednisone daily for her severe COPD, but
given
her respiratory symptoms, she self-increased her daily
prednisone
to 20 mg daily last week. She has not had any fevers. On day
of
presentation, she states that she was at a barbeque outdoors
with
significant pollen exposure (an environmental allergy for her)
after which she became severely dyspneic. She was brought by
ambulance who noted that the patient was only able to speak 2
word sentences at a timje.
Upon arrival to the ED, initial VS 99, 100, 160/90, 24, 94% on
RA. Her O2sats dropped to the upper ___ on RA while in the ED.
Initial labs showed wnl chemistries, WBC 10.2, Hgb 14.6. CXR
showed no focal consolidations. The patient was given IV
methylpred x 1, azithromycin, and duonebs prior to transfer to
the floor.
Upon arrival to the floor, the patient reports ongoing wheezing
and no significant improvement of her respiratory symptoms after
receiving IV methylpred in the ED. She states some abdominal
pain
associated with cough. She has no other acute medical
complaints.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
###RESPONSE: COPD {Chronic obstructive lung disease}, asthma {Asthma}, GERD {Gastroesophageal reflux disease}, metastatic
carcinoma to the brain {Metastatic malignant neoplasm to brain}, resection {Excision}, dyspnea {Dyspnea}, wheezing {Wheezing}, SOB {Dyspnea}, URI {Upper respiratory infection}, productive cough {Productive cough}, COPD {Chronic obstructive lung disease}, respiratory {Respiratory function finding}, fevers {Fever}, environmental allergy {Environmental allergy}, dyspneic {Dyspnea}, only able to speak 2
word sentences at a timje {Difficulty talking}, VS {Vital signs finding}, RA {Breathing room air}, RA {Breathing room air}, wnl {No abnormality detected}, WBC {White blood cell count}, Hgb {Measurement of total hemoglobin concentration}, CXR {Plain chest X-ray}, consolidations {Consolidation}, IV {Administration of drug or medicament via intravenous route}, wheezing {Wheezing}, improvement {Patient's condition improved}, respiratory symptoms {Respiratory function finding}, IV {Administration of drug or medicament via intravenous route}, abdominal
pain {Abdominal pain}, cough {Cough}, Review of Systems {Review of systems}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, headache {Headache}, vision changes {Visual disturbance}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, sore throat {Sore throat}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, BRBPR {Hematochezia}, melena {Melena}, hematochezia {Hematochezia}, dysuria {Dysuria}, hematuria {Blood in urine} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
(per chart, confirmed with pt):
- Asthma since childhood and COPD (multiple asthma attacks,
previously seen by Dr. ___ ___ FEV1 71%
predicted, FEV/FVC 46%, now follows with Dr. ___
- Bipolar disorder (history of delusions of parasitosis and
depression, on SSI, resultant rash from scratching)
- Brain Metastases (dx in ___ with headaches;, MRI showed 2.4
x 1.1 cm size mass in the intraaxial location with surrounding
edema, consistent with metastatic disease; s/p left occipital
craniotomy and excision of the tumor on ___ Path showed
metastatic poorly differentiated carcinoma with unclear etiology
for a primary; ___ whole brain XRT; ___hest
with new speculated RUL nodule and enlarged lymph node,
enlarging on PET CT on ___
- knee pain
- recommended many times to have EGD and ___, pt declines
- GERD
- Substance abuse (crack cocaine)
###RESPONSE: Asthma {Asthma}, childhood {Childhood}, COPD {Chronic obstructive lung disease}, asthma attacks {Exacerbation of asthma}, Bipolar disorder {Bipolar disorder}, delusions of parasitosis {Delusions of parasitosis}, depression {Depressive disorder}, rash {Eruption of skin}, Brain Metastases {Metastatic malignant neoplasm to brain}, headaches {Headache}, MRI {Magnetic resonance imaging of head}, mass {Mass}, edema {Edema}, metastatic disease {Metastatic malignant neoplasm}, left occipital {Left occipital lobe structure}, craniotomy {Craniotomy}, excision {Excision}, tumor {Neoplasm}, metastatic {Metastatic malignant neoplasm}, poorly differentiated carcinoma {Poorly differentiated carcinoma}, brain {Brain structure}, XRT {X-ray beam therapy}, RUL {Structure of upper lobe of right lung}, nodule {Nodule}, enlarged lymph node {Lymphadenopathy}, PET CT {Positron emission tomography}, knee pain {Pain of knee region}, EGD {Esophagogastroduodenoscopy}, GERD {Gastroesophageal reflux disease}, Substance abuse {Substance abuse} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Aunt with lupus. Mother had lung cancer, sarcoid. Father with
diabetes. Brother hit by car.
###RESPONSE: lupus {Lupus erythematosus}, lung cancer {Malignant tumor of lung}, sarcoid {Sarcoidosis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Vitals- 98.9 PO 131 / 94 R ___
GENERAL: well-appearing , appears comfortable, minimal increased
WOB with ambulation, able to speak in full sentences
HEENT: MMM, NCAT, EOMI, anicteric sclera
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
RESP: decreased air entry bilaterally, scattered wheeze
bilaterally, no accessory muscle
ABDOMEN: soft, NTND, normoactive bowel sounds
EXTREMITIES: wwp, no pitting edema of BLE
SKIN: no rash or lesions
NEUROLOGIC: AOx3, wnl gait, grossly nonfocal.
###RESPONSE: Vitals {Vital signs finding}, GENERAL {General examination of patient}, WOB {Labored breathing}, able to speak {Able to speak}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, NC {Normal head}, EOMI {Normal ocular motility}, anicteric sclera {White sclera}, CARDIAC {Cardiovascular physical examination}, Regular rhythm {Normal sinus rhythm}, normal rate {Normal heart rate}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, JVD {Jugular venous engorgement}, RESP {Examination of respiratory system}, decreased air entry {Decreased breath sounds}, wheeze {Wheezing}, accessory muscle {Accessory skeletal muscle}, ABDOMEN {Examination of abdomen}, soft {Abdomen soft}, ND {Swollen abdomen}, normoactive bowel sounds {Normal bowel sounds}, EXTREMITIES {Examination of limb}, wwp {Normal tissue perfusion}, edema {Edema}, BLE {Edema of bilateral lower legs}, SKIN {Examination of skin}, rash {Eruption of skin}, lesions {Lesion}, NEURO {Neurological examination}, GI {Examination of digestive system}, AOx3 {Oriented to person, time and place}, wnl {No abnormality detected}, gait {Gait normal} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
Admission:
___ 10:40PM BLOOD WBC-10.2*# RBC-4.92 Hgb-14.6 Hct-44.7
MCV-91 MCH-29.7 MCHC-32.7 RDW-14.8 RDWSD-49.6* Plt ___
___ 10:40PM BLOOD Glucose-147* UreaN-14 Creat-0.8 Na-144
K-3.6 Cl-99 HCO3-31 AnGap-18
Imaging/
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Studies:
___ CXR
No acute cardiopulmonary process.
Discharge:
___ 06:35AM BLOOD WBC-11.8* RBC-4.81 Hgb-13.9 Hct-43.4
MCV-90 MCH-28.9 MCHC-32.0 RDW-14.9 RDWSD-49.5* Plt ___
___ 06:35AM BLOOD Glucose-128* UreaN-18 Creat-0.7 Na-137
K-4.4 Cl-99 HCO3-26 AnGap-16
###RESPONSE: CXR {Plain chest X-ray}, 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} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Ms. ___ is a ___ pMHx COPD, asthma, GERD, and metastatic
carcinoma to the brain of unknown origin s/p resection and WBRT
in ___ who presented with an acute COPD exacerbation. No
fevers, but cough, wheeze and dyspnea consistent with COPD
exacerbation, likely precipitated by pollen exposure. Improved
slowly. Completed a 5-day course of azithromycin and placed on a
slow prednisone taper to be continued as an outpatient.
###RESPONSE: COPD {Chronic obstructive lung disease}, asthma {Asthma}, GERD {Gastroesophageal reflux disease}, metastatic
carcinoma to the brain {Metastatic malignant neoplasm to brain}, resection {Excision}, acute COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, fevers {Fever}, cough {Cough}, wheeze {Wheezing}, dyspnea {Dyspnea}, COPD
exacerbation {Acute exacerbation of chronic obstructive airways disease}, Improved {Patient's condition improved} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Montelukast 10 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Aspirin 81 mg PO DAILY
7. Cetirizine 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. PredniSONE 20 mg PO DAILY
Discharge Medications:
1. Pseudoephedrine 30 mg PO Q6H:PRN nasal congestion
RX *pseudoephedrine HCl [Nasal Decongestant (pseudoeph)] 30 mg 1
tablet(s) by mouth every six (6) hours Disp #*10 Tablet
Refills:*0
2. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. PredniSONE 50 mg PO DAILY
50 mg daily x 3 days, then decrease by 10 mg every 3 days until
taking 10 mg daily
Tapered dose - DOWN
RX *prednisone 10 mg 5 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
4. Aspirin 81 mg PO DAILY
5. Cetirizine 10 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Montelukast 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs INH every four
(4) hours Disp #*1 Inhaler Refills:*0
10. Tiotropium Bromide 1 CAP ___ DAILY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Asthma exacerbation {Exacerbation of asthma}, 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 Ms. ___,
You were admitted to the hospital with an asthma exacerbation.
You were treated with steroids and breathing treatments and you
improved.
Please try to avoid cigarettes as they make your breathing
worse.
Please continue to take the prednisone (steroids) taper as
directed.
###RESPONSE: asthma exacerbation {Exacerbation of asthma}, steroids {Steroid therapy}, breathing treatments {Inhalation therapy procedure}, improved {Patient's condition improved}, steroids {Steroid therapy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
aspirin
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
###RESPONSE: aspirin {Allergy to aspirin}, Chest Pain {Chest pain}, Cardiac Catheterization {Cardiac catheterization} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ HTN, DM, HL, CAD and b/l hearing loss pw chest pain and
abnormal stress test. Patient reports exertional, substernal
chest pain for the last 3 days. Relieved with rest. Denies
radiation. Saw neurologist today for evaluation of memory loss,
but when he described chest pain was referred for outpatient
stress test. The stress test was abnormal and he was referred
for ___. Patient reports ongoing ___ substernal chest pain
without SOB on arrival to
the ED.
Patient takes Plavix for remote history of CAD. Denies ASA use.
Chest pain nonreproducible in the ED.
In the ED initial vitals were: 97.7 56 138/70 16 96% RA
- Labs were significant for WBC 3.7 Hct 40.6 Plt 141, Cr 0.8,
INR 0.9, Troponin <0.01
- Patient was given Nitroglycerin SL, Aspirin 325, and started
on a heparin gtt. His pain resolved after the SL nitro and
aspirin
Vitals prior to transfer were: 97.6 52 ___ 97% RA
On the floor, the patient is sleeping comfortably. He denies
chest pain, dyspnea, fevers, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, HL {Hyperlipidemia}, CAD {Coronary arteriosclerosis}, b/l hearing loss {Bilateral hearing loss}, chest pain {Chest pain}, abnormal stress test {Cardiovascular stress test abnormal}, exertional {Chest pain on exertion}, substernal
chest pain {Retrosternal pain}, Relieved with rest {Pain relief by rest}, radiation {Radiating pain}, evaluation {Evaluation procedure}, memory loss {Amnesia}, chest pain {Chest pain}, stress test {Cardiovascular stress testing}, stress test was abnormal {Cardiovascular stress test abnormal}, substernal chest pain {Retrosternal pain}, SOB {Dyspnea}, CAD {Coronary arteriosclerosis}, ASA use {Administration of aspirin}, Chest pain {Chest pain}, RA {Breathing room air}, Labs {Laboratory test}, WBC {White blood cell count}, Hct {Hematocrit determination}, Plt {Platelet count}, Cr {Creatinine measurement}, INR {Calculation of international normalized ratio}, Troponin {Troponin measurement}, Aspirin {Administration of aspirin}, heparin {Heparin therapy}, pain {Chest pain}, resolved {Problem resolved}, aspirin {Administration of aspirin}, Vitals {Vital signs finding}, RA {Breathing room air}, sleeping {Asleep}, chest pain {Chest pain}, dyspnea {Dyspnea}, fevers {Fever}, chills {Chill}, night sweats {Night sweats}, headache {Headache}, vision changes {Visual disturbance}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, sore throat {Sore throat}, cough {Cough}, shortness of breath {Dyspnea}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, nausea,
vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, BRBPR {Hematochezia}, melena {Melena}, hematochezia {Hematochezia}, dysuria {Dysuria}, hematuria {Blood in urine} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
HYPERTENSION
SEASONAL ALLERGIC RHINITIS
HARD OF HEARING
PROSTATE INTRAEPITHELIAL NEOPLASIA
HYPERLIPIDEMIA
GASTROESOPHAGEAL REFLUX
CORONARY ARTERY DISEASE
ERECTILE DYSFUNCTION
GOUT
AZOTEMIA
ADENOMA
VENTRICULAR ECTOPIC ACTIVITY
###RESPONSE: HYPERTENSION {Hypertensive disorder, systemic arterial}, SEASONAL ALLERGIC RHINITIS {Seasonal allergic rhinitis}, HARD OF HEARING {Hearing loss}, PROSTATE INTRAEPITHELIAL NEOPLASIA {Prostatic intraepithelial neoplasia}, HYPERLIPIDEMIA {Hyperlipidemia}, GASTROESOPHAGEAL REFLUX {Gastroesophageal reflux disease}, CORONARY ARTERY DISEASE {Coronary arteriosclerosis}, ERECTILE DYSFUNCTION {Erectile dysfunction}, GOUT {Inflammatory disorder due to increased blood urate level}, AZOTEMIA {Azotemia}, ADENOMA {Adenoma}, VENTRICULAR ECTOPIC {Ventricular premature complex} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Father: died in his ___ from iatrogenic injury, had some degree
of loss of right hand function several years prior to his death,
Mother: no medical issues
Brother: died at ___ from cancer, not sure which type
Sister: is ___, has memory problems,
Son: healthy
Physical ___:
PHYSICAL EXAM ON ADMISSION:
Vitals - 97.9 152/92 56 18 99% RA
GENERAL: Lying comfortably, in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP and radial pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAM ON DISCHARGE:
Vitals - 98.0, 111-138/74-84, 52-59, rr18, 99% on RA
GENERAL: Sleeping peacefull in bed, in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP and radial pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
###RESPONSE: died {Dead}, injury {Traumatic or non-traumatic injury}, loss of right hand function {Difficulty performing hand functions}, death {Dead}, died {Dead}, cancer {Malignant neoplastic disease}, memory problems {Memory impairment}, Vitals {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, Lying {Lying in bed}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, AT/NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclera {White sclera}, pink conjunctiva {Conjunctival hyperemia}, nares {Structure of anterior naris}, MMM {Moist oral mucosa}, good dentition {Normal dentition}, NECK {Physical examination procedure}, nontender {Tenderness of neck}, supple neck {Normal movement of neck}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, S1/S2 {Heart sounds normal}, murmurs {Heart murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, LUNG {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, breathing comfortably {Breathing easily}, accessory muscles {Accessory skeletal muscle}, ABDOMEN {Examination of abdomen}, nondistended {Normal abdominal contour}, +BS {Normal bowel sounds}, nontender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, hepatosplenomegaly {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, moving all extremities {Does move all four limbs}, cyanosis {Cyanosis}, clubbing {Clubbing}, edema {Edema}, PULSES {Pulse finding}, 2+ DP {Dorsalis pulse present}, radial pulses {Radial pulse present}, NEURO {Neurological examination}, CN II-XII intact {Normal central nervous system}, SKIN {Examination of skin}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Skin lesion}, rashes {Eruption of skin}, Vitals {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, Sleeping {Asleep}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, AT/NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclera {White sclera}, pink conjunctiva {Conjunctival hyperemia}, nares {Structure of anterior naris}, MMM {Moist oral mucosa}, good dentition {Normal dentition}, NECK {Physical examination procedure}, nontender {Tenderness of neck}, supple neck {Normal movement of neck}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, S1/S2 {Heart sounds normal}, murmurs {Heart murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, LUNG {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, breathing comfortably {Breathing easily}, accessory muscles {Accessory skeletal muscle}, ABDOMEN {Examination of abdomen}, nondistended {Normal abdominal contour}, +BS {Normal bowel sounds}, nontender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, hepatosplenomegaly {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, moving all extremities {Does move all four limbs}, cyanosis {Cyanosis}, clubbing {Clubbing}, edema {Edema}, PULSES {Pulse finding}, 2+ DP {Dorsalis pulse present}, radial pulses {Radial pulse present}, NEURO {Neurological examination}, CN II-XII intact {Normal central nervous system}, SKIN {Examination of skin}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Skin lesion}, rashes {Eruption of skin} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
LABS ON ADMISSION:
___ 05:45PM BLOOD WBC-3.7* RBC-4.09* Hgb-14.0 Hct-40.6
MCV-100* MCH-34.3* MCHC-34.5 RDW-12.8 Plt ___
___ 05:45PM BLOOD Neuts-61.6 ___ Monos-8.1 Eos-4.8*
Baso-0.5
___ 05:45PM BLOOD ___ PTT-29.9 ___
___ 05:45PM BLOOD Glucose-86 UreaN-26* Creat-0.8 Na-138
K-4.4 Cl-94* HCO3-26 AnGap-22*
___ 02:00PM BLOOD ALT-30 AST-24 AlkPhos-44 Amylase-83
TotBili-0.7
___ 07:50AM BLOOD CK-MB-5 cTropnT-<0.01
___ 05:45PM BLOOD cTropnT-<0.01
___ 07:50AM BLOOD CK-MB-5 cTropnT-<0.01
___ 07:50AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0 Cholest-159
___ 07:50AM BLOOD %HbA1c-7.2* eAG-160*
___ 07:50AM BLOOD Triglyc-386* HDL-33 CHOL/HD-4.8
LDLcalc-49
LABS ON DISCHARGE:
___ 07:35AM BLOOD WBC-4.0 RBC-4.72 Hgb-15.7 Hct-47.6
MCV-101* MCH-33.4* MCHC-33.0 RDW-13.3 Plt ___
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD Glucose-128* UreaN-24* Creat-1.3* Na-140
K-4.9 Cl-103 HCO3-30 AnGap-12
___ 09:15AM BLOOD ALT-36 AST-38 AlkPhos-54 TotBili-0.8
___ 07:35AM BLOOD Calcium-9.6 Phos-3.2 Mg-2.1
STUDIES:
___ (outpatient) STRESS TEST
INTERPRETATION: This ___ year old man with a history of HTN, gout
and
HL was referred to the lab for evalution of chest discomfort.
The
patient exercised for 11 minutes of ___ protocol and stopped
for
fatigue. The estimated peak MET capacity was 11.9 which
represents an
excellent functional capacity for his age. Near peak exercise,
the
patient noted a non-progressive right sided chest discomfort.
This
resolved with rest by minute 2 of recovery. At peak exercise,
there was
1-1.5 mm horizontal ST segment depression in the inferolateral
leads.
This became downsloping in recovery and resovled with rest by
minute 7.
the rhythm was sinus with rare isolated apbs during exercise and
frequent isolated vpbs in recovery. Resting HTN with an
appropriate
increase in systolic BP with exercise and slight blunting or HR
on beta
blocker therapy.
IMPRESSION: Ischemic EKG changes with atypical chest discomfort.
Nuclear report sent separately.
___ EKG
Rate PR QRS QT/QTc P QRS T
56 0 92 420/413 0 -3 55
Sinus bradycardia. Baseline artifact. Initial deflections in
leads III and aVF likely preclude prior inferior wall myocardial
infarction, as reported on ___. No diagnostic interim
change. Ventricular ectopy is absent.
___ CARDIAC PERFUSION
IMPRESSION:
1. Reversible, large, moderate severity perfusion defect
involving the LCx territory.
2. Normal left ventricular cavity size and systolic function.
Compared with the study of ___, the defect is new.
___ CXR
FINDINGS:
The lungs remain clear. The cardiomediastinal silhouette is
within normal
limits. Atherosclerotic calcifications are noted at the aortic
arch. No acute osseous abnormalities identified.
IMPRESSION:
No acute cardiopulmonary process.
___ CARDIAC CATH
Coronary angiography: right dominant
LMCA: 20% minor irregularities
LAD: The LAD was heavily calcified with diffuse disease.
There was a large diagonal branch with a 80-90% stenosis at its
origin. Three was a large second diagonal branch with an
60-70%
stenosis at its origin. There was an 80% stenosis in the mid
LAD and diffusely 80-90% stenosis in the mid LAD. The distal
LAD
had minor lumen irregularities.
LCX: The LCX was a small vessel with an occlusion of the OMB.
RCA: The RCA was a large dominant vessel. It had a 50% stenosis
in the distal RCA. There was diffuse 60-70% disease throughout
the PLSA. There was a 90% stenosis in RPL2 . There were right
to
left collaterals to the OMB.
ASSESSMENT
1. Severe three vessel coronary artery disease
___ CARDIAC ECHO
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Preserved biventricular systolic function. Mildly
dilated ascending aorta. Mild mitral regurgitation. Normal
pulmonary artery systolic pressure.
Compared with the prior study (images unavailable for review) of
___, the findings are similar.
###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}, Plt {Platelet count}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium 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}, Amylase {Amylase measurement}, TotBili {Bilirubin, total measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Cholest {Cholesterol measurement}, HbA1c {Hemoglobin A1c measurement}, eAG {Glucose measurement estimated from glycated hemoglobin}, Triglyc {Triglycerides measurement}, HDL {High density lipoprotein measurement}, CHOL/HD {Cholesterol/High density lipoprotein ratio measurement}, LDLcalc {Calculated low density lipoprotein cholesterol level}, 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}, Plt {Platelet count}, Plt {Platelet count}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, 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}, STRESS TEST {Electrocardiogram with exercise test}, HTN {Hypertensive disorder, systemic arterial}, gout {Inflammatory disorder due to increased blood urate level}, HL {Hyperlipidemia}, evalution {Evaluation procedure}, chest discomfort {Chest discomfort}, exercised {Exercises}, fatigue {Fatigue}, MET {Electrocardiogram with exercise test}, exercise {Exercises}, progressive {Patient's condition worsened}, right sided {Right thorax structure}, chest discomfort {Chest discomfort}, resolved {Problem resolved}, exercise {Exercises}, ST segment depression {ST segment depression}, resovled with rest {Pain relief by rest}, rhythm was sinus {Sinus rhythm}, exercise {Exercises}, frequent isolated vpbs {Multiple premature ventricular complexes}, HTN {Hypertensive disorder, systemic arterial}, exercise {Exercises}, therapy {Therapy}, Ischemic EKG changes {Electrocardiographic myocardial ischemia}, atypical {Atypical chest pain}, chest discomfort {Chest discomfort}, EKG {Electrocardiographic procedure}, Rate {Finding of heart rate}, PR {Finding of electrocardiogram PR interval}, QRS {Finding of electrocardiogram QRS complex}, P {Finding of electrocardiogram P wave}, QRS {Finding of electrocardiogram QRS complex}, T {Finding of electrocardiogram T wave}, Sinus bradycardia {Sinus bradycardia}, Baseline {Baseline state}, artifact {Artifact}, leads III {Lead III}, aVF {aVF}, inferior wall {Structure of myocardium of diaphragmatic region}, Ventricular ectopy {Ventricular premature complex}, CARDIAC PERFUSION {Radionuclide myocardial perfusion study}, perfusion defect {Myocardial perfusion defect}, LCx {Structure of circumflex branch of left coronary artery}, left ventricular cavity {Structure of cavity of left cardiac ventricle}, size {Normal size}, systolic function {Normal left ventricular systolic function and wall motion}, study {Evaluation procedure}, CXR {Plain chest X-ray}, lungs {Lung structure}, clear {No abnormality detected}, cardiomediastinal {Mediastinal structure}, normal {No abnormality detected}, Atherosclerotic {Atherosclerosis}, calcifications {Pathologic calcification, calcified structure}, aortic
arch {Aortic arch structure}, No acute {No abnormality detected}, osseous {Bone structure}, No acute {No abnormality detected}, CARDIAC CATH {Cardiac catheterization}, Coronary angiography {Angiography of coronary artery}, LMCA {Structure of left coronary artery main stem}, irregularities {Luminal irregularities of coronary artery}, LAD {Structure of anterior descending branch of left coronary artery}, LAD {Structure of anterior descending branch of left coronary artery}, calcified {Pathologic calcification, calcified structure}, diffuse disease {Diffuse disease of coronary artery}, diagonal {Structure of diagonal branch of anterior descending branch of left coronary artery}, stenosis {Stenosis}, diagonal {Structure of diagonal branch of anterior descending branch of left coronary artery}, stenosis {Stenosis}, stenosis {Stenosis}, mid
LAD {Structure of mid portion of anterior descending branch of left coronary artery}, stenosis {Stenosis}, mid LAD {Structure of mid portion of anterior descending branch of left coronary artery}, distal
LAD {Structure of distal portion of anterior descending branch of left coronary artery}, lumen irregularities {Luminal irregularities of coronary artery}, LCX {Structure of circumflex branch of left coronary artery}, LCX {Structure of circumflex branch of left coronary artery}, small vessel {Structure of small blood vessel (organ)}, occlusion {Complete obstruction}, OMB {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, RCA {Right coronary artery structure}, RCA {Right coronary artery structure}, vessel {Blood vessel structure}, stenosis {Stenosis}, distal RCA {Structure of distal portion of right coronary artery}, diffuse 60-70% disease {Diffuse disease of coronary artery}, stenosis {Stenosis}, RPL2 {Structure of posterior lateral branch of right coronary artery}, right {Right coronary artery structure}, OMB {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, ASSESSMENT {Evaluation procedure}, three vessel coronary artery disease {Triple vessel disease of the heart}, CARDIAC ECHO {Echocardiography}, left atrium {Left atrial structure}, normal in size {Normal size}, atrial septal defect {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, right atrial {Right atrial structure}, mild symmetric left ventricular
hypertrophy {Mild left ventricular hypertrophy}, normal cavity size {Normal size}, systolic function {Normal left ventricular systolic function and wall motion}, Right ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion
are normal {Normal ventricular wall motion}, ascending aorta is mildly dilated {Ascending aorta dilatation}, aortic
valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve
leaflets are mildly thickened {Thickened mitral leaflet}, Mild (1+) mitral regurgitation {Mild mitral valve regurgitation}, pulmonary artery {Pulmonary artery structure}, systolic pressure is
normal {Normal systolic arterial pressure}, pericardial effusion {Pericardial effusion}, biventricular {Cardiac ventricular structure}, systolic function {Normal left ventricular systolic function and wall motion}, dilated ascending aorta {Ascending aorta dilatation}, Mild mitral regurgitation {Mild mitral valve regurgitation}, pulmonary artery {Pulmonary artery structure}, systolic pressure {Normal systolic arterial pressure}, study {Evaluation procedure} |
Subsets and Splits