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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:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
atorvastatin
Attending: ___.
Chief Complaint:
L ankle pain
Major Surgical or Invasive Procedure:
___ - ORIF L Ankle (___)
###RESPONSE: atorvastatin {Allergy to atorvastatin}, ankle pain {Ankle pain}, ORIF {Open reduction of fracture with internal fixation}, L Ankle {Structure of left ankle} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 F presenting s/p mechanical fall this evening. She
reports immediate pain of the left ankle after feeling it twist.
She was also unable to bear weight. Currently denies parathesias
or numbness.
###RESPONSE: fall {Falls}, pain {Pain}, left ankle {Structure of left ankle}, unable to bear weight {Unable to weight-bear}, parathesias {Paresthesia}, numbness {Numbness} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PMH/PSH:
1. Hypertension.
2. Hyperlipidemia.
3. Glucose intolerance.
4. Gastroesophageal reflux.
5. Allergic rhinitis.
6. Status post H. pylori infection - confirmed eradicated ___.
7. Breast biopsy bilateral in the ___ and ___. The patient
denies any cancer.
8. Bilateral oophorectomy and hysterectomy - ___.
###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, Glucose intolerance {Impaired glucose tolerance}, Gastroesophageal reflux {Gastroesophageal reflux disease}, Allergic rhinitis {Allergic rhinitis}, H. pylori infection {Infection caused by Helicobacter pylori}, Breast biopsy {Biopsy of breast}, cancer {Malignant neoplasm of colon}, Bilateral oophorectomy {Excision of bilateral ovaries}, hysterectomy {Hysterectomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
NC
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS: 99.1 103 148/72 18 98ra
Gen: NAD, AAOx3
LLE exam:
SILT S/S/SP/DP/T
fires ___
WWP
Splint in place
###RESPONSE: Physical Exam {Physical examination procedure}, VS {Vital signs finding}, Gen {General examination of patient}, NAD {No abnormality detected}, Ox3 {Oriented to person, time and place}, LLE {Structure of left lower limb}, SILT {Light touch sensation present}, DP {Structure of dorsalis pedis artery}, WWP {Normal tissue perfusion}, Splint {Application of splint} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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-7.0 RBC-4.03* Hgb-11.1* Hct-33.4*
MCV-83 MCH-27.6 MCHC-33.3 RDW-14.9 Plt ___
###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} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF L ankle, which the patient tolerated well (for
full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is touchdown weightbearing in the
left lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*60 Tablet Refills:*2
2. Amlodipine 2.5 mg PO DAILY
3. Calcium Carbonate 500 mg PO BID
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Omeprazole 20 mg PO BID
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*61 Tablet Refills:*0
7. Pravastatin 40 mg PO DAILY
8. Vitamin D 400 UNIT PO DAILY
9. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Days
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*14 Syringe
Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*30 Capsule Refills:*2
11. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*30 Tablet Refills:*2
###RESPONSE: emergency {Emergency treatment}, evaluated by the orthopedic surgery team {Orthopedic assessment}, L ankle {Structure of left ankle}, admitted to the orthopedic
surgery service {Admission by orthopedic surgeon}, ORIF {Open reduction of fracture with internal fixation}, L ankle {Structure of left ankle}, operative {Surgical procedure}, PACU {Postanesthesia care}, stable
condition {Patient's condition stable}, anesthesia {Administration of general anesthetic}, given IV fluids {Administration of intravenous fluids}, IV {Intravenous therapy}, pain medications {Administration of analgesic}, regular diet {Normal diet}, oral
medications {Administration of drug or medicament via oral route}, antibiotics {Antibiotic therapy}, anticoagulation {Anticoagulant therapy}, medications {Administration of drug or medicament}, unremarkable {No abnormality detected}, afebrile {Temperature normal}, stable
vital signs {Normal vital signs}, normal {No abnormality detected}, pain was well
controlled with oral medications {Demonstrates adequate pain control with oral analgesics}, incisions {Surgical incision wound}, clean/dry/intact {Wound healing well}, voiding {Normal micturition}, moving bowels {Finding of defecation}, weightbearing {Weight-bearing}, left lower extremity {Structure of left lower limb}, DVT
prophylaxis {Prevention of deep vein thrombosis}, follow up {Postoperative follow-up visit}, discussion {Patient 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: Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
L bimalleolar ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: bimalleolar ankle fracture {Bimalleolar fracture of ankle}, 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:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- Please be careful to keep your splint dry until your follow-up
appointment.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
ACTIVITY AND WEIGHT BEARING:
- Touchdown weightbearing left lower extremity
Physical Therapy:
Touchdown weightbearing in left lower extremity.
Please keep splint on until your follow-up appointment.
Treatment Frequency:
Please keep splint on until your follow-up appointment. Please
keep your splint dry. You may elevate your foot for comfort as
you like. Any sutures/staples will be removed at your follow up
appointment.
###RESPONSE: MEDICATIONS {Administration of drug or medicament}, medications {Administration of drug or medicament}, medications {Administration of drug or medicament}, Do not drink alcohol {Education about alcohol consumption}, while taking narcotic pain relievers {Narcotics education}, Narcotic pain relievers can cause {Narcotics education}, constipation {Constipation}, take a stool softener {Administration of laxative}, side effect {Medication side effects present}, ANTICOAGULATION {Anticoagulant therapy}, WOUND CARE {Wound care}, splint {Application of splint}, stitches {Removal of suture}, staples that need to be removed {Removal of staples}, ACTIVITY AND WEIGHT BEARING {Education about increasing activity tolerance}, weightbearing {Weight-bearing}, left lower extremity {Structure of left lower limb}, Physical Therapy {Physical therapy procedure}, weightbearing {Weight-bearing}, left lower extremity {Structure of left lower limb}, splint {Application of splint}, splint {Application of splint}, splint {Application of splint}, foot {Structure of left foot}, sutures {Removal of suture}, staples will be removed {Removal of staples} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
volume overload
Major Surgical or Invasive Procedure:
G-J Tube removed by interventional radiology ___
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, volume overload {Hypervolemia}, G-J Tube removed by interventional radiology {Removal of gastrojejunostomy tube using fluoroscopic guidance} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Mr. ___ is a ___ with T1DM (c/b multiple toe
amputations, gastroparesis & prior DKA), ESRD on HD (likely ___
DM, no biopsy on file), bilateral ___ DVT s/p IVC filter ___
and on warfarin, L non-occlusive jugular thrombus (___), R
thalamic bleed in the setting of HTN emergency w/ residual L
hemiparesis (___), & L hip fracture s/p fixation ___, and
recent admission from ___ for MRSA bacteremia ___ PNA on
vancomycin with HD sessions (scheduled course through ___, who
presents from rehab with a 25-lb weight gain and worsening ___
edema since discharge. The patient also had a new 2L O2
requirement in the ED.
The patient is on a MWF HD session, and had not received his
___ session. Per NP at his rehab facility, the patient had
recently been becoming hypotensive while receiving HD at his
facility, with a progressive volume overload and inability to
increase UF. He has not been on diuretics, and was not started
on
any at facility.
###RESPONSE: T1DM {Diabetes mellitus type 1}, toe
amputations {Amputated toe}, gastroparesis {Gastroparesis}, DKA {Ketoacidosis due to diabetes mellitus}, ESRD on HD {End stage renal failure on dialysis}, DM {Diabetes mellitus}, biopsy {Biopsy}, DVT {Deep venous thrombosis}, IVC filter {Inferior vena cava filter in situ}, on warfarin {Warfarin therapy}, L non-occlusive jugular {Structure of left jugular vein}, thrombus {Thrombus}, thalamic {Thalamic structure}, bleed {Bleeding}, HTN emergency {Hypertensive emergency}, L
hemiparesis {Left hemiparesis}, hip fracture {Fracture of proximal end of femur}, fixation {Fixation}, MRSA bacteremia {Bacteremia caused by Methicillin resistant Staphylococcus aureus}, PNA {Pneumonia}, vancomycin {Antibiotic therapy}, HD {Hemodialysis}, weight gain {Weight gain}, worsening {Patient's condition worsened}, edema {Edema}, HD {Hemodialysis}, hypotensive {Low blood pressure}, HD {Hemodialysis}, volume overload {Hypervolemia}, diuretics {Diuretic 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: Past Medical History:
-type I DM (A1C 4.9 ___ w/ prior DKA
-multiple amputations
-gastroparesis
-ESRD (likely ___ DM, no biopsy on file) on HD
-bilateral ___ DVT s/p IVC filter ___
-L non-occlusive jugular thrombus ___
-R thalamic bleed in the setting of HTN emergency w/ residual L
hemiparesis (___)
-L hip fracture s/p fixation ___
###RESPONSE: type I DM {Diabetes mellitus type 1}, DKA {Ketoacidosis due to diabetes mellitus}, amputations {Amputated toe}, gastroparesis {Gastroparesis}, ESRD {End-stage renal disease}, DM {Diabetes mellitus}, biopsy {Biopsy}, HD {Hemodialysis}, DVT {Deep venous thrombosis}, IVC filter ___ {Inferior vena cava filter in situ}, L non-occlusive jugular {Structure of left jugular vein}, thrombus {Thrombus}, thalamic {Thalamic structure}, bleed {Bleeding}, HTN emergency {Hypertensive emergency}, L
hemiparesis {Left hemiparesis}, hip fracture {Fracture of proximal end of femur}, fixation {Fixation} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
___ significant for stroke.
###RESPONSE: stroke {Cerebrovascular accident} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: ___ Temp: 98.4 PO BP: 114/69 R Lying HR: 128 RR:
20
O2 sat: 94% O2 delivery: RA
GENERAL: Patient lying in bed, NAD, interactive
HEAD: NC/AT, R pupil non-reactive (patient reports that it is a
false eye). L pupil reactive. EOMI intact on left side. Oral
mucosa w/o lesions, MMM.
NECK: Supple, no LAD, no thyromegaly. Elevated JVP.
CARDIAC: Tachycardic, irregular rhytm. No m/r/g.
RESPIRATORY: Speaking in full sentences. Decreased bibasilar
breath rounds and mild crackles, L > R.
ABDOMEN: Unremarkable inspection, soft, NT, +BS. No palpable
organomegaly. PEG tube in place, dressings c/d/I, no erythema or
tenderness around site.
EXTREMITIES: Severe 2+ petting edema, L > R, in both UE and ___.
SKIN: Scattered ecchymoses across both arms b/l, no other
lesions
or rashes.
NEUROLOGIC: ___ strength on left side; unable to lift L arm or L
leg (baseline per patient). Normal strength on R side.
PSYCHIATRIC: Pleasant and cooperative.
DISCHARGE PHYSICAL EXAM
========================
Temp: 98.1 PO BP: 125/76 R Lying HR: 101 RR: 18 O2
sat: 97% O2 delivery: Ra FSBG: 267
GENERAL: sitting up in bed, NAD, interactive
HEAD: NC/AT, R pupil non-reactive (false eye). L pupil reactive.
EOMI intact on left side. Oral mucosa w/o lesions, MMM.
NECK: JVP normal
CARDIAC: Tachycardic, irregular rhythm. No m/r/g.
RESPIRATORY: Nonlabored breathing, CATB.
ABDOMEN: Unremarkable inspection, soft, NT. PEG tube in place,
dressings c/d/I, no erythema or tenderness around site.
EXTREMITIES: 1+ pitting edema in left arm and leg, no edema R
SKIN: Scattered ecchymoses across both arms b/l, no other
lesions
or rashes.
NEUROLOGIC: ___ strength on left side; unable to lift L arm or L
leg (baseline per patient). Normal strength on R side.
PSYCHIATRIC: Pleasant and cooperative.
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, Lying {Lying in bed}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, GENERAL {General examination of patient}, lying in bed {Lying in bed}, NAD {No abnormality detected}, interactive {Does communicate}, HEAD {Physical examination procedure}, NC {Normal head}, R pupil {Structure of pupil of right eye}, non-reactive {No pupillary reaction to light}, false eye {Prosthetic eye in situ}, L pupil {Structure of pupil of left eye}, EOMI {Normal ocular motility}, left {Left eye structure}, Oral
mucosa {Oral mucous membrane structure}, lesions {Lesion}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, LAD {Lymphadenopathy}, thyromegaly {Goiter}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, Tachycardic {Tachycardia}, irregular rhytm {Irregular heart beat}, No m/r/g {Heart sounds normal}, RESP {Examination of respiratory system}, RA {Breathing room air}, bibasilar {Structure of base of lung}, mild {Symptom mild}, crackles {Respiratory crackles}, ABDOMEN {Examination of abdomen}, inspection {Inspection}, soft {Abdomen soft}, NT {Abdominal tenderness}, BS {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, erythema {Erythema}, tenderness {Tenderness}, EXTREMITIES {Examination of limb}, edema {Edema}, UE {Upper limb structure}, SKIN {Examination of skin}, ecchymoses {Ecchymosis}, both arms {Both upper arms}, lesions {Lesion}, rashes {Eruption of skin}, NEURO {Neurological examination}, GI {Examination of digestive system}, unable to lift {Unable to lift}, L arm {Structure of left upper limb}, L
leg {Structure of left lower limb}, baseline {Baseline state}, cooperative {Cooperative mental state}, PHYSICAL EXAM {Physical examination procedure}, Temp {Body temperature finding}, BP {Blood pressure finding}, Lying {Lying in bed}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2
sat {Oxygen saturation measurement}, GENERAL {General examination of patient}, sitting {Sitting position}, NAD {No abnormality detected}, interactive {Does communicate}, HEAD {Physical examination procedure}, NC {Normal head}, R pupil {Structure of pupil of right eye}, non-reactive {No pupillary reaction to light}, (false eye) {Prosthetic eye in situ}, L pupil {Structure of pupil of left eye}, EOMI {Normal ocular motility}, left {Left eye structure}, Oral mucosa {Oral mucous membrane structure}, lesions {Lesion}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, Tachycardic {Tachycardia}, irregular rhythm {Irregular heart beat}, No m/r/g {Heart sounds normal}, RESP {Examination of respiratory system}, RA {Breathing room air}, CATB {Normal breath sounds}, ABDOMEN {Examination of abdomen}, inspection {Inspection}, soft {Abdomen soft}, NT {Abdominal tenderness}, erythema {Erythema}, tenderness {Tenderness}, EXTREMITIES {Examination of limb}, edema {Edema}, left arm {Structure of left upper limb}, leg {Structure of left lower limb}, edema {Edema}, SKIN {Examination of skin}, ecchymoses {Ecchymosis}, both arms {Both upper arms}, lesions {Lesion}, rashes {Eruption of skin}, NEURO {Neurological examination}, GI {Examination of digestive system}, unable to lift {Unable to lift}, L arm {Structure of left upper limb}, L
leg {Structure of left lower limb}, baseline {Baseline state}, cooperative {Cooperative mental state} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS
==============
___ 10:15AM BLOOD WBC-15.4* RBC-2.27* Hgb-7.6* Hct-24.4*
MCV-108* MCH-33.5* MCHC-31.1* RDW-14.1 RDWSD-54.4* Plt ___
___ 10:15AM BLOOD Neuts-63.3 Lymphs-4.4* Monos-5.6
Eos-25.0* Baso-1.1* Im ___ AbsNeut-9.72* AbsLymp-0.67*
AbsMono-0.86* AbsEos-3.84* AbsBaso-0.17*
___ 10:15AM BLOOD ___ PTT-32.9 ___
___ 07:52PM BLOOD ___ 03:50PM BLOOD Ret Aut-2.4* Abs Ret-0.05
___ 10:15AM BLOOD Glucose-222* UreaN-107* Creat-3.8*#
Na-132* K-6.7* Cl-92* HCO3-26 AnGap-14
___ 03:50PM BLOOD ALT-23 AST-18 LD(LDH)-178 AlkPhos-190*
TotBili-0.2 DirBili-<0.2 IndBili-0.2
___ 10:15AM BLOOD ___
___ 10:15AM BLOOD Calcium-9.8 Phos-3.8 Mg-1.8
___ 03:50PM BLOOD calTIBC-165* Hapto-223* Ferritn-1616*
TRF-127*
___ 03:50PM BLOOD TSH-1.5
TROP TREND:
___ 10:15AM BLOOD cTropnT-0.56*
___ 07:52PM BLOOD cTropnT-0.61*
___ 06:47AM BLOOD cTropnT-0.63*
___ 05:25PM BLOOD CK-MB-3 cTropnT-0.72*
___ 07:40AM BLOOD CK-MB-2 cTropnT-0.62*
INR TREND:
___ 05:08AM BLOOD ___ PTT-36.3 ___
___ 06:14AM BLOOD ___ PTT-87.1* ___
___ 07:00AM BLOOD ___ PTT-63.3* ___
INTERVAL LABS
==============
___ 05:28AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 05:28AM BLOOD HCV Ab-NEG
___ 06:00PM BLOOD ___ pO2-187* pCO2-42 pH-7.39
calTCO2-26 Base XS-0 Comment-GREEN TOP
___ 06:00PM BLOOD Lactate-1.9
DISCHARGE LABS
==============
___ 05:08AM BLOOD WBC-9.2 RBC-2.40* Hgb-7.8* Hct-25.7*
MCV-107* MCH-32.5* MCHC-30.4* RDW-14.6 RDWSD-57.0* Plt ___
___ 05:08AM BLOOD Glucose-122* UreaN-44* Creat-3.0* Na-141
K-4.4 Cl-102 HCO3-26 AnGap-13
___ 05:08AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.8
MICRO:
=========
___ 10:40 am BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:00 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
___ 7:15 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
RADIOLOGY
==========
___ CXR
IMPRESSION: Interval significant increase in left base
consolidation, worrisome for ongoing, worsened pneumonia.
Possible small left pleural effusion. Equivocal new right base
opacity. Mild pulmonary vascular congestion without overt
pulmonary edema.
___ LOWER EXTREMITY US:
IMPRESSION:
1. No evidence of acutedeep venous thrombosis in the left lower
extremity
veins. A focal area of thickening along the posterior wall of
femoral vein could represent chronic changes from the previously
treated thrombus.
2. Nonspecific subcutaneous edema.
___:
CONCLUSION:
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy with a normal
cavity size. There is normal regional and global left
ventricular systolic function. Quantitative biplane left
ventricular ejection fraction is 58 %. Left ventricular cardiac
index is normal (>2.5 L/min/m2). There is
no resting left ventricular outflow tract gradient. Mildly
dilated right ventricular cavity with normal free wall
motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The
aortic valve leaflets (3) appear structurally normal. There is
no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is mild [1+]
mitral regurgitation. The pulmonic valve leaflets are normal.
The tricuspid valve leaflets appear structurally
normal. There is mild [1+] tricuspid regurgitation. The
estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Dilated right ventricle. Mild symmetric left
ventricular hypertrophy with normal
cavity size and regional/global biventricular systolic function.
mild mitral and tricuspid
regurgitation.
Compared with the prior TTE (images not available for review) of
___ , the left ventricular systolic
function appears to have improved.
___ CTA CHEST
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Multifocal pulmonary opacities in bilateral lungs have
progressed compared to ___ concerning for progression
of pneumonia.
3. Small to moderate bilateral pleural effusions.
___ G-J REMOVAL:
IMPRESSION:
Technically successful gastrojejunostomy tube removal and T
fastener button removal.
RECOMMENDATION(S): Please re-consult interventional radiology
if there is
further need for enteral access in the future. The gastrostomy
site may leak for the next few days while the site closes.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Serum lactate dehydrogenase level above reference range}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, TSH {Thyroid stimulating hormone measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, HCV {Viral hepatitis type C}, pH {pH measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, CONSISTENCY {Finding of consistency of stool}, asymptomatic {Asymptomatic}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, Nasal {Nasal structure}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, MRSA {Methicillin resistant Staphylococcus aureus infection}, CXR {Plain chest X-ray}, left base
consolidation {Lung consolidation}, pneumonia {Pneumonia}, left {Left lung structure}, pleural effusion {Pleural effusion}, right base {Structure of base of right lung}, opacity {Abnormally opaque structure}, Mild {Symptom mild}, pulmonary vascular {Structure of pulmonary blood vessel}, congestion {Congestion}, pulmonary edema {Pulmonary edema}, No evidence {No abnormality detected}, acutedeep venous thrombosis {Acute deep venous thrombosis}, left lower
extremity
veins {Structure of vein of left lower limb}, thickening {Increased thickness}, femoral vein {Femoral vein structure}, chronic {Chronic disease}, thrombus {Thrombus}, subcutaneous {Subcutaneous tissue structure of lower extremity}, edema {Edema}, left atrial {Left atrial structure}, volume index is normal {Normal size cardiac chamber}, mild symmetric
left ventricular hypertrophy {Mild left ventricular hypertrophy}, normal
cavity {Normal size cardiac chamber}, normal regional and global left
ventricular systolic function {Echocardiogram shows normal left ventricular function}, left
ventricular {Left cardiac ventricular structure}, Left ventricular {Left cardiac ventricular structure}, cardiac
index is normal {Normal cardiac index}, left ventricular outflow tract {Structure of outflow tract of left ventricle}, dilated {Dilatation}, right ventricular cavity {Structure of cavity of right cardiac ventricle}, free wall
motion {Normal ventricular wall motion}, aortic sinus {Structure of sinus of Valsalva}, ascending aorta {Ascending aorta structure}, aortic valve leaflets {Structure of cardiac valve leaflet}, structurally normal {Aortic valve normal}, aortic valve stenosis {Aortic valve stenosis}, aortic
regurgitation {Aortic valve regurgitation}, mitral valve leaflets are mildly thickened {Thickened mitral leaflet}, mitral valve prolapse {Mitral valve prolapse}, mild [1+]
mitral regurgitation {Mild mitral valve regurgitation}, pulmonic valve leaflets {Structure of cusp of pulmonic valve}, normal {No abnormality detected}, tricuspid valve leaflets appear structurally
normal {Tricuspid valve normal}, mild [1+] tricuspid regurgitation {Mild tricuspid valve regurgitation}, pulmonary artery {Pulmonary artery structure}, systolic pressure is
normal {Normal systolic arterial pressure}, pericardial effusion {Pericardial effusion}, Dilated {Dilatation}, right ventricle {Right cardiac ventricular structure}, Mild symmetric left
ventricular hypertrophy {Mild left ventricular hypertrophy}, normal
cavity {Normal size cardiac chamber}, biventricular {Cardiac ventricular structure}, systolic function {Normal left ventricular systolic function and wall motion}, mild mitral {Mild mitral valve regurgitation}, tricuspid
regurgitation {Tricuspid valve regurgitation}, TTE {Transthoracic echocardiography}, left ventricular systolic
function {Normal left ventricular systolic function and wall motion}, improved {Patient's condition improved}, CTA CHEST {Computed tomography of chest}, No evidence {No abnormality detected}, pulmonary embolism {Pulmonary embolism}, aortic {Aortic structure}, abnormality {No abnormality detected}, pulmonary {Lung structure}, opacities {Abnormally opaque structure}, lungs {Lung structure}, pneumonia {Pneumonia}, bilateral pleural effusions {Bilateral pleural effusion}, l gastrojejunostomy tube removal {Removal of gastrojejunostomy tube using fluoroscopic guidance}, removal {Removal}, gastrostomy {Gastrostomy}, leak {Anastomosis, leaking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
SUMMARY STATEMENT
=========================================================
___ chronically-ill male with T1DM, ESRD on HD, bilateral ___
DVT
s/p IVC filter ___ and on warfarin, L non-occlusive jugular
thrombus (___), R thalamic bleed in the setting of HTN
emergency w/ residual L hemiparesis (___), and recent
admission from ___ for MRSA bacteremia ___ PNA on
vancomycin
with HD sessions (scheduled course through ___, who presents
from rehab with a 25-lb weight gain and worsening ___ edema on
___.
ACTIVE ISSUES
=========================================================
# Dysphagia, s/p G-J tube placement ___
# Severe Protein Calorie Nutrition
Patient noted to have high aspiration risk over course for last
hospitalization, but decided to accept risks and trial pureed
solids with nectar-thick liquids during prior hospitalization.
Patient's G-J tube became clogged during admission. As patient
was maintaining good PO intake and eating food was important to
patient's GOC, the clogged G-J tube was pulled ___. On
discharge, patient was eating solid diet.
# ESRD on HD, secondary to T1D
Pre-admission HD sessions at facility were reported to have been
limited by hypotension and tachycardia, and with an inability to
increase UF as a result. Here, patient received hemodialysis
through admission with ultrafiltration to remove excess volume.
Repeat Echo showed recovered EF at 58%. By ___ patient did
not appear volume overloaded on clinical exam.
# HF w recovered EF (EF 45% ___
# Elevated troponins
Patient presented with volume overload and elevated proBNP,
consistent with HF exacerbation. Patient's discharge weight was
66.3kg, and reported dry weight is 63kg. Admission weight was
74.3kg. EKG w/o new ischemic changes, despite mild trop
elevation. Infectious workup negative, other than ongoing
aspiration. While here, a repeat Echo showed a recovered EF at
58%. His metoprolol was uptitrated for better rate control, and
his atorvastatin was continued.
# Pneumonia
# Recent MRSA Bacteremia
# Leukocytosis
Patient had recent admission from ___ for MRSA bacteremia
___ PNA, and has been dosed with vancomycin with HD sessions
(scheduled course through ___. He presented with increased
leukocytosis, and CXR consistent with worsened bilateral
pneumonia, likely secondary to aspiration. He received a few
days of broad spectrum treatment, prior to return to his
original Vancomycin course. Vancomycin was transitioned to
linezolid ___, as vancomycin may have been contributing to
eosinophilia (3.84 on admission). All antibiotics were stopped
on day of discharge (___) as patient had completed course
for hospital associated pneumonia.
# Anemia
Hgb notably below baseline; 7.6 on admission, from discharge Hgb
of 8.3. Had Hgb drop from 7.6 to 6.5 on ___. Anemia likely
multifactorial, including acute suppression iso infection, and
anemia of chronic disease from ESRD. Less likely GI bleed, as
patient has had no complaints of melena or BRBPR. Patient was
transfused for Hgb < 7 throughout admission. Hb was 7.8 at
discharge.
# T1DM
Patient has very brittle T1DM, and presented in DKA on recent
admission in ___. He is very sensitive to insulin and has had
hypoglycemic episodes in the past. He was continued on home
glargine 7U with Q6H insulin sliding scale for tube feeds on
admission. He was transitioned to glargine 8U and insulin lispro
2U with meals after he began to eat meals. He was discharge on
glargine 8U with lispro 2U at meals.
# Hypoxia (resolved)
Had new 2L O2 requirement in ED, after satting in low ___ on RA.
Most likely volume overload iso vs progression of pneumonia.
Resolved by time of arrival to floor.
# Goals of Care
A family meeting was held in which patient's family expressed a
clear understanding that patient was seriously ill and that
DNR/DNI status was consistent with the patient's goals. He
himself confirmed these wishes to his providers as well. At end
of hospitalization, patient filled out MOLST with DNR/DNI
status. He would like to keep eating for comfort and understands
the risks of aspiration and death.
CHRONIC ISSUES
=========================================================
# Atrial Fibrillation and tachycardia
Patient presented with HR in 120s. Patient's home metoprolol
dose was increased from 25mg q6h to 50 mg q6h.
# History of VTE
Complicated coagulation history. Patient had bilateral ___ DVT
s/p IVC
filter ___, L non-occlusive jugular thrombus (___), R
thalamic bleed in the setting of HTN emergency w/ residual L
hemiparesis (___). Patient was briefly subtherapeutic, and
therefore bridged with a heparin gtt until therapeutic again.
Patient was discharged on home dose of warfarin 2.5 mg with
therapeutic INR of 2.5 at discharge.
# GERD:
Home Pantoprazole 40 mg PO Q12H was continued.
# Mood:
Home mirtazapine 15 mg PO QHS was continued. Sertraline 25 mg PO
DAILY were held while patient was receiving Linezolid due to
risk of serotonin syndrome.
TRANSITIONAL ISSUES
=========================================================
#MRSA bacteremia s/p treatment
[ ] Surveillance blood cultures after HD on ___
#Hypertension
[ ] Uptitrate lisinopril as tolerated to goal SBP <130/80.
#Atrial fibrillation:
[ ] Uptitrated metoprolol to 50mg q6h while inpatient. If
requires further rate control, could add diltiazem or consider
amiodarone, with discussion with cardiologist.
[ ] Can consolidate Metop tartrate into Metop Succinate 200mg
daily if tolerating well.
#Diabetes mellitus
[ ] Insulin dose was increased to 8U glargine at baseline, 2U
short-acting with meals, and sliding scale. Please titrate as
needed.
#Depression:
[ ] Holding sertraline due to interaction w Linezolid (risk of
serotonin syndrome) until ___, then ok to restart.
CODE: DNR/DNI
CONTACT: ___
Relationship: wife
Phone number: ___
The total time spent today on discharge planning, counseling and
coordination of care today was greater than 30 minutes.
###RESPONSE: T1DM {Diabetes mellitus type 1}, ESRD on HD {End stage renal failure on dialysis}, DVT {Deep venous thrombosis}, IVC filter {Inferior vena cava filter in situ}, on warfarin {Warfarin therapy}, L non-occlusive jugular {Structure of left jugular vein}, thrombus {Thrombus}, thalamic {Thalamic structure}, bleed {Bleeding}, HTN
emergency {Hypertensive emergency}, L hemiparesis {Left hemiparesis}, MRSA bacteremia {Bacteremia caused by Methicillin resistant Staphylococcus aureus}, PNA {Pneumonia}, vancomycin {Antibiotic therapy}, HD {Hemodialysis}, weight gain {Weight gain}, edema {Edema}, Dysphagia {Dysphagia}, placement {Implantation procedure}, Severe Protein Calorie Nutrition {Severe protein-calorie malnutrition (Gomez: less than 60 percent of standard weight)}, aspiration risk {At increased risk for aspiration}, nectar-thick liquids {Dietary liquid consistency - nectar thick liquid}, good PO intake and eating food {Eating normal}, diet {Normal diet}, ESRD on HD {End stage renal failure on dialysis}, T1D {Diabetes mellitus type 1}, HD {Hemodialysis}, hypotension {Low blood pressure}, tachycardia {Tachycardia}, hemodialysis {Hemodialysis}, ultrafiltration {Ultrafiltration}, excess volume. {Hypervolemia}, Echo {Echocardiography}, volume overloaded {Hypervolemia}, exam {Physical examination procedure}, Elevated troponins {Troponin I above reference range}, volume overload {Hypervolemia}, HF exacerbation {Exacerbation of congestive heart failure}, weight {Weight finding}, weight {Weight finding}, weight {Weight finding}, EKG {Electrocardiographic procedure}, ischemic changes {Electrocardiographic myocardial ischemia}, Infectious {Infectious disease}, workup {Evaluation procedure}, aspiration {Aspiration pneumonia}, Echo {Echocardiography}, Pneumonia {Pneumonia}, MRSA Bacteremia {Bacteremia caused by Methicillin resistant Staphylococcus aureus}, Leukocytosis {Leukocytosis}, MRSA bacteremia {Bacteremia caused by Methicillin resistant Staphylococcus aureus}, PNA {Pneumonia}, vancomycin {Antibiotic therapy}, HD {Hemodialysis}, leukocytosis {Leukocytosis}, CXR {Plain chest X-ray}, bilateral
pneumonia {Bilateral pneumonia}, aspiration {Pulmonary aspiration}, Vancomycin {Antibiotic therapy}, Vancomycin {Antibiotic therapy}, vancomycin {Antibiotic therapy}, eosinophilia {Eosinophil count above reference range}, antibiotics {Antibiotic therapy}, hospital associated pneumonia {Nosocomial pneumonia}, Anemia {Anemia}, Hgb notably below baseline; {Hemoglobin below reference range}, Hgb {Measurement of total hemoglobin concentration}, Hgb {Measurement of total hemoglobin concentration}, Anemia {Anemia}, infection {Infectious disease}, anemia of chronic disease {Anemia of chronic disorder}, ESRD {End-stage renal disease}, GI bleed {Gastrointestinal hemorrhage}, no complaints {No complaints}, melena {Melena}, BRBPR {Hematochezia}, Hgb {Measurement of total hemoglobin concentration}, T1DM {Diabetes mellitus type 1}, T1DM {Diabetes mellitus type 1}, DKA {Ketoacidosis due to diabetes mellitus}, hypoglycemic {Hypoglycemia}, insulin sliding scale {Sliding scale insulin regime}, Hypoxia {Hypoxia}, resolved {Problem resolved}, satting {Finding of oxygen saturation}, RA {Breathing room air}, volume overload {Hypervolemia}, pneumonia {Pneumonia}, Resolved {Problem resolved}, meeting {Meetings}, DNR {Not for resuscitation}, DNR {Not for resuscitation}, aspiration {Pulmonary aspiration}, death {Dead}, Atrial Fibrillation {Atrial fibrillation}, tachycardia {Tachycardia}, HR {Finding of heart rate}, VTE {Thromboembolism of vein}, coagulation {Coagulation}, DVT {Deep venous thrombosis}, IVC
filter ___, {Inferior vena cava filter in situ}, thrombus {Thrombus}, thalamic {Thalamic structure}, bleed {Bleeding}, HTN emergency {Hypertensive emergency}, L
hemiparesis {Left hemiparesis}, heparin {Heparin therapy}, GERD {Gastroesophageal reflux disease}, serotonin syndrome {Serotonin syndrome}, MRSA bacteremia {Bacteremia caused by Methicillin resistant Staphylococcus aureus}, Surveillance blood cultures {Infection surveillance}, HD {Hemodialysis}, Hypertension {Hypertensive disorder, systemic arterial}, discussion {Discussion}, Diabetes mellitus {Diabetes mellitus}, baseline {Baseline state}, sliding scale {Sliding scale insulin regime}, serotonin syndrome {Serotonin syndrome}, DNR {Not for resuscitation}, discharge planning {Discharge planning}, counseling {Counseling} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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. Atorvastatin 40 mg PO QPM
2. Nephrocaps 1 CAP PO DAILY
3. Sertraline 25 mg PO DAILY
4. sevelamer CARBONATE 800 mg PO TID W/MEALS
5. Warfarin 2.5 mg PO DAILY16
6. Metoprolol Succinate XL 50 mg PO BID
7. Pantoprazole 40 mg PO Q12H
___ MD to order daily dose IV HD PROTOCOL
9. melatonin 6 mg oral QHS
10. Mirtazapine 15 mg PO QHS
11. Sucralfate 1 gm PO QID
12. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
13. ProMod Protein (protein supplement) 30 cc oral QID
14. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
15. Senna 17.2 mg PO BID:PRN Constipation - First Line
16. Glargine 7 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
17. Bisacodyl ___VERY OTHER DAY
Discharge Medications:
1. Lisinopril 2.5 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO Q6H
3. Miconazole Powder 2% 1 Appl TP BID rash
4. Ramelteon 8 mg PO QHS:PRN insomnia
5. Sarna Lotion 1 Appl TP TID:PRN dry skin
6. Glargine 8 Units Breakfast
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
8. Atorvastatin 40 mg PO QPM
9. Bisacodyl ___VERY OTHER DAY
10. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
11. melatonin 6 mg oral QHS
12. Mirtazapine 15 mg PO QHS
13. Nephrocaps 1 CAP PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. ProMod Protein (protein supplement) 30 cc oral QID
16. Senna 17.2 mg PO BID:PRN Constipation - First Line
17. sevelamer CARBONATE 800 mg PO TID W/MEALS
18. Sucralfate 1 gm PO QID
19. Warfarin 2.5 mg PO DAILY16
20. HELD- Sertraline 25 mg PO DAILY This medication was held.
Do not restart Sertraline until ___
###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:
End stage renal disease
Pneumonia
Heart failure with reduced ejection fraction
Anemia
Leukocytosis
Type 1 Diabetes
Dysphagia
Hypoxia
Atrial fibrillation
Deep vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
###RESPONSE: End stage renal disease {End-stage renal disease}, Pneumonia {Pneumonia}, Heart failure with reduced ejection fraction {Heart failure with reduced ejection fraction}, Anemia {Anemia}, Leukocytosis {Leukocytosis}, Type 1 Diabetes {Diabetes mellitus type 1}, Dysphagia {Dysphagia}, Hypoxia {Hypoxia}, Atrial fibrillation {Atrial fibrillation}, Deep vein thrombosis {Deep venous thrombosis}, 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}, 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:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital from rehab because you had gained 25
pounds of fluid and developed swelling in your legs.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- When you came to the hospital you were found to have symptoms
and signs on an infection in your lung, likely related to
swallowing food into your lungs. You underwent dialysis in the
hospital to remove fluid from your body. You also received
antibiotics to treat the infection in your lung. We removed your
feeding tube because you preferred to eat food, even with the
increased risk of infections in your lungs.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
###RESPONSE: swelling {Swelling}, legs {Lower limb structure}, signs {Sign}, infection {Infectious disease}, lung {Metastatic malignant neoplasm to lung}, lungs {Lung structure}, dialysis {Dialysis procedure}, antibiotics {Antibiotic therapy}, infection {Infectious disease}, lung {Lung structure}, removed {Removal}, infections {Local infection of wound}, lungs {Examination of respiratory system} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
Vicodin
Attending: ___.
Chief Complaint:
Elevated creatinine
.
Major Surgical or Invasive Procedure:
None
.
###RESPONSE: Elevated creatinine {Serum creatinine above reference range} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ yo M hx etoh cirrhosis who presented yesterday to liver
clinic for second opinion. He was diagnosed with cirrhosis in
___, course complicated by variceal bleeding, ascites. On blood
work yesterday noted to have elevated Cr to 2.8, no prior
knowledge of renal insufficiency admitted today for further
evaluation.
Pt has had a sore threat starting 5 d PTA associated with cough
productive of yellow sputum. No fever, chills, dyspnea. +Nausea
and vomiting about twice daily for 5 days, poor appetite. Urine
output unchanged. No abdominal pain, diarrhea. + sick contact,
wife had URI with sore throat and cough last week, now resolved.
.
###RESPONSE: etoh cirrhosis {Alcoholic cirrhosis}, liver {Disorder of liver}, cirrhosis {Cirrhosis of liver}, variceal bleeding {Bleeding esophageal varices}, ascites {Ascites}, elevated {Elevation}, Cr {Finding of creatinine level}, renal insufficiency {Renal insufficiency}, evaluation {Evaluation procedure}, sore {Soreness}, cough
productive of yellow sputum {Productive cough-yellow sputum}, fever {Fever}, chills {Chill}, dyspnea {Dyspnea}, Nausea
and vomiting {Nausea and vomiting}, poor appetite {Decrease in appetite}, Urine
output unchanged {Normal urinary stream}, diarrhea {Diarrhea}, sick {Illness}, URI {Upper respiratory infection}, sore throat {Sore throat}, cough {Cough}, resolved {Problem resolved} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Etoh cirrhosis, diagnosed in ___
- hx variceal bleeding in ___, controlled with medications
- hx ascites requiring periodic paracenteses
Hx sepsis from dog bite in ___ c/b multiorgan failure
L4-5 spinal fusion ___ at ___
hx heart murmur, last echo at ___ 2 weeks ago
HTN
Hypercholesterolemia
hx aortic aneurysm, stable for last ___ yrs
.
###RESPONSE: Etoh cirrhosis {Alcoholic cirrhosis}, variceal bleeding {Bleeding esophageal varices}, ascites {Ascites}, paracenteses {Abdominal paracentesis}, sepsis {Sepsis}, dog bite {Dog bite - wound}, multiorgan failure {Multiple organ failure}, spinal fusion {Spinal arthrodesis}, heart murmur {Heart murmur}, echo {Echocardiography}, HTN {Hypertensive disorder, systemic arterial}, Hypercholesterolemia {Hypercholesterolemia}, aortic aneurysm {Aortic aneurysm}, 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: 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 CABG in ___, father and paternal grandmother with
leukemia, uncle with unknown liver problem. No hx pulmonary
disease, diabetes, stroke.
.
###RESPONSE: CABG {Coronary artery bypass grafting}, leukemia {Leukemia}, liver problem {Liver problem}, pulmonary
disease {Disorder of lung}, diabetes {Diabetes mellitus}, stroke {Cerebrovascular accident} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS: T 972, BP 119/72, HR 66, RR 16, O2 sat 98% on RA
Gen: pleasant male, ill appearing, no acute distress, AOx3, NAD
HEENT: anicteric, MM dry, clear nasal discharge
Neck: no JVD
Resp: good air movement bilaterall, scaterred coarse ronchi
which improve with coughing, no wheezing
CV: RRR, nl s1, s2, III/VI systolic murmur over apex, radiates
into abdomen
Abd: +BS, soft, ND, NT, no HSM, + ascites, not tense
Extr: warm, no edema, 2+ distal pulses
Neuro: minimal asterixis, moves all exremities, no sensory
deficits
.
###RESPONSE: VS {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, Gen {General examination of patient}, ill appearing {Looks ill}, distress {Distress}, AOx3 {Oriented to person, time and place}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, anicteric {White sclera}, MM dry {Mucous membrane dryness}, clear {Normal breath sounds}, nasal discharge {Nasal discharge}, Neck {Physical examination procedure}, JVD {Jugular venous engorgement}, Resp {Examination of respiratory system}, good {No abnormality detected}, ronchi {Wheeze - rhonchi}, coughing {Cough}, wheezing {Wheezing}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, nl s1, s2 {Heart sounds normal}, murmur {Murmur}, apex {Structure of apex of heart}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, Abd {Examination of abdomen}, BS {Normal bowel sounds}, soft {Abdomen soft}, ND {Swollen abdomen}, NT {Abdominal tenderness}, HSM {Hepatosplenomegaly}, ascites {Ascites}, tense {Shoulder stiff}, Extr {Examination of limb}, warm {Warm skin}, edema {Edema}, 2+ distal pulses {Peripheral pulses normal}, Neuro {Neurological examination}, asterixis {Asterixis}, moves all exremities {Does move all four limbs}, sensory
deficits {Sensory disability} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
PERTINENT LABS:
___ 04:20PM BLOOD WBC-8.1 RBC-4.06* Hgb-13.9* Hct-42.7
MCV-105* MCH-34.4* MCHC-32.7 RDW-13.4 Plt ___
___ 05:10AM BLOOD WBC-7.5 RBC-3.32* Hgb-11.1* Hct-33.5*
MCV-101* MCH-33.6* MCHC-33.3 RDW-14.3 Plt ___
___ 09:20PM BLOOD Neuts-77.3* Lymphs-11.1* Monos-7.5
Eos-3.9 Baso-0.3
___ 04:20PM BLOOD ___ PTT-38.1* ___
___ 04:20PM BLOOD UreaN-27* Creat-2.8* Na-134 K-5.6* Cl-102
HCO3-24 AnGap-14
___ 04:20PM BLOOD ALT-37 AST-66* AlkPhos-227* TotBili-2.3*
___ 04:20PM BLOOD TotProt-7.9 Albumin-2.9* Globuln-5.0*
___ 05:45AM BLOOD Hapto-65
___ 04:20PM BLOOD TSH-3.7
___ 04:20PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
___:20PM BLOOD AFP-3.6
___ 08:16PM URINE Color-Amber Appear-Hazy Sp ___
___ 08:16PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG
___ 08:16PM URINE ___ Bacteri-FEW Yeast-NONE
___ 08:16PM URINE ___ 08:16PM URINE Eos-POSITIVE
___ 08:12AM URINE Hours-RANDOM UreaN-539 Creat-133 Na-35
TotProt-48 Prot/Cr-0.4*
.
MICRO DATA:
URINE CX (___): negative
.
STUDIES:
CXR (___): The suggestion of a small region of increased
radiopacity in the left mid lung at the level of the anterior
fourth rib, may correspond to a similar abnormality on the
lateral view projecting over the posterior aspect of the mid
thoracic spine. This could be a superimposition of normal
shadows or alternatively a very small focus of consolidation in
the left lung. Lungs are otherwise clear. There is no pleural
effusion or evidence of central adenopathy. Oblique chest views
might be helpful in determining whether the abnormality is real.
.
ABDOMINAL ULTRASOUND WITH DOPPLER (___):
1. Echogenic micronodular liver with no focal abnormalities
identified.
2. Reverse flow in the right portal vein up into the left portal
vein. Patent umbilical vein.
3. Single small gallstone with no signs of cholecystitis.
4. Large amount of ascites.
5. No hydronephrosis.
.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, TSH {Thyroid stimulating hormone measurement}, HBsAg-NEGATIVE {Hepatitis B surface antigen not detected}, NEGATIVE {No abnormality detected}, NEGATIVE {No abnormality detected}, NEGATIVE {No abnormality detected}, AFP {Alpha-1-Fetoprotein measurement}, URINE {Urine culture}, Color {Color finding}, URINE Blood {Urine blood test}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, URINE {Urine culture}, URINE {Urine culture}, URINE {Urine culture}, POSITIVE {Detected by cytology}, URINE {Urine culture}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, URINE CX {Urine culture}, negative {No abnormality detected}, CXR {Plain chest X-ray}, left {Left lung structure}, lung {Lung structure}, fourth rib {Bone structure of fourth rib}, lateral {Diagnostic radiography of chest, lateral}, thoracic spine {Structure of thoracic vertebral column}, superimposition {Superimposition}, normal {No abnormality detected}, shadows {Shadow}, consolidation {Consolidation}, left lung {Left lung structure}, Lungs {Lung structure}, clear {Normal breath sounds}, pleural
effusion {Pleural effusion}, adenopathy {Lymphadenopathy}, Oblique {Fracture, oblique}, chest {Plain chest X-ray}, abnormality {No abnormality detected}, ABDOMINAL ULTRASOUND {Ultrasonography of abdomen}, liver {Liver structure}, abnormalities {No abnormality detected}, right portal vein {Structure of right main branch of portal vein}, left portal
vein {Structure of left main branch of portal vein}, umbilical vein {Structure of umbilical vein}, gallstone {Gallbladder calculus}, signs {Sign}, cholecystitis {Cholecystitis}, ascites {Ascites}, hydronephrosis {Hydronephrosis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 man with EtOH cirrhosis admitted with elevated
creatinine.
.
# Acute renal failure - Creatinine was 3.1 on admission. No
known history of kidney disease and PCP records showed that his
creatinine had been 1.1 a few months ago. Diuretics were held.
He received albumin and a fluid challenge overnight when he was
admitted without any significant effect. Started midodrine and
octreotide as well as daily albumin in case hepatorenal was
playing a role. No new meds. No signs of obstruction and no
hydronephrosis on ultrasound. Renal was consulted. Urine
sediment with acanthocytes and possibly a couple red cell casts.
UA with small amount of hematuria ___ RBC, ___ RBC on
repeat). The renal team felt that his renal failure was likely
due to renal hypoperfusion (could even be HRS) from combination
of cirrhosis and aortic stenosis, with multiple recent large
volume paracenteses. ___ also have underlying IgA nephropathy
given proteinuria. Hep B/C serologies negative so not likely a
GN related to those. Creatinine remained stable and he was
discharged with the plan to follow-up with Renal as an
outpatient for biopsy and further evaluation.
.
# Cough - Association with sore throat, rhinorrhea, similar sick
contacts symptoms made a viral URI most likely. He remained
afebrile without leukocytosis. A very small opacity in left lung
was noted on CXR however given bacterial pneumonia was felt
unlikely, he was not treated with antibiotics.
.
# Alcoholic Cirrhosis - Complicated by varices and recurrent
ascites requiring large volume paracentesis. MELD 25. Most
recent paracentesis on ___ with 9L removed, did not receive
albumin. Diuretics were held as above for renal failure.
Continued nadolol, MVI, folate. Discontinued lactulose as
patient has no history of encephalopathy.
.
# HTN - Continued amlodipine.
.
# Hypercholesterolemia - Continued statin.
.
# Full code
###RESPONSE: EtOH cirrhosis {Alcoholic cirrhosis}, elevated
creatinine {Serum creatinine above reference range}, Acute renal failure {Acute kidney injury}, Creatinine {Creatinine measurement}, creatinine {Creatinine measurement}, Diuretics {Diuretic therapy}, received albumin {Administration of albumin}, fluid {Administration of intravenous fluids}, albumin {Administration of albumin}, signs {Sign}, obstruction {Obstruction}, hydronephrosis {Hydronephrosis}, ultrasound {Ultrasonography}, Renal {Kidney structure}, Urine {Urine culture}, cell casts {Cellular casts}, hematuria {Blood in urine}, RBC {Red blood cell count}, RBC {Red blood cell count}, renal failure {Renal failure syndrome}, renal {Kidney structure}, HRS {Hepatorenal syndrome}, cirrhosis {Cirrhosis of liver}, aortic stenosis {Aortic valve stenosis}, paracenteses {Abdominal paracentesis}, IgA nephropathy {Immunoglobulin A nephropathy}, proteinuria {Proteinuria}, Hep B {Viral hepatitis type B}, negative {No abnormality detected}, Creatinine {Creatinine measurement}, stable {Patient's condition stable}, biopsy {Biopsy}, evaluation {Evaluation procedure}, Cough {Cough}, sore throat {Sore throat}, rhinorrhea {Nasal discharge}, sick {Illness}, viral {Viral disease}, URI {Upper respiratory infection}, afebrile {Fever}, leukocytosis {Leukocytosis}, opacity {Abnormally opaque structure}, left lung {Left lung structure}, CXR {Plain chest X-ray}, bacterial pneumonia {Bacterial pneumonia}, treated with antibiotics {Antibiotic therapy}, Alcoholic Cirrhosis {Alcoholic cirrhosis}, varices {Esophageal varices}, ascites {Ascites}, paracentesis {Abdominal paracentesis}, paracentesis {Centesis}, removed {Drainage of ascites}, albumin {Administration of albumin}, Diuretics {Diuretic therapy}, renal failure {Renal failure syndrome}, encephalopathy {Disorder of brain}, HTN {Hypertensive disorder, systemic arterial}, Hypercholesterolemia {Hypercholesterolemia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Amlodipine 5mg daily
Nadolol 80mg daily
Protonix 40mg bid
Folic acid 1mg daily
Lipitor 20mg daily
Lactulose 3tsp BID
Spironolactone 50mg BID
.
###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: vicodin - itchy
.
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Nadolol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
.
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute renal failure
.
Secondary: EtOH cirrhosis, hypertension, hypercholesterolemia
.
Discharge Condition:
Stable.
.
###RESPONSE: Acute renal failure {Acute kidney injury}, EtOH cirrhosis {Alcoholic cirrhosis}, hypertension {Hypertensive disorder, systemic arterial}, hypercholesterolemia {Hypercholesterolemia}, 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:
You were admitted to the hospital for evaluation and treatment
of kidney failure. Several labs were sent to work up your kidney
failure; these were still pending at time of discharge. You will
need to have a biopsy of your kidney to help make a diagnosis.
.
You will have to follow up with the nephrologists next week for
your biopsy.
.
If you develop a tense swollen abdomen, confusion, fevers>101,
shortness of breath, chest pain, or other symptoms that are
concerning to you, you should return to the emergency room.
.
###RESPONSE: evaluation {Evaluation procedure}, kidney failure {Renal failure syndrome}, kidney
failure {Renal failure syndrome}, biopsy {Biopsy}, biopsy {Biopsy}, tense {Feeling tense}, swollen abdomen {Swollen abdomen}, confusion {Clouded consciousness}, fevers {Fever}, shortness of breath {Dyspnea}, chest pain {Chest pain}, return to the emergency room {Emergency treatment management} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Sulfa (Sulfonamide Antibiotics) / Ciprofloxacin / adhesive tape
/ Floxin / Neurontin / generic brand meds
Attending: ___.
Chief Complaint:
left knee OA
Major Surgical or Invasive Procedure:
left knee replacement ___, ___
###RESPONSE: Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, Ciprofloxacin {Allergy to ciprofloxacin}, adhesive tape {Allergy to adhesive agent}, left knee OA {Osteoarthritis of left knee joint}, left knee replacement {Total replacement of left knee joint} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 with left knee OA s/p L TKR.
###RESPONSE: left knee OA {Osteoarthritis of left knee joint}, L TKR {Total replacement of left knee joint} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
BMI 31.68, thyroid dz, dyslipidemia, eczema
Bursitis
Low back pain
Arthroscopy in ___ with Dr. ___ ___
___ History:
___
###RESPONSE: thyroid dz {Disorder of thyroid gland}, dyslipidemia {Dyslipidemia}, eczema {Eczema}, Bursitis {Bursitis}, Low back pain {Low back pain}, Arthroscopy {Arthroscopy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Non-contributory
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
###RESPONSE: Physical Exam {Physical examination procedure}, Well appearing {Well cared for appearance}, distress {Distress}, Afebrile {Fever}, stable vital signs {Normal vital signs}, Pain {Pain}, Respiratory {Examination of respiratory system}, CTAB {Normal breath sounds}, Cardiovascular {Cardiovascular physical examination}, RRR {Normal heart rate}, Gastrointestinal {Examination of digestive system}, NT {Abdominal tenderness}, ND {Swollen abdomen}, Gen {General examination of patient}, Voiding independently {Normal micturition}, Neurologic {Neurological examination}, no focal deficits {Normal nervous system function}, O x3 {Oriented to person, time and place}, Musculoskeletal {Musculoskeletal system physical examination}, Lower Extremity {Lower limb structure}, Incision {Surgical incision wound}, healing well {Wound healing well}, Thigh {Thigh structure}, soft {Abdomen soft}, tenderness {Tenderness}, SILT {Light touch sensation present}, NVI distally {Normal peripheral neurovascular function}, Toes {Structure of all toes}, warm {Warm skin} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 06:03AM BLOOD Hgb-8.4* Hct-26.6*
___ 06:07AM BLOOD Hgb-9.5* Hct-29.3*
___ 06:03AM BLOOD Creat-0.6
___ 06:07AM BLOOD Creat-0.6
###RESPONSE: Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, Creat {Creatinine measurement}, Creat {Creatinine measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
The patient was admitted to the orthopedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
POD #0 overnight, patient had high drain output and knee was
flexed with drain clamped for 4 hours with appropriate effect.
POD #1, drain was discontinued. Dressing was changed per patient
request as she felt she was developing a rash. No rash noted.
POD #2, patient complained of itchiness in morning. A dose of
Benadryl was given and the itchiness resolved. Patient cleared
___ without further issues.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Aspirin 325 mg twice
daily for DVT prophylaxis starting on the morning of POD#1. The
surgical dressing was changed on POD#2 and the surgical incision
was found to be clean and intact without erythema or abnormal
drainage. The patient was seen daily by physical therapy. Labs
were checked throughout the hospital course and repleted
accordingly. At the time of discharge the patient was tolerating
a regular diet and feeling well. The patient was afebrile with
stable vital signs. The patient's hematocrit was acceptable and
pain was adequately controlled on an oral regimen. The operative
extremity was neurovascularly intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with no range of motion
restrictions.
Ms. ___ is discharged to home with services in stable
condition.
###RESPONSE: admitted to the orthopedic surgery service {Admission by orthopedic surgeon}, procedure {Surgical procedure}, operative {Surgical procedure}, surgery {Surgical procedure}, procedure {Surgical procedure}, IV antibiotics {Intravenous antibiotic therapy}, Postoperative course {Postoperative state}, drain {Wound discharge}, knee {Structure of left knee region}, drain clamped {Clamping of drain}, drain was discontinued {Removal of drain}, Dressing was changed {Change of dressing}, rash {Eruption of skin}, rash {Eruption of skin}, itchiness {Itching}, itchiness {Itching}, pain was controlled {Demonstrates adequate pain control}, IV {Intravenous therapy}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, Aspirin {Administration of aspirin}, DVT prophylaxis {Prevention of deep vein thrombosis}, surgical dressing was changed {Change of dressing}, surgical incision {Surgical incision wound}, intact {Intact skin}, erythema {Erythema}, drainage {Wound discharge}, physical therapy {Physical therapy procedure}, regular diet {Normal diet}, feeling well {Well in self}, afebrile {Fever}, stable vital signs {Normal vital signs}, hematocrit was acceptable {Stable hematocrit}, pain was adequately controlled {Demonstrates adequate pain control}, oral {Administration of drug or medicament via oral route}, regimen {Therapeutic regimen}, operative {Operative site}, extremity {All extremities}, neurovascularly intact {Normal peripheral neurovascular function}, wound {Wound}, weight-bearing {Weight-bearing}, weight bearing {Weight-bearing}, operative {Surgical procedure}, extremity {Limb structure}, stable
condition {Patient's condition stable} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
1. BuPROPion (Sustained Release) 450 mg PO QHS
2. ClonazePAM 1 mg PO BID
3. Propranolol 20 mg PO BID
4. Atorvastatin 40 mg PO QPM
5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
6. FLUoxetine 60 mg PO QHS
7. Levothyroxine Sodium 75-150 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin EC 325 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
5. Pantoprazole 40 mg PO Q24H
Continue while on 4-week course of Aspirin 325 mg twice daily.
6. Senna 8.6 mg PO BID
7. Atorvastatin 40 mg PO QPM
8. BuPROPion (Sustained Release) 450 mg PO QHS
9. ClonazePAM 1 mg PO BID
10. FLUoxetine 60 mg PO QHS
11. Levothyroxine Sodium 75-150 mcg PO DAILY
12. Propranolol 20 mg PO BID
13. HELD- Ibuprofen 800 mg PO Q8H:PRN Pain - Mild This
medication was held. Do not restart Ibuprofen until you've been
cleared by your surgeon
###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:
left knee OA
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}, left knee OA {Osteoarthritis of left knee joint}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - requires assistance or aid {Finding of walking aid use} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Aspirin 325 mg twice
daily for four (4) weeks to help prevent deep vein thrombosis
(blood clots). Continue Pantoprazole daily while on Aspirin to
prevent GI upset (x 4 weeks). If you were taking Aspirin prior
to your surgery, take it at 325 mg twice daily until the end of
the 4 weeks, then you can go back to your normal dosing.
9. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed at your follow-up
appointment in two weeks.
10. ___ (once at home): Home ___, dressing changes as
instructed, wound checks.
11. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize. ROM as tolerated. No strenuous exercise or
heavy lifting until follow up appointment.
Physical Therapy:
WBAT LLE
ROMAT
Wean assistive device as able (i.e. 2 crutches or walker)
Mobilize frequently
Treatments Frequency:
daily dressing changes as needed for drainage
wound checks daily
ice
staple removal and replace with steri-strips at follow up visit
in clinic
###RESPONSE: severe pain {Severe pain}, medication {Administration of drug or medicament}, swelling {Swelling}, decreased
sensation {Abnormal sensation}, difficulty with movement {Difficulty moving}, fevers {Fever}, shaking {Tremor}, chills {Chill}, redness {Redness of skin over lesion}, drainage {Discharge}, incision
site {Surgical incision wound}, chest pain {Chest pain}, shortness of breath {Dyspnea}, primary physician {Primary care management}, medications {Prescription of drug}, medications {Prescription of drug}, medications {Prescription of drug}, pain control {Pain control}, while
taking these medications {Patient medication education}, pain {Pain}, medication can
cause {Patient medication education}, constipation {Constipation}, take a stool softener {Administration of laxative}, side effect {Medication side effects present}, medication so that it can be refilled {Medication prefill education}, medications {Prescription of drug}, medication {Prescription of drug}, u may not drive {Functional activity education}, SWELLING {Swelling}, Ice {Application of ice}, operative joint {Operative site}, activity {Functional activity education}, physical therapy {Physical therapy procedure}, Do not place {Wound treatment education}, ice {Application of ice}, skin {Skin structure}, knee {Structure of left knee region}, compression {Compression}, DO NOT take {Patient medication education}, non-steroidal
anti-inflammatory medications {Non-steroidal anti-inflammatory agent therapy}, ANTICOAGULATION {Anticoagulant therapy}, Aspirin {Administration of aspirin}, prevent deep vein thrombosis {Prevention of deep vein thrombosis}, blood clots {Blood clot}, Aspirin {Administration of aspirin}, GI upset {Gastrointestinal irritation}, surgery {Surgical procedure}, WOUND CARE {Wound care}, incision {Surgical incision wound}, shower {Able to shower self}, after surgery {Postoperative state}, incision {Surgical incision wound}, place a dry sterile dressing {Application of dressing}, wound {Surgical incision wound}, drainage {Wound discharge}, wound {Surgical incision wound}, signs of infection {Monitoring for signs and symptoms of infection}, redness {Redness of skin over lesion}, drainage {Wound discharge}, Staples will be removed {Removal of staples}, dressing changes {Change of dressing}, wound checks {Wound assessment}, ACTIVITY {Functional activity education}, Weight bearing {Weight-bearing}, operative {Operative site}, extremity {Limb structure}, Mobilize {Mobilizing exercises}, ROM {Range of motion activity}, exercise {Exercises}, lifting {Does lift}, Physical Therapy {Physical therapy procedure}, LLE {Structure of left lower limb}, ROM {Range of motion activity}, Mobilize {Does mobilize}, Treatments Frequency {Wound treatment education}, dressing changes {Change of dressing}, drainage {Wound discharge}, wound checks {Wound assessment}, ice {Application of ice}, staple removal {Removal of staples} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Type A aortic dissection involving b/l carotids and severe
neurologic deficits,
Major Surgical or Invasive Procedure:
none
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Type A aortic dissection {Dissection of proximal aorta}, carotids {Carotid artery structure}, neurologic deficits {Neurological deficit} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ found down at home approximately 2 hours prior to
presentation, EMS called immediately by wife. EMS noted unequal
pulses in his upper extremities during transport. Upon arrival,
he was found to be minimally responsive with a GCS of 5, with a
fixed and dilated right pupil and posturing movements of his
left
arm. He was intubated and underwent a CT of the head, which was
negative, and then a CTA of the torso with dissection protocol.
This demonstrated an aortic dissection from the root into the
abdomen with involvement of the brachiocephalic artery as well
as
the left carotid.Cardiac surgery was consulted for possible
dissection repair.
###RESPONSE: unequal
pulses {Unequal pulse}, upper extremities {Upper limb structure}, GCS of 5 {Glasgow coma scale, 5}, fixed and dilated right pupil {Fixed dilatation of right pupil}, posturing movements {Abnormal posture}, left
arm {Structure of left upper limb}, intubated {Intubation}, CT of the head {Computed tomography of head}, negative {No abnormality detected}, CTA {Computed tomography angiography of head with contrast}, torso {Trunk structure}, dissection protocol {Dissection procedure}, aortic dissection {Dissection of aorta}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, brachiocephalic artery {Structure of brachiocephalic artery}, left carotid {Structure of left carotid artery}, Cardiac surgery {Operation on heart}, dissection {Dissection of aorta}, repair {Surgical repair} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
CAD, HTN, lipids, BPH
###RESPONSE: CAD {Coronary arteriosclerosis}, HTN {Hypertensive disorder, systemic arterial}, BPH {Benign prostatic hyperplasia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
unknown
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
PE in ED:
Pulse: Resp:intubated O2 sat:100%
B/P ___ HR 44 (SR)
###RESPONSE: Pulse {Finding of pulse rate}, Resp {Examination of respiratory system}, intubated {Intubation}, O2 sat {Oxygen saturation measurement}, B/P {Blood pressure finding}, HR {Finding of heart rate} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 06:01AM BLOOD WBC-10.7 RBC-4.89 Hgb-14.5 Hct-43.8
MCV-90 MCH-29.6 MCHC-33.0 RDW-13.7 Plt ___
___ 06:01AM BLOOD ___ PTT-24.7* ___
___ 06:01AM BLOOD Glucose-178* UreaN-18 Creat-1.0 Na-143
K-4.1 Cl-108 HCO3-21* AnGap-18
___ ___ M ___ ___
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of ___ 6:17 AM
___ ___ 6:17 AM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD & PELVIS Clip #
___
Reason: aortic dissection?
Contrast: OMNIPAQUE Amt: 80
UNDERLYING MEDICAL CONDITION:
___ with decreased pulse R hand, diaphoretic, fall, altered
REASON FOR THIS EXAMINATION:
aortic dissection?
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: SJBj SAT ___ 7:41 AM
Extensive type A aortic dissection extending from the aortic
root to the
distal abdominal aorta. Dissection extends up left
bracheocephalic and left
common carotid. RCC extension cannot be assessed. Diffuse large
bowel wall
thickening raises the possibility of ischemic bowel even though
the ___
appears patent from the true lumen.
Wet Read Audit # 1
Wet Read Audit # 2 SJBj SAT ___ 6:46 AM
Extensive type A aortic dissection extending from the aortic
root to the
distal abdominal aorta. Dissection extends up both carotids.
Wet Read Audit # 3 SJBj SAT ___ 7:40 AM
Extensive type A aortic dissection extending from the aortic
root to the
distal abdominal aorta. Dissection extends up left
bracheocephalic and left
common carotid. RCC extension cannot be assessed.
Final Report
INDICATION: ___ man with collapse, decreased right hand
pulse,
question dissection.
COMPARISON: None.
TECHNIQUE: MDCT data were acquired through the chest, abdomen
and pelvis
after the administration of 80 cc of IV contrast. Images were
displayed in
multiple planes.
FINDINGS: The exam is limited by suboptimal contrast bolus
timing.
There is an extensive type-A aortic dissection extending from
the aortic root,
to the descending and abdominal aorta, to the level of the
infrarenal
abdominal aorta. Evaluation for carotid extension is severely
limited by poor
contrast bolus timing and streak artifact through the neck. The
dissection at
least extends into the proximal left subclavian and into the
proximal right
brachiocephalic artery. Approximately 1.2 cm distal to the right
brachiocephalic origin, there is a 1.3 x 0.6 cm outpouching
(300b:18) which
may represent a pseudoaneurysm. Extension into the right common
carotid
cannot be assessed. The celiac, SMA and right and left renal
arteries
originate from the true lumen. The ___ from the true
lumen.
There is no hemopericardium. There is fat stranding within the
mediastinum
without frank extravasation. Numerous chest wall collateral
vessels are
noted.
CHEST: There is dependent atelectasis plus aspiration at both
lung bases.
The remainder of the lungs are clear. The airways are patent to
the
subsegmental level. An endotracheal tube ends in the upper
trachea.
ABDOMEN: The liver parenchyma is homogeneous. The gallbladder is
thin-walled
and not distended. The pancreas, spleen, and adrenal glands are
unremarkable.
The kidneys enhance symmetrically. The stomach, small and large
bowel are of
normal caliber and appearance.
PELVIS: Diffuse diverticulosis is seen throughout the colon.
There is a
right inguinal hernia (2:35) containing loops of small bowel
with mild
fecalization, but no wall thickening or adjacent stranding.
There is no free
pelvic fluid. There is no inguinal or pelvic adenopathy. The
appendix is
normal.
BONE WINDOWS: There are moderate multilevel degenerative changes
throughout
the thoracolumbar spine. No concerning lytic or sclerotic
lesions.
IMPRESSION:
1. Extensive type-A dissection extending from the aortic root to
the
infrarenal abdominal aorta. The dissection extends into the
proximal left
subclavian and right brachiocephalic arteries. There is a small
thrombosed
pseudoaneurysm in the proximal right brachiocephalic artery.
Evaluation for
extension into the common carotid arteries is markedly limited
by poor
contrast bolus timing. Should further evaluation of the carotid
arteries be
necessary, neck CTA could be performed.
2. Right inguinal hernia containing a loop of fecalized ileum
without
inflammation or wall thickening.
3. Dependent atelectasis versus possible aspiration.
4. Haziness of the mediastinal fat may be inflammatory although
hematoma is
not excluded.
Findings were urgently conveyed to the ER physicians by Dr. ___
___
immediately after the completion of the scan by telephone on the
morning of
___ and discussed with ___ on the morning of
___ @
9:55 am by Dr. ___.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___: SAT ___ 9:55 AM
Imaging Lab
There is no report history available for viewing.
###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}, CORONARY {Atherosclerosis of coronary artery}, ABD {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, PELVIS {Structure of pelvis}, aortic dissection {Dissection of aorta}, pulse {Pulse finding}, R hand {Structure of right hand}, diaphoretic {Excessive sweating}, fall {Falls}, aortic dissection {Dissection of aorta}, AST {Aspartate aminotransferase measurement}, type A aortic dissection {Dissection of proximal aorta}, aortic
root {Supraaortic valve area structure}, abdominal aorta {Abdominal aorta structure}, Dissection {Dissection of artery}, left
bracheocephalic {Structure of left brachial artery}, left
common carotid {Left common carotid artery structure}, RCC {Renal cell carcinoma}, large
bowel wall {Structure of wall of large intestine}, thickening {Increased thickness}, ischemic bowel {Vascular insufficiency of intestine}, lumen {Structure of lumen of body system}, type A aortic dissection {Dissection of proximal aorta}, aortic
root {Supraaortic valve area structure}, abdominal aorta {Abdominal aorta structure}, Dissection {Dissection of artery}, carotids {Carotid artery structure}, type A aortic dissection {Dissection of proximal aorta}, aortic
root {Supraaortic valve area structure}, abdominal aorta {Abdominal aorta structure}, Dissection {Dissection of artery}, left
bracheocephalic {Structure of left brachial artery}, left
common carotid {Left common carotid artery structure}, RCC {Renal cell carcinoma}, collapse {Collapsing pulse}, right hand {Structure of right hand}, pulse {Pulse finding}, dissection {Dissection of artery}, chest, abdomen
and pelvis {Chest and/or abdomen and/or pelvis structure}, exam {Physical examination procedure}, type-A aortic dissection {Dissection of proximal aorta}, aortic root {Supraaortic valve area structure}, descending {Descending aorta structure}, abdominal aorta {Abdominal aorta structure}, infrarenal
abdominal aorta {Structure of infrarenal aorta}, Evaluation {Evaluation procedure}, carotid {Carotid artery structure}, artifact {Artifact}, neck {Neck structure}, dissection {Dissection of artery}, left subclavian {Structure of left subclavian artery}, right {Structure of right main branch of portal vein}, brachiocephalic artery {Structure of brachiocephalic artery}, right {Structure of right main branch of portal vein}, brachiocephalic {Structure of brachiocephalic artery}, pseudoaneurysm {Pseudoaneurysm}, right common
carotid {Right common carotid artery structure}, celiac {Structure of celiac artery}, SMA {Superior mesenteric artery structure}, right {Structure of right renal artery}, left renal
arteries {Structure of left renal artery}, lumen {Structure of lumen of body system}, lumen {Structure of lumen of body system}, hemopericardium {Hemopericardium}, fat {Structure of adipose tissue}, stranding {Density above reference range}, mediastinum {Mediastinal structure}, extravasation {Extravasation}, chest wall {Chest wall structure}, vessels {Blood vessel structure}, CHEST {Plain chest X-ray}, atelectasis {Atelectasis}, aspiration {Pulmonary aspiration}, both
lung {Both lungs}, bases {Structure of base of lung}, lungs are clear {Normal lung}, airways {Airway structure}, endotracheal tube {Insertion of endotracheal tube}, trachea {Tracheal structure}, ABDOMEN {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, liver parenchyma {Structure of parenchyma of liver}, gallbladder {Gallbladder structure}, distended {Swollen abdomen}, pancreas {Pancreatic structure}, spleen {Splenic structure}, adrenal glands {Bilateral adrenal glands}, unremarkable {No abnormality detected}, kidneys {Kidney structure}, stomach {Stomach structure}, small {Structure of small intestine}, large
bowel {Structure of large intestine}, normal {No abnormality detected}, PELVIS {Structure of pelvis}, diverticulosis {Diverticulosis of colon}, colon {Colon structure}, right inguinal hernia {Right inguinal hernia}, small bowel {Structure of small intestine}, wall {Colon wall structure}, thickening {Increased thickness}, pelvic {Structure of pelvis}, inguinal {Inguinal lymphadenopathy}, pelvic adenopathy {Pelvic lymphadenopathy}, appendix {Appendix structure}, normal {No abnormality detected}, BONE {Bone structure}, degenerative changes {Degeneration of spine}, thoracolumbar {Structure of thoracic and/or lumbar region of back}, spine {Structure of vertebral column}, lytic {Lysis}, sclerotic {Sclerosis}, lesions {Lesion}, type-A dissection {Dissection of proximal aorta}, aortic root {Supraaortic valve area structure}, infrarenal {Structure of infrarenal aorta}, abdominal aorta {Abdominal aorta structure}, dissection {Dissection of artery}, left
subclavian {Structure of left subclavian artery}, right {Structure of right main branch of portal vein}, brachiocephalic arteries {Structure of brachiocephalic artery}, thrombosed {Thrombus}, pseudoaneurysm {Pseudoaneurysm}, right {Structure of right main branch of portal vein}, brachiocephalic artery {Structure of brachiocephalic artery}, common carotid arteries {Common carotid artery structure}, evaluation {Evaluation procedure}, carotid
arteries {Carotid artery structure}, Right inguinal hernia {Right inguinal hernia}, ileum {Ileal structure}, inflammation {Inflammatory disorder}, wall {Colon wall structure}, thickening {Increased thickness}, atelectasis {Atelectasis}, aspiration {Pulmonary aspiration}, mediastinal fat {Structure of pericardial fat}, inflammatory {Inflammatory disorder}, hematoma {Hematoma} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 presents with abdominal pain secondary to back pain
and rapidly deteriorating mental status with left hemi-neglect.
He was intubated for airway protection. CT of the head was
negative, CTA of the chest showing diffuse type A dissection.
Stat consult to cardiac surgery and vascular surgery was done.
The family discussed with ___ risks of surgery. The
family were in agreement at having the pt extubated and allowing
him to die, knowing that it is what Mr. ___ would want; they
did not want to wait until his children, who live out of state,
arrive. Ms. ___ does not want an organ donation or
an autopsy. ___ was taken off the ventilator and shortly
thereafter pronounced dead. The appropriate post mortem agencies
were contacted per hospital policy.
###RESPONSE: abdominal pain {Abdominal pain}, back pain {Backache}, deteriorating {Patient's condition deteriorating}, mental status {Neurological mental status determination}, hemi-neglect {Hemi-neglect}, intubated {Intubation}, airway {Airway structure}, CT of the head {Computed tomography of head}, negative {No abnormality detected}, CTA of the chest {Computed tomography of chest}, type A dissection {Dissection of proximal aorta}, cardiac surgery {Operation on heart}, vascular surgery {Vascular surgery procedure}, surgery {Surgical procedure}, extubated {Removal of endotracheal tube}, autopsy {Autopsy examination}, dead {Dead} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Amlodipine 10'
Isosorbinde mononitrate 100'
Metoprolol 50''
Nitroglycerin PRN
Pravastatin 40'
Tamsulosin 0.8'
ASA 325'
Discharge Medications:
none
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Expired
Discharge Diagnosis:
Type A dissection
Discharge Condition:
expired
___ MD ___
Completed by: ___
###RESPONSE: Type A dissection {Dissection of proximal aorta} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Penicillins
Attending: ___.
Chief Complaint:
Trauma activation from 5 foot fall
Major Surgical or Invasive Procedure:
___ Exploratory laparotomy and splenectomy
###RESPONSE: Penicillins {Allergy to penicillin}, Trauma {Traumatic injury}, fall {Falls}, Exploratory laparotomy {Exploratory laparotomy}, splenectomy {Splenectomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
ACS is consulted to evaluate this ___ man status post
witnessed 5 foot fall into ___ pit presenting with multiple PL
Left sided rib fx, hemoperitoneum w/ liver, spleen, and left
kidney lacerations.
Per documentation following his fall he was pulled out by
bystanders and ambulatory on scene per EMS. At that time patient
unable to complete full interview secondary to intoxication with
ETOH, benzos. Patient states he is drinking, may have used
drugs
but he is not sure. Also endorses epigastric pain. States he has
history of hepatitis C, no other medical problems.
On evaluation, patient HDS. GCS 15. Abdomen soft, tender to
palpation to LUQ. Non-peritoneal.
###RESPONSE: fall {Falls}, Left sided {Bone structure of left rib}, rib fx {Fracture of rib}, hemoperitoneum {Nontraumatic hemoperitoneum}, liver {Laceration of liver}, spleen {Laceration of spleen}, left
kidney lacerations {Laceration of left kidney}, fall {Falls}, intoxication with
ETOH {Alcohol intoxication}, benzos {Benzodiazepine intoxication}, epigastric pain {Epigastric pain}, hepatitis C {Viral hepatitis type C}, evaluation {Evaluation procedure}, Abdomen soft {Abdomen soft}, tender to
palpation to LUQ {Tenderness of left upper quadrant of abdomen} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PMH:
Hep C - untreated
Depression/anxiety
History of polysubstance abuse
Right PTX s/p gunshot wound to right chest ___
PSH:
Right chest tube placement ___
Laceration repair back, posterior leg s/p stabbing
###RESPONSE: Hep C {Viral hepatitis type C}, Depression {Depressive disorder}, anxiety {Anxiety}, polysubstance abuse {Polysubstance abuse}, Right PTX {Right pneumothorax}, gunshot wound {Gunshot wound}, right chest {Right thorax structure}, Right {Right thorax structure}, chest tube placement {Insertion of pleural tube drain}, Laceration {Laceration}, repair {Surgical repair}, back {Structure of posterior surface of lower leg}, posterior leg {Structure of posterior surface of lower leg} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
FH:
No known family history
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS:
General : In no acute distress
Cardio: Normal S1, S2
Pulmonary: CTAB
Abdomen: Soft, mildy distended, mild LUQ tenderness, midline
closed with staples
Extremities: no edema, no erythema
###RESPONSE: VS {Vital signs finding}, General {General examination of patient}, distress {Distress}, Cardio {Cardiovascular physical examination}, S2 {Normal second heart sound, S>2<}, Pulm {Examination of respiratory system}, CTAB {Normal breath sounds}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, distended {Swollen abdomen}, mild {Symptom mild}, tenderness {Tenderness}, Extremities {Examination of limb}, edema {Edema}, erythema {Erythema} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 07:00AM BLOOD WBC-11.6* RBC-2.86* Hgb-8.5* Hct-25.9*
MCV-91 MCH-29.7 MCHC-32.8 RDW-13.9 RDWSD-45.4 Plt ___
___ 06:56AM BLOOD WBC-10.7* RBC-2.74* Hgb-8.4* Hct-25.0*
MCV-91 MCH-30.7 MCHC-33.6 RDW-13.9 RDWSD-46.1 Plt ___
___ 05:44PM BLOOD WBC-11.7* RBC-2.64* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.3 MCHC-33.1 RDW-14.0 RDWSD-46.5* Plt ___
___ 06:50AM BLOOD WBC-12.9* RBC-2.23* Hgb-6.9* Hct-21.0*
MCV-94 MCH-30.9 MCHC-32.9 RDW-13.7 RDWSD-46.4* Plt ___
___ 06:42AM BLOOD WBC-15.9* RBC-2.41* Hgb-7.4* Hct-22.8*
MCV-95 MCH-30.7 MCHC-32.5 RDW-14.1 RDWSD-47.8* Plt ___
___ 01:59AM BLOOD WBC-15.8* RBC-2.45* Hgb-7.6* Hct-22.4*
MCV-91 MCH-31.0 MCHC-33.9 RDW-14.0 RDWSD-46.8* Plt ___
___ 07:25AM BLOOD WBC-15.3* RBC-2.62* Hgb-8.1* Hct-23.7*
MCV-91 MCH-30.9 MCHC-34.2 RDW-14.1 RDWSD-46.1 Plt ___
___ 12:05AM BLOOD WBC-14.5* RBC-2.70* Hgb-8.4* Hct-24.1*
MCV-89 MCH-31.1 MCHC-34.9 RDW-14.1 RDWSD-45.8 Plt ___
___ 10:17PM BLOOD WBC-15.8* RBC-2.89* Hgb-9.0* Hct-26.1*
MCV-90 MCH-31.1 MCHC-34.5 RDW-14.3 RDWSD-47.0* Plt ___
___ 03:22PM BLOOD WBC-12.4* RBC-2.99* Hgb-9.3* Hct-27.0*
MCV-90 MCH-31.1 MCHC-34.4 RDW-14.2 RDWSD-46.7* Plt ___
___ 12:00PM BLOOD WBC-13.3* RBC-3.34* Hgb-10.5* Hct-30.1*
MCV-90 MCH-31.4 MCHC-34.9 RDW-14.2 RDWSD-46.5* Plt ___
___ 05:09AM BLOOD WBC-12.6* RBC-2.45* Hgb-7.6* Hct-22.3*
MCV-91 MCH-31.0 MCHC-34.1 RDW-13.2 RDWSD-43.8 Plt Ct-78*
___ 04:00AM BLOOD WBC-13.6* RBC-1.95* Hgb-6.1* Hct-18.2*
MCV-93 MCH-31.3 MCHC-33.5 RDW-13.3 RDWSD-45.2 Plt Ct-93*
___ 07:43AM BLOOD WBC-9.2 RBC-2.52* Hgb-8.0* Hct-24.2*
MCV-96 MCH-31.7 MCHC-33.1 RDW-12.6 RDWSD-43.3 Plt ___
___ 10:07AM BLOOD WBC-5.2 RBC-2.56* Hgb-8.1* Hct-25.0*
MCV-98 MCH-31.6 MCHC-32.4 RDW-12.8 RDWSD-45.1 Plt ___
___ 04:08AM BLOOD WBC-4.9 RBC-2.48* Hgb-8.0* Hct-23.9*
MCV-96 MCH-32.3* MCHC-33.5 RDW-12.7 RDWSD-44.8 Plt ___
___ 09:30PM BLOOD WBC-5.3 RBC-2.71* Hgb-8.5* Hct-26.6*
MCV-98 MCH-31.4 MCHC-32.0 RDW-12.9 RDWSD-45.8 Plt ___
___ 04:20PM BLOOD WBC-5.7 RBC-2.71* Hgb-8.6* Hct-26.0*
MCV-96 MCH-31.7 MCHC-33.1 RDW-13.0 RDWSD-45.6 Plt ___
___ 02:04PM BLOOD WBC-1.9* RBC-2.33* Hgb-7.4* Hct-22.6*
MCV-97 MCH-31.8 MCHC-32.7 RDW-13.1 RDWSD-46.7* Plt Ct-80*
___ 05:45AM BLOOD WBC-7.6 RBC-2.98* Hgb-9.5* Hct-29.1*
MCV-98 MCH-31.9 MCHC-32.6 RDW-13.0 RDWSD-46.5* Plt ___
___ 02:17AM BLOOD WBC-9.5 RBC-3.05* Hgb-9.8* Hct-29.6*
MCV-97 MCH-32.1* MCHC-33.1 RDW-12.9 RDWSD-46.0 Plt ___
___ 10:05PM BLOOD WBC-12.9* RBC-3.48* Hgb-11.2* Hct-33.7*
MCV-97 MCH-32.2* MCHC-33.2 RDW-12.8 RDWSD-45.5 Plt ___
___ 01:59AM BLOOD Neuts-78.8* Lymphs-11.8* Monos-8.2
Eos-0.1* Baso-0.1 NRBC-0.3* Im ___ AbsNeut-12.44*
AbsLymp-1.86 AbsMono-1.29* AbsEos-0.02* AbsBaso-0.02
___ 04:00AM BLOOD Neuts-74.2* Lymphs-15.3* Monos-6.3
Eos-0.1* Baso-0.1 NRBC-0.2* Im ___ AbsNeut-10.11*
AbsLymp-2.09 AbsMono-0.86* AbsEos-0.02* AbsBaso-0.02
___ 10:05PM BLOOD Neuts-66.6 ___ Monos-10.2
Eos-0.8* Baso-0.2 Im ___ AbsNeut-8.58* AbsLymp-2.81
AbsMono-1.32* AbsEos-0.10 AbsBaso-0.03
___ 07:00AM BLOOD Plt ___
___ 06:56AM BLOOD Plt ___
___ 05:44PM BLOOD Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:42AM BLOOD Plt ___
___ 01:59AM BLOOD Plt ___
___ 09:37AM BLOOD ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD ___ PTT-24.6* ___
___ 12:05AM BLOOD Plt ___
___ 10:17PM BLOOD Plt ___
___ 03:22PM BLOOD Plt ___
___ 12:00PM BLOOD Plt ___
___ 05:09AM BLOOD Plt Ct-78*
___ 05:09AM BLOOD ___ PTT-24.1* ___
___ 04:00AM BLOOD Plt Ct-93*
___ 03:49AM BLOOD ___ PTT-22.7* ___
___ 07:43AM BLOOD Plt ___
___ 10:07AM BLOOD Plt ___
___ 04:08AM BLOOD Plt ___
___ 04:08AM BLOOD ___ PTT-24.3* ___
___ 09:30PM BLOOD Plt ___
___ 08:13PM BLOOD Plt Ct-UNABLE TO
___ 04:20PM BLOOD Plt ___
___ 02:04PM BLOOD Plt Smr-VERY LOW* Plt Ct-80*
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD ___ PTT-23.9* ___
___ 10:05PM BLOOD Plt ___
___ 10:05PM BLOOD ___ PTT-22.8* ___
___ 03:49AM BLOOD ___ 04:00AM BLOOD Ret Aut-2.8* Abs Ret-0.05
___ 07:00AM BLOOD Glucose-89 UreaN-7 Creat-0.6 Na-139 K-3.9
Cl-101 HCO3-25 AnGap-13
___ 06:56AM BLOOD Glucose-92 UreaN-6 Creat-0.5 Na-137 K-3.8
Cl-97 HCO3-25 AnGap-15
___ 06:50AM BLOOD Glucose-92 UreaN-7 Creat-0.6 Na-135 K-3.8
Cl-99 HCO3-25 AnGap-11
___ 06:42AM BLOOD Glucose-99 UreaN-8 Creat-0.6 Na-137 K-4.2
Cl-100 HCO3-26 AnGap-11
___ 01:59AM BLOOD Glucose-101* UreaN-8 Creat-0.6 Na-135
K-4.1 Cl-98 HCO3-26 AnGap-11
___ 07:25AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-137
K-4.6 Cl-101 HCO3-25 AnGap-11
___ 07:25AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-137
K-4.6 Cl-101 HCO3-25 AnGap-11
___ 12:05AM BLOOD Glucose-120* UreaN-9 Creat-0.6 Na-135
K-4.3 Cl-102 HCO3-25 AnGap-8*
___ 10:17PM BLOOD Glucose-117* UreaN-9 Creat-0.7 Na-135
K-4.5 Cl-102 HCO3-25 AnGap-8*
___ 03:22PM BLOOD Glucose-128* UreaN-11 Creat-0.9 Na-136
K-4.3 Cl-101 HCO3-25 AnGap-10
___ 05:09AM BLOOD Glucose-168* UreaN-12 Creat-0.9 Na-136
K-3.4* Cl-104 HCO3-22 AnGap-10
___ 01:58AM BLOOD Glucose-269* UreaN-8 Creat-0.7 Na-131*
K-3.5 Cl-97 HCO3-14* AnGap-20*
___ 04:08AM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-134*
K-3.9 Cl-99 HCO3-27 AnGap-8*
___ 05:45AM BLOOD Glucose-111* UreaN-10 Creat-0.8 Na-139
K-4.5 Cl-104 HCO3-21* AnGap-14
___ 10:05PM BLOOD Glucose-127* UreaN-10 Creat-1.0 Na-142
K-4.5 Cl-104 HCO3-21* AnGap-17
___ 04:08AM BLOOD ALT-24 AST-39 LD(LDH)-238 AlkPhos-63
TotBili-0.6
___ 10:05PM BLOOD ALT-31 AST-61* AlkPhos-66 TotBili-0.2
___ 07:00AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0
___ 06:56AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.0
___ 06:50AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.0
___ 06:42AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.2
___ 01:59AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.2
___ 07:25AM BLOOD Calcium-7.8* Phos-2.2* Mg-2.2
___ 12:05AM BLOOD Calcium-7.7* Phos-2.6* Mg-1.7
___ 10:17PM BLOOD Calcium-7.6* Phos-2.9 Mg-1.8
___ 03:22PM BLOOD Calcium-7.4* Phos-3.2 Mg-1.8
___ 05:09AM BLOOD Calcium-7.0* Phos-4.5 Mg-2.2
___ 04:08AM BLOOD Albumin-3.6 Calcium-8.4 Phos-2.7 Mg-1.9
___ 05:45AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.8
___ 10:05PM BLOOD Albumin-4.0 Calcium-8.8 Phos-4.5 Mg-2.0
___ 10:05PM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 05:31AM BLOOD Type-ART pO2-170* pCO2-45 pH-7.32*
calTCO2-24 Base XS--3
___ 04:00AM BLOOD Type-ART Rates-___/ Tidal V-600 PEEP-5
FiO2-50 pO2-210* pCO2-44 pH-7.29* calTCO2-22 Base XS--4
Intubat-INTUBATED Vent-CONTROLLED
___ 05:31AM BLOOD Lactate-2.0
___ 04:00AM BLOOD Glucose-272* Lactate-4.9* K-3.2*
calHCO3-22
___ 02:10AM BLOOD Lactate-14.0*
___ 10:14PM BLOOD Lactate-2.5*
___ 09:00AM BLOOD Hgb-11.0* calcHCT-33
___ 04:00AM BLOOD Hgb-5.2* calcHCT-16 O2 Sat-96
___ 04:00AM BLOOD freeCa-1.09*
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, Neuts {Neutrophil count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, 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}, 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}, 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}, 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}, 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}, 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}, 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}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, pH {pH measurement}, pH {pH measurement}, Glucose {Glucose measurement, blood}, K {Blood potassium measurement}, Hgb {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, Hgb {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Mr. ___ is a ___ male with Past Medical History
significant for untreated Hep C, EtOH substance use disorder,
polysubstance use disorder who presented to ___ s/p witnessed
fall 5' into pit at ___ station. He was found to have multiple
left rib fx (___), liver, spleen, & left kidney lacerations.
eFAST w/ positive fluid in RUQ, CT scan with fluid in pelvis. He
was admitted to the trauma surgery icu for close monitoring. He
underwent serial abdominal exams, Q6H CBC and Phenobarbital
loading for ETOH prophylaxis. His hematocrit remained relatively
stable and he was called out to the floor on HD 2. He was stable
on the floor until HD 4 when he acutely decompensated with
tachycardia to the 140s with SBP ___. We gained access and took
him to the operating room emergently for an exploratory
laparotomy where he underwent a splenectomy. He received 5uprbc
total, 1 uffp. He was stabilized, extubated in the pacu and
transferred back to the floor for further management.
On
___ - discharged. Tolerating regular diet. Passing flatus
and having bowel movements. Patient received post splenectomy
vaccines on discharge with instruction to follow up with PCP for
continuous booster shots. Midline abdominal Staples to be
removed in clinic.
___ Tolerating clears and some limited regular diet.
Ambulating independently .
___ Advanced diet to regular, H/H stable. ambulating with
RN. reassess needs.
___ 1 unit PRBCs for Hct 21. post tx Hct: 24.2 ,
suppository, small liquid BM
___ blood cx, u cx pending, UA neg, walking with walker,
___ consult, oxy ___ q4hr
___ foley/JP DC
___ Temp 101.8 at ___. Resolved with Tylenol. CBC, CXR,
blood cx, UA sent stat
___ tachy 130s, SBP ___, 1L fluid, 2 uprbc, OR ex lap
###RESPONSE: Hep C {Viral hepatitis type C}, EtOH substance use disorder {Alcohol abuse}, polysubstance use disorder {Polysubstance abuse}, fall {Falls}, left {Bone structure of left rib}, rib fx {Fracture of rib}, liver {Laceration of liver}, spleen {Laceration of spleen}, left kidney lacerations {Laceration of left kidney}, eFAST {Focused assessment with ultrasonography for trauma}, RUQ {Structure of right upper quadrant of abdomen}, CT scan {Computed tomography}, pelvis {Structure of pelvis}, monitoring {Monitoring response to treatment}, abdominal exams {Examination of abdomen}, CBC {Complete blood count}, prophylaxis {Preventive procedure}, hematocrit remained relatively
stable {Stable hematocrit}, tachycardia {Tachycardia}, exploratory
laparotomy {Exploratory laparotomy}, splenectomy {Splenectomy}, extubated {Removal of endotracheal tube}, regular diet {Normal diet}, Passing flatus {Passing flatus}, splenectomy {Splenectomy}, vaccines {Administration of vaccine to produce active immunity}, Staples to be
removed {Removal of staples}, clinic {Outpatient care management}, regular diet {Normal diet}, Ambulating independently {Independent walking}, regular {Normal diet}, stable {Patient's condition stable}, ambulating {Fully mobile}, blood cx {Blood culture}, u cx {Urine culture}, UA {Urinalysis}, walking with walker {Does mobilize using walker}, Temp {Body temperature finding}, CBC {Complete blood count}, CXR {Plain chest X-ray}, blood cx {Blood culture}, UA {Urinalysis}, tachy {Tachycardia}, fluid {Administration of fluid 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:
The Preadmission Medication list is accurate and complete.
1. Methadone 80 mg PO DAILY
2. ProAir HPA - 2 puffs, every 4 hours as needed for wheezing
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. HydrOXYzine 25 mg PO TID Anxiety
Take 1 capsule three times as needed for anxiety
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
5. ProAir HFA (albuterol sulfate) Other inhalation Other
2 PUFFS , EVERY 4 HOURS AS NEEDED FOR WHEEZING
6. Methadone 80 mg PO DAILY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
1. Nondisplaced fracture posterior left 12th rib,
2. Mildly displaced, comminuted fracture posterior left ___ &
11th ribs
3. Mildly displaced fracture posterolateral left 9th rib
4. Nondisplaced fracture anterolateral left 8th rib
5. Left kidney laceration (possible extension to renal pelvis &
collecting system)
6. Multiple splenic lacerations
7. Peripheral inferior liver laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: Nondisplaced fracture {Undisplaced fracture}, left {Bone structure of left rib}, 12th rib {Bone structure of twelfth rib}, displaced {Fracture with displacement}, comminuted fracture {Fracture, comminuted}, left {Bone structure of left rib}, 11th ribs {Bone structure of eleventh rib}, displaced fracture {Fracture with displacement}, left {Bone structure of left rib}, 9th rib {Bone structure of ninth rib}, Nondisplaced fracture {Undisplaced fracture}, left {Bone structure of left rib}, 8th rib {Bone structure of eighth rib}, Left kidney laceration {Laceration of left kidney}, renal pelvis {Renal pelvis structure}, splenic lacerations {Laceration of spleen}, liver laceration {Laceration of liver}, 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 Acute Care Surgery Service on ___
after a fall sustaining left sided rib fractures, and injuries
to you spleen, liver, and left kidney. You had a large bleed
from your spleen and therefore you were taken to the operating
room and had it removed. Your spleen is important for your
immune system to function and therefore you were given vaccines
(Influenza. PCV13, Menactra, HIB) prior to leaving the hospital.
You should follow up with your primary care provider for ongoing
vaccines.
You are now doing better, tolerating a regular diet, having
bowel function (gas and bowel movements) and pain is better
controlled.
You are now ready to be discharged to home with the following
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 in 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.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Liver/ Spleen lacerations:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
###RESPONSE: fall {Falls}, left sided {Bone structure of left rib}, rib fractures {Fracture of rib}, injuries {Traumatic or non-traumatic injury}, spleen {Splenic structure}, liver {Liver structure}, left kidney {Traumatic injury of left kidney}, bleed {Bleeding}, spleen {Splenic structure}, removed {Splenectomy}, spleen {Splenic structure}, immune system {Structure of immune system}, vaccines {Administration of vaccine to produce active immunity}, regular diet {Normal diet}, pain {Pain}, chest pain {Chest pain}, pressure {Tight chest}, squeezing {Squeezing chest pain}, tightness {Tight chest}, cough {Cough}, shortness of breath {Dyspnea}, wheeze {Wheezing}, vomiting {Vomiting}, cannot keep down fluids {Nausea and vomiting}, 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}, ambulate {Ambulation training}, increased pain {Increased pain}, swelling {Swelling}, redness {Redness of skin over lesion}, drainage {Discharge}, incision
site {Surgical incision wound}, surgical incisions {Surgical incision wound}, injury {Traumatic or non-traumatic injury}, abdominal {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, dizzy {Dizziness}, lightheaded {Lightheadedness}, feeling as if you
are going to pass out {Feeling faint}, sign {Sign}, bleeding {Bleeding}, liver {Injury of liver}, spleen injury {Injury of spleen} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
abdominal pain
Major Surgical or Invasive Procedure:
___ - exploratory laparotomy, ileotomy, gallstone removal
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, abdominal pain {Abdominal pain}, exploratory laparotomy {Exploratory laparotomy}, ileotomy {Ileotomy}, gallstone removal {Cholelithotomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 dementia transfered from OSH with a 3-day history of
nausea and vomiting. Per patient/family report, pt developed
nausea with a few episodes of nonbloody, nonbilious emesis three
days ago. He became progressively weaker in the setting of
almost no oral intake during this time. The patient and family
otherwise deny complaints of abdominal pain, fevers/chills,
diarrhea, or hematochezia. He cannot recall his last bowel
movement, but feels he has not passed stool or flatus in at
least 48 hours. He presented to ___ last evening
for evaluation, and CT imaging revealed findings consistent with
gallstone ileus causing small bowel obstruction. He was
transfered to ___ for further management.
On arrival to ___, pt was found to be tachycardic (HR 115)
with mild hypotension (SBP 90), for which he was started on IVF
resuscitation. During placement of a nasogastric tube the pt
vomited, suffering a concomitant aspiration. He subsequently
developed respiratory distress and eventually required
intubation after failing noninvasive support.
###RESPONSE: dementia {Dementia}, nausea and vomiting {Nausea and vomiting}, nausea {Nausea}, emesis {Vomiting}, no oral intake {Inadequate oral intake}, abdominal pain {Abdominal pain}, fevers {Fever}, chills {Chill}, diarrhea {Diarrhea}, hematochezia {Hematochezia}, bowel
movement {Altered bowel function}, not passed stool or flatus {Constipation}, evaluation {Evaluation procedure}, CT imaging {Computed tomography}, gallstone ileus {Gallstone ileus}, small bowel obstruction {Small bowel obstruction}, tachycardic {Tachycardia}, hypotension {Low blood pressure}, IVF
resuscitation {Resuscitation using intravenous fluid}, placement of a nasogastric tube {Insertion of nasogastric tube}, vomited {Vomiting}, aspiration {Pulmonary aspiration}, respiratory distress {Respiratory distress}, intubation {Insertion of endotracheal tube} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PMH: HTN, Dementia, HLD
PSH: denies
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, Dementia {Dementia}, HLD {Hyperlipidemia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
N/C
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Admission Exam:
Vitals: 98.9 110 105/68 18 95% facemask
GEN: NAD. Alert w/ mild confusion.
HEENT: No scleral icterus. Mucous membranes dry.
CV: Reg rhythm but tachycardic.
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender to deep palpation.
DRE: Normal tone. No gross blood. Heme-occult negative.
Ext: ___ warm with palpable DP pulses and no edema.
Physical examination upon discharge: ___:
Vital signs: t=97.9, bp=135/80, hr=72, rr=20
General: Sitting comfortably in chair
CV: Ns1, s2, -3, -s4
LUNGS: Clear
ABDOMEN: soft, non-tender, midline incision with steri-strips
EXT: no pedal edema bil., + dp bil., no calf tenderness bil
NEURO: oriented to name, disoriented to time, place,
cooperative, follows commands
###RESPONSE: Vitals {Vital signs finding}, GEN {General examination of patient}, NAD {No abnormality detected}, Alert {Mentally alert}, confusion {Clouded consciousness}, HEENT {Physical examination procedure}, scleral icterus {Scleral icterus}, Mucous membranes dry {Mucous membrane dryness}, CV {Cardiovascular physical examination}, Reg rhythm {Finding of regularity of heart rhythm}, tachycardic {Tachycardia}, PULM {Examination of respiratory system}, Clear to auscultation b/l {Normal breath sounds}, ABD {Examination of abdomen}, Soft {Abdomen soft}, nondistended {Normal abdominal contour}, nontender {Abdominal tenderness}, palpation {Palpation}, Heme-occult negative {Occult blood not detected in feces}, Ext {Examination of limb}, warm {Warm skin}, palpable DP pulses {Dorsalis pulse present}, edema {Edema}, Sitting {Sitting position}, Clear {Normal breath sounds}, soft {Abdomen soft}, midline incision {Midline incision}, pedal edema {Edema of foot}, calf tenderness {Pain in calf}, oriented to name {Oriented to person}, disoriented to time {Disorientated in time}, place {Disorientated in place} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 06:55AM BLOOD WBC-6.9 RBC-3.84* Hgb-11.8* Hct-37.3*
MCV-97 MCH-30.8 MCHC-31.7 RDW-12.9 Plt ___
___ 06:55AM BLOOD Glucose-110* UreaN-20 Creat-0.9 Na-140
K-3.9 Cl-111* HCO3-22 AnGap-11
___ 06:55AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.0
___ 01:55PM BLOOD WBC-7.2 RBC-3.83* Hgb-11.9* Hct-37.3*
MCV-98 MCH-31.1 MCHC-31.9 RDW-12.9 Plt ___
___ 02:06AM BLOOD WBC-12.5* RBC-3.40* Hgb-10.5* Hct-32.3*
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.2 Plt ___
___ 07:15PM BLOOD WBC-6.0 RBC-4.26* Hgb-13.6* Hct-41.6
MCV-98 MCH-32.0 MCHC-32.7 RDW-13.3 Plt ___
___ 09:21AM BLOOD WBC-5.0 RBC-4.57* Hgb-14.3 Hct-42.9
MCV-94 MCH-31.3 MCHC-33.4 RDW-12.9 Plt ___
___ 01:20AM BLOOD WBC-5.4 RBC-5.06 Hgb-16.1 Hct-46.7 MCV-92
MCH-31.8 MCHC-34.5 RDW-12.8 Plt ___
___ 01:57AM BLOOD Neuts-69 Bands-5 Lymphs-12* Monos-7 Eos-0
Baso-0 ___ Metas-5* Myelos-2*
___ 01:55PM BLOOD Plt ___
___ 02:16AM BLOOD Plt ___
___ 12:34AM BLOOD ___ PTT-28.6 ___
___ 01:20AM BLOOD ___ PTT-28.6 ___
___ 01:55PM BLOOD Glucose-130* UreaN-21* Creat-1.0 Na-140
K-4.7 Cl-108 HCO3-19* AnGap-18
___ 02:16AM BLOOD Glucose-116* UreaN-22* Creat-0.9 Na-140
K-3.6 Cl-108 HCO3-19* AnGap-17
___ 01:54AM BLOOD Glucose-115* UreaN-25* Creat-1.0 Na-143
K-3.8 Cl-110* HCO3-25 AnGap-12
___ 07:15PM BLOOD Glucose-142* UreaN-77* Creat-1.5* Na-137
K-3.7 Cl-106 HCO3-23 AnGap-12
___ 09:21AM BLOOD Glucose-133* UreaN-91* Creat-1.8* Na-139
K-3.9 Cl-105 HCO3-23 AnGap-15
___ 01:20AM BLOOD Glucose-162* UreaN-102* Creat-2.1* Na-134
K-3.6 Cl-97 HCO3-21* AnGap-20
___ 06:04PM BLOOD CK(CPK)-25*
___ 10:04PM BLOOD Lipase-49
___ 01:08AM BLOOD CK-MB-1 cTropnT-0.40*
___ 02:00AM BLOOD cTropnT-0.68*
___ 06:04PM BLOOD CK-MB-1 cTropnT-0.78*
___ 01:55PM BLOOD Calcium-8.6 Phos-2.8 Mg-2.1
___ 02:16AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0
___ 01:57AM BLOOD Triglyc-254*
___ 10:04PM BLOOD Cortsol-28.3*
___ 08:30AM BLOOD Vanco-20.3*
___ 01:20AM BLOOD freeCa-1.09*
___ 06:51PM BLOOD freeCa-1.17
___: EKG:
Sinus rhythm. A-V conduction delay. Inferior myocardial
infarction, age
indeterminate. No previous tracing available for comparison.
___: chest x-ray:
1. Enlarged aortic arch and extensively calcified aortic arch,
worrisome for aneurysmal dilatation. If warranted by clinical
situation, further evaluation could be performed with Chest CTA.
2. Reticular pulmonary opacities, most compatible with chronic
lung disease.
3. Bibasilar atelectasis
___: chest x-ray:
FINDINGS: New right internal jugular line tip is at lower
SVC/cavoatrial
junction approximately 3.2 cm from the carina. Orogastric tube
courses below the diaphragm and ends into the body of the
stomach and is appropriately positioned. Since prior radiograph
acquired several hours apart, bibasilar atelectasis persists
with interval worsening on the right side and unchanged on the
left side. Small pleural effusion on the right side is similar.
Upper lungs are clear. There is no pneumothorax. Heart size,
mediastinal and hilar contours have stable appearance.
___: EKG:
Supraventricular rhythm at the upper limits of normal rate with
P-R interval
prolongation. Low amplitude P waves merged with the T wave.
Cannot rule out atrial tachycardia with 2:1 block. RSR' pattern
in leads V1-V2. Q waves in leads III and aVF - consider inferior
myocardial infarction. Since the previous tracing the rate is
faster. The P-R interval is longer with a difference in the P
wave which may be related to fusion with a T wave.
Clinical correlation is suggested.
TRACING #1
___: ECHO:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global systolic function. The left ventricle is
compressed by a severely dilated and hypokinetic right
ventricle. The RV apical function is relatively preserved which
is a non-specific sign but could be due to pulmonary embolism.
Moderate tricuspid regurgitation and at least moderate pulmonary
hypertension.
___: EKG:
Sinus bradycardia with sinus arrhythmia and P-R interval
prolongation.
Prolonged Q-T interval. Borderline low precordial QRS votlage. T
wave
inversions in leads VI-V4 and in the inferior leads. Slightly
delayed anterior R wave progression - cannot exclude prior
anteroseptal myocardial infarction.
Compared to the previous tracing of ___ T wave inversion is
more prominent in leads II and V3. RSR' pattern has resolved,
likely due to changes in electrode placement. Anterior R wave
progression has improved.An ongoing inferior and anterior
ischemic process cannot be excluded. Clinical correlation is
suggested
___: chest x-xay:
Moderate cardiomegaly is stable. Left lower lobe retrocardiac
consolidation and ill-defined opacities in the right mid and
lower lungs are stable, concerning for aspiration. There are no
new lung abnormalities, pneumothorax or enlarging pleural
effusions. Lines and tubes are in unchanged standard
position
___: x-ray of the abdomen:
IMPRESSION: Findings consistent with resolving small-bowel
obstruction from ___ with decreased gaseous distention of the
small bowel and progression of oral contrast into the proximal
colon.
___: cat scan of abdomen and chest:
Multifocal pneumonia/aspiration pneumonia within the right
upper, middle,
and lower lobes.
2. Small bilateral pleural effusions with associated
atelectasis.
3. Fusiform infrarenal abdominal aortic aneurysm as well as
aneurysmal
dilatation of the right common iliac artery and a saccular
aneurysm arising off the right internal iliac artery with
significant mural thrombus.
4. Dilatation of loops of small bowel within the left abdomen
and pelvis.
The degree of small bowel dilatation overall has generally
decreased and this likely reflects a persistent ileus, although
a partial small bowel obstruction is not entirely excluded.
5. Enlarged right hilar lymph node presumably reactive.
Following resolution of acute symptoms a follow-up Chest CT is
recommended.
6. Emphysema.
7. Pulmonary arterial hypertension.
8. Probably duodenal lipoma
___: EKG:
Sinus bradycardia. P-R interval prolongation. Borderline low
limb lead
voltage. Mild Q-T interval prolongation. Early R wave
progression.
RSR' pattern in lead V1. Borderline intraventricular conduction
delay.
ST-T wave abnormalities. Since the previous tracing of ___
the Q-T interval is now shorter. Otherwise, unchanged.
TRACING #1
___: EKG:
Probable sinus rhythm with atrial premature beats. Since the
previous tracing the rate has increased. Atrial ectopy is new.
The QRS complex is narrower. ST-T wave abnormalities are less
prominent.
___: chest x-ray:
FINDINGS: As compared to the previous radiograph, the known
multifocal
pneumonia, with a maximum manifestation at the right lung base,
is unchanged in extent and severity. Unchanged moderate
cardiomegaly without pulmonary edema. Unchanged monitoring and
support devices. No newly appeared focal parenchymal opacities.
___: chest x-ray:
Compared to the prior radiograph, there has been no change.
Right sided
extensive opacities remain. Left-sided patchy opacities also
remain. Moderate cardiomegaly and areas of atelectasis
bilaterally is unchanged. Right-sided IJ terminates in the
mid-to-distal SVC.
___: chest x-ray:
Rotated lordotic positioning. Allowing for this, the
cardiomediastinal
silhouette is likely stable. There are patchy opacities at the
right and left bases, similar, possibly minimally improved,
compared with ___ at 5:46 a.m. Doubt CHF. No gross
effusion.
___ 5:01 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
___ 12:29 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
___ 8:28 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___:
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, 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}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, 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}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Triglyc {Triglycerides measurement}, EKG {Electrocardiographic procedure}, Sinus rhythm {Sinus rhythm}, A-V conduction delay {Atrioventricular block}, Inferior myocardial
infarction {Inferior myocardial infarction on electrocardiogram}, Enlarged aortic arch {Abnormality of aortic arch}, aortic arch {Aortic arch structure}, aneurysmal dilatation {Aneurysm}, evaluation {Evaluation procedure}, Chest CTA {Computed tomography angiography of chest with contrast}, pulmonary {Examination of respiratory system}, opacities {Abnormally opaque structure}, chronic
lung disease {Chronic lung disease}, Bibasilar {Structure of base of lung}, atelectasis {Atelectasis}, chest x-ray {Plain chest X-ray}, lower
SVC {Structure of low superior vena cava}, carina {Structure of carina of trachea}, diaphragm {Diaphragm structure}, stomach {Stomach structure}, radiograph {Plain radiography}, bibasilar {Structure of base of lung}, atelectasis {Atelectasis}, pleural effusion {Pleural effusion}, Upper lungs {Structure of upper zone of lung}, are clear {Normal lung}, pneumothorax {Pneumothorax}, Heart {Heart structure}, mediastinal {Mediastinal structure}, stable appearance {Patient's condition stable}, upper limits of normal rate {Measurement finding above reference range}, P-R interval
prolongation {Prolonged PR interval}, Low amplitude P waves {Flattened P wave}, atrial tachycardia {Atrial tachycardia}, 2:1 block {Electrocardiogram: partial atrioventricular block - 2:1}, RSR' pattern
in leads V1-V2 {rSr pattern in V1 and V2}, leads III {Lead III}, inferior
myocardial infarction {Inferior myocardial infarction on electrocardiogram}, P-R interval is longer {Prolonged PR interval}, Mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, left ventricle {Left cardiac ventricular structure}, hypokinetic right
ventricle {Hypokinetic right ventricular wall}, RV apical {Structure of apex of right ventricle}, pulmonary embolism {Pulmonary embolism}, Moderate tricuspid regurgitation {Moderate tricuspid valve regurgitation}, moderate pulmonary
hypertension {Moderate pulmonary hypertension}, EKG {Electrocardiographic procedure}, Sinus bradycardia {Sinus bradycardia}, sinus arrhythmia {Nodal rhythm disorder}, P-R interval
prolongation {Prolonged PR interval}, Prolonged Q-T interval {Prolonged QT interval}, low precordial QRS votlage {Low QRS voltages in the precordial leads}, T
wave
inversions {Inverted T wave}, delayed anterior R wave progression {Electrocardiographic R wave abnormal}, anteroseptal myocardial infarction {Anteroseptal infarction on electrocardiogram}, T wave inversion {Inverted T wave}, leads II {Lead II}, RSR' pattern {rSr pattern in V1 and V2}, Anterior R wave
progression {Electrocardiographic R wave abnormal}, improved {Patient's condition improved}, anterior
ischemic {Electrocardiographic anterior ischemia}, cardiomegaly {Cardiomegaly}, stable {Patient's condition stable}, Left lower lobe {Structure of lower lobe of left lung}, consolidation {Lung consolidation}, opacities {Abnormally opaque structure}, lower lungs {Structure of lower lobe of lung}, stable {Patient's condition stable}, aspiration {Aspiration pneumonia}, lung abnormalities {Imaging of lung abnormal}, pneumothorax {Pneumothorax}, pleural
effusions {Pleural effusion}, small-bowel
obstruction {Small bowel obstruction}, gaseous distention {Abdominal distension, gaseous}, small bowel {Structure of small intestine}, progression of oral contrast {Diagnostic radiography with oral contrast}, proximal
colon {Ascending colon structure}, pneumonia {Pneumonia}, aspiration pneumonia {Aspiration pneumonia}, right
upper, middle,
and lower lobes {Right lung structure}, bilateral pleural effusions {Bilateral pleural effusion}, atelectasis {Atelectasis}, infrarenal abdominal aortic aneurysm {Aneurysm of infrarenal abdominal aorta}, aneurysmal
dilatation {Aneurysm}, right common iliac artery {Structure of right common iliac artery}, saccular
aneurysm {Saccular aneurysm}, right internal iliac artery {Structure of right internal iliac artery}, mural thrombus {Mural thrombus}, Dilatation {Dilatation}, small bowel {Structure of small intestine}, left abdomen {Structure of left side of abdomen}, pelvis {Structure of pelvis}, small bowel {Structure of small intestine}, partial small bowel obstruction {Partial obstruction of small bowel}, Enlarged right hilar lymph node {Localized enlarged lymph nodes}, Chest CT {Computed tomography of chest}, Emphysema {Emphysema}, Pulmonary arterial hypertension {Pulmonary hypertensive arterial disease}, duodenal {Duodenal structure}, lipoma {Lipoma}, EKG {Electrocardiographic procedure}, Sinus bradycardia {Sinus bradycardia}, P-R interval prolongation {Prolonged PR interval}, low
limb lead
voltage {Low QRS voltages in the limb leads}, Q-T interval prolongation {Prolonged QT interval}, R wave
progression {Electrocardiographic R wave abnormal}, RSR' pattern in lead V1 {rSr pattern in V1 and V2}, ST-T wave abnormalities {Nonspecific ST-T abnormality on electrocardiogram}, Q-T interval is now shorter {Shortened QT interval}, EKG {Electrocardiographic procedure}, sinus rhythm {Sinus rhythm}, atrial premature beats {Atrial premature complex}, Atrial ectopy {Premature atrial contraction}, ST-T wave abnormalities {Nonspecific ST-T abnormality on electrocardiogram}, chest x-ray {Plain chest X-ray}, radiograph {Plain radiography}, pneumonia {Pneumonia}, right lung base {Structure of base of right lung}, cardiomegaly {Cardiomegaly}, pulmonary edema {Pulmonary edema}, monitoring {Monitoring response to treatment}, opacities {Abnormally opaque structure}, chest x-ray {Plain chest X-ray}, radiograph {Plain radiography}, opacities {Abnormally opaque structure}, opacities {Abnormally opaque structure}, cardiomegaly {Cardiomegaly}, atelectasis {Atelectasis}, SVC {Superior vena cava structure}, chest x-ray {Plain chest X-ray}, Rotated lordotic {Lordosis deformity of spine}, stable {Patient's condition stable}, opacities {Abnormally opaque structure}, bases {Structure of base of lung}, improved {Patient's condition improved}, CHF {Congestive heart failure}, effusion {Pleural effusion}, RESPIRATORY CULTURE {Respiratory microbial culture}, RESPIRATORY CULTURE {Respiratory microbial culture}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS {Methicillin resistant Staphylococcus aureus detected} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
The patient presented to the ___
___ with gallstone ileus. He had a gastric tube placed, but
was removed during transport. He was hypoxic upon admission. A
___ tube was replaced with subsequent vomitting. He
was emergently intubated and taken to the operating room on
___ for exploratory laparotomy, ileotomy and stone
extraction. He tolerated the procedure well and was transferred
to the intensive care unit for further care:
Posoperatively, the patient was hypotensive and required fluid
boluses. A NICOM was placed that showed adequate cardiac output.
He was then started on intermittent levophed, vasopressin, and
dopamine. As his hemodynamic status improved, the pressors were
weaned off by HD# 5. The patient was also noted to have a
troponin increase to 0.8 and was intermittently bradycardic. He
underwent an Echocardiogaram which showed left ventricular
hypertrophy with an ejection fraction of >55%. He was seen by
Cardiology who atributed the changes to demand ischemia. On HD#4
the patient developed an arrythmia and there was concern for a
pulmonary embolism. A CTA was performed which was negative for
a pulmonary embolism. He otherwise had no cardiovascular
issues.
During the hospital course, the patient required fluid
resuscitation and became fluid overloaded. As a result of this,
he was difficult to ventilate and had to be paralyzed and
required several ventilatory mode changes. He was started on a
lasix drip to help decrease his overload. This was discontinued
after 48 hours because of an increase in his creatinine. He
subsuequently auto-diuresised down to his dry weight. On HD #5,
he was started on tube feedings and gradually advanced to his
goal. He was slowly weaned and extubated on POD#8. He was
maintained on a face mask throught POD #9 and weaned to nasal
cannula on POD #11. He was placed on a 1 week course of zosyn
and vancomycin for his aspiration pneumonitis. His oxygen
requirement slowly resolved. He was evaluated by Speech and
Swallow to determine his ability to safely swallow without
aspiration.
On HD #5, the patient was started on tube feedings and slowly
advanced to goal. He was evaluated by Speech and Swallow who
advanced him to a soft solid diet. By POD 10 he was on a
regular diet and calorie counts were begun to measure the
magnitude of his oral intake. He was tolerating a regular diet
upon discharge.
He was transferred to the surgical floor on HD #13. His vital
signs have been stabie and he has been afebrile. His white blood
cell count has normalized and his hematocrit has been stable.
He was tolerating a regular diet. He has been evaluated by
physical therapy and recommendations made for discharge to an
extended care facility where he can futhter regain his strength
and mobility.
****Of note: x-ray of the abdomen on ___ showed enlarged
right hilar lymph node and recommendation per radiology for a
repeat cat scan in the future.
###RESPONSE: gallstone ileus {Gallstone ileus}, hypoxic {Hypoxia}, vomitting {Vomiting}, intubated {Intubation}, exploratory laparotomy {Exploratory laparotomy}, ileotomy {Ileotomy}, stone
extraction {Bile duct stone removal}, hypotensive {Low blood pressure}, fluid
boluses {Intravenous injection}, NICOM was placed {Non-invasive cardiac output monitoring}, adequate cardiac output {Normal cardiac output}, improved {Patient's condition improved}, bradycardic {Bradycardia}, Echocardiogaram {Echocardiography}, left ventricular
hypertrophy {Left ventricular hypertrophy}, demand ischemia {Ischemia co-occurrent and due to increased oxygen demand}, arrythmia {Cardiac arrhythmia}, pulmonary embolism {Pulmonary embolism}, CTA {Computed tomography angiography with contrast}, pulmonary embolism {Pulmonary embolism}, fluid
resuscitation {Resuscitation using intravenous fluid}, fluid overloaded {Hypervolemia}, lasix {Diuretic therapy}, increase in his creatinine {Creatine kinase level above reference range}, tube feedings {Tube feeding of patient}, face mask {Oxygen administration by mask}, nasal
cannula {Oxygen administration by nasal cannula}, aspiration pneumonitis {Aspiration pneumonitis}, evaluated by Speech and
Swallow {Evaluation of oral stage deglutition and pharyngeal stage deglutition}, swallow {Does swallow}, aspiration {Pulmonary aspiration}, tube feedings {Tube feeding of patient}, evaluated by Speech and Swallow {Seen by speech and language therapy service}, soft solid diet {Soft diet}, regular diet {Normal diet}, measure the
magnitude of his oral intake {Nutritional monitoring}, tolerating a regular diet {Tolerating normal diet}, afebrile {Fever}, white blood
cell count {White blood cell count}, hematocrit {Hematocrit determination}, tolerating a regular diet {Tolerating normal diet}, evaluated by
physical therapy {Physical therapy management}, x-ray of the abdomen {Diagnostic radiography of abdomen}, enlarged
right hilar lymph node {Localized enlarged lymph nodes}, cat scan {Computed tomography} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Atorvastatin 20', Amlodipine 10', Losartan 100', Vitamin B12,
ASA (unknown dosage), Exelon patch 9.5mg/24hrs
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical BID
(2 times a day) as needed for fungal infection.
3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
once a day as needed for constipation.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for systolic blood pressure <110, hr <60.
7. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stool.
12. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
13. Exelon 9.5 mg/24 hour Patch 24 hr Sig: One (1) patch
Transdermal daily ().
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
aspiration
gallstone ileus
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: aspiration {Pulmonary aspiration}, gallstone ileus {Gallstone ileus}, small bowel obstruction {Small bowel obstruction}, Mental Status {Neurological mental status determination}, Alert {Mentally alert} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 with nausea and vomitting.
You were found on cat scan to have a gallstone ileus and a small
bowel obstruction. You had a tube placed into your stomach for
decompression and you subsequently vomitted with some fluid
entering your lungs and causing pneumonia. You were taken to
the operating room where you had an exploratory laparotomy and
removal of the gallstone which was causing the obstruction. You
were monitored in the intensive care unit after the surgery
where you required intravenous medication to support your blood
pressure. You vital signs gradually improved and you were
transferred to the surgical floor. You are now preparing for
discharge where you can regain your strength and mobility.
###RESPONSE: nausea {Nausea}, cat scan {Computed tomography}, gallstone ileus {Gallstone ileus}, small
bowel obstruction {Small bowel obstruction}, stomach {Stomach structure}, decompression {Decompression}, fluid
entering your lungs {Pulmonary aspiration}, pneumonia {Pneumonia}, exploratory laparotomy {Exploratory laparotomy}, removal of the gallstone {Removal of gallstones from intestine}, obstruction {Intestinal obstruction}, surgery {Surgical procedure}, improved {Patient's condition improved} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
hypoxia
Major Surgical or Invasive Procedure:
Radiation Treatments
###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, hypoxia {Hypoxia}, Radiation {Radiation oncology AND/OR radiotherapy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ M with history of SC lung cancer s/p RLL lobectomy ___,
recent hospitalization with low back pain found to have new
lesions in spine and hip, delerium, ARI improved with IVF, MSSA
bacteremia/PNA discharged on Nafcillin to be completed ___,
presents with sudden onset hypoxia this morning, with O2 sat
dropping to 81% at rehab and associated shortness of breath. He
was placed on 4L NC at that time. Notably patient also had some
urinary retention yesterday when at the hospital to have
radiation tattooing done, had a Foley placed yesterday, and he
has had gross hematuria since. He was taken to ___
___ today where he was found to be anemic as well as to
have a UTI, and an elevated troponin to .4 in the setting of
atrial flutter/sinus tachycardia. Hct was also noted to drop
from ___. H receved asa 162 mg, oxycodone 5mg, zofran 4mg and
dilaudid 0.5 mg IV there.
.
Baseline sats at rehab have been ___ on 2L intermittently per
patient. Today sat to ___ on 2L. Notes show right leg swelling
U/S two days ago negative.
.
Initial Vitals/Trigger: 97.6 114 179/95 19 97%6L. He denies
chest pain or abdominal pain, however he does endorse shortness
of breath which has somewhat resolved since he's been placed on
a nasal cannula at 4 L.
.
EKG showed atrial flutter. He was guiaic negative. Ceftriaxone
was given at 1245. Potassium was also give 1230 ___s
Oxycodone. CTA showed b/l subsegmental PEs. CT head with old
lesions.
.
VS on transfer: afebrile 94 121/94 24 94% 2L.
.
On the floor, he denies ever having any shortness of breath, and
attributes his recent symptoms to anxiety which has resolved.
He denies any chest pain, and endorses a chronic cough which is
unchanged with occasional sputum production. His hematuria began
2 days ago, prior to that, he did not have dysuria. He denies
any f/c/n/v/diarrhea. Also has bilateral ___ edema which is new.
Denies any new problems since transfer.
###RESPONSE: SC lung cancer {Squamous cell carcinoma of lung}, RLL lobectomy {Lobectomy of lower lobe of right lung}, low back pain {Low back pain}, lesions {Lesion}, spine {Structure of vertebral column}, hip {Hip region structure}, delerium {Delirium}, improved {Patient's condition improved}, IVF {Administration of intravenous fluids}, MSSA {Infection caused by methicillin susceptible Staphylococcus aureus}, bacteremia {Bacteremia caused by Staphylococcus aureus}, PNA {Pneumonia caused by methicillin susceptible Staphylococcus aureus}, hypoxia {Hypoxia}, O2 sat
dropping to 81% {Oxygen saturation below reference range}, shortness of breath {Dyspnea}, NC {Oxygen administration by nasal cannula}, urinary retention {Retention of urine}, radiation {Radiation oncology AND/OR radiotherapy}, tattooing {Tattooing}, Foley placed {Catheterization of urinary bladder}, gross hematuria {Frank hematuria}, anemic {Anemia}, UTI {Urinary tract infectious disease}, elevated troponin {Troponin I above reference range}, atrial flutter {Atrial flutter}, sinus tachycardia {Sinus tachycardia}, IV {Intravenous therapy}, Baseline {Baseline state}, right leg swelling {Swelling of right lower limb}, U/S {Ultrasonography}, Vitals {Vital signs finding}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, shortness
of breath {Dyspnea}, resolved {Problem resolved}, placed on
a nasal cannula {Oxygen administration by nasal cannula}, EKG {Electrocardiographic procedure}, atrial flutter {Atrial flutter}, CTA {Computed tomography angiography with contrast}, PEs {Pulmonary emphysema}, CT head {Computed tomography of head}, lesions {Lesion}, VS {Vital signs finding}, afebrile {Fever}, shortness of breath {Dyspnea}, anxiety {Anxiety}, chest pain {Chest pain}, chronic cough {Chronic cough}, sputum production {Productive cough}, hematuria {Blood in urine}, dysuria {Dysuria}, f/c {Fever with chills}, n/v {Nausea and vomiting}, diarrhea {Diarrhea}, edema {Edema}, problems {Problem} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
-Squamous cell lung cancer: In remission for ___. s/p RLL
resection, no chemo, radiation.
-Head and neck cancer: Remote hx. Details unknown.
-HTN
-mild COPD
-mild carotid stenosis
-Recent echo shows mild-moderate mitral valve stenosis/aortic
stenosis with preserved EF
-hx of cardiac myxoma s/p resection with CVA
###RESPONSE: Squamous cell lung cancer {Squamous cell carcinoma of lung}, In remission {Malignant neoplasm in full remission}, RLL
resection {Lobectomy of lower lobe of right lung}, chemo {Chemotherapy}, radiation {Radiation oncology AND/OR radiotherapy}, Head and neck {Structure of head and/or neck}, cancer {Malignant neoplasm}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, carotid stenosis {Carotid artery stenosis}, echo {Echocardiography}, mild {Mild mitral valve stenosis}, moderate mitral valve stenosis {Moderate mitral valve stenosis}, aortic
stenosis {Aortic valve stenosis}, cardiac myxoma {Myxoma of heart}, resection {Resection of neoplasm of heart}, CVA {Cerebrovascular accident} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Daughter with breast cancer. Denies history of other cancers or
heart disease.
###RESPONSE: breast cancer {Malignant neoplasm of breast}, cancers {Malignant neoplasm}, heart disease {Heart disease} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ON ADMISSION:
Vitals: 98.9, 97, 111/59, 65-90s, 18, 94/4L
General: Alert, oriented, no acute distress, comfortable
appearing
HEENT: Sclera anicteric, MMM, oropharynx dry
Neck: supple, JVP elevated to earlobe
Lungs: b/l diffuse end expiratory high pitched wheeze loudest in
upper lobes
CV: tachycardic rate and reg rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, b/l ___ edema pitting in R
leg, greater than left
Neuro: CNS in tact, sensation and strength in tact upper and
lower extremities, strength in left leg limited by left hip
pain.
.
ON DISCHARGE:
Vitals: 96.5-97.6, 150-168/60-72, 76-83, ___, 94-97% 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, OP clear
Neck: supple, JVP elevated to earlobe
Lungs: b/l diffuse wheezing
CV: tachycardic rate and reg rhythm, normal S1 + S2, ___ SEM
Abdomen: soft, non-tender, non-distended, bowel sounds (+) no
rebound or guarding, no HSM
GU: foley
Ext: warm, well perfused, 2+ pulses, b/l ___ edema pitting in R
leg, greater than left
Neuro: CNS in tact, sensation and strength in tact upper and
lower extremities, strength in left leg limited by left hip
pain.
###RESPONSE: Vitals {Vital signs finding}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx {Oropharyngeal structure}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, Lungs {Examination of respiratory system}, b/l {Lung structure}, expiratory high pitched wheeze {Expiratory wheezing}, upper lobes {Structure of upper lobe of lung}, CV {Cardiovascular physical examination}, tachycardic {Tachycardia}, reg rhythm {Finding of regularity of heart rhythm}, 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}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, foley in place {Urinary catheter in situ}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, edema {Edema}, R
leg {Structure of right lower leg}, left {Structure of left lower leg}, Neuro {Neurological examination}, CNS in tact {Normal central nervous system}, sensation {Normal sensation}, upper {Upper limb structure}, lower extremities {Lower limb structure}, left leg {Structure of left lower leg}, left {Left hip region structure}, pain {Pain}, Vitals {Vital signs finding}, 2L NC {Oxygen administration by nasal cannula}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP elevated {Raised jugular venous pressure}, Lungs {Examination of respiratory system}, b/l {Lung structure}, wheezing {Wheezing}, CV {Cardiovascular physical examination}, tachycardic {Tachycardia}, reg rhythm {Finding of regularity of heart rhythm}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, SEM {Ejection murmur}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds (+) {Normal bowel sounds}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, HSM {Hepatosplenomegaly}, GU {Examination of genitourinary system}, Ext {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, edema pitting {Pitting edema}, R
leg {Structure of right lower leg}, left {Structure of left lower leg}, Neuro {Neurological examination}, CNS in tact {Normal central nervous system}, sensation {Normal sensation}, upper {Upper limb structure}, lower extremities {Lower limb structure}, left leg {Structure of left lower leg}, left {Left hip region structure}, hip
pain {Hip 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: Pertinent Results:
Admission Labs:
___ 11:48AM BLOOD WBC-15.4* RBC-3.19* Hgb-9.4* Hct-27.1*
MCV-85 MCH-29.6 MCHC-34.8 RDW-15.1 Plt ___
___ 11:48AM BLOOD Neuts-80.7* Lymphs-11.4* Monos-6.1
Eos-1.1 Baso-0.7
___ 12:00PM BLOOD ___ PTT-25.0 ___
___ 11:48AM BLOOD UreaN-22* Creat-1.5* Na-138 K-3.3 Cl-95*
HCO3-31 AnGap-15
___ 11:48AM BLOOD ALT-14 AST-21 AlkPhos-97 TotBili-0.4
___ 11:48AM BLOOD TotProt-6.9 Albumin-3.2* Globuln-3.7
Calcium-8.9
___ 11:48AM BLOOD CEA-200*
Discharge Labs:
___ 07:05AM BLOOD WBC-8.8 RBC-3.31* Hgb-9.9* Hct-29.3*
MCV-89 MCH-29.8 MCHC-33.6 RDW-15.8* Plt ___
___ 07:05AM BLOOD Glucose-147* UreaN-11 Creat-1.1 Na-135
K-4.2 Cl-96 HCO3-33* AnGap-10
___ 07:05AM BLOOD ALT-19 AST-28 LD(LDH)-265* AlkPhos-80
TotBili-0.6
___ 07:05AM BLOOD Albumin-3.0* Calcium-8.6 Phos-3.3 Mg-1.7
Imaging:
CT Chest:
IMPRESSION:
1. Pulmonary emboli in the subsegmental branches of the left
lower lobe and
anterior left upper lobe with no evidence of right heart strain
or pulmonary
infarction.
2. New patchy consolidation in the dependent portion of the
right upper lobe
likely represents pneumonia or aspiration. Ground glass
opacities in a
bronchovascular distribution in the left upper lobe may
represent multifocal
pneumonia or significant aspiration event.
.
CT Head:
IMPRESSION:
1. No brain metastases identified.
2. There is no evidence of intra- or extra-axial hemorrhage;
however, subtle
subarachnoid hemorrhage cannot be excluded on this study due to
circulating
intravenous contrast.
.
CXR:
FINDINGS: As compared to the previous radiograph, the right PICC
line was
removed. Status post right lower lobe resection with subsequent
volume loss
of the right lung. Presence of a minimal right pleural effusion
cannot be
excluded.
No newly appeared parenchymal opacities. No pulmonary edema. No
pneumonia.
Unchanged asymmetry of the tracheal course through the
mediastinum.
.
___:
IMPRESSION: Peroneal calf veins not visualized in either lower
extremities.
Otherwise, no DVT present
.
CXR:
Cardiomegaly and widened mediastinum are unchanged. Patient is
status post
right lower lobectomy. The lungs are grossly clear with the
surgical clips
projecting in the right medial upper hemithorax. Unchanged right
apical
pleural thickening and blunting of the right CP angle are likely
postoperative
changes. Aeration of the right lung has improved.
###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}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin 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}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Imaging {Imaging}, CT Chest {Computed tomography of chest}, Pulmonary emboli {Pulmonary embolism}, left
lower lobe {Structure of lower lobe of left lung}, anterior left upper lobe {Structure of anterior segment of upper division of left upper lobe of lung}, right heart {Structure of right side of heart}, pulmonary
infarction {Pulmonary infarction}, consolidation {Consolidation}, right upper lobe {Structure of bronchus of right upper lobe}, pneumonia {Pneumonia}, aspiration {Pulmonary aspiration}, Ground glass
opacities {Ground glass lung opacity}, left upper lobe {Structure of upper lobe of left lung}, pneumonia {Pneumonia}, aspiration {Pulmonary aspiration}, brain metastases {Metastatic malignant neoplasm to brain}, intra {Intracranial hemorrhage}, hemorrhage {Intracranial hemorrhage}, subarachnoid hemorrhage {Subarachnoid intracranial hemorrhage}, radiograph {Plain radiography}, right {Right atrial structure}, PICC
line was
removed {Removal of peripherally inserted central catheter}, right lower lobe resection {Lobectomy of lower lobe of right lung}, volume loss {Decreased size}, right lung {Right lung structure}, right {Right pleura structure}, pleural effusion {Pleural effusion}, opacities {Abnormally opaque structure}, pulmonary edema {Pulmonary edema}, pneumonia {Pneumonia}, mediastinum {Mediastinal structure}, Peroneal {Structure of peroneal vein}, lower
extremities {Lower limb structure}, DVT {Deep venous thrombosis}, CXR {Plain chest X-ray}, Cardiomegaly {Cardiomegaly}, widened mediastinum {Widened mediastinum}, status post {Postoperative state}, right lower lobectomy {Lobectomy of lower lobe of right lung}, lungs {Lung structure}, clear {No abnormality detected}, surgical {Surgical procedure}, right {Right thorax structure}, hemithorax {Structure of half of thorax lateral to midsagittal plane}, right
apical {Structure of apex of right lung}, pleural thickening {Thickening of pleura}, right {Structure of right common femoral artery}, CP angle {Structure of costophrenic angle}, postoperative {Postoperative state}, right lung {Right lung structure}, improved {Patient's condition improved} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ M with history of SC lung cancer s/p RLL lobectomy ___,
recent hospitalization with low back pain found to have new
lesions in spine and hip, delerium, ARI improved with IVF, MSSA
bacteremia/PNA discharged on Nafcillin to be completed ___,
presented with sudden onset hypoxia found to have bilateral
subsegmental PEs, PNA and fluid overlead.
.
ACTIVE ISSUES:
# HYPOXIA: Initial deterioration was likely ___ PE and
aspiration PNA. Patient was initially started heparin gtt then
bridged to lovenox and was initially placed on Vanco/Zosyn. As
patient became afebrile, he was placed on Augmentin and remained
afebrile. ***LAST DAY OF ANTIBIOTICS WILL BE ON ___ Hypoxic
continued despite adequate PE and PNA coverage; exam revealed
hypervolemic state. Patient was diursed with IV lasix 20mg.
Serum Bicarbonate started raising patient and diuresis
terminated. Patient was briefly off oxygen however then
restarted o2 at 2 liters. This remaining hypoxia was attributed
to PE. Patient will remain on lovenox indefinitely.
.
# LOWER EXTREMITY WEAKNESS/HIP PAIN/URINARY RETENTION: Symptoms
were attributed bony metastasis. Patient started radiation
therapy and will compelte treatments on ___. Patient was
started on steroids to help with inflammation. Patient will
remain on this dose of steroids until ___ then he can began
taper (2mg Q12h for 3 days then 2mg Q24h then off). Outpatient
oncology will reassess him to see if further treatments are
necessary. Physical therapy saw patient and recommended
rehabilitation for strength training. Foley holiday was
attempted however patient continued to have retention of urine
upto 1L. Foley was then replaced resulting in hematuria, likely
___ trauma v. radiation cystitis. Hematocrit was stable and
patient was hemodynamically stable.
.
# HYPERTENSION: Patient was markedly hypertensive during this
admission and amlodipine was started with better control of BP
.
# ELEVATED TROPONIN: Patient had initial troponin leak on
admission likely ___ tachycardia and PE; there was associated
EKG changes. No changes made to medications and no further
interventions were needed.
.
# ATRIAL FLUTTER: On initially presentation, patient was
elevated HR to 120s however with treatment of PE and continued
use of metoprolol, patient had HR returned to normal.
.
# CODE STATUS: DNR/DNI
###RESPONSE: SC lung cancer {Squamous cell carcinoma of lung}, RLL lobectomy {Lobectomy of lower lobe of right lung}, low back pain {Low back pain}, lesions {Lesion}, spine {Structure of vertebral column}, hip {Hip region structure}, delerium {Delirium}, improved {Patient's condition improved}, IVF {Administration of intravenous fluids}, MSSA {Infection caused by methicillin susceptible Staphylococcus aureus}, bacteremia {Bacteremia caused by Staphylococcus aureus}, PNA {Pneumonia caused by methicillin susceptible Staphylococcus aureus}, hypoxia {Hypoxia}, PEs {Pulmonary emphysema}, PNA {Pneumonia}, fluid overlead {Hypervolemia}, HYPOXIA {Hypoxia}, PE {Pulmonary emphysema}, aspiration PNA {Aspiration pneumonia}, afebrile {Fever}, afebrile {Fever}, ANTIBIOTICS {Antibiotic therapy}, Hypoxic {Hypoxia}, PE {Pulmonary emphysema}, PNA {Pneumonia}, hypervolemic {Hypervolemia}, diursed {Diuresis}, IV {Intravenous therapy}, lasix {Diuretic therapy}, diuresis {Diuresis}, o2 {Oxygen therapy}, hypoxia {Hypoxia}, PE {Pulmonary emphysema}, LOWER EXTREMITY WEAKNESS {Paresis of lower extremity}, HIP PAIN {Hip pain}, URINARY RETENTION {Retention of urine}, bony metastasis {Metastatic malignant neoplasm to bone}, radiation
therapy {Radiation oncology AND/OR radiotherapy}, steroids {Steroid therapy}, inflammation {Inflammatory disorder}, Outpatient {Outpatient care management}, Physical therapy {Physical therapy procedure}, rehabilitation {Rehabilitation therapy}, strength training {Exercise promotion: strength training}, Foley {Catheterization of urinary bladder}, retention of urine {Retention of urine}, Foley {Catheterization of urinary bladder}, hematuria {Blood in urine}, trauma {Injury of urinary tract proper}, radiation cystitis {Irradiation cystitis}, Hematocrit was stable {Stable hematocrit}, hemodynamically stable {Hemodynamically stable}, HYPERTENSION {Hypertensive disorder, systemic arterial}, hypertensive {Hypertensive disorder, systemic arterial}, ELEVATED TROPONIN {Troponin I above reference range}, tachycardia {Tachycardia}, PE {Pulmonary emphysema}, EKG changes {Electrocardiogram abnormal}, medications {Administration of drug or medicament}, ATRIAL FLUTTER {Atrial flutter}, elevated HR {Tachycardia}, PE {Pulmonary emphysema}, DNR {Not for resuscitation} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Medications: per ___ form
Lasix 20mg daily, last ___
KCl 20meq daily, last ___
Asa 81 mg daily, last ___
Oxycontin 20mg BID, last 6am ___
Hydralazine 50 mg BID, last ___
Calcium carbonate 1250mg PO TID last ___
Oxycodone 5mg PO Q3H prn, last ___
Ativan 1mg PO Q8H prn last ___
lidoderm 5% patch topically to left hip last ___ at 7am
iron 325mg daily
metoprolol tartrate 25 mg Tab BID
colace 100mg BID prn
senna 1 tabe BID prn
insulin humalog starting at 200 increase by 2 units every 50 up
to 400
House regular Texture, Necture thick liquid
hydrochlorothiazide 25 mg daily (stopped ___
nafcillin in D2.4W 2 gram/100 mL IV Piggy Back (stopped ___
plan to change to Dicloxacillin 500 mg qid through ___
Discharge Medications:
1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. hydralazine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours): Last dose on ___.
5. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
6. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO Q8H (every 8
hours) as needed for anxiety.
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO TID (3 times a day).
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. enoxaparin 100 mg/mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
12. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for pain.
14. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
15. insulin lispro 100 unit/mL Solution Sig: One (1) bottle
Subcutaneous QACHS: For ___ 150-200 give 2 units; if 201-250 give
4 units, if 251-300 give 6 units, for 301-350 give 8 units, if >
350 alert MD; At bed time, give 1 unit 201-250, give 2 units for
251-300, give 3 units for 301-350, alert MD for > 350.
16. guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6
hours) as needed for cough.
###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:
Pulmonary Emboli
Aspiration Pneumonia
Metastatic Lung Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
###RESPONSE: Pulmonary Emboli {Pulmonary embolism}, Aspiration Pneumonia {Aspiration pneumonia}, Metastatic {Metastatic malignant neoplasm}, Lung Cancer {Malignant tumor of lung}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, 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:
You were admitted because you were having shortness of breath.
When you were admitted you were found to have blood clots in
your lungs. You were started on a blood thinning medication to
help stabilize the clots. You will remain this medication
indefinitely. You were also diagnosed pneumonia and placed on
antibiotics. You also have fluid in your lungs which we used
lasix to help remove the fluid. You however still require oxygen
which may be a result of your the lung clots.
You began your radiation treatments while you were in the
hospital for your hip pain and urinary retention. You had 4 of
the 5 treatments and will return on ___ for your final
treatment. You will be followed by your oncologist to determine
if you need treatment. We are expecting you to start feeling
better in ___ weeks. In the mean time you will be going to an
excellent rehabilitation center to get stronger.
You continue to have urinary retention likely from your cancer.
A catheter remains in your bladder to help drain the urine.
There is some blood in your urine from the catheter insertion
and should resolve within a few days.
Please see the attached sheet for your medications. Please take
them as directed
###RESPONSE: shortness of breath {Dyspnea}, blood clots {Blood clot}, lungs {Lung structure}, blood thinning medication {Administration of anticoagulant}, clots {Blood clot}, medication {Administration of drug or medicament}, pneumonia {Pneumonia}, antibiotics {Antibiotic therapy}, fluid in your lungs {Pleural effusion}, lasix {Diuretic therapy}, lung clots {Pulmonary embolism}, radiation {Radiation oncology AND/OR radiotherapy}, hip pain {Hip pain}, urinary retention {Retention of urine}, feeling
better {Well in self}, rehabilitation {Rehabilitation therapy}, urinary retention {Retention of urine}, cancer {Malignant neoplasm}, catheter remains in your bladder {Urinary catheter in situ}, blood in your urine {Blood in urine}, catheter insertion {Catheterization of urinary bladder}, medications {Administration of drug or medicament} |
Subsets and Splits