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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: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Malignant ascites, constipation, nausea
Secondary Diagnosis: Gastric cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: Home With Service {Home health aide service management}, Malignant ascites {Malignant ascites}, constipation {Constipation}, nausea {Nausea}, Gastric cancer {Malignant tumor of stomach}, 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 Mr. ___,
You were admitted to the hospital for a therapeutic
paracentesis. You had a liter of fluid removed by the
radiologists. You were also found to be constipated - you should
take stool softeners and Lactulose as needed for constipation.
The following changes were made to your medications:
#. START Lactulose as needed for constipation
#. START Compazine as needed for nausea
It was a pleasure meeting you and taking part in your care.
###RESPONSE: paracentesis {Centesis}, fluid removed {Drainage of abdomen}, constipated {Constipation}, take stool softeners {Administration of laxative}, constipation {Constipation}, constipation {Constipation}, nausea {Nausea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
latex
Attending: ___
Chief Complaint:
Traumatic brain injury
Major Surgical or Invasive Procedure:
___ - Left craniectomy and right EVD placement
___ - Right chest tube placement
___ - Left chest tube placement
___ - Right EVD removal
___ - Right EVD placement
___ - Tracheostomy
___ - PEG tube placement
___ - Intermaxillary fixation
___ - Removal of chest tubes
___ - Right EVD replacement
___ - Left cranioplasty
___ - Right EVD removal
###RESPONSE: latex {Allergy to Hevea brasiliensis latex protein}, Traumatic brain injury {Traumatic brain injury}, Left {Structure of left half of head}, craniectomy {Craniectomy}, right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, placement {Implantation procedure}, Right {Right thorax structure}, chest tube placement {Insertion of pleural tube drain}, Left {Left thorax structure}, chest tube placement {Insertion of pleural tube drain}, Right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, removal {Removal}, Right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, placement {Implantation procedure}, Tracheostomy {Exteriorization of trachea}, PEG tube placement {Percutaneous endoscopic insertion of gastrostomy tube}, Intermaxillary fixation {Intermaxillary fixation of mandible and maxilla}, Removal of chest tubes {Intercostal drain removal}, Right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, replacement {Replacement procedure}, Left {Structure of left half of head}, cranioplasty {Repair of bone of skull}, Right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, removal {Removal} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ is a ___ year old male who presented to the
Emergency Department on ___ as a transfer from an outside
facility status post fall approximately 25 feet from a
scaffolding. CT of the head at the outside facility revealed
multiple areas of acute extra-axial, subarachnoid,
intraparenchymal, and intraventricular hemorrhage with cerebral
compression as well as multiple skull and facial fractures.
Patient was transferred to ___
for further evaluation and management.
###RESPONSE: fall {Falls}, CT {Computed tomography}, head {Head structure}, extra-axial {Cerebral hemorrhage}, subarachnoid {Subarachnoid intracranial hemorrhage}, intraparenchymal {Intraparenchymal hemorrhage of brain}, intraventricular hemorrhage {Ventricular hemorrhage}, cerebral
compression {Compression of brain}, multiple skull {Multiple fractures of skull}, facial fractures {Fracture of multiple bones of face} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
- asthma
- opioid abuse
###RESPONSE: asthma {Asthma}, opioid abuse {Opioid abuse} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Noncontributory
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
On Admission:
-------------
General:
___ Coma Scale At The Scene: 4
___ Coma Scale Upon Neurosurgical Evaluation: 6T
Airway: [x]Intubated [ ]Not intubated
Eye Opening:
[x]1 Does not open eyes
Verbal:
[x]1 Makes no sounds
Motor:
___ Flexion/withdrawal to painful stimuli
###RESPONSE: General {General examination of patient}, Coma Scale At The Scene: 4 {Glasgow coma scale, 4}, Neuro {Neurological examination}, Airway {Airway structure}, Intubated {Intubation}, intubated {Intubation}, Eye Opening: {Finding of response to visual stimuli}, open eyes {Finding of response to visual stimuli}, Flexion {Flexion test}, withdrawal {Withdrawn}, pain {Pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
General: Well nourished male. Intubated, sedated, unresponsive.
Head, Eyes, Ears, Nose Throat: Open left temporal skull fracture
without obvious brain matter visible, however there is
disruption of the galea.
Extremities: Warm and well perfused.
Neurologic:
Mental Status: Intubated, sedated, unresponsive.
Orientation: Unable to assess, patient intubated, sedated,
unresponsive.
Language: Unable to assess, patient intubated, sedated,
unresponsive.
If Intubated:
[ ]Cough [ ]Gag [x]Over breathing the ventilator
Cranial Nerves:
I: Not tested.
II: Right pupil 3mm and minimally reactive to light. Left pupil
5mm and nonreactive to light.
III, IV, VI: Unable to assess, patient intubated, sedated,
unresponsive.
V, VII: Unable to assess, patient intubated, sedated,
unresponsive.
VIII: Unable to assess, patient intubated, sedated,
unresponsive.
IX, X: Unable to assess, patient intubated, sedated,
unresponsive.
XI: Unable to assess, patient intubated, sedated, unresponsive.
XII: Unable to assess, patient intubated, sedated, unresponsive.
Motor: Off sedation. Right upper extremity withdraws to noxious.
Minimal to no movement of the right lower extremity. Moves left
upper and lower extremities spontaneously.
On Discharge:
-------------
General:
Vital Signs: T 99.4F, HR 99, BP 143/63, RR 17, O2Sat 99%
tracheostomy mask
Exam:
Opens Eyes: [ ]Spontaneous [x]To voice - Right eye opens, left
does not [ ]To noxious
Orientation: [ ]Person [ ]Place [ ]Time [x]None
Follows Commands: [ ]Simple [ ]Complex [x]None
Pupils: Right pupil round, reactive to light. Left pupil round,
nonreactive to light.
Motor: Right upper extremity briskly withdraws to noxious. Right
lower extremity moves spontaneously, briskly withdraws to
noxious. Left upper and lower extremities move spontaneously and
purposefully, grossly full strength.
Surgical Incision:
[x]Clean, dry, intact
[x]Sutures
[x]Staples
###RESPONSE: Physical Exam {Physical examination procedure}, General {General examination of patient}, Well nourished {Well nourished}, Intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, Head {Head structure}, Eyes {Structure of eye proper}, Ears {Ear structure}, Nose {Nasal structure}, Throat {Structure of anterior portion of neck}, skull fracture {Fracture of skull}, brain {Brain structure}, disruption {Disruption}, galea {Structure of galea aponeurotica}, Extremities {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, Mental Status {Neurological mental status determination}, Intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, Orientation {Finding related to orientation}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, Cough {Cough}, II {Optic nerve structure}, Right pupil {Structure of pupil of right eye}, reactive to light {Finding of pupil reaction to light}, Left pupil {Structure of pupil of left eye}, nonreactive to light {Finding of pupil reaction to light}, III {Oculomotor nerve structure}, IV {Trochlear nerve structure}, VI {Abducens nerve structure}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, V {Trigeminal nerve structure}, VII {Facial nerve structure}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, VIII {Vestibulocochlear nerve structure}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, IX {Glossopharyngeal nerve structure}, X {Vagus nerve structure}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, XI {Accessory nerve structure}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, XII {Hypoglossal nerve structure}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, Motor {Motor testing}, sedation {Administration of sedative}, Right upper extremity {Structure of right upper limb}, withdraws to noxious {Responds to pain}, right lower extremity {Structure of right lower limb}, Moves {Does move}, left
upper {Structure of left upper limb}, lower extremities {Lower limb structure}, Vital Signs {Vital signs finding}, T {Body temperature finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, O2Sat {Oxygen saturation measurement}, tracheostomy {Exteriorization of trachea}, Eyes {Ophthalmic examination and evaluation}, Right eye {Right eye structure}, left {Left eye structure}, Orientation {Finding related to orientation}, Place {Oriented to place}, Time {Oriented to time}, Pupils {Pupil finding}, Right {Structure of pupil of right eye}, pupil round {Pupil round}, reactive to light {Finding of pupil reaction to light}, Left {Structure of pupil of left eye}, pupil round {Pupil round}, nonreactive to light {Finding of pupil reaction to light}, Motor {Motor testing}, Right upper extremity {Structure of right upper limb}, withdraws to noxious {Responds to pain}, Right
lower extremity {Structure of right lower limb}, moves {Does move}, withdraws to
noxious {Responds to pain}, Left upper {Structure of left upper limb}, move {Does move}, Surgical Incision {Surgical incision wound}, Clean, dry, intact {Wound healing well}, Sutures {Removal of suture} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Please see OMR for relevant laboratory and imaging results.
###RESPONSE: imaging {Imaging} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 male with a traumatic brain injury. Patient's
injuries included multiple areas of acute extra-axial,
subarachnoid, intraparenchymal, and intraventricular hemorrhage
with cerebral compression, multiple skull and facial fractures,
left clavicular fracture, multiple rib fractures, pulmonary
contusion, and hemothorax.
#Traumatic Brain Injury
Patient was taken to the operating room on ___ for a left
craniectomy and right EVD placement. Please see operative report
by Dr. ___ further details. Patient was transferred
back to the Trauma Intensive Care Unit. The patient's neurologic
exam waxed and waned throughout his hospitalization. Patient had
a progressive return of spontaneous movement on the left side
without significant progression on the right. Right EVD placed
in the operating room was subsequently removed on ___. CT
of the head on ___ showed external hydrocephalus, and the
right EVD was replaced. CT of the head on ___ showed
improvement in the patient's external hydrocephalus. Patient
returned to the operating room on ___ for a left
cranioplasty. Please see operative report by Dr. ___
further details. A subgaleal drain was left in place and
subsequently removed on postoperative day two. The right EVD was
raised over the course of several days after the left
cranioplasty, intracranial pressures remained within expected
limits. The right EVD was clamped on ___, and the patient's
intracranial pressures remained stable. CT of the head on
___ was stable and the right EVD was removed. The patient
was started on sodium tablets during this hospitalization for
management of sodium, which continue to be weaned as tolerated.
The patient was transferred to the floor on ___. On
___ the patient's neurologic exam was stable. He was
afebrile with stable vital signs, tolerating activity with
assistance, tolerating his continuous tube feedings, voiding
without difficulty, and his pain was well controlled on enteral
pain medications. Patient was discharged to ___
___ on ___ in stable condition.
#Multiple Skull and Facial Fractures
Plastic Surgery was consulted, and the patient underwent
intermaxillary fixation.
#Left Clavicular Fracture
Left clavicular fracture was nonoperable.
#Respiratory
Patient had progressive hypoxia on admission and had bilateral
chest tubes placed on ___. All chest tubes were
subsequently removed. Patient underwent tracheostomy on ___
due to prolonged intubation and was subsequently weaned to a
tracheostomy mask. The patient had multiple bronchoscopies
during this hospitalization and was treated for a ventilator
associated pneumonia with cefepime and vancomycin. The patient
was noted to be tachypneic to the high ___ and low ___. A CTA of
the chest showed no evidence of pulmonary embolism. A chest
x-ray was ordered, which showed bilateral pulmonary effusions,
which were stable compared to prior imaging. The patient's
respiratory status continued to improve throughout his
hospitalization.
#Nutrition
Patient underwent PEG tube placement on ___ due to
prolonged intubation. Nutrition was consulted for tube feeding
recommendations. The patient tolerated advancement of his
continuous tube feedings to goal.
#Right Upper Extremity Thomboses
Patient was found to have a nonocclusive right brachial, basilic
thrombus as well as an occlusive right cephalic thrombus.
Vascular Surgery consulted for question of a superior vena cava
filter, however they recommended conservative treatment.
#Loose Stools
Patient had an increase in diarrhea during this hospitalization
and was diagnosed with Clostridium difficile colitis. A rectal
tube was placed. Vancomycin was started and patient completed
the course on ___. Repeat stool sample was negative for
Clostridium difficile on ___. Patient continued to have
loose stools. Nutrition was consulted and recommended adding
banana flakes.
#Buttock Rash
Antifungal cream was started for a rash on the patient's
buttocks.
#Elevated Phosphorus
Nutrition was consulted and recommended adding Tums for elevated
phosphorus.
#Anemia
Patient's hemoglobin and hematocrit were monitored closely. They
were both low, but remained stable.
#Elevated PTT
The patient's PTT was consistently elevated and subcutaneous
heparin was held.
#Disposition
Physical Therapy and Occupational Therapy were both consulted,
and both recommended discharge to rehabilitation.
###RESPONSE: traumatic brain injury {Traumatic brain injury}, injuries {Traumatic or non-traumatic injury}, extra-axial {Cerebral hemorrhage}, subarachnoid {Subarachnoid intracranial hemorrhage}, intraparenchymal {Intraparenchymal hemorrhage of brain}, intraventricular hemorrhage {Ventricular hemorrhage}, cerebral compression {Compression of brain}, multiple skull {Multiple fractures of skull}, facial fractures {Fracture of multiple bones of face}, left clavicular {Bone structure of left clavicle}, fracture {Fracture}, multiple rib fractures {Fracture of multiple ribs}, pulmonary
contusion {Contusion of lung}, hemothorax {Hemothorax}, Traumatic Brain Injury {Traumatic brain injury}, left {Structure of left half of head}, craniectomy {Craniectomy}, right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, placement {Implantation procedure}, Trauma {Traumatic injury}, neurologic
exam {Neurological examination}, left {Structure of left half of body}, right {Structure of right half of body}, Right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, placed {Implantation procedure}, removed {Removal}, CT {Computed tomography}, head {Head structure}, external hydrocephalus {External hydrocephalus}, right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, replaced {Replacement procedure}, CT {Computed tomography}, head {Head structure}, improvement {Patient's condition improved}, external hydrocephalus {External hydrocephalus}, left {Structure of left half of head}, cranioplasty {Repair of bone of skull}, removed {Removal}, right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, left {Structure of left half of head}, cranioplasty {Repair of bone of skull}, intracranial pressures {Finding of intracranial pressure}, right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, clamped {Application of clamp}, intracranial pressures {Finding of intracranial pressure}, stable {Patient's condition stable}, CT {Computed tomography}, head {Head structure}, stable {Patient's condition stable}, right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, removed {Removal}, neurologic exam {Neurological examination}, stable {Normal vital signs}, afebrile {Fever}, stable vital signs {Normal vital signs}, activity {Finding of functional performance and activity}, tube feedings {Tube feeding of patient}, voiding
without difficulty {Normal micturition}, pain was well controlled {Demonstrates adequate pain control}, pain medications {Administration of analgesic}, stable condition {Patient's condition stable}, Multiple Skull {Multiple fractures of skull}, Facial Fractures {Fracture of multiple bones of face}, intermaxillary fixation {Intermaxillary fixation of mandible and maxilla}, Left Clavicular {Bone structure of left clavicle}, Fracture {Fracture}, Left clavicular {Bone structure of left clavicle}, fracture {Fracture}, Respiratory {Examination of respiratory system}, hypoxia {Hypoxia}, chest tubes placed {Insertion of pleural tube drain}, chest tubes {Insertion of pleural tube drain}, removed {Removal}, tracheostomy {Exteriorization of trachea}, intubation {Intubation}, tracheostomy {Exteriorization of trachea}, bronchoscopies {Bronchoscopy}, ventilator
associated pneumonia {Ventilator-acquired pneumonia}, tachypneic {Tachypnea}, CTA {Computed tomography angiography with contrast}, chest {Plain chest X-ray}, no evidence {No abnormality detected}, pulmonary embolism {Pulmonary embolism}, chest
x-ray {Plain chest X-ray}, bilateral pulmonary {Both lungs}, effusions {Pleural effusion}, stable {Patient's condition stable}, imaging {Imaging}, respiratory {Structure of respiratory system}, Nutrition {Nutritional finding}, PEG tube placement {Percutaneous endoscopic insertion of gastrostomy tube}, intubation {Intubation}, Nutrition {Nutritional finding}, tube feeding {Tube feeding of patient}, tube feedings {Tube feeding of patient}, Right Upper Extremity {Structure of right upper limb}, Thomboses {Thrombus}, nonocclusive {Partial obstruction}, right brachial {Structure of right brachial vein}, basilic {Structure of basilic vein}, thrombus {Thrombus}, occlusive {Complete obstruction}, right cephalic {Structure of right cephalic vein}, thrombus {Thrombus}, Vascular Surgery {Vascular surgery procedure}, superior vena cava {Superior vena cava structure}, Loose Stools {Loose stool}, diarrhea {Diarrhea}, Clostridium difficile colitis {Clostridium difficile colitis}, rectal
tube was placed {Insertion of tube into rectum}, stool sample {Collection of stool specimen}, loose stools {Loose stool}, Nutrition {Nutritional finding}, Buttock {Buttock structure}, Rash {Eruption of skin}, rash {Eruption of skin}, buttocks {Buttock structure}, Elevated Phosphorus {Increased phosphorus diet}, Nutrition {Nutritional finding}, elevated
phosphorus {Increased phosphorus diet}, Anemia {Anemia}, hemoglobin {Hemoglobin finding}, hematocrit {Hematocrit determination}, stable {Patient's condition stable}, Elevated PTT {Partial thromboplastin time increased}, PTT was consistently elevated {Partial thromboplastin time increased}, heparin {Heparin therapy}, Physical Therapy {Physical therapy procedure}, Occupational Therapy {Occupational therapy}, rehabilitation {Rehabilitation 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: Medications on Admission:
This Preadmission Medication List may be inaccurate and requires
further investigation.
1. buprenorphine-naloxone (8mg-2mg) one tablet sublingual twice
daily
Discharge Medications:
1. Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN Pain - Mild
Please do not take more than 3000mg in 24 hours.
2. Calcium Carbonate 500 mg PO QID
3. Famotidine 20 mg PO BID
4. Ketoconazole 2% 1 Appl TP BID Duration: 28 Doses
5. Labetalol 200 mg PO BID
Hold for HR < 55 or SBP < 90.
6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
7. Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime.
8. Sarna Lotion 1 Appl TP QID:PRN Dry skin
9. Sodium Chloride 1 gm PO BID
Goal normonatremia, wean as tolerated.
10. Tamsulosin 0.4 mg PO QHS
###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:
- traumatic brain injury with multiple areas of acute
extra-axial, subarachnoid, intraparenchymal, and
intraventricular hemorrhage with cerebral compression
- multiple skull and facial fractures
- external hydrocephalus
- left clavicular fracture
- multiple rib fractures
- pulmonary contusion
- hemothorax
- nonocclusive right brachial, basilic thrombus
- occlusive right cephalic thrombus
- Clostridium difficile colitis
Discharge Condition:
Mental Status: Confused, always.
Level of Consciousness: Lethargic, but arousable.
Activity Status: Out of bed with assistance to chair or
wheelchair.
###RESPONSE: traumatic brain injury {Traumatic brain injury}, extra-axial {Cerebral hemorrhage}, subarachnoid {Subarachnoid intracranial hemorrhage}, intraparenchymal {Intraparenchymal hemorrhage of brain}, intraventricular hemorrhage {Ventricular hemorrhage}, cerebral compression {Compression of brain}, multiple skull {Multiple fractures of skull}, facial fractures {Fracture of multiple bones of face}, external hydrocephalus {External hydrocephalus}, left clavicular {Fracture of multiple bones of face}, fracture {Fracture}, multiple rib fractures {Fracture of multiple ribs}, pulmonary contusion {Contusion of lung}, hemothorax {Hemothorax}, nonocclusive {Partial obstruction}, right brachial {Structure of right brachial vein}, basilic {Structure of basilic vein}, thrombus {Thrombus}, occlusive {Complete obstruction}, right cephalic {Structure of right cephalic vein}, thrombus {Thrombus}, Clostridium difficile colitis {Clostridium difficile colitis}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, Level of Consciousness {Assessment of consciousness level}, Lethargic {Lethargy}, Activity Status {Physical functional dependency}, Out of bed with assistance {Difficulty getting off a bed} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Surgery:
You underwent a surgery called a craniectomy. A portion of
your skull was removed to allow your brain to swell.
You also underwent surgery to have your skull bone (or an
artificial bone) placed back on.
Please keep your sutures and staples along your incision dry
until they are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
fever, redness, or drainage.
Activity:
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for six months.
Medications:
Please do NOT take any blood thinning medication (aspirin,
Coumadin, ibuprofen, Plavix) until cleared by the neurosurgeon.
You may use acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired and restlessness, irritability, and mood
swings are also common.
You may also experience some postoperative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You may apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worst in the morning after
laying flat from sleeping but should decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high fiber diet. If you are taking narcotics (prescription
pain medications), try an over the counter stool softener.
Headaches:
Headache is one of the most common symptoms after a traumatic
brain injury.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, if you have increased
sleepiness, if you develop arm or leg weakness, and/or if you
have nausea or vomiting with a headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches, including avoiding caffeine, getting enough sleep,
daily exercise, relaxation/meditation, massage, acupuncture, and
ice or heat packs.
More Information About Traumatic Brain Injuries:
You were given information about headaches after a traumatic
brain injury and the impact that a traumatic brain injury can
have on your family.
If you would like to read more about other topics such as
fatigue, balance, cognitive problems, sleeping, seizures,
driving, emotional problems, depression, sexuality after a
traumatic brain injury, and/or return to school or work, please
ask our staff for this information or visit
___.
When To Call Your Doctor At ___:
Severe pain, redness, swelling, or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or legs
Call ___ And Go To The Nearest Emergency Department If You
Experience Any Of The Following:
Sudden numbness or weakness in the face, arms, or legs
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
###RESPONSE: Surgery {Surgical procedure}, surgery {Surgical procedure}, craniectomy {Craniectomy}, skull {Bone structure of cranium}, removed {Removal}, brain {Brain structure}, swell {Swelling}, surgery {Surgical procedure}, skull {Bone structure of cranium}, sutures {Removal of suture}, incision {Incision}, removed {Removal of dressing}, incision {Incision}, signs of infection {Monitoring for signs and symptoms of infection}, fever {Fever}, redness {Redness of skin over lesion}, drainage {Discharge}, lifting {Does lift}, running {Does run}, climbing {Does climb}, strenuous exercise {Physical activity target strenuous exercise}, walks {Does walk}, activity {Functional activity education}, seizure {Seizure}, tired {Tired}, restlessness {Restlessness}, irritability {Feeling irritable}, mood
swings {Mood swings}, swelling {Swelling}, face {Face structure}, eyes {Structure of eye proper}, after surgery {Postoperative state}, surgery {Surgical procedure}, eyes {Structure of eye proper}, swelling {Swelling}, swelling {Swelling}, sleeping {Asleep}, soreness {Soreness}, surgery {Surgical procedure}, Constipation {Constipation}, high fiber diet {High residue diet}, narcotics {Narcotherapy}, pain medications {Administration of analgesic}, stool softener {Administration of laxative}, Headache {Headache}, traumatic
brain injury {Traumatic brain injury}, headaches {Headache}, headache {Headache}, sleepiness {Drowsy}, arm {Monoparesis - arm}, leg weakness {Monoparesis of lower limb}, nausea {Nausea}, vomiting {Vomiting}, headache {Headache}, Mild {Symptom mild}, pain medications {Administration of analgesic}, headaches {Headache}, pain medications {Administration of analgesic}, headaches {Headache}, exercise {Exercises}, relaxation {Relaxation training therapy}, meditation {Transcendental meditation therapy}, massage {Massage physiotherapy}, acupuncture {Acupuncture}, ice {Cold pack treatment}, heat packs {Thermotherapy with hot packs}, headaches {Headache}, traumatic
brain injury {Traumatic brain injury}, traumatic brain injury {Traumatic brain injury}, fatigue {Fatigue}, cognitive problems {Impaired cognition}, sleeping {Asleep}, seizures {Seizure}, emotional problems {Emotional problems}, depression {Depressive disorder}, sexuality {Finding related to sexual state}, traumatic brain injury {Traumatic brain injury}, Severe pain {Severe pain}, redness {Redness of skin over lesion}, swelling {Swelling}, drainage {Discharge}, incision
site {Surgical incision wound}, Fever {Fever}, Nausea {Nausea}, vomiting {Vomiting}, sleepiness {Drowsy}, awake {Awake}, headaches {Headache}, pain relievers {Administration of analgesic}, Seizures {Seizure}, problems with your vision {Abnormal vision}, ability to speak {Difficulty using language}, Weakness {Asthenia}, changes in sensation {Altered sensation of skin}, face {Face structure}, arms {Upper limb structure}, legs {Lower limb structure}, numbness {Numbness}, weakness {Asthenia}, face {Face structure}, arms {Upper limb structure}, legs {Lower limb structure}, confusion {Clouded consciousness}, walking {Does walk}, dizziness {Dizziness}, loss of balance {Unable to balance}, coordination {Finding related to coordination / incoordination}, headaches {Headache} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
Gatifloxacin / Penicillins / Ciprofloxacin / Bactrim
Attending: ___.
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
None
###RESPONSE: Gatifloxacin {Allergy to fluoroquinolone}, Penicillins {Allergy to penicillin}, Ciprofloxacin {Allergy to ciprofloxacin}, Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, Nausea and vomiting {Nausea and vomiting} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ with a history of diabetes (thought to be type I) and
chronic ___ erythema who presents with nausea vomiting without
abdominal pain for the past day. Pateint reports she began
vomiting this am and in total has had 4 episodes of non bloody
vomiting in addition to loose stools and dysuria. She denies
associated chest pain, fevers, chills or shortness of breath.
She has not been able to tolerate oral intake at home. She
additionally notes an associated HA with photophobia starting
this am. Of note the patient also has a history of frequent
UTIs. She has been checking blood sugars at home and states they
have been in the 150s throughout the day.
Initial VS in the ED:97.2 79 ___ 93% Exam notable for
bilateral ___ edema and eryhtema with chronic skin changes
consistent with venous stasis. Labs notable for BG of 455, AG of
16 and trop negative x 2. VBG was 7.42/34/70. UA showed ketones
of 10 in addition to > 182 WBC, 17 RBC, moderate bacteria and
moderate nitrites. Head CT was negative for acute process.
Patient was given vanco for cellulitis, ctx for UTI. She was
started on IVF (received 3 L total). She was given 8 units IB
insulin and BG fell to 25. She was therefore given D50 with
increase to 417. In terms of blood pressure control she was
given her home losartan 50 mg with improvment in BP to systolics
of 160. VS prior to transfer: 77 167/62 16 99%.
###RESPONSE: diabetes {Diabetes mellitus}, erythema {Erythema}, nausea vomiting {Nausea and vomiting}, abdominal pain {Abdominal pain}, vomiting {Vomiting}, bloody
vomiting {Hematemesis}, loose stools {Loose stool}, dysuria {Dysuria}, chest pain {Chest pain}, fevers {Fever}, chills {Chill}, shortness of breath {Dyspnea}, able to tolerate oral intake {Tolerating oral fluid}, HA {Headache}, photophobia {Photophobia}, frequent
UTIs {Recurrent urinary tract infection}, blood sugars {Glucose measurement, blood}, VS {Vital signs finding}, Exam {Physical examination procedure}, edema {Edema}, eryhtema {Erythema}, skin changes {Skin appearance abnormal}, venous stasis {Venous stasis}, Labs {Laboratory test}, UA {Urinalysis}, moderate bacteria {Bacteriuria}, Head CT {Computed tomography of head}, cellulitis {Cellulitis}, UTI {Urinary tract infectious disease}, IVF {Administration of intravenous fluids}, VS {Vital signs finding} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
1. DM2: insulin-dependent may be Type 1
-followed by ___
-c/b recurrent ulcers, urosepsis
-Charcot deformity
2. s/p amputation of L ___ & ___ toe
3. chronic ulcer of R pretibia
4. hx of MRSA foot ___
5. HTN
6. PVD
7. hypercholesterolemia
8. Anemia, ? ACD, baseline low ___
9. Hematemesis in ___ thought to be ___ small ___,
EGD ulcer in GE junction
###RESPONSE: DM2 {Diabetes mellitus type 2}, Type 1 {Diabetes mellitus type 1}, ulcers {Ulcer}, urosepsis {Sepsis due to urinary tract infection}, Charcot deformity {Charcot's arthropathy}, amputation of L ___ & ___ toe {Amputated toe of left foot}, chronic ulcer of R pretibia {Chronic ulcer of skin of lower leg}, MRSA {Methicillin resistant Staphylococcus aureus infection}, foot {Structure of left foot}, HTN {Hypertensive disorder, systemic arterial}, PVD {Peripheral vascular disease}, hypercholesterolemia {Hypercholesterolemia}, Anemia {Anemia}, Hematemesis {Hematemesis}, EGD ulcer {Gastrointestinal ulcer}, GE junction {Cardioesophageal junction 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:
Mother had DM2, died of diabetes related coma
Father has DM2, still alive
Several family members on paternal side with DM2
No FH of CAD, MI, or cancer.
###RESPONSE: DM2 {Diabetes mellitus type 2}, died {Dead}, diabetes related coma {Coma due to diabetes mellitus}, DM2 {Diabetes mellitus type 2}, alive {Alive}, DM2 {Diabetes mellitus type 2}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, cancer {Malignant neoplasm of colon} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Admission
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Vitals: T: 98.2 BP: 191/110 P: 89 R:20 O2: 96% RA
General: Alert, oriented, appears mildly uncomfortable
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, erythma of the shins bilaterally, bilateral peeling
scaling, several toes amputated.
Neuro: CN II-XII, strength ___, sensation in tact to light touch
Discharge Physical Exam:
T 97.6 BP 170/65 (150-194/65-91) HR 86 RR 20 O2 sat 98% FSG @
0600 160 (61-267)
GEN: Alert, oriented, no acute distress
HEENT: NCAT MMM EOMI sclera anicteric, OP clear, poor dentition
NECK: supple, no JVD, no LAD
PULM: Good aeration, CTAB no wheezes, rales, ronchi
CV: RRR normal S1/S2, no mrg
ABD: soft obese NT ND normoactive bowel sounds, no r/g, no
suprapubic tenderness, no CVA tenderness
EXT: Erythema in lower extremities bilaterally with peeling
skin, no purulent drainage. Left toes amputated. No edema,
thready DP pulses.
NEURO: CNs2-12 intact, motor function grossly normal, sensation
grossly intact
###RESPONSE: Physical Exam {Physical examination procedure}, Vitals {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, P {Finding of pulse rate}, R {Finding of rate of respiration}, O2 {Oxygen saturation measurement}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, dry mucous membranes {Mucous membrane dryness}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, 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}, Ext {Examination of limb}, Warm {Warm skin}, erythma {Erythema}, shins {Shin structure}, peeling {Peeling of skin}, scaling {Scaly skin}, toes amputated {Amputation of toe}, Neuro {Neurological examination}, CN II-XII {Normal central nervous system}, sensation in tact to light touch {Normal sensation}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, GEN {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, NCAT {Normal head}, MMM {Moist oral mucosa}, EOMI {Normal ocular motility}, sclera anicteric {White sclera}, OP clear {Pharynx normal}, poor dentition {Impaired dentition}, supple {Normal movement of neck}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, ronchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, normal S1/S2 {Heart sounds normal}, no mrg {Heart sounds normal}, ABD {Examination of abdomen}, soft {Abdomen soft}, obese {Obese}, NT {Abdominal tenderness}, ND {Normal abdominal contour}, normoactive bowel sounds {Normal bowel sounds}, suprapubic tenderness {Suprapubic pain}, CVA tenderness {Renal angle tenderness}, EXT {Examination of limb}, Erythema {Erythema}, lower extremities {Lower limb structure}, peeling
skin {Peeling of skin}, purulent drainage {Purulent discharge from wound}, Left toes amputated {Amputated toe of left foot}, edema {Edema}, DP pulses {Dorsalis pulse present}, NEURO {Neurological examination}, CNs2-12 intact {Normal nervous system function}, motor function grossly normal {Normal motor response to command}, sensation
grossly intact {Normal sensation} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
Admission:
___ 06:00PM BLOOD WBC-10.3 RBC-4.99# Hgb-15.5# Hct-47.3#
MCV-95 MCH-31.1 MCHC-32.9 RDW-13.6 Plt ___
___ 06:00PM BLOOD Neuts-91.0* Lymphs-5.9* Monos-2.6 Eos-0.1
Baso-0.4
___ 06:00PM BLOOD ___ PTT-22.7* ___
___ 06:00PM BLOOD Glucose-445* UreaN-31* Creat-1.4* Na-136
K-4.9 Cl-99 HCO3-20* AnGap-22*
___ 06:00PM BLOOD ALT-12 AST-25 AlkPhos-113* TotBili-0.6
___ 06:00PM BLOOD Albumin-4.2
___ 10:52PM BLOOD Osmolal-313*
___ 06:14PM BLOOD pO2-70* pCO2-34* pH-7.42 calTCO2-23 Base
XS--1 Comment-GREEN TOP
___ 06:14PM BLOOD Lactate-3.2*
Discharge:
___ 07:55AM BLOOD WBC-7.7# RBC-4.17* Hgb-12.8 Hct-39.6
MCV-95 MCH-30.7 MCHC-32.3 RDW-13.7 Plt ___
___ 07:55AM BLOOD ___ PTT-26.7 ___
___ 07:55AM BLOOD Glucose-168* UreaN-24* Creat-1.3* Na-138
K-4.7 Cl-107 HCO3-22 AnGap-14
___ 07:55AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.0
___ 11:44AM BLOOD Lactate-2.4*
___ 11:44AM BLOOD ___ pO2-90 pCO2-54* pH-7.27*
calTCO2-26 Base XS--2 Comment-GREEN TOP
___ 10:52PM BLOOD CK-MB-5 cTropnT-<0.01
___ 06:00PM BLOOD cTropnT-<0.01
Microbiology:
___ and ___ Blood Cultures: Pending
___ Urine Culture: Negative
___ Urinalysis: Large leukocytes, positive nitrite, >182 WBC,
17 RBC, moderate bacteria
Imaging:
___ CCR: Limited, with mild cardiomegaly and no definite signs
of
pneumonia or overt CHF.
___ CT Head: No acute intracranial process. Sinus disease in
the right
sphenoid sinus.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, pH {pH measurement}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, 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}, pH {pH measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, Blood Cultures {Blood culture}, Urine Culture {Urine culture}, Urinalysis {Urinalysis}, Large leukocytes {Leukocytes in urine}, positive nitrite {Nitrite detected in urine}, moderate bacteria {Bacteriuria}, cardiomegaly {Cardiomegaly}, pneumonia {Pneumonia}, CHF {Congestive heart failure}, CT Head {Computed tomography of head}, intracranial {Intracranial structure}, Sinus disease {Disorder of nasal sinus}, right
sphenoid sinus {Right sphenoid sinus structure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Brief Course:
___ yo female with hx of likely type I diabetes presents with
nausea and vomiting, found to have elevated blood glucose to 455
and anion gap in the setting of UTI. Patient's blood sugars were
controlled and her anion gap resolved with subcutaneous insulin
and IV fluids. She was treated for her UTI with IV ceftriaxone
and discharged on oral cefuroxime.
Active Issues:
# DKA: Patient presented with elevated blood glucose, increased
anion gap, and ketones in urine reflective of some degree of
DKA. UTI is most likely precipitant. Patient recieved 8 units of
IV insulin and was transitioned to subcutaneous insulin regimen
which was taylored per ___ recommendations. Her electrolytes
were monitored and repleated as necessary and her anion gap
closed. She received IV fluids and was able to tolerated po.
Patient's blood glucose stabilized and she was discharged on her
home insulin regimen.
# Hypertensive emergency: Patient presented with elevated blood
pressures to 200 systolic. She had a headache on admission
concerning for some level of end organ ischemia, which resolved
with blood pressure control. Patient maintained good urine
output with stable creatinine. Head CT negative. Trop negative x
2, EKG without evidence of ischemic changes. Patient was
continued on her home antihypertensive medication and required 2
prn doses of 12.5 mg captopril.
# UTI: Patient with grossly positive UA and leukocytosis,
although urine culture was negative. Patient has history of UTI
with culture growing pan sensitive proteus and ecoli. She was
initially treated with IV ceftriaxone then transitioned to oral
cefuroxime for total 10 day course, given her multiple
medication allergies and history of frequent UTIs.
# Lower extremity erythema: Per patient lower extremity edema
currently at baseline. No obvious signs of cellulitis. Likely
combination of venous stasis dermatitis and arterial
insufficiency. Patient will fo home with ___ for wound care and
dressing changes.
Inactive Issue:
# CKD: Creatinine was below baseline (1.5-1.8).
Transitional Issues:
1. Code Status: FULL
2. Communication: Patient
3. Medication changes:
-START Cefuroxime for UTI
4. Follow up: PCP
5. Pending studies: Blood cultures
###RESPONSE: type I diabetes {Diabetes mellitus type 1}, nausea and vomiting {Nausea and vomiting}, elevated blood glucose {Glucose level above reference range}, UTI {Urinary tract infectious disease}, blood sugars {Glucose measurement, blood}, subcutaneous insulin {Subcutaneous injection of insulin}, IV fluids {Administration of intravenous fluids}, UTI {Urinary tract infectious disease}, DKA {Ketoacidosis due to diabetes mellitus}, elevated blood glucose {Glucose level above reference range}, increased
anion gap {Increased anion gap}, ketones in urine {Ketonuria}, DKA {Ketoacidosis due to diabetes mellitus}, UTI {Urinary tract infectious disease}, subcutaneous insulin {Subcutaneous injection of insulin}, regimen {Therapeutic regimen}, electrolytes
were monitored {Electrolyte monitoring}, anion gap
closed {Reduced anion gap}, IV fluids {Administration of intravenous fluids}, able to tolerated po {Tolerating oral fluid}, blood glucose stabilized {Blood glucose within reference range}, insulin regimen {Insulin regime}, Hypertensive emergency {Hypertensive emergency}, elevated blood
pressures {Finding of increased blood pressure}, headache {Headache}, ischemia {Ischemia}, urine
output {Finding of measures of urine output}, stable creatinine {Creatinine clearance-glomerular filtration within reference range}, Head CT {Computed tomography of head}, Trop {Troponin measurement}, EKG {Electrocardiographic procedure}, without evidence of ischemic changes {Electrocardiogram: no myocardial ischemia}, antihypertensive medication {Antihypertensive therapy}, UTI {Urinary tract infectious disease}, UA {Urinalysis}, leukocytosis {Leukocytosis}, urine culture was negative {Urine culture - no growth}, UTI {Urinary tract infectious disease}, culture {Microbial culture}, medication allergies {Allergy to drug}, frequent UTIs {Recurrent urinary tract infection}, Lower extremity {Lower limb structure}, erythema {Erythema}, lower extremity edema {Edema of lower extremity}, cellulitis {Cellulitis}, venous stasis dermatitis {Stasis dermatitis of lower limb due to chronic peripheral venous hypertension}, arterial
insufficiency {Arterial insufficiency}, wound care {Wound care}, dressing changes {Change of dressing}, CKD {Chronic kidney disease}, Creatinine was below baseline {Creatine kinase below reference range}, UTI {Urinary tract infectious disease}, 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:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientwebOMR.
1. Vitamin D 50,000 UNIT PO MONTHLY
2. Nortriptyline 150 mg PO HS
3. Rosuvastatin Calcium 20 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Hydrochlorothiazide 25 mg PO DAILY
7. Detemir 70 Units Bedtime
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Nortriptyline 150 mg PO HS
4. Pantoprazole 40 mg PO Q24H
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Vitamin D 50,000 UNIT PO MONTHLY
7. cefUROXime axetil *NF* 500 mg Oral BID Duration: 8 Days
RX *cefuroxime axetil 500 mg 1 tablet(s) by mouth twice a day
Disp #*16 Tablet Refills:*0
8. Detemir 70 Units Bedtime
###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: Diabetic ketoacidosis
UTI
Dehydration
CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: Home With Service {Home health aide service management}, Diabetic ketoacidosis {Ketoacidosis due to diabetes mellitus}, UTI {Urinary tract infectious disease}, Dehydration {Dehydration}, CKD {Chronic kidney disease}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}, walker {Uses zimmer frame}, cane {Uses single walking stick} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
for nausea and vomiting, and your blood sugars were found to be
very high and you were in DKA. We were able to control your
blood sugar level with insulin and your nausea and vomiting
improved.
You were also suspected to have a urinary tract infection which
we treating with antibiotics.
Please make the following changes to your medications:
START Cefuroxime for your UTI
###RESPONSE: nausea and vomiting {Nausea and vomiting}, blood sugars {Glucose measurement, blood}, DKA {Ketoacidosis due to diabetes mellitus}, nausea and vomiting {Nausea and vomiting}, improved {Patient's condition improved}, urinary tract infection {Urinary tract infectious disease}, antibiotics {Antibiotic therapy}, UTI {Urinary tract infectious disease} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Enbrel / Methotrexate / Ampicillin
Attending: ___
Chief Complaint:
chest and arm pain
Major Surgical or Invasive Procedure:
___ CABG x6(LIMA-LAD,SVG-OM2-D2-D1,SVG-OM1,SVG-PDA)
###RESPONSE: Methotrexate {Allergy to methotrexate}, Ampicillin {Allergy to ampicillin}, chest {Chest pain}, arm pain {Pain in upper limb}, CABG {Coronary artery bypass grafting}, LIMA {Structure of left internal thoracic artery}, LAD {Structure of anterior descending branch of left coronary artery}, SVG {Aortocoronary artery bypass graft with saphenous vein graft}, OM2 {Structure of second obtuse marginal branch of circumflex branch of left coronary artery}, D2 {Structure of second diagonal branch of anterior descending branch of left coronary artery}, D1 {Structure of first diagonal branch of anterior descending branch of left coronary artery}, SVG {Aortocoronary artery bypass graft with saphenous vein graft}, OM1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, SVG {Aortocoronary artery bypass graft with saphenous vein graft}, PDA {Structure of posterior descending coronary artery} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ year old female who presented to ___ yesterday
with substernal chest pain radiating to her left arm that woke
her from sleep. She reports these symptoms have been occurring
intermittently over the last one month. At
___ she ruled out for MI per enzymes. Stress test
showed small LV apex ischemia and mild inferior wall basal
hypokinesis, EF 57%. She was transferred to ___ for cardiac
catheterization and further evaluation. She was found to have
three vessel disease upon cardiac catheterization and is now
being referred to cardiac surgery for revascularization.
###RESPONSE: substernal chest pain {Retrosternal pain}, radiating to her left arm {Pain radiating to left arm}, MI {Myocardial infarction}, Stress test {Electrocardiogram with exercise test}, LV apex {Structure of apex of left ventricle}, ischemia {Ischemia}, inferior wall {Structure of myocardium of inferior surface of left ventricle}, hypokinesis {Behavior showing reduced motor activity}, cardiac
catheterization {Cardiac catheterization}, evaluation {Evaluation procedure}, three vessel disease {Triple vessel disease of the heart}, cardiac catheterization {Cardiac catheterization}, revascularization {Heart revascularization} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
Hypertension
Dyslipidemia
Tobacco abuse (currently smoking 1 PPD)
Peripheral artery disease
Hypothyroid
Anxiety
Depression
Osteoporosis
Rheumatoid arthritis
Psoriasis
Lupus (remote)
C-diff (___)
Past Surgical History:
Choleysectomy
Bilateral Cataract
###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, Dyslipidemia {Dyslipidemia}, Tobacco abuse {Tobacco dependence syndrome}, smoking {Smoker}, Peripheral artery disease {Peripheral arterial disease}, Hypothyroid {Hypothyroidism}, Anxiety
Depression {Mixed anxiety and depressive disorder}, Osteoporosis {Osteoporosis}, Rheumatoid arthritis {Rheumatoid arthritis}, Psoriasis {Psoriasis}, Lupus {Lupus erythematosus}, Choleysectomy {Cholecystectomy}, Bilateral Cataract {Bilateral cataracts} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Premature coronary artery disease- non contributory
###RESPONSE: coronary artery disease {Coronary arteriosclerosis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Pulse:67 Resp:18 O2 sat:99/RA
B/P Right:158/103 Left:155/88
Height:5'5" Weight:64.3 kgs
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x] MMM
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur -none
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm x[], well-perfused [x] Edema none
rash bilat upper and lower legs, red/dry/puritic w/ecoriated
ankles and feet
Varicosities: None [x]
Neuro: Grossly intact [x] A&O x3, MAE, nonfocal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: dop Left: dop
___ Right: dop Left: dop
Radial Right: cath Left: 2+
Carotid Bruit none
###RESPONSE: Pulse {Finding of pulse rate}, Resp {Examination of respiratory system}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, B/P {Blood pressure finding}, Right {Right upper arm structure}, Left {Left upper arm structure}, Weight {Weight finding}, General {General examination of patient}, NAD {No abnormality detected}, Skin {Examination of skin}, Dry {Xeroderma}, intact {Intact skin}, HEENT {Physical examination procedure}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Full ROM {Normal range of cervical spine movement}, MMM {Moist oral mucosa}, Chest {Examination of respiratory system}, Lungs {Examination of respiratory system}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, Irregular {Irregular heart beat}, Murmur {Heart murmur}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-distended {Normal abdominal contour}, non-tender {Abdominal tenderness}, +BS {Normal bowel sounds}, Extremities {Examination of limb}, Warm {Warm skin}, well-perfused {Normal tissue perfusion}, Edema {Edema}, rash {Eruption of skin}, upper {Upper limb structure}, lower legs {Lower limb structure}, dry {Xeroderma}, puritic {Pruritic disorder of skin}, ecoriated {Excoriation of skin}, ankles {Ankle region structure}, feet {Foot structure}, Varicosities {Venous varices}, Neuro {Neurological examination}, Grossly intact {Normal nervous system function}, A {Mentally alert}, O x3 {Oriented to person, time and place}, MAE {Does move all four limbs}, Femoral {Structure of femoral artery}, DP {Structure of dorsalis pedis artery}, Radial {Structure of radial artery}, Right {Structure of right radial artery}, cath {Cardiac catheterization}, Left: 2 {Normal radial pulse}, Carotid Bruit {Carotid bruit} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ECHO ___
Prebypass:
The left atrium is normal in size. No thrombus is seen in the
left atrial appendage. There is mild symmetric left ventricular
hypertrophy. There is mild global left ventricular systolic
dysfunction with estimated Ejection Fraction 50-55%. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the ascending aorta. There are complex
(>4mm) atheroma in the aortic arch, maximum dimension 0.8 cm.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no pericardial effusion.
Dr. ___ was notified in person of the results on
___ at 1400.
Postbypass:
The patient is AV paced on epinephrine, phenylephrine,
norepinephrine & vasopressin infusions. There is moderate mitral
regurgitation. There is mild tricuspid regurgitation. The
remaining valves are unchanged. Biventricular function is
maintained on multiple agents. There is biatrial enlargement and
bowing of the interatrial septum L->R. The aorta is intact.
Prior to chest closure, biventricular function remains intact on
only norepinephrine & vasopressin infusions. The tricuspid
regurgitation is trace to mild. The mitral regurgitation is now
mild to moderate.
___ 04:44AM BLOOD WBC-9.5 RBC-2.90* Hgb-8.8* Hct-25.3*
MCV-87 MCH-30.4 MCHC-34.7 RDW-13.2 Plt ___
___ 04:29AM BLOOD WBC-10.6 RBC-2.97* Hgb-8.8* Hct-26.1*
MCV-88 MCH-29.7 MCHC-33.8 RDW-13.2 Plt ___
___ 02:53PM BLOOD WBC-11.4* RBC-3.35* Hgb-9.8* Hct-29.4*
MCV-88 MCH-29.3 MCHC-33.4 RDW-13.2 Plt ___
___ 04:44AM BLOOD Glucose-88 UreaN-16 Creat-0.7 Na-130*
K-4.2 Cl-95* HCO3-25 AnGap-14
___ 04:29AM BLOOD Glucose-90 UreaN-14 Creat-0.6 Na-126*
K-4.6 Cl-95* HCO3-27 AnGap-9
___ 02:53PM BLOOD Glucose-121* UreaN-10 Creat-0.6 Na-127*
K-4.4 Cl-94* HCO3-25 AnGap-12
___ 10:58AM BLOOD Glucose-102* Na-129* K-3.9 Cl-96
###RESPONSE: ECHO {Echocardiography}, left atrium {Left atrial structure}, normal in size {Normal size}, thrombus {Thrombus}, left atrial appendage {Structure of left auricular appendage}, mild symmetric left ventricular
hypertrophy {Mild left ventricular hypertrophy}, left ventricular systolic
dysfunction {Left ventricular systolic dysfunction}, Right
ventricular chamber {Right cardiac ventricular structure}, wall motion are normal {Normal ventricular wall motion}, atheroma {Atheroma}, ascending aorta {Ascending aorta structure}, atheroma {Atheroma}, aortic arch {Aortic arch structure}, atheroma {Atheroma}, descending thoracic aorta {Structure of descending thoracic aorta}, 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 valve appears structurally normal {Mitral valve normal}, trivial mitral regurgitation {Mild mitral valve regurgitation}, pericardial effusion {Pericardial effusion}, moderate mitral
regurgitation {Moderate mitral valve regurgitation}, mild tricuspid regurgitation {Mild tricuspid valve regurgitation}, Biventricular {Cardiac ventricular structure}, biatrial {Atrial structure}, enlargement {Enlargement}, interatrial septum {Interatrial septum structure}, aorta {Aortic structure}, chest {Thoracic structure}, closure {Reparative closure}, biventricular {Cardiac ventricular structure}, infusions {Infusion}, tricuspid
regurgitation is trace to mild {Mild tricuspid valve regurgitation}, mitral regurgitation is now
mild {Mild mitral valve regurgitation}, moderate {Moderate mitral valve regurgitation}, 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}, 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}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on ___ where the patient underwent urgent
coronary artery bypass graft times six. Left internal mammary
artery to left anterior descending artery and saphenous vein
grafts to posterior descending artery, obtuse marginal 1 and 2,
and diagonal 1 and 2, and Endoscopic harvesting of the long
saphenous vein. See operative note for full deatils. Overall
the patient tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and invasive monitoring. Post-operative day one found the
patient extubated, alert and oriented and breathing comfortably.
Initially she had no underlying rhythm and remained DDD paced.
The electrophysiology service was consulted. Lopressor was
initiated once the patient regained her rhythm and she was
tolerating beta blockers with a rate in the 80's. The patient
was neurologically intact and hemodynamically stable on no
inotropic or vasopressor support. She was gently diuresed toward
the preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Mediastinal chest tubes
were removed and the pleural chest tube stayed in an additional
day due to an air leak. After the pleural chest tube was on
waterseal for greater than ___ hours with a small stable
left pneumothorax, pleural chest tube was pulled. Follow up
chest radiograph showed small stable left pneumothorax. Pacing
wires were discontinued without complication on post-operative
day four. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on post-operative day six the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to ___
Rehab in good condition with appropriate follow up instructions.
###RESPONSE: coronary artery bypass graft {Coronary artery bypass grafting}, Left internal mammary
artery {Structure of left internal thoracic artery}, left anterior descending artery {Structure of anterior descending branch of left coronary artery}, saphenous vein
grafts {Arterial bypass using vein graft}, posterior descending artery {Structure of posterior descending branch of right coronary artery}, obtuse marginal 1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, 2 {Structure of second obtuse marginal branch of circumflex branch of left coronary artery}, diagonal 1 {Structure of first diagonal branch of anterior descending branch of left coronary artery}, 2 {Structure of second diagonal branch of anterior descending branch of left coronary artery}, long
saphenous vein {Great saphenous vein structure}, stable condition {Patient's condition stable}, Post-operative {Postoperative state}, extubated {Removal of endotracheal tube}, alert {Mentally alert}, oriented {Oriented to person}, breathing comfortably {Breathing easily}, neurologically intact {Normal nervous system function}, hemodynamically stable {Hemodynamically stable}, vasopressor support {Vasopressor therapy}, diuresed {Diuretic therapy}, telemetry {Cardiac telemetry}, Mediastinal chest tubes
were removed {Removal of tube from mediastinum}, left pneumothorax {Left pneumothorax}, pleural chest tube was pulled {Intercostal drain removal}, chest radiograph {Plain chest X-ray}, left pneumothorax {Left pneumothorax}, ambulating {Fully mobile}, wound was healing {Wound healing well}, pain was controlled
with oral analgesics {Demonstrates adequate pain control}, instructions {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: Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Atenolol 150 mg PO DAILY
2. Enalapril Maleate 20 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Diazepam 5 mg PO Q12H:PRN anxiety
7. Carbamazepine 400 mg PO DAILY
8. Nortriptyline 200 mg PO HS
9. Aspirin 81 mg PO DAILY
10. Calcium Carbonate 500 mg PO QID:PRN reflux
11. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN prn
Discharge Medications:
1. Albuterol-Ipratropium ___ PUFF IH Q6H
2. Aspirin 81 mg PO DAILY
3. Carbamazepine 400 mg PO DAILY
4. Enalapril Maleate 10 mg PO BID
Hold for sbp<100
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Nortriptyline 200 mg PO HS
7. Rosuvastatin Calcium 20 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
poor grafts
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
11. Ranitidine 150 mg PO BID
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg one tablet(s) by mouth every six hours Disp
#*40 Tablet Refills:*0
13. Calcium Carbonate 500 mg PO QID:PRN reflux
14. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN prn
15. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
16. Diazepam 5 mg PO Q12H:PRN anxiety
17. Furosemide 40 mg PO DAILY Duration: 1 Weeks
18. Potassium Chloride 40 mEq PO DAILY Duration: 1 Weeks
Hold for K >4.5
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
coronary artery disease, Hypertension, Dyslipidemia,
Tobacco(currently 1 PPD), Peripheral artery disease,
Hypothyroid, Anxiety, Depression, Osteoporosis,
Rheumatoid arthritis, Psoriasis, Lupus(remote), ___,
Choleysectomy, Bilateral Cataract
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Trace Edema bilaterally
###RESPONSE: coronary artery disease {Coronary arteriosclerosis}, Hypertension {Hypertensive disorder, systemic arterial}, Dyslipidemia {Dyslipidemia}, Tobacco {Tobacco dependence syndrome}, Peripheral artery disease {Peripheral arterial disease}, Hypothyroid {Hypothyroidism}, Osteoporosis {Osteoporosis}, Rheumatoid arthritis {Rheumatoid arthritis}, Psoriasis {Psoriasis}, Lupus {Lupus erythematosus}, Choleysectomy {Cholecystectomy}, Bilateral Cataract {Bilateral cataracts}, Alert {Mentally alert}, oriented x3 {Oriented to person, time and place}, Ambulating {Fully mobile}, steady gait {Gait normal}, Incisional {Surgical incision wound}, pain {Pain}, Incisions {Surgical incision wound}, Sternal {Wound of structure of sternal region}, healing well {Wound healing well}, erythema {Erythema}, drainage {Wound discharge}, Leg Left {Structure of left lower leg}, healing well {Wound healing well}, erythema {Erythema}, drainage {Wound 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 approximately one month and while taking
narcotics, 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 with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
###RESPONSE: incisions {Surgical incision wound}, incisions {Surgical incision wound}, redness {Redness of skin over lesion}, drainage {Wound discharge}, incisions {Surgical incision wound}, incision {Surgical incision wound} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP: single stone in CBD removed + sphincterotomy.
###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, Abdominal pain {Abdominal pain}, ERCP {Endoscopic retrograde cholangiopancreatography}, stone in CBD {Common bile duct calculus}, removed + sphincterotomy {Endoscopic sphincterotomy of sphincter of Oddi and removal of calculus} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
HPI:This is a ___ yo male who was transfered from ___ today where he was admitted on ___ for abdominal
discomfort, vomiting and substernal chest pain. The patient has
a
history of ischemic cardiomyopathy (EF:20%), Coronary artery
disease and atrial fibrillation. He spiked a fever on the day of
admission, blood cultures were obtained and yielded
pansensitive
E.coli. Repeated liver funtion tests showed an increase of total
bilirubin (2.7 > 5.4) LFT's ( AST 52>343, ALT 33> 269). A RUQ
ultrasound didn't yield any evicence of gallstones, no intra or
extrahepatic dilation. HIDA scan was performed on ___ and
showed non-opacification of the gallbladder, consitant with
acute
cholecystitis. He was transferred to the ___ today for further
evaluation and treatment.
###RESPONSE: abdominal
discomfort {Abdominal discomfort}, vomiting {Vomiting}, substernal chest pain {Retrosternal pain}, ischemic cardiomyopathy {Generalized ischemic myocardial dysfunction}, Coronary artery
disease {Coronary arteriosclerosis}, atrial fibrillation {Atrial fibrillation}, fever {Fever}, blood cultures {Blood culture}, liver funtion tests {Hepatic function panel}, total
bilirubin {Bilirubin, total measurement}, RUQ {Structure of right upper quadrant of abdomen}, ultrasound {Ultrasonography of abdomen}, gallstones {Gallbladder calculus}, intra {Intrahepatic biliary tract structure}, dilation {Dilatation}, HIDA scan {Radionuclide imaging of liver and/or biliary tract using radioactive isotope}, gallbladder {Gallbladder structure}, acute
cholecystitis {Acute cholecystitis}, evaluation {Evaluation procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
Cardiomyopathy with EF of 20%, Atrial fibrillation,
hypertension, hyperlipidemia, h/o ventricular tachycardia,
status
post ICD placement, CAD, compensated congested heart failure,
status post aortobi-iliac stent graft placement in ___, h/o
renal lesion, presumed cacinoma, treated conservatively in the
past, h/o prostate cancer
###RESPONSE: Cardiomyopathy {Cardiomyopathy}, Atrial fibrillation {Atrial fibrillation}, hypertension {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, ventricular tachycardia {Ventricular tachycardia}, ICD placement {Automatic defibrillator procedure}, CAD {Coronary arteriosclerosis}, congested heart failure {Congestive heart failure}, stent graft placement {Insertion of arterial stent}, renal {Kidney structure}, lesion {Lesion}, cacinoma {Carcinoma}, prostate cancer {Carcinoma of prostate} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
VS: 97.2 HR 81 BP 94/68 RR 18 Sat 100% RA
General: awake and alert
HEENT: no cervical or supraclavicular adenopathy noted,
Skin:dry
CV: regular rhythm, II/VI SEM
Lungs: CTA bilaterally
Abdomen: soft, +BS, non-tender, no rebound/guarding
Extremities: warm,no edema
###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}, RA {Breathing room air}, General {General examination of patient}, awake {Awake}, alert {Mentally alert}, HEENT {Physical examination procedure}, cervical {Cervical lymphadenopathy}, supraclavicular adenopathy {Supraclavicular lymphadenopathy}, Skin {Examination of skin}, dry {Xeroderma}, CV {Cardiovascular physical examination}, regular rhythm {Normal sinus rhythm}, SEM {Ejection murmur}, Lungs {Examination of respiratory system}, CTA {Normal breath sounds}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, +BS {Normal bowel sounds}, non-tender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, Extremities {Examination of limb}, warm {Warm skin}, 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: Pertinent Results:
___ 04:40AM BLOOD WBC-6.2 RBC-4.20* Hgb-13.1* Hct-40.3
MCV-96 MCH-31.2 MCHC-32.5 RDW-13.7 Plt ___
___ 06:35AM BLOOD ___ PTT-34.3 ___
___ 06:50AM BLOOD Glucose-124* UreaN-35* Creat-1.6* Na-137
K-4.1 Cl-98 HCO3-27 AnGap-16
___ 06:50AM BLOOD ALT-47* AST-23 AlkPhos-271* TotBili-2.7*
___ 06:50AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.5
ERCP ___
Impression: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique.
Periampullary diverticulum.
A single 1 cm round stone that was causing partial obstruction
was seen at the middle third of the common bile duct. A
successful biliary sphincterotomy was performed in the 12
o'clock position using a sphincterotome over an existing
guidewire. A biliary balloon sphincteroplasty was performed. A
12mm balloon was introduced for dilation successfully. The
stone was extracted successfully using a balloon catheter.
Occlusion cholangiogram revealed no residual filling defects.
The cystic duct was dilated and widely patent. Partial
pancreatogram was normal.
###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}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, ERCP {Endoscopic retrograde cholangiopancreatography}, Cannulation {Cannulation}, biliary duct {Bile duct structure}, Periampullary diverticulum {Diverticulum of peri-ampullary tissue of hepatopancreatic ampulla}, stone {Calculus}, partial obstruction {Partial obstruction}, common bile duct {Common bile duct structure}, biliary sphincterotomy {Endoscopic incision of sphincter of Oddi}, dilation {Dilatation}, stone was extracted {Extraction of calculus of biliary tract}, Occlusion {Complete obstruction}, cholangiogram {Cholangiogram}, filling defects {Filling defect}, cystic duct {Cystic duct structure}, dilated {Dilatation}, pancreatogram {Pancreatic contrast procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. On ___ the patient underwent ERCP
and were able to extract a CBD stone and performed a
sphincterotomy and sphincteroplasty which went well without
complication (reader referred to the Operative Note for
details). The patient arrived on the floor NPO, on IV fluids and
antibiotics. The patient was hemodynamically stable.
Neuro: The patient did not have any complaints of pain on
arrival to the floor.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. He did have a urine
culture that showed enterococcus ___. ID was curbsided
and they did not recommend antibiotics for treatment. Repeat UA
x 2 was negative. They suspect that it is colinization of the
UT. He was also on Zosyn for the ERCP.
Endocrine: The patient's blood sugar was monitored throughout
his stay.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
###RESPONSE: General Surgical Service {Admission to surgical department}, evaluation {Evaluation procedure}, ERCP {Endoscopic retrograde cholangiopancreatography}, CBD {Common bile duct structure}, stone {Extraction of calculus of biliary tract}, sphincterotomy {Endoscopic incision of sphincter of Oddi}, Operative {Surgical procedure}, NPO {Nil by mouth}, IV fluid {Administration of intravenous fluids}, antibiotics {Antibiotic therapy}, hemodynamically stable {Hemodynamically stable}, Neuro {Neurological examination}, pain {Pain}, CV {Cardiovascular physical examination}, stable {Patient's condition stable}, cardiovascular {Cardiovascular physical examination}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, Pulmonary {Examination of respiratory system}, stable {Patient's condition stable}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, pulmonary
toilet {Airway toilet}, incentive spirrometry {Incentive spirometry}, GI {Examination of digestive system}, GU {Examination of genitourinary system}, NPO {Nil by mouth}, IV
fluids {Administration of intravenous fluids}, Diet {Dietary finding}, intake and output {Measuring intake and output}, IV fluid {Administration of intravenous fluids}, white blood count {White blood cell count}, fever {Fever}, signs of infection {Monitoring for signs and symptoms of infection}, urine
culture {Urine culture}, antibiotics {Antibiotic therapy}, UA {Urinalysis}, UT {Structure of urinary tract proper}, ERCP {Endoscopic retrograde cholangiopancreatography}, blood sugar {Glucose measurement, blood}, complete blood count {Complete blood count}, transfusions {Transfusion}, Prophylaxis {Preventive procedure}, afebrile {Fever}, stable vital signs {Normal vital signs}, regular
diet {Normal diet}, ambulating {Fully mobile}, voiding without assistance {Continence independent}, pain was well
controlled {Demonstrates adequate pain control}, teaching {Patient education}, follow-up {Follow-up arranged}, instructions {Patient education}, discharge plan {Discharge planning} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
(updated per documented OSH record ___
Coumadin 4mg PO daily (on hold)
Coreg 12.5mg po BID
Amiodarone 200mg PO BID
Trazodone 50 mg po QHS
Nitro-patch 0.4mg/Hr TD overnight only
Lasix 80 mg po dialy
Spironolactone 12.5mg PO daily
Digoxin 0.125 po daily
Zocor 20mg PO QHS
Colace 100mg PO BID
Milk of Magnesia prn
Zofran prn
Morphine 2 to 4 mg q3h prn
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
###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:
Choledocholithiasis
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
###RESPONSE: Home With Service {Home health aide service management}, Choledocholithiasis {Gallbladder and bile duct calculi}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
###RESPONSE: chest pain {Chest pain}, pressure {Tight chest}, squeezing {Squeezing chest pain}, tightness {Tight chest}, cough {Cough}, shortness of breath {Dyspnea}, wheeze {Wheezing}, vomiting {Vomiting}, medications {Medication education}, dehydrated {Dehydration}, vomiting {Vomiting}, diarrhea {Diarrhea}, Signs {Sign}, dehydration {Dehydration}, dry mouth {Xerostomia}, rapid
heartbeat {Tachycardia}, dizzy {Dizziness}, faint {Feeling faint}, standing {Orthostatic body position}, blood or dark/black material when you vomit {Vomit contains blood}, bowel movement {Hematochezia}, burning {Burning sensation}, urinate {Micturition finding}, blood in your
urine {Blood in urine}, discharge {Discharge}, pain {Pain}, pain {Pain}, chest {Thoracic structure}, back {Structure of back of trunk}, shaking {Tremor}, chills {Chill}, fever {Fever}, medications {Medication education}, medication {Medication education}, medications {Medication education}, Avoid lifting
weights {Functional activity education}, follow-up {Follow-up arranged}, activity
restrictions {Functional activity education}, while taking pain
medications {Patient medication education}, follow-up {Follow-up arranged}, PCP {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: M
Service: SURGERY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ulcerative colitis
Major Surgical or Invasive Procedure:
___ ileostomy takedown
###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, ulcerative colitis {Ulcerative colitis}, ileostomy takedown {Closure of ileostomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
A ___ man who previously underwent
abdominal colectomy, laparoscopic proctectomy, and diverting
loop ileostomy, J pouch on ___. The pouch study was normal.
Risks
and benefits included, but not limited to, infection,
bleeding, leak, need for more procedures were discussed. The
patient understood and agreed.
###RESPONSE: colectomy {Excision of colon}, laparoscopic {Laparoscopic procedure}, proctectomy {Resection of rectum}, loop ileostomy {Creation of loop ileostomy}, J pouch {J pouch}, normal {No abnormality detected}, infection {Infectious disease}, bleeding {Bleeding}, leak {Anastomosis, leaking}, procedures {Procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PMH:
Ulcerative Colitis
PSH:
Lap colectomy w/ end ileostomy (___)
###RESPONSE: Ulcerative Colitis {Ulcerative colitis}, Lap colectomy w/ end ileostomy {Laparoscopic total colectomy and ileostomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
M: CAD, HLD
Maternal GM: RA
DM in father's side of family
###RESPONSE: CAD {Coronary arteriosclerosis}, HLD {Hyperlipidemia}, RA {Rheumatoid arthritis}, DM {Diabetes mellitus} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
NAD
CV: RRR
Resp: nl breathing effort
GI: inc c/d/i, ND, NT, soft
###RESPONSE: NAD {No abnormality detected}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, Resp {Examination of respiratory system}, nl breathing {Normal respiratory function}, GI {Examination of digestive system}, ND {Swollen abdomen}, NT {Abdominal tenderness}, soft {Abdomen soft} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
###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: Brief Hospital Course Template:
Mr ___ presented to ___ holding at ___ on ___ for
a ileostomy takedown. He tolerated the procedure well without
complications (Please see operative note for further details).
After a brief and uneventful stay in the PACU, the patient was
transferred to the floor for further post-operative management.
On ___, the patient was discharged to home. At discharge,
he was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. He will follow-up in the
clinic in ___ weeks. This information was communicated to the
patient directly prior to discharge.
Include in Brief Hospital Course for Every Patient and check of
boxes that apply:
Post-Surgical Complications During Inpatient Admission:
[x] None
Social Issues Causing a Delay in Discharge:
[x] No social factors contributing in delay of discharge.
###RESPONSE: ileostomy takedown {Closure of ileostomy}, procedure {Surgical procedure}, operative {Surgical procedure}, PACU {Postanesthesia care}, post-operative management {Postoperative care}, regular diet {Normal diet}, passing flatus {Passing flatus}, stooling {Able to defecate}, voiding {Normal micturition}, ambulating independently {Independent walking}, follow-up {Follow-up arranged}, clinic {Outpatient care management}, Post-Surgical Complications {Postoperative complication}, social factors {Social factor} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
do not take more than 3000mg of Tylenol or drink alcohol
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*50 Tablet Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drink alcohol or drive a car while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
3. Tamsulosin 0.4 mg PO QHS
please take for 5 more days at home
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*5
Capsule Refills:*0
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Ileostomy Takedown
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Ileostomy Takedown {Closure of ileostomy}, Mental Status {Neurological mental status determination}, Clear {No abnormality detected}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were admitted to the hospital after an ileostomy takedown.
You have recovered from this procedure well and you are now
ready to return home. You have tolerated a regular diet, passing
gas and your pain is controlled with pain medications by mouth.
You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but your should not have prolonged constipation. Some loose
stool and passing of small amounts of dark, old appearing blood
are expected however, if you notice that you are passing bright
red blood with bowel your please seek medical attention. If you
are passing loose stool without improvement please call the
office or go to the emergency room if the symptoms are severe.
If you are taking narcotic pain medications there is a risk that
you will have some constipation. Please take an over the counter
stool softener such as Colace, and if the symptoms does not
improve call the office. It is also not uncommon after an
ileostomy takedown to have frequent loose stools until you are
taking more regular food however this should improve.
The muscles of the sphincters have not been used in quite some
time and you may experience urgency or small amounts of
incontinence however this should improve. If you do not show
improvement in these symptoms within ___ days please call the
office for advice. Occasionally, patients will need to take a
medication to slow their bowel movements as their bodies adjust
to the new normal without an ileostomy, you should consult with
our office for advice. If you have any of the following symptoms
please call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or constipation.
You have a small wound where the old ileostomy once was. This
should be covered with a dry sterile gauze dressing. The wound
no longer requires packing with gauze packing strip. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the wound line and pat the
area dry with a towel, do not rub. Please apply a new gauze
dressing after showering.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by your surgical team. You may gradually
increase your activity as tolerated but clear heavy exercise
with your surgical team.
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 3000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
###RESPONSE: ileostomy takedown {Closure of ileostomy}, recovered from this procedure well {Good recovery following surgery}, ready to return {Ready for discharge}, regular diet {Normal diet}, passing
gas {Passing flatus}, pain {Pain}, pain medications {Administration of analgesic}, by mouth {Administration of drug or medicament via oral route}, monitor your bowel function {Monitoring bowel motility}, bowel movement {Able to defecate}, bowel
movement {Able to defecate}, anesthesia {Administration of anesthesia}, decrease in bowel function {Altered bowel function}, constipation {Constipation}, loose
stool {Loose stool}, dark {Dark stools}, old appearing blood {Melena}, bright
red blood {Hematochezia}, bowel {Intestinal structure}, seek medical attention {Recommendation to seek attention}, loose stool {Loose stool}, improvement {Patient's condition improved}, emergency {Emergency treatment}, taking narcotic pain medications {Narcotics education}, constipation {Constipation}, take an over the counter
stool softener {Administration of laxative}, ileostomy takedown {Closure of ileostomy}, loose stools {Loose stool}, e regular food {Normal diet}, muscles of the sphincters {Structure of sphincter ani muscle}, urgency {Urgent desire for stool}, small {Symptom mild}, incontinence {Incontinence of feces}, improvement {Patient's condition improved}, medication {Administration of drug or medicament}, bowel movements {Altered bowel function}, ileostomy {Ileostomy - stoma}, emergency {Emergency treatment}, abdominal distension {Swollen abdomen}, abdominal
pain {Abdominal pain}, nausea, vomiting {Nausea and vomiting}, inability to tolerate food or liquids {Nausea and vomiting}, loose stool {Loose stool}, constipation {Constipation}, wound {Wound}, ileostomy {Ileostomy operation}, sterile gauze dressing {Application of dressing, sterile}, wound {Wound}, packing {Packing of wound}, packing {Packing of wound},
monitor {Monitoring for signs and symptoms of infection}, incision {Surgical incision wound}, signs {Sign}, infection {Local infection of wound}, redness {Redness of skin over lesion}, incision {Surgical incision wound}, incision {Surgical incision wound}, increased pain {Increased pain}, incision {Surgical incision wound}, draining {Wound discharge}, drainage {Wound discharge}, fever {Fever}, emergency {Emergency treatment}, shower {Functional activity education}, wound {Wound}, dressing {Application of dressing}, No heavy lifting {Functional activity education}, after surgery {Postoperative state}, activity as tolerated {Education about increasing activity tolerance}, t clear heavy exercise {Functional activity education}, Please take this medication exactly as prescribed {Patient medication education}, pain {Pain}, do not take {Patient medication education}, Do not drink alcohol {Education about alcohol consumption}, while
taking narcotic pain medication {Narcotics education}, Please do not drive
a car {Patient medication education}, while taking narcotic pain medication {Narcotics education}, activities {Finding of functional performance and activity} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Metastatic colon cancer to left ureter
Major Surgical or Invasive Procedure:
Left nephroureterectomy
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Metastatic colon cancer {Metastatic carcinoma to colon}, left ureter {Metastatic malignant neoplasm to ureter}, Left {Left kidney structure}, nephroureterectomy {Nephroureterectomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Dear Doctors:
I had the pleasure of seeing our mutual patient, Ms. ___, today at the ___ in
followup. I performed cystoscopy on her today after a urine
cytology demonstrated malignant cells consistent with colon
cancer. I had previously counseled her and seen her regarding
her positive PET scan, which demonstrated a potential tumor in
the left ureter. However, she has a history of a completely
obstructed left upper tract. Therefore, I did not expect to see
a positive urine cytology if she was indeed completely
obstructed
and the only disease was in her ureter. I, therefore, brought
her back for a cystoscopy to evaluate her bladder to make sure
that there were no additional tumors in her bladder.
I performed flexible cystoscopy today, which is dictated
separately. It turns out that she does have a tumor in her
bladder, near her left ureteral orifice. This was pedunculated
in nature, and had appearance similar to transitional cell
carcinoma, although I could not make a diagnosis visually. I
did
take a small biopsy of it for histologic diagnosis and
cauterized
the biopsy defect.
This is a surprising finding, but it is a good thing that we
evaluated the bladder, for we were planning left
nephroureterectomy, and this would have been an unexpected
finding. Depending on what the histology shows, this will have
different implications for her prognosis and for the future
treatment plan.
For example, if this is colon cancer, then a left
nephroureterectomy with a larger bladder cuff, encompassing this
tumor could be a reasonable treatment, as there is no other
obvious site of disease. If this is TCC, then this is a
different story and I would not be able to fully explain her
elevated CEA. She would likely still need removal of this
bladder tumor as well as left kidney and ureter, but her
prognosis would likely be different, and we would have to look
for other sites of disease. I will bring her back in two weeks
for a revisit and discussion of the biopsy results, and we will
have a conversation then about what this implies and what we can
do for her going forward. Dr. ___ was present in clinic
today, so I did show him the results of the cystoscopy visually,
and we are in agreement in regards to the plan going forward.
Thank you very much again for allowing me to participate in her
care, and please feel free to contact me with any questions or
concerns that you may have.
Sincerely,
___ MD, ___
###RESPONSE: cystoscopy {Transurethral cystoscopy}, urine
cytology {Urine cytology}, malignant cells {Tumor cells, malignant}, colon
cancer {Malignant neoplasm of colon}, PET scan {Positron emission tomography}, tumor {Tumor finding}, left ureter {Structure of left ureter}, obstructed {Obstruction}, upper tract {Structure of upper urinary system}, positive {Detected by cytology}, urine cytology {Urine cytology}, obstructed {Obstruction}, disease {Disease}, ureter {Ureteric structure}, cystoscopy {Transurethral cystoscopy}, bladder {Urinary bladder structure}, tumors in her bladder {Neoplasm of bladder}, flexible cystoscopy {Flexible cystoscopy}, tumor in her
bladder {Neoplasm of bladder}, left ureteral orifice {Structure of left ureteral orifice}, transitional cell
carcinoma {Transitional cell carcinoma}, biopsy {Biopsy}, biopsy {Biopsy}, bladder {Urinary bladder structure}, left {Left kidney structure}, nephroureterectomy {Nephroureterectomy}, colon cancer {Malignant neoplasm of colon}, left {Left kidney structure}, nephroureterectomy {Nephroureterectomy}, TCC {Transitional cell carcinoma of bladder}, elevated CEA {Carcinoembryonic antigen above reference range}, removal {Removal}, bladder tumor {Neoplasm of bladder}, left kidney {Laceration of left kidney}, ureter {Ureteric structure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
- Stage I (pT1 pN0 cM0) sigmoid colon adenocarcinoma in ___
- Stage IIA (pT3 pN0 cM0) rectosigmoid colon adenoCA ___
intact IHC for MLH1, MSH2, MSH6, and PMS2; microsatellite stable
(MSS) by PCR; KRAS wild-type, BRAF wild-type
-obesity
-asthma
- HTN
- lipomatosis
- depression
SurgHx:
___ surgical history, in addition to the two colectomies, by
her report includes a cesarean section and possible bilateral
salpingo-oophorectomies. She also states that she underwent a
benign breast biopsy in the 1980s. I could find no record of the
pelvic surgery or any breast surgery by operative note or
pathology.
###RESPONSE: sigmoid colon adenocarcinoma {Adenocarcinoma of sigmoid colon}, rectosigmoid colon {Rectosigmoid structure}, adenoCA {Malignant adenomatous neoplasm}, obesity {Obesity}, asthma {Asthma}, HTN {Hypertensive disorder, systemic arterial}, lipomatosis {Lipomatosis}, depression {Depressive disorder}, colectomies {Excision of colon}, cesarean section {Cesarean section}, bilateral
salpingo-oophorectomies {Excision of bilateral fallopian tubes and ovaries}, breast biopsy {Biopsy of breast}, pelvic {Structure of pelvis}, surgery {Surgical procedure}, breast {Breast structure}, surgery {Surgical procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
___ family history is significant for her father who had a
laryngeal cancer, but was a heavy smoker. She has two children
who are well. There are no other family members with colon
cancer, sarcoma or any other malignancy that she was aware of.
###RESPONSE: laryngeal cancer {Malignant tumor of larynx}, smoker {Smoker}, colon
cancer {Malignant neoplasm of colon}, sarcoma {Sarcoma}, malignancy {Malignant neoplasm} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
NAD
WWP
No respiratory distress
Abdomen S, appropriately TTP, ND, incision c/d/i with staples
No focal deficits
###RESPONSE: NAD {No abnormality detected}, WWP {Normal tissue perfusion}, distress {Distress}, Abdomen {Examination of abdomen}, TTP {Tenderness}, ND {Swollen abdomen}, incision {Surgical incision wound}, No focal deficits {Normal nervous system function} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 07:10AM BLOOD WBC-4.7 RBC-2.78* Hgb-8.3* Hct-24.8*
MCV-89 MCH-29.8 MCHC-33.4 RDW-13.0 Plt ___
___ 07:10AM BLOOD Glucose-88 UreaN-11 Creat-1.5* Na-138
K-4.6 Cl-100 HCO3-29 AnGap-14
___ 07:10AM BLOOD Calcium-8.8 Phos-5.0*# Mg-2.1
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Patient was admitted to Urology after undergoing laparoscopic
left nephrectomy, open distal ureterectomy, transurethral
resection of bladder cuff, retroperitoneal lymph node
dissection. The surgery was complicated by an iatrogenic
incision into the vagina, which was repaired. Please see
dictated operative note for details.
The patient received perioperative antibiotic prophylaxis. The
patient was transferred to the floor from the PACU in stable
condition. On POD0-1, pain was well controlled on PCA, hydrated
for urine output >30cc/hour, and provided with pneumoboots and
incentive spirometry for prophylaxis. On POD1, the patient
ambulated, restarted on home medications, basic metabolic panel
and complete blood count were checked. The patient was a little
nauseated for the first couple days post-operatively and she was
kept on sips. A KUB was performed, which did not show any
evidence of an ileus. The patient was started on anti-emetics
and an aggressive bowel regimen. She started to have bowel
movements on POD4 and her diet was slowly advanced. She was also
transitioned from a PCA to oral analgesics. On POD6, JP
creatinine was sent and showed no evidence of a urine leak. Her
JP was subsequently removed. The patient was discharged in
stable condition, eating well, ambulating independently, and
with pain control on oral analgesics. On exam, incision was
clean, dry, and intact, with no evidence of hematoma collection
or infection. The patient will go home with a foley catheter for
another ___ weeks and she will follow-up in clinic for a void
trial.
###RESPONSE: laparoscopic {Laparoscopic procedure}, left nephrectomy {Excision of left kidney}, ureterectomy {Ureter excision}, transurethral
resection of bladder {Transurethral bladder excision}, retroperitoneal lymph node
dissection {Excision of retroperitoneal lymph node group}, incision {Surgical incision wound}, vagina {Vaginal structure}, repaired {Surgical repair}, antibiotic prophylaxis {Administration of prophylactic antibiotic}, stable
condition {Patient's condition stable}, pain was well controlled {Demonstrates adequate pain control}, PCA {Patient controlled analgesia}, incentive spirometry {Incentive spirometry}, prophylaxis {Preventive procedure}, ambulated {Ambulation training}, restarted {Restart of medication}, complete blood count {Complete blood count}, nauseated {Nausea}, post-operatively {Postoperative state}, KUB {Radiography of kidney-ureter-bladder}, ileus {Intestinal obstruction co-occurrent and due to decreased peristalsis}, bowel regimen {Bowel care}, bowel
movements {Does defecate}, PCA {Patient controlled analgesia}, oral analgesics {Administration of analgesic}, creatinine {Creatinine measurement}, no evidence {No abnormality detected}, urine leak {Urinary incontinence}, stable condition {Patient's condition stable}, ambulating independently {Independent walking}, pain control on oral analgesics {Demonstrates adequate pain control with oral analgesics}, incision {Surgical incision wound}, clean, dry, and intact {Wound healing well}, no evidence {No abnormality detected}, hematoma {Hematoma}, infection {Infectious disease} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ipratropium-Albuterol Inhalation Spray 2 INH IH Q6H:PRN
wheezing, SOB
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Multivitamins 1 TAB PO DAILY
6. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN pain
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Ciprofloxacin HCl 500 mg PO Q12H
9. albuterol sulfate 90 mcg/actuation inhalation BID wheezing,
SOB
10. Vitamin D 50,000 UNIT PO DAILY
Discharge Medications:
1. Diltiazem Extended-Release 120 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Acetaminophen 1000 mg PO Q6H
5. Enoxaparin Sodium 30 mg SC Q24H
Start: Today - ___, First Dose: Next Routine Administration
Time
6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
7. albuterol sulfate 90 mcg/actuation inhalation BID wheezing,
SOB
8. Ipratropium-Albuterol Inhalation Spray 2 INH IH Q6H:PRN
wheezing, SOB
9. Multivitamins 1 TAB PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Vitamin D 50,000 UNIT PO DAILY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic colon cancer
Discharge Condition:
Alert and oriented
Ambulating
Stable
###RESPONSE: Home With Service {Home health aide service management}, Metastatic colon cancer {Metastatic carcinoma to colon}, Alert {Mentally alert}, oriented {Orientated}, Ambulating {Fully mobile}, Stable {Patient's condition stable} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
-Please also refer to the provided written instructions on
post-operative care, instructions and expectations made
available from Dr. ___.
-Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor.
-___ reduce the strain/pressure on your abdomen and incision
sites; remember to log roll onto your side and then use your
hands to push yourself upright while taking advantage of the
momentum of putting your legs/feet to the ground.
--There may be bandage strips called steristrips which have
been applied to reinforce wound closure. Allow these bandage
strips to fall off on their own over time but PLEASE REMOVE ANY
REMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may
get the steristrips wet.
-Please AVOID aspirin or aspirin containing products and
supplements that may have blood-thinning effects (like Fish
Oil, Vitamin E, etc.) unless you have otherwise been advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your
doctor should you develop blood in your stool (dark, tarry
stools)
-Call your Urologist's office to schedule/confirm your follow-up
appointment in ___ weeks AND if you have any questions.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised. Light household chores/activity and leisurely
walking/activity is OK and should be continued. Do NOT be a
couch potato
-Tylenol should be your first-line pain medication. A narcotic
pain medication has been
prescribed for breakthrough pain ___. REPLACE the Tylenol with
this narcotic pain medication if additional pain control is
needed..
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-You may shower normally but do NOT immerse your incisions or
bathe
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool-softener, NOT a laxative
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
-Follow up in ___ weeks for wound check and Foley removal. DO
NOT
allow anyone that is outside of the urology team remove your
Foley for any reason.
-Wear Large Foley bag for majority of time; the leg bag is only
for short-term when leaving the house, etc.
###RESPONSE: strain {Muscle strain}, pressure {Pressure}, abdomen {Skin structure of anterior abdominal wall}, incision
sites {Surgical incision wound}, wound closure {Wound healed}, pain control {Pain control}, pain
control {Pain control}, narcotic {Narcotherapy}, pain relief {Pain relief}, blood in your stool {Hematochezia}, dark {Dark stools}, tarry
stools {Melena}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, breakthrough pain {Breakthrough pain}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, pain control {Pain control}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, constipation {Constipation}, constipation {Constipation}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, loose stool {Loose stool}, diarrhea {Diarrhea}, stool-softener {Administration of laxative}, fevers {Fever}, vomiting {Vomiting}, redness {Redness of skin over lesion}, swelling {Swelling}, incision {Surgical incision wound}, Foley {Urinary catheter in situ}, thigh {Thigh structure}, wound check {Wound assessment}, Foley removal {Removal of urinary bladder catheter} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
etoh withdrawal
Major Surgical or Invasive Procedure:
None
###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, etoh withdrawal {Alcohol withdrawal syndrome} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ y/o, primarily ___ speaking (but conversational in
___ presents with HA and shaking after stopping drinking.
Pt reports drinking 1 large bottle of cognac daily x `1 week. He
attests to being sober for 3 months prior to this binge. Last
drink was ___ afternoon. The HA is frontal and intense but
similar to prior HA. no Vision or hearing changes. Pt also
reports N/V and diffuse abd pain starting today. No
hematemeisis. Pain is discribed as intense. He says it is
different than his typical pancreatitis pain, but he can not
discribe in what way. Pain improves with vomitting. No diarrhea
or constipation. Pt reports feeling tremulous. Subjective
fevers. Pt endorses h/o etoh withdrawal seizures. He endorses
depression but denies SI/HI now or ever.
.
In the ED, initial VS: 98.0, 78, 150/89, 17, 100%RA. Pt received
10mg PO valium and 4mg IV zofran in ED. CIWA of ___. Pt was
tachy in ED and diaphoretic. Also complained of belly discomfort
and vomitted. Labs and abd exam benign. MS oriented. VS prior to
transfer 125/78, 93, 17, 95% RA.
.
Upon arrival to the floor the pt was seen inducing vomitting
multiple times and complained of a headache. He complains of a
HA.
.
Pt was admitted ___ with etoh withdrawal and abd pain but
left AMA the same day.
.
ROS: Denies, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
###RESPONSE: HA {Headache}, shaking {Tremor}, drinking {Current drinker of alcohol}, drinking {Current drinker of alcohol}, binge {Drinking binge}, drink {Drinking episode}, HA is frontal {Frontal headache}, HA {Headache}, Vision {Visual disturbance}, hearing changes {Hearing change}, N/V {Nausea and vomiting}, diffuse {Diffuse pain}, abd pain {Abdominal pain}, hematemeisis {Hematemesis}, Pain {Pain}, pancreatitis {Pancreatitis}, pain {Pain}, Pain {Pain}, vomitting {Vomiting}, diarrhea {Diarrhea}, constipation {Constipation}, fevers {Fever}, etoh withdrawal seizures {Alcohol withdrawal-induced convulsion}, depression {Depressive disorder}, SI/HI {Suicidal intent}, tachy {Tachycardia}, diaphoretic {Excessive sweating}, discomfort {Discomfort}, Labs {Laboratory test}, abd exam {Examination of abdomen}, oriented {Orientated}, inducing vomitting {Self-induced vomiting}, headache {Headache}, HA {Headache}, etoh withdrawal {Alcohol withdrawal syndrome}, abd pain {Abdominal pain}, ROS {Review of systems}, chills {Chill}, night sweats {Night sweats}, vision changes {Visual disturbance}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, sore throat {Sore throat}, cough {Cough}, shortness of breath {Dyspnea}, chest pain {Chest pain}, diarrhea {Diarrhea}, constipation {Constipation}, BRBPR {Hematochezia}, melena {Melena}, hematochezia {Hematochezia}, dysuria {Dysuria}, hematuria {Blood in urine} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
1. Recurrent pancreatitis complicated by necrosis in ___ secondary to alcohol abuse.
2. Hypertension.
3. History of a seizure disorder; status post a motor vehicle
accident in ___ (negative magnetic resonance
imaging and electroencephalogram).
4. Status post left knee surgery.
5. History of alcohol abuse with episodes of withdrawal.
###RESPONSE: Recurrent pancreatitis {Recurrent pancreatitis}, necrosis {Necrosis}, alcohol abuse {Alcohol abuse}, Hypertension {Hypertensive disorder, systemic arterial}, seizure disorder {Seizure disorder}, motor vehicle
accident {Motor vehicle accident victim}, negative {No abnormality detected}, magnetic resonance
imaging {Magnetic resonance imaging}, electroencephalogram {Electroencephalogram}, left knee {Structure of left knee region}, surgery {Surgical procedure}, alcohol abuse {Alcohol abuse}, withdrawal {Alcohol withdrawal syndrome} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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 had kidney cancer
###RESPONSE: kidney cancer {Malignant tumor of kidney} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae erythematous, MMM, OP clear
NECK - supple, no JVD,
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft/ND, mild epigastric tenderness. No rebound or
guarding. no masses or HSM,
EXTREMITIES - WWP, no c/c/e, 2+ DPs
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, not tremulous.
muscle strength ___ throughout, sensation grossly intact
throughout, DTRs 2+ and symmetric, cerebellar exam intact,
steady gait. Normal visual fields
###RESPONSE: GENERAL {General examination of patient}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, comfortable {Comfortable appearance}, HEENT {Physical examination procedure}, NC {Normal head}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, sclerae {Scleral structure}, erythema {Erythema}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, NECK {Physical examination procedure}, supple {Normal movement of neck}, JVD {Jugular venous engorgement}, LUNGS {Examination of respiratory system}, CTA {Normal breath sounds}, rh/wh {Wheeze - rhonchi}, good air movement {Breath normal}, resp unlabored {Labored breathing}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, S2 {Normal second heart sound, S>2<}, ABDOMEN {Examination of abdomen}, soft {Abdomen soft}, ND {Swollen abdomen}, mild {Symptom mild}, tenderness {Tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, no c/c/e {No abnormality detected}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, LYMPH {Lymphatic system physical examination}, LAD {Lymphadenopathy}, NEURO {Neurological examination}, awake {Awake}, Ox3 {Oriented to person, time and place}, grossly intact {Normal nervous system function}, tremulous {Tremor}, muscle strength {Muscle weakness}, sensation grossly intact {Normal sensation}, DTRs 2 {Normal tendon reflex}, steady gait {Gait normal}, Normal visual fields {Normal visual field} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 07:20AM BLOOD WBC-7.2 RBC-4.89 Hgb-14.6 Hct-40.8 MCV-83
MCH-29.8 MCHC-35.8* RDW-13.4 Plt ___
___ 07:50PM BLOOD WBC-5.6 RBC-5.12 Hgb-15.7 Hct-42.4 MCV-83
MCH-30.6 MCHC-37.0* RDW-13.2 Plt ___
___ 07:50PM BLOOD Neuts-50.4 Lymphs-42.3* Monos-5.1 Eos-1.0
Baso-1.2
___ 07:20AM BLOOD Glucose-98 UreaN-9 Creat-0.9 Na-138 K-3.8
Cl-100 HCO3-24 AnGap-18
___ 07:50PM BLOOD Glucose-125* UreaN-11 Creat-1.1 Na-135
K-3.5 Cl-94* HCO3-24 AnGap-21*
___ 07:50PM BLOOD ALT-27 AST-30 AlkPhos-42 TotBili-0.9
___ 07:20AM BLOOD Albumin-4.3 Mg-1.9
___ 07:50PM BLOOD Lipase-31
___ 07:50PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 08:09AM BLOOD Lactate-2.4*
.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, 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}, Albumin {Albumin 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:
HOSPITAL COURSE
This is a ___ year old gentleman with a history of multiple
admissions for alcohol withdrawal who presented with
tachycardia, vomitting, diaphoresis consistent with Etoh
withdrawal. He was treated with diazepam overnight and left
against medical advice the following morning
.
ACTIVE ISSUES
# ETOH WITHDRAWAL: History of chronic ETOH use complicated by
pancreatitis in the past with recent admission in ___ for
management of withdrawal symptoms. The patient's CIWA scale was
24 on admission which improved significantly with 10mg diazepam.
He only scored positive on the CIWA scale twice. The patient
reports a history of withdrawal seizures however on
clarification appears to be more consistent with tremors.
History of prior seizure after motor vehicle accident ___ years
ago. No evidence of pancreatitis on lab work. Alchohol cessation
was discussed with the patient who wanted treatment only for
withdrawal not abstinence. A social work consult was requested.
He was given thiamine folate and a multivitamin intravenously.
At mid-day following admission the patient was dressed and found
at the elevators preparing to leave. The danger of alcohol
withdrawal and risk of seizures and even death was discussed.
The patient understood the importance of seeking medical
attention if his withdrawal returned.
.
# ELEVATED AG: AG 17 on admission improved to 14 the following
morning. Likely in setting of etoh and with ketones in UA.
Lactate only marginally elevated at 2.4.
.
# HEADACHE: Headache per review of prior discharge summaries is
a typical withdrawal symptoms for this patient. Improved
headache with treatment of withdrawal symptoms overnight with
valium.
.
# N/V, ABDOMINAL PAIN: Abdominal pain in this patient concerning
for pancreatitis given multiple admissions in past for alcohol
induced pancreatitis. No evidence of pancreatitis on admission.
Patient report frequent emesis is causing abdominal pain.
He tolerated a solid diet prior to leaving AMA.
.
# HISTORY OF DEPRESSION: The patient has a history of depression
with psychiatric evaluations in the past for suicidal ideation.
He did not present expressing suicidal ideation however
completely off all psychiatric medications and more frequent
admissions for alcohol withdrawal. The patient did not stay long
enough to meet with social work. Prior to leaving, the
importance of following up with his psychiatrist was stressed.
.
TRANSITIONAL ISSUES:
The patient left against medical advice. Follow-up with his
primary care physician and psychiatrist was urged. He does not
take any medications regularly.
###RESPONSE: alcohol withdrawal {Alcohol withdrawal syndrome}, tachycardia {Tachycardia}, vomitting {Vomiting}, diaphoresis {Excessive sweating}, Etoh
withdrawal {Alcohol withdrawal syndrome}, left
against medical advice {Left against medical advice}, ETOH WITHDRAWAL {Alcohol withdrawal syndrome}, ETOH {Alcohol abuse}, pancreatitis {Pancreatitis}, management of withdrawal symptoms {Management of withdrawal symptom}, CIWA scale {Assessment using alcohol withdrawal scale}, improved {Patient's condition improved}, CIWA scale {Assessment using alcohol withdrawal scale}, withdrawal seizures {Alcohol withdrawal-induced convulsion}, tremors {Tremor}, seizure {Seizure}, motor vehicle accident {Motor vehicle accident victim}, No evidence {No abnormality detected}, pancreatitis {Pancreatitis}, withdrawal {Alcohol withdrawal syndrome}, alcohol
withdrawal {Alcohol withdrawal syndrome}, seizures {Seizure}, death {Dead}, withdrawal {Alcohol withdrawal syndrome}, ELEVATED AG {Increased anion gap}, improved {Patient's condition improved}, etoh {Alcohol abuse}, Lactate {Lactic acid measurement}, HEADACHE {Headache}, Headache {Headache}, withdrawal symptoms {Withdrawal symptom}, Improved {Patient's condition improved}, headache {Headache}, withdrawal symptoms {Withdrawal symptom}, ABDOMINAL PAIN {Abdominal pain}, Abdominal pain {Abdominal pain}, pancreatitis {Pancreatitis}, alcohol
induced pancreatitis {Inflammation of pancreas caused by alcohol}, No evidence {No abnormality detected}, pancreatitis {Pancreatitis}, emesis {Vomiting}, abdominal pain {Abdominal pain}, solid diet {Normal diet}, leaving AMA {Patient self-discharge against medical advice}, DEPRESSION {Depressive disorder}, depression {Depressive disorder}, psychiatric evaluations {Evaluation of psychiatric state of patient}, suicidal ideation {Suicidal thoughts}, suicidal ideation {Suicidal thoughts}, psychiatric {Psychiatry procedure or service}, medications {Administration of drug or medicament}, alcohol withdrawal {Alcohol withdrawal syndrome}, social {Social therapy}, psychiatrist {Psychiatric follow-up}, left against medical advice {Left against medical advice}, primary care {Primary care management}, psychiatrist {Psychiatric follow-up}, medications {Patient medication education} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
not regularly taking any medications
occasionally takes atenolol for HTN when he "feels his BP is
bad".
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
###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:
Alcohol withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Alcohol withdrawal {Alcohol withdrawal syndrome}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You left the hospital against medical advice. We discussed the
risks of leaving including further alcohol withdrawal leading to
possible seizures and even death. You were aware of these risks
and decided to leave. Please follow up with your primary care
physician and psychiatrist. No changes were made to your
medications.
###RESPONSE: alcohol withdrawal {Alcohol withdrawal syndrome}, seizures {Seizure}, death {Dead}, primary care {Primary care management}, psychiatrist {Psychiatric follow-up}, changes were made to your
medications {Change of medication} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Occluded suprapubic catheter, urinary tract infection
Major Surgical or Invasive Procedure:
Exchange of suprapubic catheter
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Occluded suprapubic catheter {Obstruction of suprapubic catheter}, urinary tract infection {Urinary tract infectious disease}, Exchange of suprapubic catheter {Change of cystostomy 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:
___ with rectal cancer, stage IV with extensive pelvic nodal
involvement, receiving palliative CAPOX, s/p palliative
resection of his lower rectum and anus with diverting colostomy
and suprapubic tube for urethral injury who presented to ___
with urinary retention since last night. The patient reports
that no urine has come through catheter since yesterday evening.
Suprapubic tube was just replaced on ___. Pt also having
decreased ostomy output since this AM. Normally empties ___ per
day. He also has significant abdominal discomfort.
- In the ED, initial VS were 9 98.6 117 149/69 99% RA.
- Exam was notable for purulent discharge surrounding SP tube,
extreme discomfort & abdominal tenderness.
- Labs were notable for lactate 2.6, cr 0.6, na 131, k 4.6, wbc
10.3, hct 40, plt 202, UA was grossly +ve.
- Imaging was notable for AXR which showed a non obstructive
bowel gas pattern.
- Consulted services included urology who recommended no need
for further studies if Cr, lytes WNL. At 21:00, ED flushed
foley, removed and manually drained bladder. Replaced with new
___ foley. Urine with purulent material draininage. Pt's pain
was much improved
with this.
- Patient was given IV ceftriaxone.
- Patient was admitted to OMED for management of complicated
UTI.
- VS prior to ED transfer were 2 98.1 72 120/65 20 100% RA.
On presentation to floor, patient was pain free, after having
catheter excahnged. no anusea, said emptied colostomy bag prior
to coming to ED. No fevers, chills, nausea or vomitting.
###RESPONSE: rectal cancer {Malignant tumor of rectum}, stage IV {Clinical stage IV}, pelvic nodal {Pelvic lymphadenopathy}, CAPOX {Chemotherapy}, resection {Excision}, rectum {Rectum structure}, anus {Anal structure}, diverting colostomy {Construction of diverting colostomy}, suprapubic tube {Procedure involving suprapubic catheter}, urethral injury {Injury of urethra}, urinary retention {Retention of urine}, urine {Urinalysis}, Suprapubic tube {Procedure involving suprapubic catheter}, abdominal discomfort {Abdominal discomfort}, VS {Vital signs finding}, RA {Breathing room air}, Exam {Physical examination procedure}, purulent discharge {Purulent discharge}, SP tube {Procedure involving suprapubic catheter}, discomfort {Discomfort}, abdominal tenderness {Abdominal tenderness}, wbc {White blood cell count}, hct {Hematocrit determination}, UA {Urinalysis}, Imaging {Imaging}, AXR {Diagnostic radiography of abdomen}, obstructive {Obstruction}, bowel gas pattern {Finding of gastrointestinal tract gas}, foley, removed {Removal of urinary bladder catheter}, drained bladder {Drainage of bladder}, Replaced with new
___ foley {Replacement of urinary catheter}, Urine {Urinalysis}, purulent {Purulent}, draininage {Drainage procedure}, pain {Pain}, improved {Patient's condition improved}, IV {Administration of drug or medicament via intravenous route}, UTI {Urinary tract infectious disease}, VS {Vital signs finding}, RA {Breathing room air}, pain free {No present pain}, catheter excahnged {Replacement of catheter}, anusea {Nausea}, colostomy {Colostomy}, fevers {Fever}, chills {Chill}, nausea {Nausea}, vomitting {Vomiting} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
Past medical history: hyperlipidemia, cataracts, lymphadenopathy
(supraclavicular, mediastinal, RP, pelvic sidewall, iliac,
cervical)
Past oncologic history:
Presumed rectal cancer stage IV
- ___ Began having anal irritation and pain with blood
streaked stools and changing bowel habits.
- ___ Presented to his PCP, who found inguinal adenopathy.
- ___ Evaluated in the Hematologic Malignancies Clinic by
Dr. ___.
- ___ PET CT showed, "Widespread FDG-avid cervical,
supraclavicular, mediastinal, retroperitoneal, pelvic sidewall,
iliac, and inguinal lymphadenopathy, consistent with lymphoma."
- ___iopsy revealed adenocarcinoma
consistent with a colorectal or appendiceal origin, positive for
CK7, CK20 and CDX-2.
PSH: cataract surgery, excision of right groin node ___,
Dr ___
###RESPONSE: hyperlipidemia {Hyperlipidemia}, cataracts {Cataract}, lymphadenopathy {Lymphadenopathy}, supraclavicular {Supraclavicular lymphadenopathy}, mediastinal {Mediastinal lymphadenopathy}, RP {Retroperitoneal lymphadenopathy}, pelvic sidewall {Pelvic lymphadenopathy}, iliac {Iliac lymphadenopathy}, cervical {Cervical lymphadenopathy}, rectal cancer {Malignant tumor of rectum}, stage IV {Clinical stage IV}, pain {Abdominal pain}, blood
streaked stools {Hematochezia}, changing bowel habits {Altered bowel function}, adenopathy {Lymphadenopathy}, Hematologic Malignancies {Malignant tumor of lymphoid, hemopoietic AND/OR related tissue}, PET CT {Positron emission tomography}, FDG-avid {Positron emission tomography with computed tomography using fluorodeoxyglucose (18-F)}, cervical {Cervical lymphadenopathy}, supraclavicular {Supraclavicular lymphadenopathy}, mediastinal {Mediastinal lymphadenopathy}, retroperitoneal {Retroperitoneal lymphadenopathy}, pelvic {Pelvic lymphadenopathy}, iliac {Iliac lymphadenopathy}, inguinal lymphadenopathy {Inguinal lymphadenopathy}, lymphoma {Malignant lymphoma}, adenocarcinoma {Adenocarcinoma}, colorectal {Structure of colon and/or rectum}, appendiceal {Appendix structure}, cataract surgery {Cataract surgery}, excision {Excision}, right groin {Right inguinal region structure}, node {Inguinal lymph node structure} |
Subsets and Splits