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###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: 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:
Codeine / Quinine
Attending: ___
Chief Complaint:
non-small cell lung cancer
Major Surgical or Invasive Procedure:
video assisted cervical mediastinoscopy, flexible bronchoscopy
###RESPONSE: Codeine {Allergy to codeine}, Quinine {Allergy to quinine}, non-small cell lung cancer {Non-small cell lung cancer}, cervical mediastinoscopy {Cervical mediastinoscopy}, flexible bronchoscopy {Flexible bronchoscopy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 ___ current ___ py smoker, hx Hep C & HCC s/p
liver transplant ___, with 3cm RUL PET-avid nodule with
pathology showing non-small cell carcinoma, here for follow-up.
He has been asymptomatic since previous visit. No SOB, cough. No
fevers, chills, nightsweats. He had EBUS which biopsied lesion
showing non-small cell carcinoma. Lymph nodes were not biopsied.
PET negative for distant metastasis.
###RESPONSE: smoker {Smoker}, Hep C {Viral hepatitis type C}, HCC {Liver cell carcinoma}, liver transplant {Transplantation of liver}, RUL {Structure of upper lobe of right lung}, PET {Positron emission tomography}, nodule {Nodule}, non-small cell carcinoma {Non-small cell carcinoma}, asymptomatic {Asymptomatic}, SOB {Dyspnea}, cough {Cough}, fevers {Fever}, chills {Chill}, nightsweats {Night sweats}, biopsied {Biopsy}, lesion {Lesion}, non-small cell carcinoma {Non-small cell carcinoma}, Lymph nodes {Structure of lymph node}, biopsied {Biopsy}, PET {Positron emission tomography}, distant metastasis {Distant metastasis present} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
HEPATITIS C (genotype 1a, no sequelae of chronic liver disease
at this point, stage III fibrosis on biopsy; now s/p liver
transplant)
HEPATOCELLULAR CARCINOMA (s/p RFA on ___ to segment VIa
lesion; now s/p liver transplant)
HYPERTENSION
LUNG NODULE
DIABETES MELLITUS
H/O ALCOHOL ABUSE
H/O INTRAVENOUS DRUG ABUSE
###RESPONSE: HEPATITIS C {Viral hepatitis type C}, genotype {Genotype determination}, no sequelae {Sequelae of disorders}, chronic liver disease {Chronic liver disease}, fibrosis {Fibrosis of lung}, biopsy {Biopsy}, liver
transplant {Transplantation of liver}, HEPATOCELLULAR CARCINOMA {Hepatocellular carcinoma}, RFA {Radiofrequency ablation}, lesion {Lesion}, liver transplant {Transplantation of liver}, HYPERTENSION {Hypertensive disorder, systemic arterial}, LUNG NODULE {Nodule of lung}, DIABETES MELLITUS {Diabetes mellitus}, ALCOHOL ABUSE {Alcohol abuse}, DRUG ABUSE {Drug abuse} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Positive for a mother with stomach cancer diagnosed at age of ___
and father with diabetes and also alcoholic with diabetes and
coronary artery disease.
###RESPONSE: stomach cancer {Malignant tumor of stomach}, diabetes {Diabetes mellitus}, alcoholic {Problem drinker}, diabetes {Diabetes mellitus}, coronary artery disease {Coronary arteriosclerosis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Gen: Awake, alert, NAD
CV: +RRR
Chest: incisions and dressing over prior CT site c/d/i
Resp: Normal WOB, no distress on 2L NC; +CTAB, no wheezes or
crackles
Abdomen: Soft, non-distended, non-TTP
Ext: Warm, well-perfused
###RESPONSE: Gen {General examination of patient}, Awake {Awake}, alert {Mentally alert}, NAD {No abnormality detected}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, Chest {Examination of respiratory system}, incisions {Surgical incision wound}, dressing {Application of dressing}, Resp {Examination of respiratory system}, WOB {Labored breathing}, distress {Distress}, NC {Normal head}, CTAB {Normal breath sounds}, wheezes {Wheezing}, crackles {Respiratory crackles}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-distended {Normal abdominal contour}, TTP {Tenderness}, Ext {Examination of limb}, Warm {Warm skin}, well-perfused {Normal tissue perfusion} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ Liver Doppler US:
IMPRESSION:
1. Patent transplant hepatic vasculature with appropriate
waveforms.
2. Unremarkable appearance of the transplant liver with no
biliary dilatation.
3. Small left pleural effusion noted.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final ___:
~3000 CFU/mL Commensal Respiratory Flora.
MORAXELLA CATARRHALIS. >100,000 CFU/mL.
###RESPONSE: Liver {Liver structure}, Doppler US {Doppler ultrasonography}, transplant {Structure of transplant}, hepatic vasculature {Vascular structure of liver}, transplant {Structure of transplant}, liver {Liver structure}, biliary dilatation {Hypertrophy of bile duct}, left {Left lung structure}, pleural effusion {Pleural effusion}, GRAM STAIN {Gram stain method}, CULTURE {Microbial culture} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ presented to ___ pre-op holding on ___ and
underwent video assisted right upper lobectomy and flexible
bronchoscopy (please see operative note for details). Patient
was extubated post procedure, however in the OR, he became
dyspneic, moving minimal air. He was reintubated given his
respiratory distress and transferred to the ICU (___).
The details of his/her course are as follows:
Neuro: Given history of chronic pain on home suboxone, patient
was maintained on Tylenol and narcotics and the suboxone was
held. He was ultimately discharged with a supply of oxycodone
called to his pharmacy to last until his next appointment with
his PCP ___ ___.
CV: History of hypertension, continued on home lisinopril and
carvedilol. Remained hemodynamically stable, no active issues.
Pulm: Respiratory distress was likely secondary to lung
contusion when attempting to remove specimen, as well as post op
pain. He was extubated on POD1. He underwent bedside
bronchoscopies for clearing of mucous plugs, with BAL (___)
growing Moraxella. Both ___ drain and chest tube was put to
water seal on POD1. ___ drain was pulled on POD5, chest tube
was pulled on POD9, both with stable post pull films. His
progress was monitored with daily CXR. Encouraged IS,
ambulation.
FEN/GI: Transplant hepatology following, given his history of
___ s/p liver transplant. He was continued on home tacrolimus
dosing with monitoring of tacrolimus levels (goal ___ and LFTs.
Liver duplex was done due to persistently elevated LFTs per
hepatology recs, which showed no abnormalities. LFTs continued
to trend down. Follow up was set up with transplant hepatology
to recheck labs outpatient. Once extubated, diet was advanced as
tolerated. He tolerated a regular diet without nausea/vomiting
and was passing flatus and stool appropriately.
GU: He was able to void spontaneously without issue after foley
removal. Initial ___ with Cr 1.8 post op, which returned to his
baseline. History of CKD with baseline Cr 1.3-1.5.
Heme: H/H remained stable and he did not require any
transfusions. He was kept on prophylactic SQH while inpatient.
ID: He was treated with azithromycin x5 days for Moraxella
growing on BAL.
Dispo: He worked with physical therapy with a final
recommendation for discharge to home with home ___ services.
By day of discharge on ___, he was hemodynamically stable,
pain was well controlled on oral medications, he was tolerating
a regular diet without issue, and was ready for discharge.
###RESPONSE: right upper lobectomy {Lobectomy of upper lobe of right lung}, flexible
bronchoscopy {Flexible bronchoscopy}, extubated {Removal of endotracheal tube}, procedure {Procedure}, dyspneic {Dyspnea}, moving minimal air {Difficulty breathing}, reintubated {Intubation}, respiratory distress {Respiratory distress}, Neuro {Neurology service}, chronic pain {Chronic pain}, CV {Cardiovascular physical examination}, hypertension {Hypertensive disorder, systemic arterial}, hemodynamically stable {Hemodynamically stable}, Pulm {Examination of respiratory system}, Respiratory distress {Respiratory distress}, lung {Metastatic malignant neoplasm to lung}, contusion {Contusion}, pain {Abdominal pain}, extubated {Removal of endotracheal tube}, bronchoscopies {Bronchoscopy}, CXR {Plain chest X-ray}, GI {Structure of digestive system}, Transplant {Transplantation}, liver transplant {Transplantation of liver}, LFTs {Hepatic function panel}, Liver {Liver structure}, elevated {Elevation}, LFTs {Hepatic function panel}, abnormalities {No abnormality detected}, LFTs {Hepatic function panel}, transplant {Transplantation}, extubated {Removal of endotracheal tube}, diet {Dietary finding}, regular diet {Normal diet}, nausea/vomiting {Nausea and vomiting}, passing flatus {Passing flatus}, GU {Examination of genitourinary system}, able to void {Normal micturition}, foley
removal {Removal of urinary bladder catheter}, CKD {Chronic kidney disease}, Heme {Hematology test}, H {Hemoglobin finding}, stable {Patient's condition stable}, transfusions {Transfusion}, ID {Infectious disease}, physical therapy {Physical therapy procedure}, hemodynamically stable {Hemodynamically stable}, pain was well controlled {Demonstrates adequate pain control}, oral medications {Administration of drug or medicament via oral route}, regular diet {Normal diet}, ready for discharge {Ready for discharge} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Lisinopril 5 mg PO DAILY
2. Nicotine Patch 21 mg/day TD DAILY
3. Nicotine Polacrilex 4 mg PO Q2H:PRN cigarette craving
4. CARVedilol 25 mg PO BID
5. Tacrolimus 1.5 mg PO QAM
6. docosahexanoic acid-epa 120-180 mg oral DAILY
7. Multivitamins 1 TAB PO DAILY
8. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL BID
9. sildenafil 25 mg oral DAILY:PRN ED
10. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
11. Tacrolimus 1 mg PO QPM
12. Chantix Starting Month Box (varenicline) 0.5 mg (11)- 1 mg
(42) oral ASDIR
Discharge Medications:
1. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*12 Tablet Refills:*0
2. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL BID
Consider prescribing naloxone at discharge
3. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
4. CARVedilol 25 mg PO BID
5. Chantix Starting Month Box (varenicline) 0.5 mg (11)- 1 mg
(42) oral ASDIR
6. docosahexanoic acid-epa 120-180 mg oral DAILY
7. Lisinopril 5 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Nicotine Patch 21 mg/day TD DAILY
10. Nicotine Polacrilex 4 mg PO Q2H:PRN cigarette craving
11. sildenafil 25 mg oral DAILY:PRN ED
12. Tacrolimus 1.5 mg PO QAM
13. Tacrolimus 1 mg PO QPM
###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:
right upper lobe non-small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: right upper lobe {Structure of upper lobe of right lung}, non-small cell lung cancer {Non-small cell lung cancer}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
* You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You may need pain medication once you are home but you can
wean it over the next week as the discomfort resolves. Make
sure that you have regular bowel movements while on narcotic
pain medications as they are constipating which can cause more
problems. Use a stool softener or gentle laxative to stay
regular.
* No driving while taking narcotic pain medication.
* Take Tylenol on a standing basis to avoid more opiod use.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other
symptoms that concern you.
** If pathology specimens were sent at the time of surgery, the
reports will be reviewed with you in detail at your follow up
appointment. This will give both you and your doctor time to
understand the pathology, its implications and discuss options
going forward.**
###RESPONSE: lung {Lung structure}, surgery {Surgical procedure}, ready for discharge {Ready for discharge}, incisions {Surgical incision wound}, redness {Redness of skin over lesion}, drainage {Discharge}, draining {Discharge}, removed {Removal of dressing}, drain {Discharge}, dressing {Application of dressing}, pain medication {Administration of analgesic}, discomfort {Discomfort}, pain medications {Administration of analgesic}, constipating {Constipation}, problems {Problem}, stool softener {Administration of laxative}, regular {Normal heart rate}, while taking narcotic pain medication {Narcotics education}, incision {Surgical incision wound}, incision {Surgical incision wound}, Fevers {Fever}, chills {Chill}, shortness of breath {Dyspnea}, chest pain {Chest pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
fever
Major Surgical or Invasive Procedure:
none
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, fever {Fever} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
HISTORY OF PRESENTING ILLNESS:
Mr. ___ is a ___ male with asplenia,
polycythemia ___, and secondary AML with CNS disease s/p allo
SCT (D0 = ___ with relapsed disease s/p 3 cycles of
decitabine/venetoclax and DLI on ___ currently on ___
with recent admission for pneumonia who presents with fever.
Patient was recently admitted ___ to ___ with right lower lobe
pneumonia in the setting of neutropenia. He was treated with
14-day course of meropenem and vancomycin. Infectious work-up,
including bronchoscopy, was unrevealing. Hospitalization was
complicated by transaminitis, presumed to be due to drug-induced
liver injury, and persistent thrombocytopenia requiring several
transfusions. He was also seen by dermatology for new nodules on
his lower extremities and had a biopsy. Repeat chest imaging
prior to discharge showed resolving right lower lobe pneumonia
containing a fluid filled pneumatocele or early lung abscess. He
was discharged to complete a further 14-day course of
levofloxacin and metronidazole.
He reports fever to ___ yesterday and 101.7 the morning of
admission. He notes feeling more flushed. He also notes mild
rhinorrhea over past few days which seems to be improving as
well
as right ear discomfort. He also notes some right lung pain
which
feels different and less intense then the pain he had prior to
his last admission. The notes a mild cough, poor appetite, and
chronic right foot neuropathy.
On arrival to the ED, initial vitals were 98.3 86 113/85 20 98%
RA. Exam was unremarkable. Labs were notable for WBC 6.9 (ANC
100), H/H 7.7/24.0, Plt 12, INR 1.6, fibrinogen 761, Na 137, K
4.1, BUN/Cr ___, ALP 266, LDH 317, and lactate 1.6. Influenza
PCR was negative. CXR showed worsening right lower lobe
consolidative opacity. Patient was given cefepime 2g IV and
flagyl 500mg IV. Prior to transfer vitals were 99.2 100 122/70
16
96% RA.
On arrival to the floor, patient endorses the above history. He
has no acute issues or concerns. He headache, vision changes,
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, hemoptysis, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, and hematuria.
###RESPONSE: asplenia {Asplenia}, polycythemia {Erythrocytosis}, secondary {Metastatic malignant neoplasm}, AML {Acute myeloid leukemia}, CNS disease {Disorder of the central nervous system}, allo
SCT {Allogeneic peripheral blood stem cell transplant}, relapsed {Relapsing acute myeloid leukemia}, disease {Disease}, pneumonia {Pneumonia}, fever {Fever}, right lower lobe
pneumonia {Right lower zone pneumonia}, neutropenia {Neutropenia}, vancomycin {Antibiotic therapy}, Infectious {Infectious disease}, work-up {Evaluation procedure}, bronchoscopy {Bronchoscopy}, transaminitis {Aspartate transaminase level above reference range}, drug-induced
liver injury {Drug-induced disorder of liver}, thrombocytopenia {Thrombocytopenic disorder}, transfusions {Transfusion}, nodules {Nodule}, lower extremities {Lower limb structure}, biopsy {Biopsy}, chest imaging {Chest imaging}, right lower lobe pneumonia {Right lower zone pneumonia}, fluid {Effusion}, pneumatocele {Air cyst}, lung abscess {Abscess of lung}, fever {Fever}, mild {Symptom mild}, rhinorrhea {Nasal discharge}, right ear {Right ear structure}, discomfort {Discomfort}, right lung {Right lung structure}, pain {Pain}, pain {Pain}, mild {Symptom mild}, cough {Cough}, poor appetite {Decrease in appetite}, chronic {Chronic disease}, right foot {Structure of right foot}, neuropathy {Neuropathy}, vitals {Vital signs finding}, RA {Breathing room air}, unremarkable {No abnormality detected}, WBC {White blood cell count}, H/H {Measurement of total hemoglobin concentration and hematocrit}, INR {Calculation of international normalized ratio}, LDH {Serum total lactate dehydrogenase measurement}, lactate {Lactic acid measurement}, Influenza
PCR {Detection of Influenza A virus using polymerase chain reaction technique}, CXR {Plain chest X-ray}, right lower lobe {Structure of lower lobe of right lung}, consolidative {Lung consolidation}, opacity {Abnormally opaque structure}, vitals {Vital signs finding}, RA {Breathing room air}, headache {Headache}, vision changes {Visual disturbance}, dizziness {Dizziness}, lightheadedness {Lightheadedness}, weakness {Asthenia}, numbnesss {Numbness}, shortness of
breath {Dyspnea}, hemoptysis {Hemoptysis}, chest pain {Chest pain}, palpitations {Palpitations}, abdominal pain {Abdominal pain}, nausea/vomiting, diarrhea {Nausea, vomiting and diarrhea}, hematemesis {Hematemesis}, hematochezia {Hematochezia}, melena {Melena}, dysuria {Dysuria}, hematuria {Blood in urine} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: Initial BMBx, dx AML
- ___: Leukopheresis
- ___: Induction Therapy 7+3 cytarabine + daunorubicin
- ___: Hypercellular marrow with extensive fibrosis, 5%
blasts
- ___: IT Ara-C, TNC2 postive cytospin
- ___: Triple therapy TNC 1, negative cytospin
- ___: Triple therapy TNC 1 negative cytospin
- ___: Triple therapy TNC 1 negative cytospin
- ___: Triple therapy TNC 6 negative cytospin
- ___: Admitted for URD ablative Allogeneic stem cell
transplant with Fludarabine/Busulfan for conditioning regimen.
Day 0 = ___. Enrolled into ___.
- ___: BMBX D+24, PB Chimerism CD33 100 D, CD3 70%. BM JAK2
1%
- ___: BM Chimerism D87% (CD33 100 CD3 D68%)
- ___: BM Chimerism D91% (DCD33 100 CD3 D68%)
- ___ apheresis unsuccessful
- ___: PB chimersims D93% (CD33 100, CD3 80%)
- ___: RLE DVT started on LMWH
- ___: PB chimersims D97% (CD33 99, CD3 97%)
- ___: BMBX 8% blasts, Stoped tacrolimus
- ___: C1D1 Dacogen/Venetoclax
- ___: C2D1 Dacogen/Venetoclax
- ___: DLI
- ___: C3D1 Dacogen/Venetoclax
Polycythemia ___ as described above
-CAD status post PCI
___ Splenectomy
###RESPONSE: BMBx {Bone marrow sampling}, AML {Acute myeloid leukemia}, Leukopheresis {Leukopheresis}, Therapy {Therapy}, fibrosis {Fibrosis}, Allogeneic stem cell
transplant {Allogeneic peripheral blood stem cell transplant}, regimen {Therapeutic regimen}, BMBX {Bone marrow sampling}, Chimerism {Cellular mosaicism}, BM {Bone marrow structure}, BM {Bone marrow structure}, Chimerism {Cellular mosaicism}, BM {Bone marrow structure}, Chimerism {Cellular mosaicism}, apheresis {Apheresis}, RLE {Structure of right lower limb}, DVT {Deep venous thrombosis}, BMBX {Bone marrow sampling}, Polycythemia {Erythrocytosis}, CAD {Coronary arteriosclerosis}, status post {Postoperative state}, PCI {Percutaneous coronary intervention}, 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: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Mother with polycythemia ___.
###RESPONSE: polycythemia {Erythrocytosis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 99.6, BP 118/69, HR 89, RR 18, O2 sat 97% RA.
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, no murmurs.
LUNG: Appears in no respiratory distress, right basilar rhonchi.
ABD: Soft, non-tender, non-distended, positive bowel sounds,.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: Multiple pink-to-violaceous firm papules on bilateral
lower
extremities as well as several on bilateral upper extremities.
DISCHARGE PHYSICAL EXAM:
moderate distress apneic restless at times
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, GENERAL {General examination of patient}, distress {Distress}, lying in bed {Lying in bed}, HEENT {Physical examination procedure}, Anicteric {White sclera}, PERLL {Pupils equal, react to light and accommodation}, OP clear {Pharynx normal}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, murmurs {Murmur}, LUNG {Examination of respiratory system}, distress {Distress}, right basilar {Structure of base of right lung}, rhonchi {Wheeze - rhonchi}, ABD {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, positive bowel sounds {Normal bowel sounds}, EXT {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, edema {Edema}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, attention {Finding related to attentiveness}, sensation intact {Normal sensation}, SKIN {Examination of skin}, papules {Papule}, bilateral
lower
extremities {Both lower extremities}, bilateral upper extremities {Both upper extremities}, moderate {Symptom moderate}, distress {Distress}, apneic {Apnea}, restless {Restlessness} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 05:55PM BLOOD WBC: 6.9 RBC: 2.46* Hgb: 7.7* Hct: 24.0*
MCV: 98 MCH: 31.3 MCHC: 32.1 RDW: 16.6* RDWSD: 54.1* Plt Ct: 12*
___ 05:55PM BLOOD Neuts: 1* Lymphs: ___ Monos: 9 Eos: 1
Baso:
0 Blasts: 69* NRBC: 108.0* AbsNeut: 0.10* AbsLymp: 1.92 AbsMono:
0.62 AbsEos: 0.07 AbsBaso: 0.00*
___ 05:55PM BLOOD ___: 17.2* PTT: 30.2 ___: 1.6*
___ 05:55PM BLOOD Fibrino: ___
___ 05:55PM BLOOD Glucose: 104* UreaN: 14 Creat: 0.8 Na:
137
K: 4.1 Cl: 99 HCO3: 26 AnGap: 12
___ 05:55PM BLOOD ALT: 22 AST: 33 LD(LDH): 317* AlkPhos:
266* TotBili: 0.8
___ 05:55PM BLOOD Albumin: 3.4*
___ 06:16PM BLOOD Lactate: 1.6
DISCHARGE LABS
none-CMO
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hct {Hematocrit determination}, BLOOD Glucose {Glucose measurement, blood}, TotBili {Bilirubin, total measurement}, Lactate {Lactic acid measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Mr. ___ is a ___ male with asplenia,
polycythemia ___, and secondary AML with CNS disease s/p allo
SCT (D0 = ___ with relapsed disease s/p 3 cycles of
decitabine/venetoclax and DLI on ___ most recently on
Ivisidenib with recent admission for pneumonia who presented
with febrile neutropenia with persistent RLL pneumonia with
course c/b SVT with unfortunate overwhelming infection now
transitioned to comfort measures only and transition to home
hospice.
ACUTE CONDITIONS
====================
#RIGHT LOWER LOBE PNEUMONIA:
#FEBRILE NEUTROPENIA (Fevers persist]:
Patient is status post recent prolonged admission with right
lobe pneumonia that was concerning for possible abscess as well
as viral or fungal etiology. BAL and induced sputum studies were
negative at the time. He recently completed prolonged course of
antibiotics; however, he was re-admitted with febrile
neutropenia and persistent RLL pneumonia concerning of fungal
etiology on imaging vs. lung abscess formation per ID. Further
work up of PNA with urine legionella (neg), strep pneumo (neg),
MRSA (neg) and parvovirus (neg). Sinus CT ___ obtained for
continued sinus
pressure showed a right obstructive sinusitis. He was started on
IV Vancomycin (D1 ___ and IV Ceftaz 2gm Q8 hours
(D1 ___. Beta glucan elevated at 424, could be
false elevation, galactomannan negative. Repeat BD glucan
negative, Asp galactomannan ___ PND. MRSA negative;
therefore, vancomycin
was discontinued. Patient had continued fevers, which prompted
re-imaging on ___. Chest CT showed progression of pneumonia,
now involving majority of the right lower lobe with surrounding
ground-glass opacities. Given concern for fungal pneumonia,
patient was started on Ambisone. ID re-consulted ___, recs
biopsy and induced sputum. Per ID, would need biopsy of his RLL
consolidation but deferred in light of profound TCP and GOC.
Unfortunately, patient developed worsening pulmonary symptoms
(increased WOB ___ and tachycardia) and his
antibiotics was escalated from ceftazidime to meropenem (D1:
___. He also developed new SVT which may have
exacerbated his pulmonary symptoms. He was given Solumedrol 50mg
IVPx1 and was continued daily through ___, d/c'd as has not
been efficacious for his pulmonary symptoms. Given ongoing high
fevers, added Linezolid (D1 ___. Chest CT showed
worsening PNA on ___, after discussing the results with
primary oncologist, patient decided to transition care from
aggressive treatment to focus on symptom management and comfort.
His antibiotics were discontinued on ___ and he was started
on Morphine IV/PO for dyspnea management. He was discharged home
on ___ and after multiple discussions, agreed to home with
hospice services.
-per palliative recommendations will be discharged home with:
morphine ___ po suspension q2 prn, Ativan 0.5-1mg po q4 prn,
Tylenol ___ po prn.
#RELAPSED AML: He is s/p allogeneic SCT (D0 = ___ with
relapsed disease s/p 3 cycles of decitabine/venetoclax and DLI
on ___. BMBx ___ consistent with persistent leukemia,
based on (+)IDH1 mutation. He was started on ivosidenib ___,
and venetoclax was stopped. Patient w/ lesions to extremities
that
was concerning for leukemia cutis. Dermatology biopsied site on
___ result c/w leukemia cutis. Given persistent PNA despite
ABX and progressive disease, had GOC discussion with primary
oncologist on ___ and patient was made DNR/DNI, and on
___ as above with transition to CMO.
#DISCHARGE PLANNING: patient with difficult non compliance in
the past and patient was eager to leave the hospital ASAP ___
AM. He initially was refusing home services, including hospice
care but after discussion with RN, SW, palliative team agreed to
go home with hospice services. Initially consulted ethics and
psychiatry with concern of patient leaving AMA however after
multiple discussions with ___ team patient agreed to resuming
hospice services and abiding by recommendations. Patient had
safety evaluation before discharge and appropriate to discharge
home with hospice.
d/c planning > 30 min
###RESPONSE: asplenia {Asplenia}, polycythemia {Erythrocytosis}, secondary {Metastatic malignant neoplasm}, AML {Acute myeloid leukemia}, CNS disease {Disorder of the central nervous system}, allo
SCT {Allogeneic peripheral blood stem cell transplant}, relapsed {Relapsing acute myeloid leukemia}, disease {Disease}, pneumonia {Pneumonia}, febrile neutropenia {Febrile neutropenia}, RLL pneumonia {Right lower zone pneumonia}, SVT {Supraventricular tachycardia}, infection {Infectious disease}, comfort measures {Comfort measures}, RIGHT LOWER LOBE PNEUMONIA {Right lower zone pneumonia}, FEBRILE NEUTROPENIA {Febrile neutropenia}, Fevers {Fever}, status post {Postoperative state}, right
lobe pneumonia {Right lower zone pneumonia}, abscess {Abscess of lung}, viral {Viral disease}, fungal {Mycosis}, induced sputum {Collection of induced sputum}, antibiotics {Antibiotic therapy}, febrile
neutropenia {Febrile neutropenia}, RLL pneumonia {Right lower zone pneumonia}, fungal {Mycosis}, imaging {Imaging}, lung abscess {Abscess of lung}, PNA {Pneumonia}, urine {Evaluation of urine specimen}, legionella {Legionella infection}, MRSA {Methicillin resistant Staphylococcus aureus infection}, parvovirus {Parvovirus infection}, Sinus {Nasal sinus structure}, CT {Computed tomography}, sinus
pressure {Sensation of nasal sinus pressure}, right {Right sphenoid sinus structure}, obstructive sinusitis {Obstructive sinusitis}, Vancomycin {Antibiotic therapy}, MRSA {Methicillin resistant Staphylococcus aureus infection}, vancomycin {Antibiotic therapy}, fevers {Fever}, imaging {Imaging}, Chest CT {Computed tomography of chest}, pneumonia {Pneumonia}, right lower lobe {Structure of lower lobe of right lung}, ground-glass opacities {Ground glass lung opacity}, fungal pneumonia {Fungal pneumonia}, biopsy {Biopsy}, induced sputum {Collection of induced sputum}, biopsy {Biopsy}, RLL {Structure of lower lobe of right lung}, consolidation {Consolidation}, TCP {Thrombocytopenic disorder}, worsening pulmonary symptoms {Decreased respiratory function}, WOB {Labored breathing}, tachycardia {Tachycardia}, antibiotics {Antibiotic therapy}, SVT {Supraventricular tachycardia}, exacerbated his pulmonary symptoms {Decreased respiratory function}, pulmonary {Structure of respiratory system}, fevers {Fever}, Chest CT {Computed tomography of chest}, PNA {Pneumonia}, symptom management {Symptom management}, antibiotics {Antibiotic therapy}, dyspnea {Dyspnea}, discussions {Discussion}, RELAPSED AML {Relapsing acute myeloid leukemia}, allogeneic SCT {Allogeneic peripheral blood stem cell transplant}, relapsed {Relapsing acute myeloid leukemia}, disease {Disease}, BMBx {Bone marrow sampling}, leukemia {Leukemia}, mutation {Genetic mutation}, lesions {Skin lesion}, extremities {All extremities}, leukemia cutis {Leukemic infiltration of skin}, Dermatology biopsied {Biopsy of skin}, leukemia cutis {Leukemic infiltration of skin}, PNA {Pneumonia}, ABX {Antibiotic therapy}, disease {Disease}, discussion {Discussion}, DNR {Not for resuscitation}, non compliance {Drug compliance poor}, hospice
care {Hospice care}, discussion {Discussion}, hospice services {Hospice care}, leaving AMA {Patient self-discharge against medical advice}, discussions {Discussion}, hospice services {Hospice care}, evaluation {Evaluation procedure}, hospice {Hospice care}, d/c planning {Discharge planning} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevoFLOXacin 750 mg PO DAILY
2. Ursodiol 300 mg PO QAM
3. Ursodiol 600 mg PO QPM
4. Magnesium Oxide 800 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Isavuconazonium Sulfate 372 mg PO DAILY
7. Gabapentin 400 mg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Acyclovir 400 mg PO Q8H
11. Pentamidine-Inhalation 300 mg IH MONTHLY
12. Tibsovo (ivosidenib) 500 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. LORazepam 0.5-1 mg PO Q4H:PRN anxiety
RX *lorazepam 0.5 mg ___ tabs by mouth every 4 hours as needed
Disp #*42 Tablet Refills:*0
3. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q2H:PRN
pain/dyspnea
RX *morphine 10 mg/5 mL ___ ml by mouth every 2 hours as needed
Refills:*0
4. Gabapentin 400 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 With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=============
febrile neutropenia
AML
Pneumonia
Sinusitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: With Service {Home health aide service management}, febrile neutropenia {Febrile neutropenia}, AML {Acute myeloid leukemia}, Pneumonia {Pneumonia}, Sinusitis {Sinusitis}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Mr. ___,
You were admitted for fevers while your blood counts were low.
You were found to have persistent pneumonia which did not
improve with antibiotics. With worsening pneumonia, you
transitioned to comfort measures and supportive care. You are
not being discharge home.
Sincerely,
Your ___ team
###RESPONSE: fevers {Fever}, blood counts {Blood test}, pneumonia {Pneumonia}, antibiotics {Antibiotic therapy}, pneumonia {Pneumonia}, comfort measures {Comfort measures}, supportive care {Support} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending: ___.
Chief Complaint:
left ankle cellulitis
Major Surgical or Invasive Procedure:
none
###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, left ankle cellulitis {Cellulitis 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 female with HCV p/w 2 days of left ankle pain and redness
and also new low back/buttocks pain. She recently attempted to
clip an ingrown toenail on her left foot although she reports no
toe pain or redness. She denies fevers and chills although has
been having daily hot flashes. Denies trauma to the ankle. No
prior cellulitis or joint infections.
.
Ortho was consulted in ED in regards to question of a septic
joint. No joint aspiration was performed as clinically felt to
be low chance of joint involvement. She was given Vanco and
Cefazolin and pain control in ER.
.
Also got Cipro for + UA.
###RESPONSE: HCV {Viral hepatitis type C}, left ankle {Structure of left ankle}, pain {Pain}, redness {Redness of skin over lesion}, low back {Low back pain}, buttocks pain {Pain in buttock}, ingrown toenail {Ingrowing toenail}, left foot {Structure of left foot}, toe pain {Pain in toe}, redness {Redness of skin over lesion}, fevers {Fever}, chills {Chill}, hot flashes {Menopausal flushing}, trauma {Traumatic injury}, ankle {Structure of left ankle}, cellulitis {Cellulitis}, joint infections {Infectious disorder of joint}, septic
joint {Arthritis of knee}, joint aspiration {Arthrocentesis}, joint {Joint structure}, pain control {Pain control}, ER {Emergency treatment}, + UA {Abnormal urinalysis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
HCV
Hypertension
Hypothyroidism
h/o pneumonia at ___ yrs and ___ yrs
MR/CHF - in the setting of pneumonia
Preeclampsia
Anxiety
h/o Kidney stones
s/p C-section
Chronic pain secondary to bilateral foot deformities.
s/p removal of left breast cysts
left neck cyst removal
anemia
###RESPONSE: HCV {Viral hepatitis type C}, Hypertension {Hypertensive disorder, systemic arterial}, Hypothyroidism {Hypothyroidism}, pneumonia {Pneumonia}, MR {Mitral valve regurgitation}, CHF {Congestive heart failure}, pneumonia {Pneumonia}, Preeclampsia {Pre-eclampsia}, Anxiety {Anxiety}, Kidney stones {Kidney stone}, C-section {Cesarean section}, Chronic pain {Chronic pain}, foot deformities {Deformity of foot}, removal {Removal}, left breast {Left breast structure}, cysts {Cyst}, left neck {Structure of left half of neck}, cyst {Cyst}, removal {Removal}, anemia {Anemia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Mother with hypothyroidism. Father with hypertension and
alcoholism. Grandfather with jaw cancer. No known family history
of liver disease.
###RESPONSE: hypothyroidism {Hypothyroidism}, hypertension {Hypertensive disorder, systemic arterial}, alcoholism {Alcoholism}, jaw {Structure of left half of neck}, cancer {Malignant neoplasm}, liver disease {Disorder of liver} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS: 97.2 140/100 72 20 100%RA
GEN: Well appearing, Comfortable, NAD
HEENT: NCAT, PERRL, OP clear, no thrush
NECK: Supple, no LAD
CV: RRR, III/VI SM LSB
LUNGS: CTABL
ABD: Soft, NTND, no masses, no bruits
EXT: No ___ edema, erythema and warmth present over left ankle
and anterior leg. Slightly decreased ROM on active and passive
movement. 2+ ___ pulses. Right knee without warmth or
swelling. No palpable LNs in popliteal fossa.
BACK: No midline tenderness. Small, mobile, tender lymph nodes
palpable over bilateral iliac crests.
###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, GEN {General examination of patient}, Well appearing {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, PERRL {Pupils equal and reacting to light}, OP clear {Pharynx normal}, thrush {Candidiasis}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, SM {Systolic murmur}, LUNGS {Examination of respiratory system}, CTABL {Normal breath sounds}, ABD {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, masses {Abdominal mass}, EXT {Examination of limb}, edema {Edema}, erythema {Erythema}, warm {Warm skin}, left ankle {Structure of left ankle}, anterior leg {Skin structure of anterior surface of lower leg}, decreased ROM {Limitation of joint movement}, active {Active range of joint movement reduced}, passive
movement {Passive range of joint movement reduced}, 2+ ___ pulses {Lower limb pulse present}, Right knee {Structure of right knee region}, warm {Warm skin}, swelling {Joint swelling}, palpable {Finding by palpation}, LNs in popliteal fossa {Popliteal lymph node structure}, tenderness {Tenderness}, tender {Abdominal tenderness}, palpable {Finding by palpation}, iliac crests {Structure of iliac lymph node} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ 08:50AM BLOOD WBC-9.6
___ 10:00PM BLOOD WBC-7.1 RBC-4.00* Hgb-12.2 Hct-35.0*
MCV-88 MCH-30.6 MCHC-35.0 RDW-13.3 Plt ___
___ 10:00PM BLOOD Neuts-54.5 ___ Monos-4.9 Eos-3.8
Baso-0.6
___ 08:50AM BLOOD UreaN-13 Creat-0.9
___ 10:00PM BLOOD Glucose-118* UreaN-18 Creat-0.9 Na-141
K-4.1 Cl-107 HCO3-28 AnGap-10
___ 10:00PM BLOOD CRP-14.5*
___ 10:10PM BLOOD Lactate-1.5
___ 12:50AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
___ 12:50AM URINE RBC-0 ___ Bacteri-NONE Yeast-NONE
___
Blood and urine culture neg (urine culture was done after
antibiotics)
###RESPONSE: WBC {White blood cell count}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine 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}, URINE {Evaluation of urine specimen}, Color {Color finding}, Clear {Urine looks clear}, Protein {Measurement of protein in urine}, pH {pH measurement}, URINE {Evaluation of urine specimen}, RBC {Red blood cell count}, Blood {Blood culture}, urine culture {Urine culture}, urine culture {Urine culture}, antibiotics {Antibiotic therapy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Left ankle celluliis improved with vancomycin and pt was
discharged on keflex. Oxycodone controlled pain well.
Cipro was continued for UTI.
Patient is known to have intraabdominal lymphadenopathy in past
and has noted low back lymph nodes. She was advised to follow up
with PCP regarding further follow up.
Also she was concered of a breast mass and was advised to
discuss with PCP ___. mammogram/US.
###RESPONSE: Left ankle {Structure of left ankle}, celluliis {Cellulitis}, improved {Patient's condition improved}, vancomycin {Antibiotic therapy}, controlled pain {Demonstrates adequate pain control}, UTI {Urinary tract infectious disease}, intraabdominal lymphadenopathy {Disorder of intra-abdominal lymph nodes}, low back {Lower back structure}, lymph nodes {Structure of lymph node}, follow up {Follow-up arranged}, PCP {Primary care management}, follow up {Follow-up arranged}, breast mass {Breast lump}, PCP {Primary care management}, mammogram {Mammography}, US {Ultrasonography of bilateral breasts} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Clonazepam 1mg BID at 7PM and bedtime
Clonazepam 2 mg BID prn
Diltiazem 240mg daily
HCTZ 25mg daily
Synthroid ___ microgram daily x 6 days and then 100 microgram on
___ day
Olmesartan 40 mg daily
Darvon 65mg PRN
Prilosec OTC
Propanolol 40 mg TID
Discharge Medications:
1. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO twice a day as
needed for anxiety: Do not take with alcohol, do not drive or
use machinery while on this medicaton. Can make you drowsy. .
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY AT 7PM
(): Do not take with alcohol, do not drive or use machinery
while on this medicaton. Can make you drowsy. .
3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed: Do not take with alcohol, do not drive
or use machinery while on this medicaton. Can make you drowsy. .
4. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
5. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
6. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO 6X/WEEK
(___).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 1X/WEEK
(___).
8. Olmesartan 20 mg Tablet Sig: Two (2) Tablet PO Daily () as
needed for HTN.
9. Propranolol 40 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
10. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11. Oxycodone 5 mg Tablet Sig: ___ Tablets PO every eight (8)
hours as needed for pain: Do not take with alcohol, do not drive
or use machinery while on this medicaton. Can make you drowsy. .
Disp:*10 Tablet(s)* Refills:*0*
12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Left leg/ankle cellulitis
Urinary tract infection, bacterial likely
Lymphadenopathy
Concern for breast mass
History of hypertension and anxiety
Tobacco user
Discharge Condition:
stable
###RESPONSE: Left leg {Structure of left lower leg}, ankle {Structure of left ankle}, cellulitis {Cellulitis}, Urinary tract infection {Urinary tract infectious disease}, bacterial {Bacterial infectious disease}, Lymphadenopathy {Lymphadenopathy}, breast mass {Breast lump}, hypertension {Hypertensive disorder, systemic arterial}, anxiety {Anxiety}, Tobacco user {Tobacco user}, 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:
Return to the hospital if you have new fevers, chills, worsening
ankle swelling or pain or any new symptoms of concern to you.
Take the antibiotocs as prescribed for cellulitis.
Keep your appointments.
Discuss your concern about breast mass and also enlarged lymph
nodes with your primary care doctor - Dr ___ you se him
this week. You will need further work up for it. Dr ___
arrange for it in clinic.
Do not take oxycodone and drive or use machinery or cook.
###RESPONSE: Discharge Instructions {Final inpatient visit with instructions at discharge}, fevers {Fever}, chills {Chill}, ankle swelling {Swollen ankle}, pain {Abdominal pain}, antibiotocs {Ankle pain}, cellulitis {Cellulitis}, breast mass {Breast lump}, enlarged lymph
nodes {Lymphadenopathy}, work up {Evaluation procedure}, clinic {Outpatient care management} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Penicillins / Aspirin / Sulfa (Sulfonamide Antibiotics) / Latex
/ banana / kiwi / peanut / clindamycin / salicylates
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
###RESPONSE: Penicillins {Allergy to penicillin}, Aspirin {Allergy to aspirin}, Antibiotics {Antibiotic therapy}, peanut {Allergy to peanut}, shortness of breath {Dyspnea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Ms. ___ is a ___ history of
asthma, PCOS, hypertension, G6PD, and PTSD, presenting with
worsening shortness of breath with concern for asthma
exacerbation.
Of note, patient recently presented to ___ ___ with
worsening shortness of breath and coughing. Patient stated this
felt like her prior asthma exacerbations. Given documented
minimal wheezing on exam and with normal O2 saturation, she was
treated with duonebs as well as prednisone. She was discharged
on
prednisone 50 mg daily x 5 days.
Patient states that she never felt better after being discharged
from the ___. She completed her 5 day course of
prednisone 50 mg daily ___. She has continued to have
worsening
shortness of breath, was told by co-workers this morning that
she
was gasping for air and he could hear her audibly wheezing.
States she has been adherent to her home Advair inhalers, has
been using her albuterol rescue inhaler every couple of minutes
without relief. Today has noted new worsening productive cough
with phlegm. Denies any fevers or chills. Denies any sore throat
or rhinorrhea.
In the ED, initial VS were: T 98.1 HR 106 BP 175/96 RR 24 O2
100%RA
On Exam:
Gen: Moderate distress, unable to speak in full sentences,
severe
cough
CV: RRR, normal S1/S2
Pulm: +accessory muscle use, diffuse end expiratory wheezing,
diminished breath sounds R lung base, bibasilar crackles
Labs notable for:
- WBC 8.1, Hb 11.7, PLT 280
- Na 142, K 3.8, BUN 5, Cr 0.5
- VBG 7.41/___
- Flu: Negative
- UA: Moderate leuks, negative nitrite, 2 WBC, few bacteria
Imaging showed:
CXR ___:
1. Slightly increased interstitial opacities in the right lower
lung field may represent bronchovascular crowding secondary to
decreased inspiratory effort however an early infectious or
inflammatory process cannot be excluded, particularly in this
patient with productive cough.
Consults: None
Patient received:
___ 07:51 IH Albuterol 0.083% Neb Soln
___ 07:51 IH Ipratropium Bromide Neb 1 NEB
___ 08:09 IH Albuterol 0.083% Neb Soln 1 NEB
___ 08:09 IH Ipratropium Bromide Neb 1 NEB
___ 08:09 PO Ondansetron ODT 4 mg
___ 09:51 IV Magnesium Sulfate
___ 09:51 IV MethylPREDNISolone Sodium Succ 125 mg
___ 09:53 IH Albuterol 0.083% Neb Soln 1 NEB
___ 09:53 IH Ipratropium Bromide Neb 1 NEB
___ 10:53 IV Magnesium Sulfate 2 gm
___ 11:09 IV Azithromycin
___ 13:10 IV Azithromycin 500 mg
___ 14:22 IV CefTRIAXone
___ 14:29 IV CefTRIAXone 2 g
___ 16:16 PO/NG Spironolactone 100 mg
___ 16:16 IVF LR
___ 17:39 IVF LR 1000 mL
___ 20:21 PO/NG Acetaminophen 1000 mg
___ 20:38 PO TraMADol 50 mg
Transfer VS were: T 98.9 HR 114, BP 158/89 RR 18 O2 100%RA
On arrival to the floor, patient confirms the above
history. States that at present she does not feel short of
breath, however endorsing frequent coughing (with occasional
brownish phlegm).
###RESPONSE: asthma {Asthma}, PCOS {Polycystic ovary syndrome}, hypertension {Hypertensive disorder, systemic arterial}, G6PD {Glucose-6-phosphate dehydrogenase deficiency anemia}, PTSD {Posttraumatic stress disorder}, shortness of breath {Dyspnea}, asthma
exacerbation {Exacerbation of asthma}, shortness of breath {Dyspnea}, coughing {Cough}, asthma exacerbations {Exacerbation of asthma}, wheezing {Wheezing}, normal O2 saturation {Oxygen saturation within reference range}, shortness of breath {Dyspnea}, gasping {Gasping for breath}, wheezing {Wheezing}, inhalers {Oxygen therapy}, inhaler {Oxygen therapy}, relief {Feeling relief}, productive cough {Productive cough}, fevers {Fever}, chills {Chill}, sore throat {Sore throat}, rhinorrhea {Nasal discharge}, VS {Vital signs finding}, RA {Breathing room air}, Gen {General examination of patient}, distress {Distress}, unable to speak {Unable to speak}, cough {Cough}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, Pulm {Examination of respiratory system}, accessory muscle {Accessory skeletal muscle}, expiratory wheezing {Expiratory wheezing}, diminished breath sounds {Decreased breath sounds}, R lung base {Structure of base of right lung}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, Flu {Influenza}, UA {Urinalysis}, CXR {Plain chest X-ray}, opacities {Abnormally opaque structure}, lung field {Structure of lung field}, infectious {Infectious disease}, inflammatory {Inflammatory disorder}, productive cough {Productive cough}, IV {Intravenous therapy}, IV {Intravenous therapy}, IV {Intravenous therapy}, IV {Intravenous therapy}, IV {Intravenous therapy}, IV {Intravenous therapy}, IV {Intravenous therapy}, IVF {Administration of intravenous fluids}, IVF {Administration of intravenous fluids}, VS {Vital signs finding}, RA {Breathing room air}, short of
breath {Dyspnea}, coughing {Cough}, brownish phlegm {Brown sputum} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
Asthma
Obstructive sleep apnea
PCOS (polycystic ovarian syndrome)
Psychosocial stressors, PTSD
Iron deficiency anemia
G6PD deficiency
Headaches/Migraines
Menorrhagia
Atypical squamous cells of undetermined significance (ASCUS) on
___ smear of cervix
h/o STD, Herpes simplex vulvovaginitis
###RESPONSE: Asthma {Asthma}, Obstructive sleep apnea {Obstructive sleep apnea syndrome}, PCOS {Polycystic ovary syndrome}, polycystic ovarian syndrome {Polycystic ovary syndrome}, PTSD {Posttraumatic stress disorder}, Iron deficiency anemia {Iron deficiency anemia}, G6PD deficiency {Glucose-6-phosphate dehydrogenase deficiency anemia}, Headaches {Headache}, Migraines {Migraine}, Menorrhagia {Menorrhagia}, Atypical squamous cells of undetermined significance {Atypical squamous cells of undetermined significance}, smear of cervix {Cytopathology procedure, preparation of smear, genital source}, STD {Sexually transmitted infectious disease}, Herpes simplex {Herpes simplex}, vulvovaginitis {Vulvovaginitis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
- Sister w/ arrhythmia on rhythm control - unable to specify
further
- brother with cardiomyopathy
- low potassium in family
- Hypertension
- Malignancy (sarcoma in mother, leukemia in father)
- Depression
- Obesity
- T2DM
- Keratoconus (multiple family members)
###RESPONSE: arrhythmia {Cardiac arrhythmia}, cardiomyopathy {Cardiomyopathy}, low potassium {Hypokalemia}, Hypertension {Hypertensive disorder, systemic arterial}, Malignancy {Malignant neoplasm}, sarcoma {Sarcoma}, leukemia {Leukemia}, Depression {Depressive disorder}, Obesity {Obesity}, T2DM {Diabetes mellitus type 2}, Keratoconus {Keratoconus} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: T 98.2 BP 166/98 HR 118 RR 18 O2 97%RA
Gen: Intermittently coughing, however speaking in full sentences
HEENT: NC/AT, PERRLA, EOMI
Lungs: Decreased breath sounds throughout, however with good air
movement. Diffuse expiratory wheezing throughout all lung
fields.
CV: Tachycardic, regular rhythm, no murmurs, rubs, or gallops
Abdomen: Soft, NT/ND. Normoactive bowel sounds. No evidence of
organomegaly
Neuro: CN II-XII intact. No focal neurological deficits.
Extremities: 2+ peripheral pulses, no C/C/E
DISCHARGE PHYSICAL EXAM:
========================
VS: ___ 0714 Temp: 98.2 PO BP: 130/88 HR: 91 RR: 20 O2 sat:
98% O2 delivery: RA
Gen: Young F in NAD. Appears stated age. Intermittently coughing
HEENT: NC/AT, EOMI
Lungs: CTABL, no wheezes appreciated. Breathing comfortably on
RA
without use of accessory muscles.
CV: RRR, no murmurs, rubs, or gallops
Abdomen: Soft, NT/ND. NABS. No evidence of organomegaly
Neuro: No focal neurological deficits. A&Ox3. Moving all
extremities.
Extremities: warm and well-perfused, no edema
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, Gen {General examination of patient}, coughing {Cough}, HEENT {Physical examination procedure}, NC {Normal head}, AT {No injuries apparent}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, Lungs {Examination of respiratory system}, Decreased breath sounds {Decreased breath sounds}, wheezing {Wheezing}, lung
fields {Structure of lung field}, CV {Cardiovascular physical examination}, Tachycardic {Tachycardia}, regular rhythm {Normal sinus rhythm}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, Normoactive bowel sounds {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, Neuro {Neurological examination}, CN II {Normal central nervous system}, XII intact {Normal central nervous system}, neurological deficits {Neurological deficit}, Extremities {Examination of limb}, 2+ peripheral pulses {Peripheral pulses normal}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, Gen {General examination of patient}, NAD {No abnormality detected}, coughing {Cough}, HEENT {Physical examination procedure}, NC {Normal head}, AT {No injuries apparent}, EOMI {Normal ocular motility}, Lungs {Examination of respiratory system}, CTABL {Normal breath sounds}, wheezes {Wheezing}, Breathing comfortably {Normal respiratory function}, RA {Breathing room air}, accessory muscles {Accessory skeletal muscle}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, NABS {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, Neuro {Neurological examination}, neurological deficits {Neurological deficit}, all
extremities {All extremities}, Extremities {All extremities}, warm {Warm skin}, well-perfused {Normal tissue perfusion}, edema {Edema} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS:
===============
___ 08:08AM HCG-<5
___ 08:08AM CALCIUM-9.5 PHOSPHATE-4.6* MAGNESIUM-1.7
___ 08:08AM GLUCOSE-107* UREA N-5* CREAT-0.5 SODIUM-142
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-22 ANION GAP-16
___ 09:07AM URINE MUCOUS-FEW*
___ 09:07AM URINE RBC-1 WBC-2 BACTERIA-FEW* YEAST-NONE
EPI-2
___ 09:07AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD*
___ 09:07AM URINE COLOR-Straw APPEAR-Hazy* SP ___
___ 09:07AM URINE UCG-NEGATIVE
___ 12:06PM PLT COUNT-280
___ 12:06PM NEUTS-45.7 ___ MONOS-12.2 EOS-3.2
BASOS-0.4 IM ___ AbsNeut-3.72 AbsLymp-3.12 AbsMono-0.99*
AbsEos-0.26 AbsBaso-0.03
___ 12:06PM WBC-8.1 RBC-4.59 HGB-11.7 HCT-38.1 MCV-83
MCH-25.5* MCHC-30.7* RDW-13.5 RDWSD-40.3
___ 02:13PM ___ PO2-49* PCO2-39 PH-7.41 TOTAL CO2-26
BASE XS-0 COMMENTS-PERIPHERAL
___ 02:25PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MICROBIOLOGY:
=============
__________________________________________________________
___ 7:57 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
__________________________________________________________
___ 2:25 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
__________________________________________________________
___ 11:05 am BLOOD CULTURE SET#2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 11:02 am BLOOD CULTURE SET#1.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 9:07 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
========
___ CXR
FINDINGS:
When compared to most recent prior chest radiograph, there is
slightly
increased interstitial opacity projecting over the right lower
lung field
which appears more conspicuous . This may represent crowding of
pulmonary
vasculature due to decreased inspiratory effort however an early
infectious or inflammatory process cannot be excluded. There is
otherwise no other areas of focal consolidation. There is no
pleural effusion or pneumothorax. The cardiomediastinal
silhouette is within normal limits. There is no acute osseous
abnormality or free intraperitoneal air under the diaphragm.
IMPRESSION:
1. Slightly increased interstitial opacities in the right lower
lung field may represent bronchovascular crowding secondary to
decreased inspiratory effort however an early infectious or
inflammatory process cannot be excluded, particularly in this
patient with productive cough.
DISCHARGE LABS:
===============
(from day prior, no labs obtained on day of discharge)
___ 06:50AM BLOOD WBC-15.1* RBC-4.91 Hgb-12.8 Hct-40.0
MCV-82 MCH-26.1 MCHC-32.0 RDW-13.2 RDWSD-38.9 Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-84 UreaN-10 Creat-0.6 Na-142
K-4.7 Cl-105 HCO3-25 AnGap-12
___ 06:50AM BLOOD Calcium-9.5 Phos-4.6* Mg-2.___RIEF HOSPITAL SUMMARY:
========================
Ms. ___ is a ___ history of asthma, PCOS, hypertension, G6PD
deficiency, and PTSD, who recently presented to ___
with worsening shortness of breath treated with prednisone
burst, now re-presenting with worsening shortness of breath and
wheezing, admitted with asthma exacerbation and community
acquired pneumonia.
TRANSITIONAL ISSUES:
====================
[ ] Patient hypertensive and with headaches while hospitalized.
Started on verapamil 120mg qd with some improvement in blood
pressure and headaches. Will require close-follow up, especially
once she completes the steroid taper as it was felt her steroids
contributed to her hypertension.
[ ] Patient discharged on steroid taper as follows: 50mg qd x2d,
40mg x2d, 30mg x2d, 20mg x2d, and 10mg x2d. PCP should reassess
respiratory symptoms and determine if a longer taper is
necessary.
[ ] Pending tests: ___ Blood cultures x2- no growth to date.
[ ] Patient was tachycardic during admission to 100-120s. Was
thought to be secondary to frequent albuterol use prior to
admission and ultimately improved during the majority of her
stay. Low risk for DVT/PE per Wells criteria and other vital
signs remained stable. Please follow up at next PCP ___.
[ ] Patient had a significant headache during admission, with a
known history of migraines. She required IV ketorolac, PO
fioricet, and IV Compazine during admission. She was discharged
with PO Compazine and ibuprofen. Further headache management
should be considered in the outpatient setting.
ACUTE ISSUES:
===============
#Asthma exacerbation
#?CAP
Patient has a history of asthma and has approximately 5
exacerbations per year with no prior intubations. She recently
presented to ___ on ___ with worsening dyspnea, s/p
inhalers and prednisone 50mg x5d completed ___ but without
subjective improvement. She presented to ___ ED with severe
dyspnea with diffuse wheezing on exam. She received
methylprednisolone 125mg x1 in the ED and then was started on
prednisone 60mg qd. There was question of new RLL infiltrate on
CXR on admission concerning for pneumonia, which could possibly
have been the trigger for her asthma exacerbation. She was
afebrile and without leukocytosis on admission but did have a
productive cough. Sputum culture was contaminated by upper
respiratory flora. Influenza PCR was negative. Respiratory viral
panel and culture were negative. She completed a 5-day course of
Ceftriaxone and azithromycin for empiric CAP treatment prior
discharge. There was some concern for PE in this young female
with wheezing and tachycardia but had low risk per Wells
criteria (see below), with ultimate improvement in her
tachycardia for the majority of her hospitalization. She was
continued on home Advair and received duonebs q6h. She was
switched from her home albuterol to levalbuterol nebs q2h:prn
given tachycardia, but was switched back to albuterol on
discharge. Patient was discharged on steroid taper for 10 days
(50mg qd x2d, 40 x2d, 30 x2d, 20 x2d, 10 x2d) and will follow up
with her PCP prior to the end of the taper to assess symptom
resolution. She also received guaifenison for cough.
#HTN
Patient hypertensive to 180s on admission. She is only on
spironolactone at home. She was previously hospitalized in ___
for wide-ranging SBP to 180-190s, requiring nifedipine and was
started on labetalol at that time. Neuro workup at that time
with negative CTA/CTV. Subsequently had BP med overdose
requiring dopamine in MICU during prior hospitalization. During
hospitalization, her hypertension was felt to be related to
steroids. She was continued on home spironolactone and received
hydralazine prn. She was also started on verapamil 120mg qd for
both hypertension and headache. BPs were improved with addition
of verapamil and were 130-150s/70-90s on day of discharge. At
her PCP follow up, please evaluate her blood pressures (given
the prednisone will be tapering) and determine if Verapamil
should be continued.
#Tachycardia
Patient tachycardia to the 90-120s on admission. EKG showed
sinus tachycardia. Differential included ___ albuterol (patient
endorsed using albuterol frequently prior to admission) vs PE.
There was lower suspicion for PE manifested as tachycardia and
wheezing given recent high frequency of albuterol nebs and low
risk per Wells criteria. Patient had no recent travel or
immobilization, no history of DVT/PE, and no known
hypercoagulable state. Her tachycardia improved during the
majority of her hospitalization.
#Headache
Patient presented with right sided headache since ED, no focal
neurological deficits. Patient has history of migraines. No
improvement with APAP, tramadol or ibuprofen so patient received
ketorolac and Fioricet as well as IV Compazine as needed.
CHRONIC ISSUES:
===============
#Hypokalemia - Continued on home K supplementation
#PCOS - Continued on home spironolactone 100mg PO BID
#OSA - History of CPAP previously non-adherent.
#CODE: Full (presumed)
#CONTACT:
Name of health care proxy: ___
Relationship: sister
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO 1X/WEEK (WE)
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN Shortness of breath
3. Spironolactone 100 mg PO BID
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Vitamin D ___ UNIT PO DAILY
7. Potassium Chloride 20 mEq PO TID
8. Prenatal Vitamins 1 TAB PO DAILY
Discharge Medications:
1. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild NOT relieved by
Acetaminophen
RX *ibuprofen 600 mg 1 tablet(s) by mouth four times a day Disp
#*12 Tablet Refills:*0
2. PredniSONE 50 mg PO DAILY Duration: 2 Doses
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
This is dose # 1 of 5 tapered doses
RX *prednisone 10 mg 5 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 2 Doses
Start: After 50 mg DAILY tapered dose
This is dose # 2 of 5 tapered doses
RX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*8
Tablet Refills:*0
4. PredniSONE 30 mg PO DAILY Duration: 2 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 3 of 5 tapered doses
RX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
5. PredniSONE 20 mg PO DAILY Duration: 2 Doses
Start: After 30 mg DAILY tapered dose
This is dose # 4 of 5 tapered doses
RX *prednisone 10 mg 2 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
6. PredniSONE 10 mg PO DAILY Duration: 2 Doses
Start: After 20 mg DAILY tapered dose
This is dose # 5 of 5 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by
mouth four times a day Disp #*12 Tablet Refills:*0
8. Verapamil SR 120 mg PO Q24H
RX *verapamil [Calan SR] 120 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
9. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
10. Albuterol Inhaler 1 PUFF IH Q6H:PRN Shortness of breath
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Potassium Chloride 20 mEq PO TID
13. Prenatal Vitamins 1 TAB PO DAILY
14. Spironolactone 100 mg PO BID
15. Vitamin D ___ UNIT PO DAILY
16. Vitamin D ___ UNIT PO 1X/WEEK (WE)
###RESPONSE: CALCIUM {Blood calcium measurement}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, URINE {Urine culture}, URINE {Urine culture}, RBC {Red blood cell count}, WBC {White blood cell count}, AST {Aspartate aminotransferase measurement}, PROTEIN {Measurement of protein in urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, COLOR {Color finding}, URINE {Urine culture}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PH {pH measurement}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, SPUTUM {Sputum finding}, Expectorated {Does expectorate}, GRAM STAIN {Gram stain method}, cells {Cell structure}, Gram stain {Gram stain method}, respiratory {Examination of respiratory system}, Bacterial culture {Bacterial culture}, invalid {Invalidism}, RESPIRATORY {Examination of respiratory system}, CULTURE {Microbial culture}, Respiratory {Examination of respiratory system}, Culture {Microbial culture}, Respiratory {Examination of respiratory system}, Viral Culture {Viral culture}, respiratory {Examination of respiratory system}, Culture {Microbial culture}, Influenza {Influenza}, Parainfluenza {Parainfluenza}, Respiratory {Examination of respiratory system}, Detection of viruses {Detection of virus}, Respiratory {Examination of respiratory system}, Respiratory {Examination of respiratory system}, Parainfluenza {Parainfluenza}, Influenza {Influenza}, immunofluorescence {Fluorescent immunoassay}, respiratory {Examination of respiratory system}, viral culture {Viral culture}, Influenza {Influenza}, tab {Therapeutic abortion procedure}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, URINE {Urine culture}, URINE CULTURE {Urine culture}, SKIN {Examination of skin}, CXR {Plain chest X-ray}, chest {Thoracic structure}, radiograph {Plain radiography}, opacity {Abnormally opaque structure}, lung field {Structure of lung field}, infectious {Infectious disease}, inflammatory {Inflammatory disorder}, consolidation {Consolidation}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, osseous {Bony labyrinth structure}, diaphragm {Diaphragm structure}, opacities {Abnormally opaque structure}, lung field {Structure of lung field}, infectious {Infectious disease}, inflammatory {Inflammatory disorder}, productive cough {Productive cough}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, asthma {Asthma}, PCOS {Polycystic ovary syndrome}, hypertension {Hypertensive disorder, systemic arterial}, G6PD
deficiency {Glucose-6-phosphate dehydrogenase deficiency anemia}, PTSD {Posttraumatic stress disorder}, shortness of breath {Dyspnea}, shortness of breath {Dyspnea}, wheezing {Wheezing}, asthma exacerbation {Exacerbation of asthma}, community
acquired pneumonia {Community acquired pneumonia}, hypertensive {Hypertensive disorder, systemic arterial}, headaches {Headache}, blood
pressure {Blood pressure finding}, headaches {Headache}, hypertension {Hypertensive disorder, systemic arterial}, PCP {Primary care management}, respiratory {Examination of respiratory system}, Blood cultures {Blood culture}, tachycardic {Tachycardia}, improved {Patient's condition improved}, DVT {Deep venous thrombosis}, PE {Pulmonary embolism}, vital
signs {Vital signs finding}, stable {Patient's condition stable}, PCP {Primary care management}, headache {Headache}, migraines {Migraine}, IV {Intravenous therapy}, IV {Intravenous therapy}, headache {Headache}, Asthma exacerbation {Exacerbation of asthma}, asthma {Asthma}, intubations {Intubation}, dyspnea {Dyspnea}, inhalers {Oxygen therapy}, dyspnea {Dyspnea}, wheezing {Wheezing}, infiltrate {Infiltration}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, asthma exacerbation {Exacerbation of asthma}, afebrile {Temperature normal}, leukocytosis {Leukocytosis}, productive cough {Productive cough}, Sputum culture {Microbial culture of sputum}, respiratory {Examination of respiratory system}, Influenza {Influenza}, Respiratory {Examination of respiratory system}, culture {Microbial culture}, PE {Pulmonary embolism}, wheezing {Wheezing}, tachycardia {Tachycardia}, tachycardia {Tachycardia}, tachycardia {Tachycardia}, PCP {Primary care management}, cough {Cough}, HTN {Hypertensive disorder, systemic arterial}, hypertensive {Hypertensive disorder, systemic arterial}, Neuro {Neurological examination}, CTA {Computed tomography angiography with contrast}, CTV {Computed tomography venography with contrast}, overdose {Overdose}, hypertension {Hypertensive disorder, systemic arterial}, hypertension {Hypertensive disorder, systemic arterial}, headache {Headache}, improved {Patient's condition improved}, PCP {Primary care management}, blood pressures {Blood pressure finding}, Tachycardia {Tachycardia}, tachycardia {Tachycardia}, sinus tachycardia {Sinus tachycardia}, PE {Pulmonary embolism}, suspicion {Suspicion}, PE {Pulmonary embolism}, tachycardia {Tachycardia}, wheezing {Wheezing}, frequency {Increased frequency of urination}, DVT {Deep venous thrombosis}, PE {Pulmonary embolism}, hypercoagulable state {Hypercoagulability state}, tachycardia {Tachycardia}, improved {Patient's condition improved}, Headache {Headache}, right sided headache {Unilateral headache on right side of head}, neurological deficits {Neurological deficit}, migraines {Migraine}, IV {Intravenous therapy}, Hypokalemia {Hypokalemia}, PCOS {Polycystic ovary syndrome}, OSA {Obstructive sleep apnea syndrome}, Inhaler {Oxygen therapy}, Shortness of breath {Dyspnea}, wheeze {Wheezing}, TAB {Therapeutic abortion procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Asthma exacerbation
Community acquired pneumonia
Secondary Diagnosis:
Hypertension
Tachycardia
Headache
Hypokalemia
Polycystic ovarian syndrome
Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Asthma exacerbation {Exacerbation of asthma}, Community acquired pneumonia {Community acquired pneumonia}, Hypertension {Hypertensive disorder, systemic arterial}, Tachycardia {Tachycardia}, Headache {Headache}, Hypokalemia {Hypokalemia}, Polycystic ovarian syndrome {Polycystic ovary syndrome}, Obstructive sleep apnea {Obstructive sleep apnea syndrome}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you were having difficulty
breathing.
What did you receive in the hospital?
- You received steroids to treat an asthma exacerbation.
- You received antibiotics to treat any infection in lungs.
- You received medications to treat your headache.
- You were started on a new blood pressure medication because
your blood pressure was high.
What should you do once you leave the hospital?
- You should take all of your medications as prescribed (see
below).
- You should attend all of your scheduled outpatient
appointments.
We wish you the best!
Your ___ Care Team
###RESPONSE: difficulty
breathing {Difficulty breathing}, asthma {Asthma}, antibiotics {Antibiotic therapy}, infection {Infectious disease}, lungs {Lung structure}, headache {Headache}, blood pressure {Blood pressure finding}, blood pressure was high {Hypertensive disorder, systemic arterial} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
###RESPONSE: Chest pain {Chest pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ with prior history of cocaine abuse presents from jail with
chest pain. He awoke from sleep at 1AM with sharp sub sternal
chest pain, ___ in intensity, non-radiating, worse with deep
inspiration. Pain has been constant. Never had this type of pain
before. No recent chest wall injuries or strenuous activities.
Went to ___ and had a concerning EKG with ?STE and
hyperacute T's that didn't meet criteria. Got ASA, had negative
trop @ 0230, negative d-dimer. Pain unrelieved with nitro,
morphine, dilaudid so patient transferred to ___ for further
eval.
In the ED intial vitals were: 97 58 100/69 16 100%
Labs were significant for WBC 12.1, Troponin <.01, Phos 1.4
Patient was given: Dilaudid IV and lorazepam
Vitals on transfer: 66 120/64 7 98%
On the floor patient reports improvement in chest pain, now
___. Denies fever, chills, cough, SOB, orthopnea.
###RESPONSE: cocaine abuse {Cocaine abuse}, chest pain {Chest pain}, chest pain {Chest pain}, radiating {Radiating pain}, Pain {Pain}, constant {Constant pain}, pain {Pain}, chest wall injuries {Injury of chest wall}, EKG {Electrocardiographic procedure}, Pain {Pain}, vitals {Vital signs finding}, Vitals {Vital signs finding}, chest pain {Chest pain}, fever {Fever}, chills {Chill}, cough {Cough}, SOB {Dyspnea}, orthopnea {Orthopnea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
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: 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:
MGF- CAD
Father- cirrhosis
Mother- lung cancer
###RESPONSE: CAD {Coronary arteriosclerosis}, lung cancer {Malignant tumor of lung} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Admission:
VS: T=97.6 BP=107/62 HR=68 RR=18 O2 sat=99% RA
General: Well developed male in NAD
HEENT: EOMI, PERRL, sclera anicteric
Neck: JVP not elevated, supple, no LAD
CV: RRR, normal S1 and S2, no mrg. Chest wall is mildly tender
to palpation over left and right margins of sternum and xyphoid
process
Lungs: CTAB, no wheezes or rales
Abdomen: Soft, nontender, non-distended, no palpable
organomegaly
GU: No foley
Ext: Warm, well perfused, no edema, 2+ DP pulses
Discharge:
General: Well developed male in NAD
HEENT: EOMI, PERRL, sclera anicteric
Neck: JVP not elevated, supple, no LAD
CV: RRR, normal S1 and S2, no mrg. Chest wall is mildly tender
to palpation over left and right margins of sternum and xyphoid
process
Lungs: CTAB, no wheezes or rales
Abdomen: Soft, nontender, non-distended, no palpable
organomegaly
GU: No foley
Ext: Warm, well perfused, no edema, 2+ DP pulses
###RESPONSE: VS {Vital signs 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}, General {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, sclera anicteric {White sclera}, Neck {Physical examination procedure}, JVP not elevated {Normal jugular venous pressure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, Chest {Examination of respiratory system}, tender {Abdominal tenderness}, palpation {Palpation}, sternum {Bone structure of sternum}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, nontender {Abdominal tenderness}, non-distended {Normal abdominal contour}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, foley {Catheterization of urinary bladder}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, edema {Edema}, 2+ DP pulses {All pulses present in bilateral lower limbs}, General {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, sclera anicteric {White sclera}, Neck {Physical examination procedure}, JVP not elevated {Normal jugular venous pressure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, Chest wall is mildly tender {Chest wall tenderness}, sternum {Bone structure of sternum}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, foley {Catheterization of urinary bladder}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, edema {Edema}, 2+ DP pulses {All pulses present in bilateral lower limbs} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
Admission:
___ 04:35AM BLOOD WBC-12.1* RBC-4.66 Hgb-14.3 Hct-42.7
MCV-92 MCH-30.6 MCHC-33.5 RDW-11.8 Plt ___
___ 04:35AM BLOOD Neuts-86.0* Lymphs-9.9* Monos-3.3 Eos-0.2
Baso-0.5
___ 04:35AM BLOOD Glucose-91 UreaN-17 Creat-0.9 Na-138
K-4.1 Cl-104 HCO3-22 AnGap-16
___ 04:35AM BLOOD CK(CPK)-98
___ 04:35AM BLOOD cTropnT-<0.01
___ 04:35AM BLOOD CK-MB-2
___ 04:35AM BLOOD Calcium-9.3 Phos-1.4* Mg-1.6
Imaging:
Surface Echo ___:
IMPRESSION: Normal biventricular regional/global systolic
function.
CTA ___:
1. No evidence of acute aortic syndrome.
2. Heart size is top normal with a dilated right atrium. No
pericardial
effusion.
3. No focal consolidation. Bilateral centrilobular nodules may
represent respiratory bronchiolitis in the setting of smoking
history. Mild paraseptal emphysema.
Discharge:
___:05PM BLOOD CK-MB-2 cTropnT-<0.___ with prior history of cocaine abuse presents from jail with
chest pain.
#Chest Pain: Most likely costochondtritis versus other
musculoskeletal pain. Pain is atypical for angina given lack of
association with exertion, lack of improvement with nitro and
reproducibility on exam albeit patient is at risk of CAD with
history of cocaine use. CTA is unrevealing for aortic dissection
or PE and troponin is negative x3 along with a normal surface
ECHO which are reassuring. ECG shows submillimeter ST elevations
that are concave up and may be normal variant. Patient was
started on daily aspirin daily 81mg and pain was improved with
tylenol and ibuprofen. Patient should continue to take ibuprofen
as needed for pain anti-inflammatory effect.
#Hypophosphatemia: Patient was repleted with neutraphos.
#Psych: Continue home seroquel
Transitional Issues:
-Patient was ruled out for MI with negative trop x3. EKG showed
precordial J-point elevation which may be normal variant.
-Patient was started on aspirin 81 mg daily
-Patient was advised to take ibuprofen for pain
-Patient will need to establish PCP once released from jail
-Full code
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Imaging {Imaging}, regional/global systolic
function {Normal left ventricular systolic function and wall motion}, aortic {Aortic structure}, syndrome {Disease}, Heart {Heart structure}, dilated right atrium {Right atrial dilatation}, pericardial
effusion {Pericardial effusion}, consolidation {Consolidation}, nodules {Nodule}, bronchiolitis {Bronchiolitis}, smoking {Smoker}, paraseptal emphysema {Paraseptal emphysema}, cTropnT {Troponin T cardiac measurement}, cocaine abuse {Cocaine abuse}, chest pain {Chest pain}, Chest Pain {Chest pain}, costochondtritis {Costal chondritis}, musculoskeletal pain {Musculoskeletal pain}, Pain {Pain}, angina {Angina}, CAD {Coronary arteriosclerosis}, CTA {Computed tomography angiography with contrast}, aortic dissection {Dissection of aorta}, normal surface
ECHO {Electrocardiogram normal}, ECG {Electrocardiographic procedure}, ST elevations {ST segment elevation}, aspirin {Administration of aspirin}, pain {Pain}, improved {Patient's condition improved}, pain {Pain}, Hypophosphatemia {Hypophosphatemia}, Psych {Psychiatric procedure, interview AND/OR consultation}, MI {Myocardial infarction}, EKG {Electrocardiographic procedure}, aspirin {Administration of aspirin}, pain {Pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. QUEtiapine Fumarate Dose is Unknown PO DAILY
Discharge Medications:
1. QUEtiapine Fumarate 0 mg PO DAILY
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
once a day Disp #*30 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q8H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
every six (6) hours Disp #*30 Tablet Refills:*0
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Discharge Diagnosis:
Chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Chest pain {Chest pain}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for chest pain. Based on your
physical examination, EKG, ultrasound of your heart and blood
tests we do not feel that your chest pain is related to a heart
attack. Your pain may be from inflammation of you muscles or
cartilage. Please take ibuprofen as needed for pain which will
help with the inflammation. Please establish a primary care
physician when you are released from jail.
###RESPONSE: chest pain {Chest pain}, physical examination {Physical examination procedure}, EKG {Electrocardiographic procedure}, ultrasound of your heart {Echocardiography}, blood
tests {Blood test}, chest pain {Chest pain}, heart
attack {Myocardial infarction}, pain {Pain}, inflammation {Inflammatory disorder}, muscles {Skeletal and/or smooth muscle structure}, pain {Pain}, inflammation {Inflammatory disorder} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization (___)
###RESPONSE: Chest pain {Chest pain}, Cardiac catheterization {Cardiac catheterization} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ yo male history of CAD IMI in ___ and 3VD with stent to LAD
in ___, HTN, presenting with chest pain. Patient noitces for
the last 2 weeks or so he has been having chest discomfort with
minimal activity. Specifically having chest heaviness taking in
his garbage cans, pushing a golf cart, or talking short walks.
For the last 2 days, patient noticed with minimal exertion and
short walks, would have chest heaviness/discomfort that would
resolve after several minutes of rest. The day of presentation,
the patient went for a walk at 3 ___ had had right sided chest
pressure, which resolved with rest. He was home and doing
chores, and decided to go for a walk again and said after about
___ a mile the chest discomfort returned prompting him to go
to the hospital for further evaluation.
He was seen at an outside hospital where a CTA of the chest was
performed it showed no evidence of pulmonary embolism. He was
sent here for further eval. He received an aspirin. Trop 0.02 at
OSH.
Initial VS in the ED: T 97.5 HR 68 BP 157/103 RR 16 satting 97%
on RA. Labs were all normal including tropinins, CMP, CBC. EKG
showed sinus rhythm Q waves inferiorly consistent with prior.
VSS at time of transfer.
CP feels different than his MI in the past, which was burning
pain. This has felt more like pressure.
Apparently gets nuclear studies as part of a research protocol
at ___ serially.
On the floor, pt. in NAD.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
###RESPONSE: CAD {Coronary arteriosclerosis}, IMI {Old inferior myocardial infarction}, 3VD {Triple vessel disease of the heart}, stent to LAD {Placement of stent in anterior descending branch of left coronary artery}, HTN {Hypertensive disorder, systemic arterial}, chest pain {Chest pain}, chest discomfort {Chest discomfort}, chest {Thoracic structure}, heaviness {Heavy feeling}, walks {Does walk}, exertion {Chest pain on exertion}, short walks, would have chest heaviness/discomfort {Chest pain on exertion}, resolve {Problem resolved}, walk {Does walk}, right sided {Right thorax structure}, chest {Thoracic structure}, resolved {Problem resolved}, walk {Does walk}, chest discomfort {Chest discomfort}, evaluation {Evaluation procedure}, CTA of the chest {Computed tomography angiography of chest with contrast}, no evidence {No abnormality detected}, pulmonary embolism {Pulmonary embolism}, aspirin {Administration of aspirin}, VS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, satting {Finding of oxygen saturation}, RA {Breathing room air}, Labs {Laboratory test}, normal {No abnormality detected}, tropinins {Troponin measurement}, CBC {Complete blood count}, EKG {Electrocardiographic procedure}, sinus rhythm {Sinus rhythm}, VSS {Vital signs finding}, CP {Chest pain}, MI {Myocardial infarction}, burning
pain {Burning pain}, pressure {Pressure}, nuclear studies {Nuclear medicine diagnostic procedure on cardiovascular system}, Review of systems {Review of systems}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, headache {Headache}, sinus tenderness {Tenderness over frontal sinus}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, cough {Cough}, shortness of breath {Dyspnea}, nausea,
vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, change in bowel {Altered bowel function}, bladder habits {Alteration in patterns of urinary elimination}, dysuria {Dysuria}, arthralgias {Joint pain}, myalgias {Muscle pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
- CAD s/p IMI ___ when playing basketball, cath about one year
later showed 3VD, stent in ___ to LAD by Dr. ___.
- Hypertension
- H/o hernia repair
- H/o pilonidal cysts
- Achilles tendon tear Left leg
###RESPONSE: CAD {Coronary arteriosclerosis}, IMI {Old inferior myocardial infarction}, cath {Cardiac catheterization}, 3VD {Triple vessel disease of the heart}, stent {Insertion of arterial stent}, LAD {Structure of anterior descending branch of left coronary artery}, Hypertension {Hypertensive disorder, systemic arterial}, hernia repair {Hernia repair}, pilonidal cysts {Pilonidal cyst}, Achilles tendon tear Left leg {Rupture of left Achilles tendon} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Father died from MI, mother with valvular disorder in ___.
###RESPONSE: died {Dead}, MI {Myocardial infarction}, valvular disorder {Heart valve disorder} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM
Gen: well appearing, NAD, lying flat
Heent: OP clear, moist, anicteric
Neck: supple, JVP flat
Lungs: CTAB
___: nl S1 S2 PMI non displaced, RRR, no m/r/g
Abd: soft, NT/ND, BS+
Ext: warm, 1+ edema to ankles b/l
Neuro: A&O, appropriate, full strength, normal senstation
throughout
DISCHARGE PHYSICAL EXAM:
Vitals: T 97.5 BP 131/74 HR 69 RR 18 SaO2 98% on RA
Gen: well appearing, NAD, lying flat
Heent: OP clear, moist, anicteric
Neck: supple, JVP flat
Lungs: CTAB
___: nl S1 S2 PMI non displaced, RRR, no m/r/g
Abd: soft, NT/ND, BS+
Ext: warm, 1+ edema to ankles b/l
Neuro: A&O, appropriate, full strength, normal senstation
throughout
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, Gen {General examination of patient}, well appearing {Well cared for appearance}, NAD {No abnormality detected}, lying {Lying in bed}, Heent {Physical examination procedure}, OP clear {Pharynx normal}, moist {Moist oral mucosa}, anicteric {White sclera}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, S2 {Normal second heart sound, S>2<}, displaced {Apex beat displaced}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, Abd {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, BS+ {Normal bowel sounds}, Ext {Examination of limb}, warm {Warm skin}, edema {Edema}, Neuro {Neurological examination}, normal senstation {Normal sensation}, Vitals {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, Gen {General examination of patient}, well appearing {Well cared for appearance}, lying {Lying in bed}, Heent {Physical examination procedure}, OP clear {Pharynx normal}, moist {Moist oral mucosa}, anicteric {White sclera}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP flat {Normal jugular venous pressure}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, nl S1 S2 {Heart sounds normal}, displaced {Apex beat displaced}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, Abd {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, BS+ {Normal bowel sounds}, Ext: {Examination of limb}, edema {Edema}, Neuro {Neurological examination}, normal senstation {Normal sensation} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 06:58AM BLOOD cTropnT-<0.01
___ 02:00AM BLOOD cTropnT-<0.01
___ 02:00AM BLOOD Glucose-104* UreaN-20 Creat-1.0 Na-141
K-4.1 Cl-106 HCO3-25 AnGap-14
___ 06:58AM BLOOD Glucose-94 UreaN-17 Creat-0.9 Na-143
K-4.1 Cl-106 HCO3-28 AnGap-13
___ 02:00AM BLOOD WBC-5.1 RBC-4.68 Hgb-14.7 Hct-41.3 MCV-88
MCH-31.4 MCHC-35.6* RDW-12.6 Plt ___
___ 06:58AM BLOOD WBC-4.4 RBC-4.63 Hgb-14.4 Hct-41.2 MCV-89
MCH-31.1 MCHC-34.8 RDW-12.5 Plt ___
CARDIAC CATH (___)
- Final results pending at the time of discharge but verbal
signout and images reviewed, revealing existing known CAD plus a
lesion in the mLAD s/p DES.
###RESPONSE: cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac 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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, CARDIAC CATH {Cardiac catheterization}, CAD {Coronary arteriosclerosis}, lesion {Lesion}, mLAD {Structure of mid portion of anterior descending branch of left coronary artery}, DES {Endovascular insertion of drug eluting stent} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ yo male with CAD presenting with symptoms concerning for
unstable angina.
#) UNSTABLE ANGINA: Known CAD with stent in past. Has stressed
himself with pain with minimal exertion. No evidence of cardiac
enzyme leak. TIMI risk = 4. Started on heparin gtt. Given
atorvastatin 80mg, metoprolol. Cath revealed similar findings
as prior cath with known occluded RCA, but now mLAD lesion felt
to be culprit s/p DES.
#) HYPERTENSION: Not optimally controlled. Consider increasing
losartan as outpatient.
# Code: Full code
# Communication: Patient/ Wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
hold for SBP<100/ HR<60
5. Fish Oil (Omega 3) 2400 mg PO QHS
6. Vitamin D ___ UNIT PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
hold for SBP<100 or K+>5.5
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Fish Oil (Omega 3) 2400 mg PO QHS
5. FoLIC Acid 1 mg PO DAILY
6. Losartan Potassium 50 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
###RESPONSE: CAD {Coronary arteriosclerosis}, unstable angina {Preinfarction syndrome}, UNSTABLE ANGINA {Preinfarction syndrome}, CAD {Coronary arteriosclerosis}, stent {Placement of stent in coronary artery}, pain with minimal exertion {Chest pain on exertion}, No evidence {No abnormality detected}, cardiac
enzyme leak {Cardiac enzyme or marker above reference range}, heparin {Heparin therapy}, Cath {Cardiac catheterization}, cath {Cardiac catheterization}, occluded RCA {Right coronary artery occlusion}, mLAD {Structure of mid portion of anterior descending branch of left coronary artery}, lesion {Lesion}, DES {Endovascular insertion of drug eluting stent}, HYPERTENSION {Hypertensive disorder, systemic arterial}, increasing {Prescription dose change}, Aspirin {Administration of aspirin}, SBP {Blood pressure monitoring}, HR {Cardiotachometry}, SBP {Blood pressure monitoring} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Unstable angina
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Unstable angina {Preinfarction syndrome}, Coronary artery disease {Coronary arteriosclerosis}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were
admitted for chest pain and were found to have a blockage in one
of your heart arteries. A stent was placed in this artery,
relieving the blockage. Please refrain from vigorous physical
activity for one week. You must take your medications EVERY
DAY.
###RESPONSE: chest pain {Chest pain}, blockage in one
of your heart arteries {Coronary occlusion}, stent was placed in this artery {Placement of stent in coronary artery}, blockage {Coronary occlusion}, refrain from vigorous physical
activity {Recommendation regarding functional activity}, must take your medications {Recommendation to continue with drug treatment} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
Acute onset Nausea and vomiting
Major Surgical or Invasive Procedure:
None
###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, Nausea and vomiting {Nausea and vomiting} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ with panhypopituitarism presenting with acute onset nausea
vomiting and fever.
Patient had cough and congestion for approximately one week,
mild chills, but no recorded fevers. Yesterday prior to
admission, he had sudden onset nausea, vomiting. He called his
PCP, who told him to increase his dose of PO prednisone, but he
was unable to tolerate PO. He vomited a total of ___ times. At
9PM, he vomited, then "blacked out" for ___ minutes, not
responding to wife calling his name, woke up spontaneously and
felt ok. No abnormal limb movements, tongue biting, or
incontinence. Wife called ___ and he was brought to the
emergency department. No preceeding chest pain or palpitations.
This is his first syncopal episode.
Of note, per recent discharge summary, patient has a history of
not consistently taking his medications, including his PO
prednisone, resulting in nausea/vomiting, and admission for IV
steroids. It was emphasized at that time that he must take all
his medications as prescribed.
In the ED, initial VS were: 101.3 82 159/64 18 96% 2L Nasal
Cannula
.
Labs were notable for a TSH of 0.25 and a Lactate of 2.2. He was
given 100 mg IV hydrocortisone, 1g of tylenol, zofran for his
vomiting, 1 L NS.
.
On arrival to the floor he is in no pain and resting
comfortably.
He is most concerned about dizziness he has been experienced,
which has been persistent since ___. He
experiences lightheadedness, inability to walk, feels
disoriented "loses himself in space", and his legs feel weak.
Dizziness occurs ___ times daily, and experiences this sensation
for ___ minutes at a time. He usually just rests and feels
better. Never had a loss of consciousness or fall. No abnormal
limb movements, no history of seizure, stroke, or MI. Only
experiences dizziness when moving, never while lying still in
bed.
Also complains of chest pressure lasting ___ minutes at night,
never occurs with activity, now happening ___ weekly. Had this
complaint during last hospitalization, was recommended to get
outpatient nuclear stress. No changes recently.
.
REVIEW OF SYSTEMS:
(+)Per HPI
Pertinent negatives: abdominal pain, dysuria / polyuria, vision
changes, unilateral weakness, confusion or altered mental
status, abnormal limb movements
###RESPONSE: panhypopituitarism {Panhypopituitarism}, nausea
vomiting {Nausea and vomiting}, fever {Fever}, cough {Cough}, congestion {Nasal congestion}, mild {Symptom mild}, chills {Chill}, fevers {Fever}, nausea, vomiting {Nausea and vomiting}, vomited {Vomiting}, vomited {Vomiting}, blacked out {Syncope}, not
responding to wife calling {No response to sound}, No abnormal limb movements {Able to move all four limbs}, tongue biting {Tongue biting}, incontinence {Incontinence}, chest pain {Chest pain}, palpitations {Palpitations}, syncopal {Syncope}, not consistently taking his medications {Drugs - partial non-compliance}, nausea/vomiting {Nausea and vomiting}, IV {Intravenous therapy}, steroids {Steroid therapy}, VS {Vital signs finding}, Nasal
Cannula {Oxygen administration by nasal cannula}, IV {Intravenous therapy}, vomiting {Vomiting}, dizziness {Dizziness}, lightheadedness {Lightheadedness}, inability to walk {Unable to walk}, disoriented "loses himself in space" {Spatial disorientation}, legs {Lower limb structure}, Dizziness {Dizziness}, loss of consciousness {Loss of consciousness}, fall {Falls}, No abnormal
limb movements {Able to move all four limbs}, seizure {Seizure}, stroke {Cerebrovascular accident}, MI {Myocardial infarction}, dizziness {Dizziness}, chest pressure {Tight chest}, abdominal pain {Abdominal pain}, dysuria {Dysuria}, polyuria {Polyuria}, vision
changes {Visual disturbance}, weakness {Asthenia}, confusion {Clouded consciousness}, altered mental
status {Altered mental status}, limb {Limb structure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
- DM2
- acromegaly s/p transsphenoidal resection and proton beam
irradiation in ___
- panhypopituitarism
- Multiple hospitalizations for nausea, vomiting, dizziness,
most recently dc'ed ___ for n/v and was not taking PO
prednisone consistently; had n/v and headache with negative
neurologic workup ___
- Thyroid nodules
- cholecystectomy
###RESPONSE: DM2 {Diabetes mellitus type 2}, acromegaly {Acromegaly}, proton beam
irradiation {External beam radiation therapy protons}, panhypopituitarism {Panhypopituitarism}, nausea, vomiting {Nausea and vomiting}, dizziness {Dizziness}, n/v {Nausea and vomiting}, n/v {Nausea and vomiting}, headache {Headache}, neurologic {Neurological examination}, Thyroid nodules {Thyroid nodule}, cholecystectomy {Cholecystectomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Negative for headache, migraine, stroke.
###RESPONSE: headache {Headache}, migraine {Migraine}, 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 - 98.2 117/52 64 18 98% 3L
GENERAL - well-appearing man in NAD, comfortable, appropriate,
large set jaw
HEENT - NC/AT dry MM
NECK - supple
LUNGS - Bibasilar crackles, R > L
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), +large hands and feet c/w acromegaly
SKIN - no rashes or lesions
NEURO - A&O, answers questions appropriately, no nystagmus, gait
steady
DISCHARGE PHYSICAL EXAM
VS - Tm 98.7 Tc 98.4 BP 102/46 64 18 89% on RA -> 100% on RA
with deep breathing and coughing; ambulatory sats maintained at
99%, transiently dropped only as low as 95%
GENERAL - well-appearing ___ man in NAD, comfortable,
appropriate, large set jaw
HEENT - NC/AT dry MM
NECK - supple
LUNGS - Bibasilar crackles, R > L
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), +large hands and feet c/w acromegaly
SKIN - no rashes or lesions
NEURO - A&O, answers questions appropriately, no nystagmus, gait
steady
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, GENERAL {General examination of patient}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, jaw {Jaw region structure}, HEENT {Physical examination procedure}, NC/AT {Normal head}, dry MM {Mucous membrane dryness}, NECK {Physical examination procedure}, LUNGS {Examination of respiratory system}, Bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, S2 {Normal second heart sound, S>2<}, ABDOMEN {Examination of abdomen}, NABS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, 2+ peripheral pulses {Peripheral pulses normal}, radials {Structure of radial artery}, DPs {Structure of dorsalis pedis artery}, large hands {Large hand}, feet {Large, broad feet}, acromegaly {Acromegaly}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, NEURO {Neurological examination}, nystagmus {Nystagmus}, gait
steady {Gait normal}, PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, BP {Blood pressure finding}, RA {Breathing room air}, RA {Breathing room air}, deep breathing {Deep breathing}, coughing {Cough}, GENERAL {General examination of patient}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, jaw {Jaw region structure}, HEENT {Physical examination procedure}, NC/AT {Normal head}, dry MM {Mucous membrane dryness}, NECK {Physical examination procedure}, supple {Normal movement of neck}, LUNGS {Examination of respiratory system}, Bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, S2 {Normal second heart sound, S>2<}, ABDOMEN {Examination of abdomen}, NABS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, 2+ peripheral pulses {Peripheral pulses normal}, radials {Structure of radial artery}, DPs {Structure of dorsalis pedis artery}, large hands {Large hand}, feet {Large, broad feet}, acromegaly {Acromegaly}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, NEURO {Neurological examination}, nystagmus {Nystagmus}, gait
steady {Gait normal} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS
___ 01:10AM BLOOD WBC-6.4 RBC-3.79* Hgb-11.8* Hct-34.4*
MCV-91 MCH-31.2 MCHC-34.3 RDW-14.4 Plt ___
___ 01:10AM BLOOD Neuts-84.4* Lymphs-9.0* Monos-5.5 Eos-1.0
Baso-0.1
___ 09:00AM BLOOD ___ PTT-27.1 ___
___ 03:35PM BLOOD UreaN-32* Creat-1.1 Na-141 K-5.3* Cl-102
HCO3-28 AnGap-16
OTHER RELEVANT LABS
___ 03:35PM BLOOD Albumin-4.1 Calcium-9.5 Cholest-127
___ 03:35PM BLOOD Triglyc-153* HDL-47 CHOL/HD-2.7
LDLcalc-49
___ 03:35PM BLOOD %HbA1c-8.1* eAG-186*
___ 03:35PM BLOOD TSH-0.25*
___ 03:35PM BLOOD Free T4-1.1
DISCHARGE LABS
___ 12:45PM BLOOD WBC-6.3 RBC-3.37* Hgb-10.4* Hct-31.2*
MCV-93 MCH-31.0 MCHC-33.5 RDW-14.4 Plt ___
___ 06:40AM BLOOD Glucose-182* UreaN-30* Creat-0.8 Na-140
K-3.9 Cl-107 HCO3-25 AnGap-12
___ 06:40AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.8
IMAGING
CHEST X-RAY: Peribronchial opacification at both lung bases is
most likely atelectasis, but on the right, there is also a small
right pleural effusion, raising concern for pneumonia. Heart
size is top normal, exaggerated by exceedingly low lung volumes.
There is no pulmonary edema.
MICROBIOLOGY
NEGATIVE: Influenza A/B by ___ DIRECT INFLUENZA A ANTIGEN
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL; Respiratory
Viral Culture-FINAL INPATIENT
___ URINE Legionella Urinary Antigen -FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, AnGap {Anion gap measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Cholest {Cholesterol measurement}, Triglyc {Triglycerides measurement}, HDL {High density lipoprotein measurement}, CHOL/HD {Cholesterol/High density lipoprotein ratio measurement}, eAG {Glucose measurement estimated from glycated hemoglobin}, TSH {Thyroid stimulating hormone measurement}, Free T4 {T4 free measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, IMAGING {Imaging}, CHEST X-RAY {Plain chest X-ray}, lung bases {Structure of base of lung}, atelectasis {Atelectasis}, right {Right lung structure}, right pleural {Right pleura structure}, effusion {Pleural effusion}, pneumonia {Pneumonia}, Heart {Heart structure}, lung volumes {Finding of respiratory volume}, edema {Edema}, MICROBIOLOGY {Microbiology}, INFLUENZA B ANTIGEN TEST {Influenza B virus antigen assay}, Viral Culture {Viral culture}, URINE {Urine culture}, Urinary {Urinary system structure}, URINE {Urine culture}, URINE CULTURE {Urine culture} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ YOM with panhypopituitaryism presented to ___ with fever,
sudden onset nausea/vomiting, syncope, and hypoxemia, found to
have possible pneumonia on CXR. He most likely had a viral
illness and required stress-dose steroids, but was unable to
tolerate PO due to inractable nausea/vomiting. He likely
experienced syncope from dehydration related to viral illness,
nausea, vomiting.
# Panhypopituitarism, central adrenal insufficiency: Patient
presented with nausea, vomiting, diarrhea; has been admitted
with similar presentations. Nausea and vomiting improved with 1
dose IV steroids, and was able to tolerate oral steroids. Home
prednisone was increased to 15mg daily. Patient was instructed
to continue stress dose prednisone 15mg daily for duration of
pneumonia treatment, patient has appointment with outpatient
endocrinologist on ___, who was endocrinologist was updated
on hospitalization.
# Fever, Hypoxemia, Healthcare associated pneumonia vs
aspiration: Patient reported respiratory illness ongoing for
approximately 1 week. Chest x-ray showed possible pneumonia.
His CURB-65 score was 2, moderate severity. Alternatively, he
may have had aspiration event during vomiting / syncopal
episode. He recently traveled to ___, but given Wells Score
of 0, suspicion for PE was low. Started levofloxacin 750 mg
daily for HCAP (___). He was successfully weaned off of
supplemental O2, and ambulatory sats remained in the high ___.
Influenza A/B and urine legionella were negative. Other
infectious workup with pertinent negatives: Urinalysis and
urine culture negative. Blood cultures NGTD at the time this
note is written.
# Syncope: Likely vasovagal in setting of vomiting and
dehydration versus orthostatic hypotension in the setting of
inability to take PO steroids. Family denies abnormal movements
to suggest seizure, awoke spontaneously with no residual
deficits. EKG showed RBB but no significant change from prior.
Was monitored on telemetry overnight with no events recorded.
# Dizziness: Adrenal insufficiency vs vertigo (associated with
movement and relieved with meclizine); orthostatics were normal,
negative workup on prior admissions.
# Anemia: HCT has been mid 30's in past, most recently 31
___, with normal iron studies. Rectal exam done and was
found to be guaiac negative. HCT was stable
# Hypertension: Quinapril was held given low/normal blood
pressures during hospitalization, and possible contribution to
syncope. PCP was informed and may restart if needed.
# Chest pain: Patient presented with atypical chest pain during
last admission, ruled out for MI seen by cardiology, recommended
outpatient stress test; History not consistent with cardiac
etiology, may be GI (esophageal irritation, acid reflux)
Continued home aspirin 325mg, atorva 80mg, quinapril 10mg daily.
Recommended outpatient stress test
# DM: Held oral diabetes meds and placed on insulin SS
# CONTACT: patient, son ___ ___ ___
(daughter in law)
other transitional issues (per PACT):
- Inconsistent with metformin and glimeperide; consider reducing
regimen to single agent for compliance (perhaps XR version of
metformin which would be $4/month and provide better daily
coverage). Taking an ACEI (MA-) and an ASA.
- Overdue for eye clinic f/up.
###RESPONSE: panhypopituitaryism {Panhypopituitarism}, fever {Fever}, nausea/vomiting {Nausea and vomiting}, syncope {Syncope}, hypoxemia {Hypoxemia}, pneumonia {Pneumonia}, CXR {Plain chest X-ray}, viral
illness {Viral disease}, steroids {Steroid therapy}, nausea/vomiting {Nausea and vomiting}, syncope {Syncope}, dehydration {Dehydration}, viral illness {Viral disease}, nausea, vomiting {Nausea and vomiting}, Panhypopituitarism {Panhypopituitarism}, adrenal insufficiency {Adrenal cortical hypofunction}, nausea, vomiting {Nausea and vomiting}, Nausea and vomiting {Nausea and vomiting}, improved {Patient's condition improved}, IV {Intravenous therapy}, steroids {Steroid therapy}, oral {Administration of drug or medicament via oral route}, steroids {Steroid therapy}, pneumonia {Pneumonia}, Fever {Fever}, Hypoxemia {Hypoxemia}, Healthcare associated pneumonia {Nosocomial pneumonia}, aspiration {Aspiration pneumonia}, ted respiratory illness {Disorder of respiratory system}, Chest x-ray {Plain chest X-ray}, pneumonia {Pneumonia}, aspiration {Aspiration into respiratory tract}, vomiting {Vomiting}, syncopal {Syncope}, PE {Pulmonary embolism}, HCAP {Nosocomial pneumonia}, infectious {Infectious disease}, workup {Evaluation procedure}, Urinalysis {Urinalysis}, urine culture {Urine culture}, Blood cultures {Blood culture}, Syncope {Syncope}, vasovagal {Vasovagal syncope}, vomiting {Vomiting}, dehydration {Dehydration}, orthostatic hypotension {Orthostatic hypotension}, abnormal movements {Abnormal movement}, seizure {Seizure}, EKG {Electrocardiographic procedure}, RBB {Right bundle branch block}, telemetry {Electroencephalogram telemetry}, Dizziness {Dizziness}, Adrenal insufficiency {Adrenal cortical hypofunction}, vertigo {Vertigo}, orthostatics {Orthostatic body position}, Anemia {Anemia}, Rectal exam {Rectal examination}, guaiac {Guaiac test for occult blood in feces specimen}, HCT was stable {Stable hematocrit}, Hypertension {Hypertensive disorder, systemic arterial}, normal blood
pressures {Normal blood pressure}, syncope {Syncope}, Chest pain {Chest pain}, atypical chest pain {Atypical chest pain}, MI {Myocardial infarction}, stress test {Electrocardiogram with exercise test}, cardiac {Heart structure}, GI {Structure of digestive system}, acid reflux {Acid reflux}, stress test {Electrocardiogram with exercise test}, DM {Diabetes mellitus}, diabetes {Diabetes mellitus} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. glimepiride *NF* 1 mg Oral daily
3. Levothyroxine Sodium 75 mcg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. PredniSONE 5 mg PO DAILY
6. Quinapril 10 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Vitamin D 3000 UNIT PO DAILY
9. Docusate Sodium 100 mg PO DAILY
10. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. PredniSONE 15 mg PO DAILY
RX *prednisone 5 mg 3 tablet(s) by mouth DAILY Disp #*15 Tablet
Refills:*0
6. Senna 1 TAB PO BID:PRN constipation
7. Vitamin D 3000 UNIT PO DAILY
8. Calcium Carbonate 1500 mg PO DAILY
Do not take within 1 hour of taking levothyroxine
9. Levofloxacin 750 mg PO DAILY Duration: 7 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth DAILY Disp #*5
Tablet Refills:*0
10. MetFORMIN (Glucophage) 1000 mg PO 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: Discharge Disposition:
Home
Discharge Diagnosis:
Community acquired pneumonia, panhypopituitarism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Community acquired pneumonia {Community acquired pneumonia}, panhypopituitarism {Panhypopituitarism}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
You were ___ to ___ for nausea, vomiting, and fever. The
nausea, vomiting, and dizziness that you experience periodically
is most likely a result of low levels of steroids in your blood
because your pituitary gland, which controls release of
hormones, has been partially resected. It is very important
that you take prednisone as prescribed every day to prevent
these symptoms.
You had fevers and your chest x-ray showed evidence of
pneumonia, so we started you on an antibiotic called
levofloxacin.
###RESPONSE: nausea, vomiting {Nausea and vomiting}, fever {Fever}, nausea, vomiting {Nausea and vomiting}, dizziness {Dizziness}, low levels of steroids {Abnormal steroid hormone}, pituitary gland {Pituitary structure}, fevers {Fever}, chest x-ray {Plain chest X-ray}, pneumonia {Pneumonia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: PSYCHIATRY
###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:
"What about my headaches?"
Major Surgical or Invasive Procedure:
None
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, headaches {Headache} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
HISTORY OF PRESENT ILLNESS: Please see Dr. ___ Dr.
___ consult note from ___ for further details of
the
HPI, PPHx, PMHx, Substance Use Hx, SHx.
Briefly, this is a ___ year old woman with history of chronic
headaches and dyspepsia who originally came to the hospital on
___ for sudden catatonic like symptoms in the setting of
topiramate overuse for treatment of chronic headaches. She was
transferred to neurology for workup of her catatonic features,
her EEG showed diffuse slowing, and her symptoms improved
significantly after a trial of lorazepam 2mg IM x 1.
She was revisited by psychiatry consult services who felt that
she seemed to have new-onset psychotic processes, expressing
paranoia and emotional lability.
Upon arrival to the unit she stated she did not understand why
she was on the psychiatric ward. She was concerned about her
previous headaches and felt they were not adequately addressed
but expressed she had not had a headache for the past 2 days.
She
did not express any complaints, though stated she felt better
when she sang, and sang church hymns through the remainder of
the
interview.
After speaking with her husband who came to visit, he states
that
she is still, at times, not at her baseline. He stated she is
sometimes confused and has difficulty concentrating. He does
acknowledge that she is significantly improved from when she was
first admitted.
###RESPONSE: chronic
headaches {Chronic headache disorder}, dyspepsia {Indigestion}, catatonic {Catatonia}, chronic headaches {Chronic headache disorder}, neurology {Neurological examination}, workup {Evaluation procedure}, catatonic {Catatonia}, EEG {Electroencephalogram}, improved {Patient's condition improved}, paranoia {Paranoid disorder}, emotional lability {Mood swings}, psychiatric {Psychiatry procedure or service}, headaches {Headache}, headache {Headache}, baseline {Baseline state}, confused {Clouded consciousness}, difficulty concentrating {Unable to concentrate}, 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: Past Medical History:
Headaches
###RESPONSE: Headaches {Headache} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
SAFETY: The pt. was placed on 15 minute checks on admission and
remained here on that level of observation throughout. She was
unit-restricted. There were no acute safety issues during this
hospitalization.
LEGAL: ___
PSYCHIATRIC:
Catatonia had resolved before admission with ativan. On
admission, she endorsed depressed mood with neurovegetative
symptoms including reduced sleep, interest, energy,
concentration, and appetite. She exhibited transient psychotic
symptoms including a paranoid delusion that somebody was coming
to hurt her, and auditory hallucinations where she heard the
voice of her cousin and her brother. On admission, pt was
started on mirtazapine 7.5mg PO QHS, olanzapine 5mg PO BID, and
lorazepam 1mg PO BID with 1mg PO Q6H prn. On this regimen, she
improved significantly. Her mood improved, and her psychotic
symptoms resolved. Whereas on admission she was significantly
fixated on somatic symptoms, in which these complaints
represented the ___ her focus, by the time of discharge,
these complaints were only mentioned in passing. She has poor
insight, and she does not wish to take medications after
discharge, as she believes that taking medication will make her
dependent on them for further functioning.
GENERAL MEDICAL CONDITIONS:
PSYCHOSOCIAL:
#) GROUPS/MILIEU: pt was visible on the unit but did not attend
many groups.
#) COLLATERAL CONTACTS:
Husband denied previous depression or psychosis.
RISK ASSESSMENT:
#) Chronic/Static Risk Factors:
-mood disorder
#) Modifiable Risk Factors:
-mood disorder
-psychosocial stressors
-poor insight, doesn't believe medications have helped her
#) Protective Factors:
-married with children
-gender
-no past suicide attempts
PROGNOSIS: Guarded
Ms. ___ will need ___ follow-up with a
psychiatrist and therapist. If she adheres to her medications
and appointments, she will likely do well. However, as she does
not believe that medications are helping her, and she does not
want to take psychotropic medications long-term, non-compliance
is a significant risk.
###RESPONSE: SAFETY {Safety case management}, level of observation {Levels of observation}, no acute {No abnormality detected}, PSYCHIATRIC {Psychiatry procedure or service}, Catatonia {Catatonia}, resolved {Problem resolved}, depressed mood {Depressed mood}, reduced sleep {Short-sleeper}, interest {Loss of interest}, energy {Lack of energy}, concentration {Unable to concentrate}, appetite {Decrease in appetite}, psychotic
symptoms {Psychotic symptom present}, paranoid delusion {Paranoid delusion}, auditory hallucinations {Auditory hallucinations}, regimen {Therapeutic regimen}, improved {Patient's condition improved}, mood improved {Improved mood}, psychotic
symptoms resolved {Psychotic symptom finding}, somatic symptoms {Somatic pain}, insight {Finding related to ability to comprehend}, does not wish to take medications {Non-compliance of drug therapy}, medication {Administration of drug or medicament}, MILIEU {Environmental intervention}, did not attend {Did not attend}, depression {Depressive disorder}, psychosis {Psychotic disorder}, mood disorder {Mood disorder}, mood disorder {Mood disorder}, insight {Finding related to ability to comprehend}, medications {Administration of drug or medicament}, married {Married}, suicide attempts {Suicidal intent}, PROGNOSIS {Determination of prognosis}, follow-up {Follow-up arranged}, psychiatrist {Psychiatric follow-up}, medications {Prescription of drug}, medications {Administration of drug or medicament}, psychotropic medications {On psychotropic medication}, non-compliance {Non-compliance of drug 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. OLANZapine 2.5 mg PO QHS
2. timolol maleate 5 mg oral BID
3. Omeprazole 20 mg PO 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: Discharge Disposition:
Home
Discharge Diagnosis:
MDD with psychotic features
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: MDD with psychotic features {Severe mood disorder with psychotic features}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
-please take your medications as prescribed
-please follow-up with outpatient appointments
___ MD ___
Completed by: ___
###RESPONSE: take your medications as prescribed {Patient medication education}, follow-up {Follow-up arranged} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___ Cardiac catheterization
###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, chest pain {Chest pain}, Cardiac catheterization {Cardiac catheterization} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Patient is a ___ year old male with history of coronary artery
disease status-post catherization in ___ with stent to OM1,
and hypertension who presents with chest pain.
.
Patient reports that he had a "stabbing" chest pain this
morning. He states he had "a lot" of chest pain, more than the
___ episodes per day he had been having previously. He states it
improved with nitroglycerin that he took at home. He also had
had a positive stress test about a week ago and an outpatient
catherization at ___ had been planned.
.
He initially presented to ___, where he
received nitropaste. Vitals there were 94/22, HR 94, RR 18, 97%
on RA, and no pain. Cardiac enzymes there were CK 170 and
Troponin 0.02 at 12:30 ___.
Upon arrival to ___, his blood pressure was 104/52, HR 52, RR
18, temperature 96.2, and respiratory rate of 18. He was given
325 mg of aspirin and tolerated it well--of note there is a
possible allergy to aspirin noted in his admission intake form.
.
Patient was resting comfortably in his bed without any
complaints when interviewed. He denied chest pain or shortness
of breath.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. He denies recent fevers, chills or rigors. No
exertional buttock or calf pain. All of the other review of
systems were negative except for pain in his right hand that
patient relates has continued to bother him since a fall earlier
in the year.
.
Cardiac review of systems is notable for chest pain as discussed
above, accompanied by lightheadedness this morning. No worsening
dypsnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
###RESPONSE: coronary artery
disease {Coronary arteriosclerosis}, stent {Insertion of arterial stent}, OM1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, hypertension {Hypertensive disorder, systemic arterial}, chest pain {Chest pain}, stabbing {Stabbing pain}, chest pain {Chest pain}, chest pain {Chest pain}, improved {Patient's condition improved}, stress test {Electrocardiogram with exercise test}, catherization {Cardiac catheterization}, Vitals {Vital signs finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, pain {Chest pain}, Cardiac enzymes {Finding of cardiac enzyme levels}, Troponin {Troponin measurement}, blood pressure {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, temperature {Body temperature finding}, respiratory rate {Finding of rate of respiration}, allergy to aspirin {Allergy to aspirin}, chest pain {Chest pain}, shortness
of breath {Dyspnea}, review of systems {Review of systems}, stroke {Cerebrovascular accident}, TIA {Transient ischemic attack}, deep venous thrombosis {Deep venous thrombosis}, pulmonary embolism {Pulmonary embolism}, bleeding {Bleeding}, surgery {Surgical procedure}, myalgias {Muscle pain}, cough {Cough}, hemoptysis {Hemoptysis}, black stools {Dark stools}, red stools {Red stools}, fevers {Fever}, chills {Chill}, rigors {Rigor}, exertional {Pain provoked by exertion}, buttock {Pain in buttock}, calf pain {Pain in calf}, review of
systems {Review of systems}, negative {No abnormality detected}, pain {Hand pain}, right hand {Structure of right hand}, fall {Falls}, Cardiac {Structure of cardiovascular system}, review of systems {Review of systems}, chest pain {Chest pain}, lightheadedness {Lightheadedness}, dypsnea on exertion {Dyspnea on exertion}, paroxysmal nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, ankle edema {Ankle edema}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
- CAD s/p BMS to OM1 (see below)
- HTN
- renal calculi s/p surgery
- hip replacement x 2 on right r/t injuries
- GSW to pelvis/femur WWII; left hip replacement r/t war
injuries (left leg is shorter than right)
- BPH
- pneumonia
- appendectomy
.
Cardiac Risk Factors: (-)Diabetes, (-)Dyslipidemia,
(+)Hypertension
.
Cardiac History:
Percutaneous coronary intervention, in ___ anatomy as
follows: BMS to the OM with rotational atherectomy. Had to have
___ cath 10 days after first as first attempt at stent placement
was unsuccessful.
###RESPONSE: CAD {Coronary arteriosclerosis}, OM1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, HTN {Hypertensive disorder, systemic arterial}, renal calculi {Kidney stone}, surgery {Surgical procedure}, hip replacement {Prosthetic arthroplasty of hip}, right {Structure of right knee region}, injuries {Traumatic or non-traumatic injury}, GSW {Gunshot wound}, pelvis {Structure of pelvis}, femur {Bone structure of femur}, left hip replacement {Total replacement of left hip joint}, war
injuries {War injury}, left leg {Structure of left lower leg}, shorter {Short leg}, right {Structure of right lower limb}, BPH {Benign prostatic hyperplasia}, pneumonia {Pneumonia}, appendectomy {Excision of appendix}, Cardiac Risk Factors {Assessment for risk of cardiovascular disease}, Diabetes {Diabetes mellitus}, Dyslipidemia {Dyslipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, Cardiac {Structure of cardiovascular system}, Percutaneous coronary intervention {Percutaneous coronary intervention}, OM {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, rotational atherectomy {Atherectomy by rotary cutter}, cath {Cardiac catheterization}, stent placement {Placement of stent} |
Subsets and Splits