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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: 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:
There is no family history of premature coronary artery disease.
A brother died suddenly in sleep at age ___.
###RESPONSE: coronary artery disease {Coronary arteriosclerosis}, died {Dead} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS: 97.7, 158/67, 56, 18, 97% on RA, 161 lbs.
GENERAL: Elderly male, sleeping, easily awaken, NAD. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Bradycardic, irregularly irregular, S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi. Transmitted noises from abdomen appreciated
at times. Fleshy nodule in middle of upper back.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Bilateral: Carotid 2+ Very strong bilateral DP 2+ ___ 2+
###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, sleeping {Asleep}, awake {Awake}, NAD {No abnormality detected}, Oriented
x3 {Oriented to person, time and place}, Mood {Level of mood - normal}, affect {Mood finding}, HEENT {Physical examination procedure}, NC {Normal head}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva were
pink {Conjunctiva normal}, pallor {Pallor of skin of face}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthalesma {Xanthelasma}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, intercostal space {Structure of intercostal space}, midclavicular
line {Midclavicular line}, Bradycardic {Bradycardia}, irregularly irregular {Heart irregularly irregular}, S2 {Normal second heart sound, S>2<}, thrills {Thrill}, No S3 {Third heart sound, S>3<, inaudible}, S4 {Fourth heart sound, S>4<, inaudible}, LUNGS {Examination of respiratory system}, chest wall deformities {Deformity of chest wall}, scoliosis {Scoliosis deformity of spine}, kyphosis {Kyphosis deformity of spine}, Resp {Examination of respiratory system}, accessory muscle {Accessory skeletal muscle}, CTAB {Normal breath sounds}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, Transmitted noises {Transmitted sounds}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, nodule {Nodule}, upper back {Upper back structure}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, Abd {Examination of abdomen}, enlarged {Enlargement}, palpation {Palpation}, abdominial bruits {Abdominal bruit}, EXTREMITIES {Examination of limb}, femoral bruits {Femoral bruit}, SKIN {Examination of skin}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, PULSES {Pulse finding}, Carotid 2 {Normal carotid arterial pulse}, DP 2+ {Dorsalis pulse 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: Pertinent Results:
___ Cardiac cath:
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated no significant obstructive CAD. The LMCA had mild
disease.
The LCX/OM1 stents were patent. The LA and RCA had moderate
diffuse disease, unchanged from the prior catheterization in
___.
2. Limited resting hemodynamics demonstrated systemic arterial
hypertension (154/61).
FINAL DIAGNOSIS:
1. No significant obstructive CAD. Patent OM stents.
###RESPONSE: Cardiac cath {Cardiac catheterization}, coronary angiography {Angiography of coronary artery}, right {Right coronary artery structure}, CAD {Coronary arteriosclerosis}, LMCA {Structure of left coronary artery main stem}, disease {Disease}, LCX {Stent in circumflex branch of left coronary artery}, OM1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, stents were patent {Coronary stent patent}, LA {Structure of circumflex branch of left coronary artery}, RCA {Right coronary artery structure}, disease {Disease}, catheterization {Cardiac catheterization}, hemodynamics {Hemodynamic monitoring}, systemic arterial
hypertension {Hypertensive disorder, systemic arterial}, CAD {Coronary arteriosclerosis}, OM {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, stents {Coronary stent patent} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Patient is a ___ year old male with history of coronary artery
disease and hypertension who presents with chest pain in the
setting of a recent positive stress test.
.
# CORONARIES: Patient has known CAD, has prior BMS to OM1 in
___. His recurrent chest pain is concerning for stuttering
angina given his known disease and response to nitroglycerin.
Report of his out-patient stress test (reportedly positive per
patient) was not available for review at time of admission, but
plans were already being made for repeat catherization given
worsening symptoms in the setting of a good medical regimen.
Cardiac enzymes were negative times three and no ischemic
changes were seen on EKG. Cardiac catheterization was performed
which revealed no significant lesions or stenosis. Pt remained
pain free throughout his hospitalization. He was instructed to
continue his home cardiac medications as previously directed and
follow up with his primary care physician within one week of
discharge.
.
# RHYTHM: Pt has no history of arrhythmias. Sinus bradycardia
with 1st degree AV block is an old finding. Given pts known
bradycardia and new history of dizziness and fatigue, pt was
evaluated by the Electrophysiology team. There was no
indication for pacemaker placement during this admission. Pt
was discharged home with a holter monitor to observe the extent
of his bradycardia. Pt will follow up with his primary care
provider and cardiologist to determine the benefit of a
pacemaker in the future.
.
# PUMP: No evidence of failure on history or exam.
.
# HTN: Continue home medications (mayzide, terazosin, diovan,
metoprolol in lieu of atenolol given advanced age and atenolol
is renally cleared)
.
# BPH: Continue terazosin.
.
# Anemia: Stable from one year ago. Will defer any desired
further work-up to outpatient providers.
.
# FEN: Precath hydration was provided.
.
# ACCESS: PIV's
.
# CODE: Full
.
# Contact: Daughter ___:
Phone: ___
###RESPONSE: coronary artery
disease {Coronary arteriosclerosis}, hypertension {Hypertensive disorder, systemic arterial}, chest pain {Chest pain}, stress test {Electrocardiogram with exercise test}, CAD {Coronary arteriosclerosis}, OM1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, chest pain {Chest pain}, angina {Angina}, stress test {Electrocardiogram with exercise test}, no ischemic
changes {Electrocardiogram: no myocardial ischemia}, EKG {Electrocardiographic procedure}, Cardiac catheterization {Cardiac catheterization}, lesions {Lesion}, stenosis {Stenosis}, pain {Chest pain}, arrhythmias {Cardiac arrhythmia}, Sinus bradycardia {Sinus bradycardia}, 1st degree AV block {First degree atrioventricular block}, bradycardia {Bradycardia}, dizziness {Dizziness}, fatigue {Fatigue}, evaluated {Evaluation procedure}, pacemaker placement {Implantation of cardiac pacemaker}, bradycardia {Bradycardia}, follow up {Follow-up arranged}, HTN {Hypertensive disorder, systemic arterial}, BPH {Benign prostatic hyperplasia}, Anemia {Anemia}, Stable {Patient's condition stable}, PIV {Peripheral intravenous catheter care} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Atenolol 25 mg daily
Plavix 75 mg daily
___ 12.5 mg daily
Omeprazole 40 mg daily
Zocor 20 mg daily
Terazosin 10 mg daily
Diovan 80 mg daily
Imdur 60 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Terazosin 10 mg Capsule Sig: One (1) Capsule PO once a day.
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Maxzide-25mg Oral
###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:
___
___ Diagnosis:
Primary
1. Coronary artery disease
2. Hypertension
3. Bradycardia
Discharge Condition:
Hemodynamically stable, chest pain free
###RESPONSE: Home With Service {Home health aide service management}, Coronary artery disease {Coronary arteriosclerosis}, Hypertension {Hypertensive disorder, systemic arterial}, Bradycardia {Bradycardia}, Hemodynamically stable {Hemodynamically stable}, 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: Discharge Instructions:
You came into the hospital because of chest pain. You underwent
a repeat cardiac catheterization that showed no major new
blockages.
.
At the other hospital, you had evidence of an irregular heart
rhythm (atrial fibrillation or flutter) but your heart rhythm
here looked regular. You will need a heart monitor for 48 hours
following discharge from the hospital to see if the irregular
rhythm recurs.
.
We stopped your atenolol because it may be contributing to the
dizzy episodes you were having prior to coming into the
hospital.
Please take your medications as directed and keep your followup
appointments.
.
Call your doctor and seek medical attention if you develop:
** worsening chest discomfort, shortness of breath,
lightheadedness or dizziness, bleeding, swelling, or pain at the
procedure site at your groin, or if you have any other symptoms
that worry you
###RESPONSE: chest pain {Chest pain}, cardiac catheterization {Cardiac catheterization}, irregular heart
rhythm {Irregular heart beat}, atrial fibrillation {Atrial fibrillation}, flutter {Atrial flutter}, heart rhythm {Finding of heart rhythm}, regular {Normal sinus rhythm}, irregular
rhythm {Irregular heart beat}, dizzy {Dizziness}, chest discomfort {Chest discomfort}, shortness of breath {Dyspnea}, lightheadedness {Lightheadedness}, dizziness {Dizziness}, bleeding {Bleeding}, swelling {Swelling}, pain {Chest pain}, procedure {Procedure}, groin {Inguinal region 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: 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:
abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
None
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, abdominal pain {Abdominal pain}, diarrhea {Diarrhea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 ___ yo M w/hx of DVT, hyponatremia, and chronic
pancreatic abnormalitiy of unknown etiology presenting with
lower abdominal pain and diarrhea. His symptoms began with
diarrhea on ___ happening twice a day, was nonbloody. He
developed abdominal pain on ___, constant,
nonradiating, and in the lower central abdomen. His abdominal
pain progressed over three days to ___, and his diarrhea did
not improve. His last bowel movement was yesterday and is
currently passing gas. He has been able to eat and drink, denies
any fevers, chills, vomiting, hematemesis, melena, hematochezia,
travel, sick contacts, food ingestion. He finished triple
therapy for H. Pylori 1 month ago. He did endorse urinary
hesitancy, no dysuria. He has no history of alcohol use, did
smoke with 2.5 pack years.
On arrival to the ED, initial vitals were: T97.8 HR84 BP136/84
RR16 O296% ra. Exam notable for mild diffuse ttp, no
rebound/guarding. Labs notable for: ALT 87 AP 60 Tbili: 0.2 Na:
129 BUN/crea: ___ Lip: 171 WBC: 8.2. CT abdomen showed
pancreatitis of body and tail and likely distal splenic vein
thrombosis. In ED, patient received Morphine 5 mg IV, 4mg
zofran, and 2L IV NS. Patient evaluated by ACS who recommended
admission to medicine for suspected pancreatitis. VS prior to
transfer: 98.3 76 116/72 14 100% RA.
Currently, he is feeling ___ abdominal pain, which he calls
comfortable. It is in the center lower abdomen, nonradiating.
He denies any vomiting, fevers, chills, or SOB.
Of note, he has had a 25 lb weight loss since ___ and has had
a poor appetite. He has some chronic symptoms that began with
constipation. Sometime in ___ he was admitted to the ___
for hyponatremia and was found to have a chronic pancreatic
abnormality of unknown etiology s/p biopsy, colonoscopy, and
endoscopy. He also had a DVT that he is on Lovenox for
currently. He expresses some chronic lower abdominal pain that
sometimes involves testicular pain.
ROS: per HPI, denies fever, chills, night sweats, vision
changes, shortness of breath, chest pain, vomiting, BRBPR,
melena, hematochezia, dysuria, hematuria. Did endorse headache.
###RESPONSE: DVT {Deep venous thrombosis}, hyponatremia {Hyponatremia}, chronic
pancreatic abnormalitiy {Disorder of pancreas}, lower abdominal pain {Lower abdominal pain}, diarrhea {Diarrhea}, diarrhea {Diarrhea}, abdominal pain {Abdominal pain}, constant {Constant pain}, nonradiating {Radiating pain}, lower central abdomen {Lower abdomen structure}, abdominal
pain {Abdominal pain}, diarrhea {Diarrhea}, passing gas {Passing flatus}, able to eat {Able to eat}, fevers {Fever}, chills {Chill}, vomiting {Vomiting}, hematemesis {Hematemesis}, melena {Melena}, hematochezia {Hematochezia}, travel {Travel abroad}, triple
therapy for H. Pylori {Triple therapy helicobacter pylori}, urinary
hesitancy {Delay when starting to pass urine}, dysuria {Dysuria}, alcohol use {Current drinker of alcohol}, did
smoke {Ex-smoker}, vitals {Vital signs finding}, diffuse {Diffuse pain}, ttp {Tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, ALT {Alanine aminotransferase above reference range}, WBC {White blood cell count}, CT abdomen {Computed tomography of abdomen}, pancreatitis {Pancreatitis}, splenic vein
thrombosis {Splenic vein thrombosis}, pancreatitis {Pancreatitis}, VS {Vital signs finding}, RA {Breathing room air}, abdominal pain {Abdominal pain}, lower abdomen {Lower abdomen structure}, nonradiating {Radiating pain}, vomiting {Vomiting}, fevers {Fever}, chills {Chill}, SOB {Dyspnea}, weight loss {Weight loss}, poor appetite {Decrease in appetite}, constipation {Constipation}, hyponatremia {Hyponatremia}, chronic pancreatic
abnormality {Disorder of pancreas}, biopsy {Biopsy}, colonoscopy {Colonoscopy}, endoscopy {Endoscopy}, DVT {Deep venous thrombosis}, lower abdominal pain {Lower abdominal pain}, testicular pain {Pain in testicle}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, vision
changes {Visual disturbance}, shortness of breath {Dyspnea}, chest pain {Chest pain}, vomiting {Vomiting}, BRBPR {Hematochezia}, melena {Melena}, hematochezia {Hematochezia}, dysuria {Dysuria}, hematuria {Blood in urine}, headache {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: Past Medical History:
pancreatic mass s/p biopsy, colonoscopy, and endoscopy, the most
recent endoscopy in ___
H pylori gastritis s/p triple therapy 1 month ago
DVT in ___
Diabetes Mellitus (reported by patient, on no therapy)
###RESPONSE: pancreatic mass {Mass of pancreas}, biopsy {Biopsy}, colonoscopy {Colonoscopy}, endoscopy {Endoscopy}, endoscopy {Endoscopy}, H pylori gastritis {Gastritis caused by Helicobacter pylori}, triple therapy {Triple therapy helicobacter pylori}, DVT {Deep venous thrombosis}, Diabetes Mellitus {Diabetes mellitus}, therapy {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: 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:
Denies any family history of pancreatic or other GI disease,
cancer, or autoimmune disease
###RESPONSE: pancreatic {Pancreatic structure}, GI disease {Disorder of gastrointestinal tract}, cancer {Malignant neoplasm}, autoimmune disease {Autoimmune disease} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
======================
Admission Physical Exam
======================
VS - Temp 97.8F, BP 125/62, HR 106, R 18, O2-sat 98% RA
General: NAD, appears comfortable
HEENT: normocephalic, no scleral icterus, OP clear.
Neck: supple, no cervical ___.
CV: regular rhymthm, tachycardic, nl S1 S2, no r/m/g
appreciated.
Lungs: CTAB, no rales
Abdomen: +BS.Soft,nondistended,tender to palpation in the
central lower abdomen and epigastric regions, worse in lower
abdomen. ___ and Grey-Turner's signs negative. No fluid
wave. No hepatosplenomegaly. No rebound or guarding.
GU: no Foley. No LAD,no testicular pain to palpation. No CVA
tenderness.
Ext: WWP, +2 pulses. No pedal edema.
Neuro: A+Ox3, attentive. Memory intact. Motor and sensory
function grossly intact.
Skin: no rashes. No spider angiomata.
=====================
Discharge Physical Exam
=====================
VS- 98.7 119/72 83 18 95RA
General: NAD, appears comfortable
HEENT: no scleral icterus
CV: regular rhythm, normal rate, S1 and S2 clear and of good
quality, no r/m/g appreciated.
Lungs: CTAB bilaterally with good air movement.
Abdomen: +BS. Soft, non-tender, slightly distended. No rebound
or guarding.
Extremities: Warm and well perfused with 2+ DP pulses, no
cyanosis, edema, or excoriations.
Neuro: A+Ox3, attentive.
###RESPONSE: Physical Exam {Physical examination procedure}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, O2-sat {Oxygen saturation measurement}, RA {Breathing room air}, General {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, normocephalic {Normal head}, scleral icterus {Scleral icterus}, OP clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, cervical {Cervical lymphadenopathy}, CV {Cardiovascular physical examination}, regular rhymthm {Normal sinus rhythm}, tachycardic {Tachycardia}, S2 {Normal second heart sound, S>2<}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, rales {Respiratory crackles}, Abdomen {Examination of abdomen}, BS {Normal bowel sounds}, Soft {Abdomen soft}, nondistended {Normal abdominal contour}, tender {Abdominal tenderness}, palpation {Palpation}, lower abdomen {Lower abdomen structure}, epigastric regions {Epigastric region structure}, lower
abdomen {Lower abdomen structure}, Grey-Turner's signs {Grey Turner's sign}, hepatosplenomegaly {Hepatosplenomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, GU {Examination of genitourinary system}, Foley {Catheterization of urinary bladder}, LAD {Lymphadenopathy}, pain {Pain}, palpation {Palpation}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, 2 pulses {Peripheral pulses normal}, edema {Edema}, Neuro {Neurological examination}, Ox3 {Oriented to person, time and place}, Memory intact {Memory function normal}, grossly intact {Normal nervous system function}, Skin {Examination of skin}, rashes {Eruption of skin}, spider angiomata {Spider telangiectasis of skin}, Physical Exam {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, scleral icterus {Scleral icterus}, CV {Cardiovascular physical examination}, regular rhythm {Normal sinus rhythm}, normal rate {Normal heart rate}, S2 {Normal second heart sound, S>2<}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, good air movement {Breath normal}, Abdomen {Examination of abdomen}, BS {Normal bowel sounds}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, distended {Swollen abdomen}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, Extremities {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ DP pulses {All pulses present in bilateral lower limbs}, cyanosis {Cyanosis}, edema {Edema}, excoriations {Excoriation}, Neuro {Neurological examination}, A {Mentally alert}, Ox3 {Oriented to person, time and place}, attentive {Well controlled integrated attention} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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
=============================
___ 12:45AM BLOOD WBC-8.2 RBC-4.53* Hgb-12.4* Hct-40.2
MCV-89 MCH-27.4 MCHC-30.9* RDW-12.3 Plt ___
___ 12:45AM BLOOD Neuts-59.0 ___ Monos-7.6 Eos-2.0
Baso-0.5
___ 12:45AM BLOOD Plt ___
___ 10:30AM BLOOD Glucose-110* UreaN-4* Creat-0.4* Na-134
K-4.1 Cl-99 HCO3-27 AnGap-12
___ 12:45AM BLOOD Glucose-151* UreaN-6 Creat-0.6 Na-129*
K-4.5 Cl-97 HCO3-27 AnGap-10
___ 12:45AM BLOOD ALT-87* AST-35 AlkPhos-60 TotBili-0.2
___ 12:45AM BLOOD Lipase-171*
___ 10:30AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.8
___ 12:45AM BLOOD Albumin-4.4 Calcium-8.9 Phos-4.3 Mg-2.0
___ 12:45AM BLOOD Osmolal-266*
___ 08:06PM BLOOD CA ___ -Test
================
Imaging
================
CT Abd/Pelv w/Contrast ___: IMPRESSION:
1. Pancreatitis most prominent in the body and tail of the
pancreas with
areas of pancreatic parenchymal hypoenhancement in the body and
tail,
concerning for edema or impending pancreatic necrosis, involving
less than ___ of the gland. The areas of hypodensity in the
pancreas are round and focal lesions cannot be excluded. No
peripancreatic fluid collection. The splenic vein is attenuated
proximally and likely narrowed in the region adjacent to the
body and tail of the pancreas.
2. Multiple bilateral solid and ground glass nodules throughout
both lung
bases most likely represents infection, however, further
characterization withdedicated chest CT could be considered on a
non-emergent basis to exclude the possibility of malignancy.
==================
Discharge Results
==================
___ 07:15AM BLOOD Hct-38.3*
___ 07:10AM BLOOD Na-132* K-3.9 Cl-97
___ 07:10AM BLOOD ALT-149* AST-50* AlkPhos-87 TotBili-0.4
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Lipase {Serum lipase measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Imaging {Imaging}, Pancreatitis {Pancreatitis}, pancreas {Pancreatic structure}, pancreatic parenchymal {Structure of parenchyma of pancreas}, edema {Edema}, pancreatic necrosis {Necrosis of pancreas}, pancreas {Pancreatic structure}, lesions {Lesion}, fluid collection {Accumulation of fluid}, splenic vein {Structure of splenic vein}, pancreas {Pancreatic structure}, ground glass {Ground glass lung opacity}, nodules {Nodule}, lung
bases {Structure of base of lung}, infection {Infectious disease}, malignancy {Malignant neoplasm}, Hct {Hematocrit determination}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Mr. ___ is a ___ yo M with hx of DVT, hyponatremia, and
pancreatic mass suggestive of malignancy presenting with
pancreatitis secondary to pancreatic mass.
# Pancreatitis: Patient was treated conservatively for
pancreatitis. Morphine IV administered for pain control, he
remained NPO and given intravenous fluids. Diet was advanced
slowly once pain resolved and prior to discharge was tolerating
food and fluids without pain. Started pancreatic enzymes for
diarrhea. He remained hemodynamically stable throughout.
# Pancreatic mass: FNA biopsy at outside hospital suggests
adenocarcinoma versus neuroendocrine tumor. Records from ___
including MRI showed pancreatic ductal mass and PET with uptake
in the lungs. Chest CT with nodules suggestive of metastatic
disease. The oncology team was consulted, and additional biopsy
was recommended however can be completed in the outpatient
setting. ___ was consulted and will set patient up for biopsy
post discharge.
# Hyponatremia: Secondary to SIADH given low sodium with
euvolemia, elevated urine sodium, and improvement of sodium with
fluid restriction. He has a history of SIADH and presented with
a sodium of 129 that improved over the course of his admission
with fluid restriction. He had no neurologic symptoms at any
point during his admission.
# Splenic vein thrombosis: Imaging findings were suggestive of
splenic vein thrombosis, which based on prior ___ imaging is
chronic. He was maintained on his home Lovenox dose.
==================
Transitions of Care
==================
- To undergo outpatient retroperitoneal lymph node biopsy for
final diagnosis of his pancreatic mass
- Oncology outpatient eval to determine next treatment steps
- Follow up with PCP regarding ___ enzyme titration to
help with diarrhea
- Follow up with PCP regarding BPH
- Monitor Hyponatremia
- Code Status: Full code
- Additional contact: Brother ___ ___
###RESPONSE: DVT {Deep venous thrombosis}, hyponatremia {Hyponatremia}, pancreatic mass {Mass of pancreas}, malignancy {Malignant neoplasm}, pancreatitis {Pancreatitis}, pancreatic mass {Mass of pancreas}, Pancreatitis {Pancreatitis}, pancreatitis {Pancreatitis}, pain control {Pain control}, remained NPO {On nothing by mouth status}, intravenous fluids {Intravenous infusion}, pain resolved {No present pain}, tolerating
food {Tolerating normal diet}, fluids {Tolerating oral fluid}, without pain {No present pain}, diarrhea {Diarrhea}, hemodynamically stable {Hemodynamically stable}, Pancreatic mass {Mass of pancreas}, FNA biopsy {Fine needle biopsy}, adenocarcinoma {Adenocarcinoma}, neuroendocrine tumor {Neuroendocrine tumor}, MRI {Magnetic resonance imaging}, pancreatic ductal mass {Mass of pancreas}, PET {Positron emission tomography}, lungs {Metastatic malignant neoplasm to lung}, Chest CT {Computed tomography of chest}, nodules {Nodule}, metastatic
disease {Metastatic malignant neoplasm}, biopsy {Biopsy}, biopsy {Biopsy}, Hyponatremia {Hyponatremia}, SIADH {Syndrome of inappropriate vasopressin secretion}, euvolemia {Normal blood volume}, urine sodium {Sodium measurement, urine}, fluid restriction {Fluid restriction}, SIADH {Syndrome of inappropriate vasopressin secretion}, sodium {Sodium measurement}, improved {Patient's condition improved}, fluid restriction {Fluid restriction}, no neurologic symptoms {Normal nervous system function}, Splenic vein thrombosis {Splenic vein thrombosis}, Imaging findings {Imaging finding}, splenic vein thrombosis {Splenic vein thrombosis}, imaging {Imaging}, retroperitoneal lymph node {Structure of retroperitoneal lymph node}, biopsy {Biopsy}, pancreatic mass {Mass of pancreas}, outpatient eval {Outpatient procedure}, PCP {Primary care management}, diarrhea {Diarrhea}, PCP {Primary care management}, BPH {Benign prostatic hyperplasia}, Hyponatremia {Hyponatremia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. Pancrelipase 5000 1 CAP PO TID W/MEALS
Please talk with your doctors about ___ the medicine to
help with diarrhea.
RX *lipase-protease-amylase [Pancrelipase 5000] 5,000
unit-17,000 unit-27,000 unit 1 capsule(s) by mouth three times a
day Disp #*90 Capsule Refills:*0
2. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: First Routine Administration Time
3. Tamsulosin 0.4 mg PO HS
Follow up with your primary care doctor about this medication
and your symptoms.
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
4. Benzonatate 100 mg PO TID:PRN Cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Active:
- Pancreatitis
- Pancreatic malignancy
Chronic:
- Pancreatic cancer
- Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Pancreatitis {Pancreatitis}, Pancreatic malignancy {Malignant tumor of pancreas}, Pancreatic cancer {Malignant tumor of pancreas}, Hyponatremia {Hyponatremia}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Mr. ___,
You were admitted to the hospital because of abdominal pain and
diarrhea caused by inflammation of your pancreas. You received
fluids and pain medication and improved. You were tolerating
food and liquids by mouth at discharge. You were given some
pancreatic enzymes to help with the diarrhea.
We acquired records from the ___, which along with your
symptoms of weight loss are concerning for cancer. We scheduled
an outpatient biopsy of a lymph node for you. It is very
important that you have that procedure done and follow up with
the oncologists to continue your care. You were complaining of
some tenderness around your bladder and some difficulty
initiating urination, so you were starting on a medication to
help with that and should follow up with your primary care
doctor. Thank you for having us be a part of your care team.
The Interventional Radiology team will be contacting you to
schedule an appointment for your biopsy. If you do not hear by
___ next week please call the floor ___
###RESPONSE: abdominal pain {Abdominal pain}, diarrhea {Diarrhea}, inflammation of your pancreas {Pancreatitis}, pain medication {Administration of analgesic}, improved {Patient's condition improved}, tolerating
food {Tolerating diet}, liquids by mouth {Tolerating oral fluid}, diarrhea {Diarrhea}, weight loss {Weight loss}, cancer {Malignant neoplasm}, biopsy {Biopsy}, lymph node {Structure of lymph node}, tenderness {Tenderness}, bladder {Urinary bladder structure}, difficulty
initiating urination {Delay when starting to pass urine}, biopsy {Biopsy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: PLASTIC
###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:
Compazine
Attending: ___.
Chief Complaint:
abdominal wound
Major Surgical or Invasive Procedure:
Abdominal wound exploration and removal of infected mesh.
###RESPONSE: Compazine {Allergy to prochlorperazine}, abdominal wound {Wound of abdomen}, Abdominal wound exploration {Exploration of penetrating wound of abdomen}, removal of infected mesh {Removal of mesh from wound} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ is a ___ year old female with history of lower
abdominal desmoid tumor removal and reconstruction with mesh
with subsequent infection and resection of mesh and replacement,
eventually wound which required delayed primary closure. She
presented to clinic with a small wound in the middle ofher lower
abdominal incision site. She is here today for abdominal wound
exploration.
###RESPONSE: abdominal desmoid tumor removal {Excision of subfascial abdominal wall tumor}, reconstruction {Reconstruction procedure}, infection {Postoperative wound infection}, resection of mesh {Removal of mesh from wound}, replacement {Replacement procedure}, wound {Surgical incision wound}, closure {Reparative closure}, wound {Surgical incision wound}, abdominal incision {Abdomen incision}, abdominal wound
exploration {Exploration of penetrating wound of abdomen} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
depression, chronic headaches, presyncope, type 2 diabetes
mellitus, hyperlipidemia, obesity, chronic urinary tract
infections, and chronic back pain. She has a longstanding
microcytosis with a negative workup in the past.
.
PSH
D&C, right first metatarsal bunion, cesarean section
with placenta previa, bilateral breast reduction, bilateral ORIF
of the hips for congenital dysplasia.
###RESPONSE: depression {Depressive disorder}, chronic headaches {Chronic headache disorder}, presyncope {Near syncope}, type 2 diabetes
mellitus {Diabetes mellitus type 2}, hyperlipidemia {Hyperlipidemia}, obesity {Obesity}, chronic urinary tract
infections {Chronic urinary tract infection}, chronic back pain {Chronic back pain}, microcytosis {Microcytosis, red cells}, negative {No pathologic diagnosis}, workup {Evaluation procedure}, D&C {Dilation and curettage}, right first metatarsal {Structure of first metatarsal bone of right foot}, bunion {Swelling of first metatarsophalangeal joint of hallux}, cesarean section {Cesarean section}, placenta previa {Placenta previa}, bilateral breast reduction {Reduction plasty of bilateral breasts}, congenital dysplasia {Congenital hip dysplasia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Non-contributory
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Physical exam per PRS post operative note ___ 1844 Temp: 97.5 PO BP: 111/63 L Lying HR: 106 RR: 20 O2
sat: 100% O2 delivery: RA
Gen: NAD, A&Ox3, lying on stretcher.
HEENT: Normocephalic.
CV: RRR
R: Breathing comfortably on room air. No wheezing.
Abd: Lower abd with VAC in place, holding suction, trace SS
output. No surrounding erythema.
Ext: WWP.
###RESPONSE: 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}, Gen {General examination of patient}, NAD {No abnormality detected}, Ox3 {Oriented to person, time and place}, lying {Lying in bed}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, Breathing comfortably on room air {Breathing room air}, wheezing {Wheezing}, Abd {Examination of abdomen}, erythema {Erythema}, Ext {Examination of limb}, WWP {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:
___ 10:20PM GLUCOSE-210* UREA N-11 CREAT-0.7 SODIUM-139
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-25 ANION GAP-13
___ 10:20PM estGFR-Using this
___ 10:02PM URINE HOURS-RANDOM
___ 10:02PM URINE UCG-NEGATIVE
.
IMAGING:
Radiology Report CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS
Study Date of ___ 12:08 AM
IMPRESSION:
1. Interval decrease in size of the prior anterior abdominal
wall collections.
2. No fistula. No hernia.
3. Cholelithiasis, but no features of cholecystitis.
4. Rest of the findings as described above.
###RESPONSE: GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, CT ABD & PELVIS W {Computed tomography of abdomen and pelvis with contrast}, W/O CONTRAST {Computed tomography of abdomen and pelvis without contrast}, decrease in size {Decreased size}, anterior abdominal
wall {Anterior abdominal wall structure}, fistula {Fistula}, hernia {Hernia of abdominal cavity}, Cholelithiasis {Calculus in biliary tract}, cholecystitis {Cholecystitis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
The patient was admitted to the plastic surgery service on
___ and had a abdominal wound exploration and removal of
mesh. The patient tolerated the procedure well.
.
Neuro: Post-operatively, the patient received IV pain
medications with good effect and adequate pain control. When
tolerating oral intake, the patient was transitioned to oral
pain medications.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced when appropriate,
which was tolerated well. She was also started on a bowel
regimen to encourage bowel movement. Intake and output were
closely monitored.
.
ID: Post-operatively, the patient was started on IV cefazolin,
then switched to PO cefadroxil for discharge home. The patient's
temperature was closely watched for signs of infection.
.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
.
At the time of discharge on POD#2, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. She was discharged with wound vac in place.
###RESPONSE: abdominal wound exploration {Exploration of penetrating wound of abdomen}, removal of
mesh {Removal of mesh from wound}, Neuro {Neurological assessment}, Post-operatively {Postoperative state}, IV {Intravenous therapy}, pain
medications {Administration of analgesic}, good effect {Good therapeutic response}, adequate pain control {Demonstrates adequate pain control}, tolerating oral intake {Tolerating diet}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, stable {Patient's condition stable}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, Pulmonary {Examination of respiratory system}, stable {Patient's condition stable}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, Post-operatively {Postoperative state}, given IV fluids {Administration of intravenous fluids}, tolerating oral intake {Tolerating diet}, diet was advanced {Advance diet as tolerated}, bowel
regimen {Bowel care}, Intake and output {Measuring intake and output}, Post-operatively {Postoperative state}, temperature {Temperature taking}, watched for signs of infection {Monitoring for signs and symptoms of infection}, Prophylaxis {Preventive procedure}, subcutaneous heparin {Subcutaneous injection of heparin}, ambulate {Ambulation training}, afebrile {Temperature normal}, stable vital signs {Normal vital signs}, tolerating a regular diet {Tolerating normal diet}, ambulating {Fully mobile}, voiding without assistance {Normal micturition}, pain was well
controlled {Demonstrates adequate pain control}, wound vac {Vacuum assisted skin closure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Carbamazepine (Extended-Release) 100 mg PO QAM
3. Carbamazepine (Extended-Release) 200 mg PO QHS
4. cefaDROXil 500 mg oral BID
5. FLUoxetine 60 mg PO DAILY
6. Gabapentin 300 mg PO QHS
7. Gabapentin 100 mg PO BID
8. MetFORMIN (Glucophage) 850 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. Ondansetron 8 mg PO DAILY:PRN nausea
11. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
13. RisperiDONE 0.5 mg PO DAILY
14. Simvastatin 40 mg PO QPM
15. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
16. Aspirin 81 mg PO DAILY
17. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
18. Senna 8.6 mg PO BID:PRN Constipation - Second Line
Discharge Medications:
1. cefaDROXil 500 mg oral BID
RX *cefadroxil 500 mg 1 capsule(s) by mouth twice a day Disp
#*56 Capsule Refills:*2
2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
3. Simethicone 40-80 mg PO QID:PRN abdominal gas
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
7. Aspirin 81 mg PO DAILY
8. Carbamazepine (Extended-Release) 100 mg PO QAM
9. Carbamazepine (Extended-Release) 200 mg PO QHS
10. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
11. FLUoxetine 60 mg PO DAILY
12. Gabapentin 300 mg PO QHS
13. Gabapentin 100 mg PO BID
14. MetFORMIN (Glucophage) 850 mg PO BID
15. Omeprazole 20 mg PO DAILY
16. Ondansetron 8 mg PO DAILY:PRN nausea
17. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
18. RisperiDONE 0.5 mg PO DAILY
19. Senna 8.6 mg PO BID:PRN Constipation - Second Line
20. Simvastatin 40 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 With Service
Facility:
___
Discharge Diagnosis:
1) Infected mesh
2) Poor coping skills in setting of depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Home With Service {Home health aide service management}, depression {Depressive disorder}, 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:
Personal Care:
1. You will have a wound VAC dressing with a wound vac machine
in place for discharge home. This will remain in place until
you come back on ___ for the OR.
2. While VAC is in place, please clean around the VAC site and
monitor for air leaks of the VAC
3. A written record of the daily output from the VAC drain
should be brought to every follow-up appointment.
4. You may shower daily with assistance as needed. You should
do this with wound vac apparatus disconnected from you. Once
you have showered you will need to reconnect your dressing to
the wound vac apparatus and make sure it is functioning
properly.
5. No baths until after directed by your surgeon.
.
Activity:
1. Avoid strenuous activity with wound vac in place.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered .
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take your antibiotic as prescribed if you are discharged on
one.
5. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
6. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
###RESPONSE: wound VAC {Vacuum assisted skin closure}, dressing {Application of dressing}, in place {Device in situ}, output from the VAC drain {Monitoring of fluid output from drain}, Signs of infection {Monitoring for signs and symptoms of infection}, fever with chills {Fever with chills}, redness {Redness of skin over lesion}, swelling {Swelling}, warmth {Warm skin}, tenderness {Tenderness}, surgical site {Operative site}, drainage {Wound discharge}, incision {Surgical incision wound}, bleeding {Bleeding}, incision {Surgical incision wound}, drain {Wound discharge}, Fever {Fever}, Severe pain {Severe pain}, vomiting {Vomiting}, cannot keep in fluids {Unable to drink}, shaking {Tremor}, chills {Chill}, fever {Fever}, redness {Redness of skin over lesion}, swelling {Swelling}, incision {Surgical incision wound}, chest pain {Chest pain}, shortness of breath {Dyspnea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
morphine
Attending: ___.
Chief Complaint:
Dyspnea, cough
Major Surgical or Invasive Procedure:
Intubation ___
Extubation ___
###RESPONSE: morphine {Allergy to morphine}, Dyspnea {Dyspnea}, cough {Cough}, Intubation {Insertion of endotracheal tube}, Extubation {Removal of endotracheal tube} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Ms ___ is a ___ woman with a history of CHF (LVEF 70% in
___, on Bumex), Afib (on Abixiban), and HTN who presents with
worsening shortness of breath over the past week. Dyspnea has
been on exertion and at rest. Associated with PND and orthopnea.
Also associated with 1 month of increased bilateral lower
extremity swelling, R>L. Not associated with chest pain or
palpitations. During this time, she has had a non-productive
cough, as well as intermittent dysuria and increased urinary
frequency. She notes an odor to urine, but denies fevers,
chills, chest pain, abdominal pain, or pain in legs. No recent
sick contacts, no recent travel. No nasal congestion, cough, or
other URI symptoms preceding dyspnea.
In the ED, initial vitals were: T 98.3 HR 110 BP 142/74 RR 24
SaO2 94% on nc
Exam: Rales at both lung bases. RLE edema > LLE (stable from
previous PCP ___
Labs: proBNP 7388, K 3.0, Cr 1.7, Mg 1.3, WBC 12.3, Hgb 11.2,
Plt 286, INR 1.4, lacate 1.7
Imaging: EKG: HR 130, AFib w RVR, Left axis, Normal QRS and
QTc, no STE. CXR: Mild pulmonary edema, worse in the interval.
Bedside U/S: mild pericardial effusion
Consults: Cardiology, Respiratory therapy
Patient was given Nitro gtt for control of shortness of breath.
She developed AF + RVR, so was started on Esmolol gtt. She
became hypotensive to ___, so Esmolol gtt was stopped, and her
HR improved without further intervention. She also received
Aspirin, Lasix 80mg IVx1 & 40mg IVx2, K 40mg POx1, Mg 2gm IV.
Decision was made to admit to CCU for CHF exacerbation with
pulmonary edema requiring BiPAP
Vitals on transfer were: HR 100 BP 113/56 RR 25 SaO2 98% ra
On the floor, patient reports feeling well. She continues to be
a little short of breath, but the facemask is bothering her. She
denies current chest pain. Has been coughing and short of breath
for the past week. Cough is nonproductive. No current abdominal
pain or dysuria.
REVIEW OF SYSTEMS:
(+) per HPI
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.
Denies any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools.
Denies recent fevers, chills or rigors. Denies exertional
buttock or calf pain. All of the other review of systems were
negative.
###RESPONSE: CHF {Congestive heart failure}, Afib {Atrial fibrillation}, HTN {Hypertensive disorder, systemic arterial}, worsening {Patient's condition worsened}, shortness of breath {Dyspnea}, Dyspnea {Dyspnea}, exertion {Dyspnea on exertion}, at rest {Dyspnea at rest}, PND {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, bilateral lower
extremity swelling {Swelling of bilateral lower limbs}, chest pain {Chest pain}, palpitations {Palpitations}, non-productive
cough {Dry cough}, dysuria {Dysuria}, urinary
frequency {Increased frequency of urination}, odor to urine {Abnormal urine odor}, fevers {Fever}, chills {Chill}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, pain in legs {Pain in lower limb}, travel {Travel abroad}, nasal congestion {Nasal congestion}, cough {Cough}, URI {Upper respiratory infection}, dyspnea {Dyspnea}, vitals {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, SaO2 {Finding of oxygen saturation}, on nc {Oxygen administration by nasal cannula}, Exam {Physical examination procedure}, Rales {Respiratory crackles}, lung bases {Structure of base of lung}, RLE edema > LLE {Edema of bilateral lower limbs}, stable {Patient's condition stable}, PCP {Primary care management}, Labs {Laboratory test}, WBC {White blood cell count}, INR {Calculation of international normalized ratio}, Imaging {Imaging}, EKG {Electrocardiographic procedure}, HR {Finding of heart rate}, AFib w RVR {Atrial fibrillation with rapid ventricular response}, Left {Structure of left side of heart}, axis {Electrocardiographic axis finding}, Normal {No abnormality detected}, QRS {Finding of electrocardiogram QRS complex}, QTc {Finding of electrocardiogram QT interval}, STE {ST segment elevation}, CXR {Plain chest X-ray}, Mild {Symptom mild}, pulmonary edema {Pulmonary edema}, worse {Patient's condition worsened}, U/S {Ultrasonography}, mild {Symptom mild}, pericardial effusion {Pericardial effusion}, Cardiology {Cardiology service}, Respiratory therapy {Respiratory therapy}, shortness of breath {Dyspnea}, AF + RVR {Atrial fibrillation with rapid ventricular response}, hypotensive {Low blood pressure}, Esmolol gtt was stopped {Recommendation to stop drug treatment}, HR {Finding of heart rate}, improved {Patient's condition improved}, Aspirin {Administration of aspirin}, Lasix {Diuretic therapy}, IV {Intravenous therapy}, CHF exacerbation {Exacerbation of congestive heart failure}, pulmonary edema {Pulmonary edema}, BiPAP {Bilevel positive airway pressure titration}, Vitals {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, SaO2 {Finding of oxygen saturation}, ra {Breathing room air}, feeling well {Well in self}, short of breath {Dyspnea}, facemask {Oxygen administration by mask}, chest pain {Chest pain}, coughing {Cough}, short of breath {Dyspnea}, Cough is nonproductive {Dry cough}, abdominal
pain {Abdominal pain}, dysuria {Dysuria}, REVIEW OF SYSTEMS {Review of systems}, Cardiac {Cardiovascular physical examination}, review of systems {Review of systems}, chest pain {Chest pain}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope}, stroke {Cerebrovascular accident}, TIA {Transient ischemic attack}, deep venous thrombosis {Deep venous thrombosis}, pulmonary embolism {Pulmonary embolism}, bleeding {Bleeding}, surgery {Surgical procedure}, myalgias {Muscle pain}, joint pains {Joint pain}, cough {Cough}, hemoptysis {Hemoptysis}, black stools {Dark stools}, red stools {Red stools}, fevers {Fever}, chills {Chill}, rigors {Rigor}, exertional {Pain provoked by exertion}, buttock {Pain in buttock}, calf pain {Pain in calf}, review of systems {Review of systems}, negative {No abnormality detected} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
Hypertension
hyperlipidemia
peripheral vascular disease
venous insufficiency
peripheral neuropathy
history of colon CA (no rad/chem)
rosacea
intertrigo
L5-S1 radiculopathy
PSH:
partial colectomy 93'
R ___ angio;
PTA R SFA c stent x 2 at mid/distal SFA ___ (Zilver
stent)
###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, peripheral vascular disease {Peripheral vascular disease}, venous insufficiency {Vascular insufficiency}, peripheral neuropathy {Peripheral nerve disease}, colon CA {Malignant neoplasm of colon}, rad {Radiation oncology AND/OR radiotherapy}, chem {Chemotherapy}, rosacea {Rosacea}, intertrigo {Intertrigo}, L5-S1 {Structure of intervertebral disc of L5 and S1}, radiculopathy {Nerve root disorder}, partial colectomy {Partial resection of colon}, angio {Angiography}, PTA {Percutaneous transluminal angioplasty}, SFA {Structure of superficial femoral artery}, stent {Insertion of arterial stent}, SFA {Structure of superficial femoral artery}, stent {Insertion of arterial 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: 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:
CAD in brother
Physical ___:
ADMISSION PHYSICAL EXAMINATION:
VS: T 97.1 HR 113 BP 121/76 RR 25 SaO2 100% on facemask
Gen: elderly woman, labored breathing, nontoxic, NAD
HEENT: no scleral icterus, erythema and ecchymosis over nose
and mouth, mmm
NECK: +JVD (JVP 12cm)
CV: tachycardic, irregular rhythm, no m/r/g
LUNGS: on facemask, coughing, junky breath sounds with
bilateral wheezing and rhonchi; wheezing
ABD: soft, NT/ND, +bs, no suprapubic tenderness
EXT: warm, 2+ edema in bilateral ___ to knees, venous stasis
changes R>L
SKIN: erythema and ecchymosis over nose and mouth
NEURO: alert, moving all 4 extremities, no gross deficits
DISCHARGE PHYSICAL EXAM:
Discharge Weight: 72.9 kg
VS: 97-98.6 90-110s/50-60s ___ RA
Weight: 74.4 <--75.4 <--75.1 kg <-- 75.8 kg
Tele: short asymptomatic sinus pauses while sleeping
Gen: elderly woman, NAD
HEENT: no scleral icterus, erythema and ecchymosis over nose
and mouth, mmm
NECK: no JVD
CV: regular rate, irregularly irregular rhythm, no m/r/g
LUNGS: wheezing and rhonchi have resolved
ABD: soft, NT/ND, +bs, no ttp
EXT: warm, no edema, venous stasis changes R>L
SKIN: erythema and ecchymosis over nose and mouth mostly
resolved
NEURO: alert, moving all 4 extremities, no gross deficits,
oriented to person, time, and place
###RESPONSE: CAD {Coronary arteriosclerosis}, PHYSICAL EXAMINATION {Physical examination procedure}, VS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, SaO2 {Finding of oxygen saturation}, facemask {Oxygen administration by mask}, Gen {General examination of patient}, labored breathing {Labored breathing}, HEENT {Physical examination procedure}, scleral icterus {Scleral icterus}, erythema {Erythema}, ecchymosis {Ecchymosis}, nose {Nasal structure}, mouth {Mouth region structure}, mmm {Moist oral mucosa}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, JVP {Finding of jugular venous pressure}, CV {Cardiovascular physical examination}, tachycardic {Tachycardia}, irregular rhythm {Irregular heart beat}, no m/r/g {Heart sounds normal}, LUNGS {Examination of respiratory system}, facemask {Oxygen administration by mask}, coughing {Cough}, breath sounds {Finding of breath sounds}, wheezing {Wheezing}, rhonchi {Wheeze - rhonchi}, wheezing {Wheezing}, 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 in bilateral ___ to knees {Edema of bilateral lower legs}, venous stasis {Venous stasis}, SKIN {Examination of skin}, erythema {Erythema}, ecchymosis {Ecchymosis}, nose {Nasal structure}, mouth {Mouth region structure}, NEURO {Neurological examination}, alert {Mentally alert}, moving all 4 extremities {Does move all four limbs}, deficits {Neurological deficit}, Weight {Weight finding}, VS {Vital signs finding}, RA {Breathing room air}, Weight {Weight finding}, Tele {Cardiac telemetry}, asymptomatic {Asymptomatic}, sinus pauses {Sinus arrest}, sleeping {Asleep}, Gen {General examination of patient}, HEENT {Physical examination procedure}, scleral icterus {Scleral icterus}, erythema {Erythema}, ecchymosis {Ecchymosis}, nose {Nasal structure}, mouth {Mouth region structure}, mmm {Moist oral mucosa}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, CV {Cardiovascular physical examination}, regular rate {Normal heart rate}, irregularly irregular {Heart irregularly irregular}, rhythm {Irregular heart beat}, no m/r/g {Heart sounds normal}, LUNGS {Examination of respiratory system}, wheezing {Wheezing}, rhonchi {Wheeze - rhonchi}, 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}, venous stasis {Venous stasis}, SKIN {Examination of skin}, erythema {Erythema}, ecchymosis {Ecchymosis}, nose {Nasal structure}, mouth {Mouth region structure}, NEURO {Neurological examination}, alert {Mentally alert}, moving all 4 extremities {Does move all four limbs}, deficits {Neurological deficit}, oriented to person, time, and place {Oriented to person, time and place} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS:
======================
___ 01:40PM BLOOD WBC-12.3*# RBC-4.03 Hgb-11.2 Hct-35.9
MCV-89 MCH-27.8 MCHC-31.2* RDW-16.2* RDWSD-52.7* Plt ___
___ 01:40PM BLOOD ___ PTT-33.7 ___
___ 01:40PM BLOOD Glucose-132* UreaN-35* Creat-1.7* Na-140
K-3.0* Cl-93* HCO3-26 AnGap-24*
___ 01:40PM BLOOD ALT-16 AST-22 AlkPhos-131* TotBili-1.0
___ 01:40PM BLOOD proBNP-___*
___ 01:40PM BLOOD cTropnT-<0.01
___ 01:40PM BLOOD Albumin-4.1 Calcium-7.2* Phos-4.0 Mg-1.3*
___ 03:29AM BLOOD Type-ART Temp-36.3 Rates-/29 pO2-152*
pCO2-120* pH-7.07* calTCO2-37* Base XS-0 Intubat-NOT INTUBA
___ 02:14PM BLOOD Lactate-1.7
___ 03:29AM BLOOD freeCa-0.93*
OTHER PERTINENT LABS:
======================
___ 08:53PM BLOOD cTropnT-<0.01
___ 01:40PM BLOOD cTropnT-<0.01
___ 06:55AM BLOOD TSH-7.9*
___ 06:55AM BLOOD Free T4-1.2
MICRO:
======================
___ Blood culture: negative
___ MRSA screen: negative
___ Urine culture: KLEBSIELLA PNEUMONIAE. >100,000
ORGANISMS/ML..
___ Sputum culture: MORAXELLA CATARRHALIS. MODERATE GROWTH.
IMAGING/STUDIES:
======================
CXR ___: Comparison to ___. Decrease in extent
of a pre-existing left pleural effusion. Unchanged appearance
of the right lung. Moderate cardiomegaly. Mild retrocardiac
atelectasis. Unchanged fibrotic right upper lobe changes.
Right PICC line is constant.
ECHO ___:
The left atrium is moderately dilated. The estimated right
atrial pressure is at least 15 mmHg. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Doppler parameters are
indeterminate for left ventricular diastolic function. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are moderately
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad.
Compared with the prior study (images reviewed) of ___,
pulmonary artery systolic pressure is higher and mild mitral
regurgitation is now appreciated. Other findings are similar.
DISCHARGE LABS:
======================
___ 07:14AM BLOOD WBC-6.4 RBC-3.48* Hgb-9.6* Hct-31.4*
MCV-90 MCH-27.6 MCHC-30.6* RDW-16.8* RDWSD-53.8* Plt ___
___ 07:14AM BLOOD Glucose-107* UreaN-27* Creat-1.7* Na-144
K-3.7 Cl-104 HCO3-34* AnGap-10
___ 07:14AM BLOOD Calcium-7.4* Phos-3.3 Mg-2.___RIEF SUMMARY STATEMENT:
=========================
___ woman with a history of CHF (LVEF 70% in ___, on Bumex),
Afib (on Apixiban), and HTN who presented with worsening
shortness of breath over the past week and cough found to have R
sided pneumonia and acute on chronic diastolic heart failure
exacerbation requiring BiPAP, complicated by hypercarbic
respiratory failure requiring intubation. Sputum culture grew
Moraxella and was treated with ceftriaxone (___) and
azithromycin (___). Patient was given steroids, d/c'ed
after 3 days due to worsening delirium. Delirium improved after
steroids were d/c'ed and with Seroquel. Pt. with afib with RVR
during hospitalization. Started on metoprolol and amiodarone
with improvement in rates.
ACTIVE ISSUES:
=========================
#) ACUTE DECOMPENSATED DIASTOLIC HEART FAILURE: LVEF 70% in
___. On admission, her exam was consistent with fluid overload,
with elevated JVP and 2+ pitting edema in both legs. LVEF 55-60%
on this admission. She was diuresed with 120 mg IV Lasix boluses
and Lasix gtt. Patient was transitioned to her home Bumex prior
to discharge. Of note, her Bumex had recently been increased as
an outpatient but she was not aware of this increase and had
continued at her previous dose, possibly leading to the present
admission.
#) HYPOXIA/CAP: Patient presented with hypoxia, was likely due
to CHF exacerbation and community acquired pneumonia. Although
patient stated she had no history of asthma or COPD, she had
episodes of wheezing and was given standing ipratropium nebs
which improved wheezing and hypoxia. Patient was found to have R
lobe pneumonia on CXR and sputum culture grew Moraxella. She was
treated with 7 day course of Ceftriaxone. Due to worsening
hypercarbia and wheezing, she was treated with prednisone for
CAP, however prednisone was stopped after 3 days due to
worsening delirium. Patient had aggressive pulmonary toilet for
copious secretions and productive cough. Hypoxia had resolved
prior to discharge.
#) ACUTE HYPERCARBIC RESPIRATORY FAILURE: Patient had episode of
agitation and altered mental status on first night of admission,
was found to have pCO2 120 and pH 7.07. She was intubated for
hypercarbic respiratory failure and treated with diuretics and
antibiotics for pneumonia. She was extubated the next day
(___). She had subsequent episodes of respiratory distress
that resolved with BiPAP.
#) AFIB with RVR: At home patient took Apixiban 2.5mg BID and
Diltiazem 180mg BID. On this admission, pt. with RVR. HRs were
140s-150s during admission which was controlled with a diltiazem
gtt. She was started back on her PO diltiazem and started on
metoprolol 100 XL. She still had difficult to control rates.
As such, patient was started on amiodarone with improvement.
She eventually was transitioned back to PO medications and was
discharged on Metoprolol succinate 100 XL daily, Diltiazem 120
mg daily, and amiodarone. She was discharged on her home
apixaban for anticoagulation.
#) ALTERED MENTAL STATUS: Patient had worsening delirium after
extubation most likely due to steroids, scopolamine, and ICU
hospitalization. The scopolamine patch and steroids were d/c'ed
and patient improved slowly. She was started on 50 mg Seroquel
at 4 pm and 10 pm daily for continued agitation and sundowning.
Mental status improved prior to discharge and she was AAOX3.
She was discontinued off of Seroquel with stable mental status
for over 72 hours.
CHRONIC ISSUES:
=========================
#) GERD:
- Continued home omeprazole 20 mg daily
#) CHRONIC PAIN
- Continued home Gabapentin 300mg qhs
TRANSITIONAL ISSUES:
======================
# Discharge Weight: 72.9kg (standing, day of discharge)
# s/p CAP Course: Completed Ceftriaxone 7 days, Prednisone 3
days
# Afib Outpatient Management: Patient needs to follow up with
Dr. ___ Dr. ___ from cardiology.
# Afib with RVR: Pt. with difficult to control ventricular rates
in the setting of her illness. She was started on metoprolol
and amiodarone. Continued on dilt and apixaban.
# Amio: Would consider discontinuing amiodarone now that
patient is stable with rate-controlled Afib. Otherwise, patient
needs safety monitoring if she remains on Amiodarone long term.
Please check PFTs and TFTs as an outpatient. On ___,
TSH:7.9 Free-T4:1.2.
# Amiodarone Dosing: Given 400 BID for 1 week (to ___, 200
BID for 3 weeks (to ___, then 200 daily (Starting
___
# Consider cardioversion as outpatient
# Patient noticed to have painless lump underneath R mandible.
Please evaluate as outpatient.
# Code: DNR/DNI
# HCP: ___ (pt's niece): ___
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, cTropnT {Troponin T cardiac measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, pH {pH measurement}, Lactate {Lactic acid measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, TSH {Thyroid stimulating hormone measurement}, Free T4 {T4 free measurement}, Blood culture {Blood culture}, negative {No abnormality detected}, MRSA {Methicillin resistant Staphylococcus aureus infection}, negative {No abnormality detected}, Urine culture {Urine culture}, Sputum culture {Microbial culture of sputum}, CXR {Plain chest X-ray}, left {Left lung structure}, pleural effusion {Pleural effusion}, right lung {Right lung structure}, cardiomegaly {Cardiomegaly}, Mild {Symptom mild}, atelectasis {Atelectasis}, right upper lobe {Structure of upper lobe of right lung}, PICC line {Peripherally inserted central venous catheter in situ}, ECHO {Echocardiography}, left atrium is moderately dilated {Left atrial dilatation}, right
atrial {Right atrial structure}, pressure {Pressure}, mild symmetric
left ventricular hypertrophy {Mild left ventricular hypertrophy}, normal cavity {Normal size cardiac chamber}, regional/global systolic function {Normal left ventricular systolic function and wall motion}, mild
symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, left ventricular
cavity {Structure of cavity of left cardiac ventricle}, size is normal {Normal size}, left ventricular systolic
function is normal {Normal left ventricular systolic function and wall motion}, left ventricular {Structure of myocardium of left ventricle}, Right
ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Finding of right ventricular wall motion}, aortic valve leaflets {Structure of cardiac valve leaflet}, structurally normal {Aortic valve normal}, good {No abnormality detected}, leaflet {Structure of cardiac valve leaflet}, aortic stenosis {Aortic valve stenosis}, aortic
regurgitation {Aortic valve regurgitation}, mitral valve leaflets {Structure of leaflet of mitral valve}, thickened {Increased thickness}, Mild (1+) mitral regurgitation {Mild mitral valve regurgitation}, mitral regurgitation {Mitral valve regurgitation}, pulmonary
artery systolic hypertension {Pulmonary hypertensive arterial disease}, pericardial effusion {Pericardial effusion}, fat pad {Structure of normal fat pad}, study {Evaluation procedure}, systolic pressure {Increased systolic arterial pressure}, mild mitral
regurgitation {Mild mitral valve regurgitation}, 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}, CHF {Congestive heart failure}, Afib {Atrial fibrillation}, HTN {Hypertensive disorder, systemic arterial}, worsening {Patient's condition worsened}, shortness of breath {Dyspnea}, cough {Cough}, R
sided {Right lung structure}, pneumonia {Pneumonia}, acute on chronic diastolic heart failure {Acute on chronic diastolic heart failure}, BiPAP {Bilevel positive airway pressure titration}, hypercarbic
respiratory failure {Hypercapnic respiratory failure}, intubation {Insertion of endotracheal tube}, Sputum culture {Microbial culture of sputum}, steroids {Steroid therapy}, worsening {Patient's condition worsened}, delirium {Delirium}, Delirium {Delirium}, improved {Patient's condition improved}, steroids {Steroid therapy}, afib with RVR {Atrial fibrillation with rapid ventricular response}, improvement {Patient's condition improved}, rates {Finding of heart rate}, DECOMPENSATED DIASTOLIC HEART FAILURE {Decompensated cardiac failure}, exam {Physical examination procedure}, fluid overload {Hypervolemia}, JVP {Finding of jugular venous pressure}, 2+ pitting edema {2+ pitting edema}, both legs {Both lower legs}, diuresed {Diuretic therapy}, IV {Intravenous therapy}, Lasix {Diuretic therapy}, Lasix {Diuretic therapy}, increased {Increasing dosage of medication}, HYPOXIA {Hypoxia}, CAP {Community acquired pneumonia}, hypoxia {Hypoxia}, CHF exacerbation {Exacerbation of congestive heart failure}, community acquired pneumonia {Community acquired pneumonia}, asthma {Asthma}, COPD {Chronic obstructive lung disease}, wheezing {Wheezing}, standing {Orthostatic body position}, improved {Patient's condition improved}, wheezing {Wheezing}, hypoxia {Hypoxia}, pneumonia {Pneumonia}, CXR {Plain chest X-ray}, sputum culture {Microbial culture of sputum}, worsening {Patient's condition worsened}, hypercarbia {Hypercapnia}, wheezing {Wheezing}, CAP {Community acquired pneumonia}, worsening {Patient's condition worsened}, delirium {Delirium}, pulmonary toilet {Airway toilet}, copious secretions {Copious sputum}, productive cough {Productive cough}, Hypoxia {Hypoxia}, resolved {Problem resolved}, HYPERCARBIC RESPIRATORY FAILURE {Hypercapnic respiratory failure}, agitation {Feeling agitated}, altered mental status {Altered mental status}, intubated {Insertion of endotracheal tube}, hypercarbic respiratory failure {Hypercapnic respiratory failure}, diuretics {Diuretic therapy}, antibiotics {Antibiotic therapy}, pneumonia {Pneumonia}, extubated {Removal of endotracheal tube}, respiratory distress {Respiratory distress}, resolved {Problem resolved}, BiPAP {Bilevel positive airway pressure titration}, AFIB with RVR {Atrial fibrillation with rapid ventricular response}, RVR {Atrial fibrillation with rapid ventricular response}, HRs {Finding of heart rate}, rates {Finding of heart rate}, improvement {Patient's condition improved}, PO medications {Administration of drug or medicament via oral route}, apixaban {Anticoagulant therapy}, anticoagulation {Anticoagulant therapy}, ALTERED MENTAL STATUS {Altered mental status}, worsening {Patient's condition worsened}, delirium {Delirium}, extubation {Removal of endotracheal tube}, steroids {Steroid therapy}, ICU {Admission to intensive care unit}, steroids {Steroid therapy}, improved {Patient's condition improved}, agitation {Feeling agitated}, sundowning {Sundowning}, Mental status {Altered mental status}, improved {Patient's condition improved}, OX3 {Oriented to person, time and place}, discontinued {Recommendation to stop drug treatment}, stable {Patient's condition stable}, mental status {Mental state finding}, GERD {Gastroesophageal reflux disease}, CHRONIC PAIN {Chronic pain}, Weight {Weight finding}, standing {Orthostatic body position}, CAP {Community acquired pneumonia}, Afib {Atrial fibrillation}, Outpatient {Outpatient care management}, follow up {Follow-up arranged}, cardiology {Cardiology service}, Afib with RVR {Atrial fibrillation with rapid ventricular response}, ventricular {Cardiac ventricular structure}, rates {Finding of heart rate}, stable {Patient's condition stable}, rate {Finding of heart rate}, Afib {Atrial fibrillation}, monitoring {Monitoring procedure}, PFTs {Measurement of respiratory function}, TFTs {Thyroid panel}, TSH {Thyroid stimulating hormone measurement}, Free-T4 {T4 free measurement}, cardioversion {Cardioversion}, lump {Mass}, mandible {Bone structure of mandible}, evaluate {Evaluation procedure}, DNR {Not for resuscitation} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bumetanide 2 mg PO QAM
2. bumetanide 1 mg oral QPM
3. Diltiazem Extended-Release 180 mg PO BID
4. Apixaban 2.5 mg PO BID
5. Gabapentin 300 mg PO QHS
6. Omeprazole 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. miconazole nitrate unknown strength topical apply underneath
breasts and groin as needed for rash
Discharge Medications:
1. Apixaban 2.5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Bumetanide 2 mg PO QAM
4. Bumetanide 1 mg ORAL QPM
5. Diltiazem Extended-Release 120 mg PO DAILY
6. Gabapentin 300 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Amiodarone 400 mg PO BID
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. miconazole nitrate unknown TOPICAL APPLY UNDERNEATH BREASTS
AND GROIN AS NEEDED FOR RASH
12. Docusate Sodium 100 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 8.6 mg PO BID:PRN constipation
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
===================
Acute on chronic diastolic heart failure
Community Acquired Pneumonia
Hypercarbic respiratory failure
Delirium
SECONDARY DIAGNOSES
=====================
Hypertension
Hyperlipidemia
Intertrigo
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: Acute on chronic diastolic heart failure {Acute on chronic diastolic heart failure}, Community Acquired Pneumonia {Community acquired pneumonia}, Hypercarbic respiratory failure {Hypercapnic respiratory failure}, Delirium {Delirium}, Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, Intertrigo {Intertrigo}, 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 - requires assistance or aid {Finding of walking aid use}, walker {Uses zimmer frame}, cane {Uses single walking stick} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
because you had shortness of breath and cough. You were having
trouble breathing so you were placed on BiPAP machine and sent
to the cardiac ICU. You were found to have a pneumonia and heart
failure exacerbation causing fluid to accumulate in your lungs.
You required a breathing tube and breathing machine for a short
time to help you breathe during the beginning of your
hospitalization. You were given medications to treat your
pneumonia and medications to help remove fluid from your lungs.
You were given steroids to help decrease inflammation in your
lungs, but this caused you to be agitated and confused in the
ICU. Your confusion improved off of the steroids. Your exercise
tolerance decreased from your baseline, so you are being
discharged to rehab before you go home.
Sincerely,
Your ___ Team
###RESPONSE: shortness of breath {Dyspnea}, cough {Cough}, trouble breathing {Difficulty breathing}, BiPAP {Bilevel positive airway pressure titration}, cardiac ICU {Admission to cardiac intensive care unit}, pneumonia {Pneumonia}, heart
failure {Heart failure}, lungs {Lung structure}, breathing tube {Insertion of endotracheal tube}, breathing {Dual pressure spontaneous ventilation support}, medications {Prescription of drug}, pneumonia {Pneumonia}, medications {Prescription of drug}, lungs {Lung structure}, steroids {Steroid therapy}, inflammation {Inflammatory disorder}, lungs {Lung structure}, agitated {Feeling agitated}, confused {Clouded consciousness}, ICU {Admission to intensive care unit}, confusion {Clouded consciousness}, improved {Patient's condition improved}, steroids {Steroid therapy}, exercise
tolerance {Exercise tolerance finding}, baseline {Baseline state} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
Demerol / Zestril / adhesive tape / ondansetron / ondansetron
HCl
Attending: ___.
Chief Complaint:
Vomiting
Major Surgical or Invasive Procedure:
none
###RESPONSE: adhesive tape {Allergy to adhesive agent}, Vomiting {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:
___ yo M with metastatic esophageal cancer presents with
refractory nausea and vomiting. History was obtained from the
patient's wife as the patient was too confused. According to his
wife, Mr. ___ has had mild nausea periodically until ___
night, when he started vomiting coffee grounds every 2 hrs. On
___ morning the vomiting stopped, but he was still not able
to tolerate any solid foods. On ___ and ___ mornings he
vomited yellow, frothy emesis between ___, but had no further
vomiting. On ___ he was able to eat half an egg and some
chicken noodle soup, but that was it. Of note, mid last week he
also had some diarrhea, but that has resolved. Confusion began
today, previously he was not confused. His wife does note that
he has been very weak, with occasional tremors/"spasms" in the
legs. He has not complained of a headache. He has been urinating
normally, and had a BM today or yesterday. His wife notes that
she is a ___, and would have been able to manage taking care
of him at home, but she was concerned that he might have an
aspiration pneumonia.
His wife also reports that his pain (in neck, shoulders, right
hip/pelvis) has been well-controlled on methadone 20mg tid. He
has not required oxycodone for breakthrough in over a week. His
oncologist did increase his methadone to 25mg tid two weeks ago,
but he opted to return to the lower dose as he felt that the
higher dose was causing worsening nausea.
Review of Systems:
(+) Per HPI
(-) Denies chills, night sweats. Denies blurry vision, diplopia,
loss of vision, photophobia. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies palpitations, lower extremity
edema. Denies shortness of breath. Denies melena, hematemesis,
hematochezia. Denies dysuria, stool or urine incontinence.
Denies arthralgias or myalgias. Denies rashes. All other systems
negative.
###RESPONSE: metastatic {Metastatic malignant neoplasm}, esophageal cancer {Malignant tumor of esophagus}, refractory nausea and vomiting {Intractable nausea and vomiting}, confused {Clouded consciousness}, nausea {Nausea}, vomiting coffee grounds {Coffee ground vomiting}, vomiting {Vomiting}, vomited {Vomiting}, emesis {Vomiting}, vomiting {Vomiting}, able to eat {Able to eat}, diarrhea {Diarrhea}, Confusion {Clouded consciousness}, not confused {Not confused}, weak {Asthenia}, tremors {Tremor}, spasms {Spasm}, legs {Lower limb structure}, headache {Headache}, aspiration pneumonia {Aspiration pneumonia}, pain {Pain}, neck {Cervical region back structure}, shoulders {Shoulder region structure}, right
hip {Right hip region structure}, pelvis {Structure of right half of pelvis}, nausea {Nausea}, chills {Chill}, night sweats {Night sweats}, blurry vision {Blurring of visual image}, diplopia {Diplopia}, loss of vision {Blindness AND/OR vision impairment level}, photophobia {Photophobia}, headache {Headache}, sinus {Nasal sinus structure}, tenderness {Tenderness}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, palpitations {Palpitations}, lower extremity
edema {Edema of lower extremity}, shortness of breath {Dyspnea}, melena {Melena}, hematemesis {Hematemesis}, hematochezia {Hematochezia}, dysuria {Dysuria}, stool or urine incontinence {Double incontinence}, arthralgias {Joint pain}, myalgias {Muscle pain}, rashes {Eruption of skin} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PAST ONCOLOGIC HISTORY:
- Stage IV metastatic poorly differentiated esophageal
adenocarcinoma diagnosed in ___
PAST MEDICAL HISTORY:
- dCHF
- CABG: ___ (LIMA to LAD) due to CCATH showing total occlusion
of the RCA and circumflex arteries and an 80% left main
stenosis.
- CAD: CCATH/PCI: ___ - PTCA and DES x2 of the LMCA
bifurcation (LAD and ramus), ___ - ___
___, ___ - ___, ___ - ___ anastomotic site
of LIMA to LAD, ___, ___
- s/p St. ___ Aortic Valve Replacement ___ - on coumadin in
past
- "Intractable angina" on methadone
- Hypertension
- Dyslipidemia
- h/o defibrillation in ___
- Nephrolithiasis
- s/p lap cholecystectomy in ___
- Horner's syndrome - mild
###RESPONSE: Stage IV {Clinical stage IV}, metastatic {Metastatic malignant neoplasm}, esophageal
adenocarcinoma {Adenocarcinoma in situ of esophagus}, dCHF {Diastolic heart failure}, CABG {Coronary artery bypass grafting}, LIMA {Structure of left internal thoracic artery}, LAD {Structure of anterior descending branch of left coronary artery}, CCATH {Cardiac catheterization}, total occlusion {Complete obstruction}, RCA {Right coronary artery structure}, circumflex arteries {Structure of circumflex branch of left coronary artery}, left main {Left coronary artery structure}, stenosis {Stenosis}, CAD {Coronary arteriosclerosis}, CCATH {Cardiac catheterization}, PCI {Percutaneous coronary intervention}, PTCA {Percutaneous transluminal coronary angioplasty}, DES {Endovascular insertion of drug eluting stent}, LMCA {Left coronary artery structure}, bifurcation {Bifurcation}, LAD {Structure of anterior descending branch of left coronary artery}, LIMA {Structure of left internal thoracic artery}, LAD {Structure of anterior descending branch of left coronary artery}, Aortic Valve Replacement {Replacement of aortic valve}, Intractable angina {Refractory angina}, Hypertension {Hypertensive disorder, systemic arterial}, Dyslipidemia {Dyslipidemia}, Nephrolithiasis {Kidney stone}, 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:
Many family members with CAD.
###RESPONSE: CAD {Disorder of coronary artery} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ADMISSION
VITALS: Afebrile, T 97.9, 140/90, ___, RR 20, 95% on room air
GENERAL: Middle aged man laying in bed, in NAD
HEENT: NCAT, EOMI, PERRL, anicteric sclera, poor dentition, MMM
NECK: supple, no LAD
CARDIAC: RRR, S1 normal, mechanical S2, ___ systolic murmur hear
throughout precordium.
LUNG: Bilateral rales half-way up, no rhonchi, diminished breath
sounds at bases bilaterally
ABDOMEN: Soft, generalized ttp, normoactive bowel sounds
throughout, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: WWP, no c/c/e, 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in bilateral triceps,
biceps, deltoid, handgrip, and bilateral quads, ankle
flexion/extension, sensation intact. Oriented to ___ and ___,
not oriented to date. Having difficulty answering questions, not
sure how many days he has been vomiting
###RESPONSE: VITALS {Vital signs finding}, Afebrile {Temperature normal}, RR {Finding of rate of respiration}, on room air {Breathing room air}, GENERAL {General examination of patient}, laying in bed {Lying in bed}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclera {White sclera}, dentition {Finding of dentition}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, S1 normal {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmur {Murmur}, precordium {Structure of precordium}, LUNG {Examination of respiratory system}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, diminished breath
sounds {Decreased breath sounds}, bases {Structure of base of lung}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, generalized ttp {Generalized abdominal tenderness}, normoactive bowel sounds {Normal bowel sounds}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, hepatosplenomegaly {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, 2+ DP pulses {All pulses present in bilateral lower limbs}, NEURO {Neurological examination}, CN II-XII intact {Normal central nervous system}, triceps {Triceps brachii muscle structure}, biceps {Biceps brachii muscle structure}, deltoid {Structure of deltoid muscle}, quads {Structure of quadriceps femoris muscle}, ankle {Ankle region structure}, sensation intact {Normal sensation}, Oriented {Orientated}, oriented {Orientated}, vomiting {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: Pertinent Results:
___ 12:25PM BLOOD WBC-15.7*# RBC-4.55*# Hgb-11.7*#
Hct-35.7*# MCV-78* MCH-25.6* MCHC-32.7 RDW-22.0* Plt ___
___ 12:25PM BLOOD UreaN-21* Creat-1.3*
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ yo M with h/o metastatic esophageal cancer presented with
nausea, vomiting, dehydration, hypercalcemia (14), and failure
to thrive, and also with significant multifactorial
encephalopathy (likely toxic-metabolic encephalopathy).
#Hypercalcemia: numerous ___, elev alk phos, malignancy
related (Not working up with PTH levels, etc). Likely
precipitated by dehydration. Provided IVF with NS and K
repletion >200cc/hr (despite sig CAD history has preserved EF on
last echo). Pt developed mild SOB with diffuse rales, so IVF
subsequently d/c'd. Calcium improved. No reaction to test dose
calcitonin and started calcitonin 250units SC (4mg/kg) q12h.
Received IV pamidronate 90mg on ___.
# Acute multifactorial encephalopathy; likely multifactorial
toxic metabolic due to hypercalcemia, pain and progression of
malignancy. Treated with olanzapine.
#Metastatic Esophageal Cancer with bone and lung ___: disease
progessing, he did not tolerate first round of chemo and does
not want further chemo or treatment. On admission focus was
sympom control and hospice care with plan to discharge to
nursing home. However on ___ pt became intolerant of all po
including fluids and medications. I had a conversation with his
wife on ___ regarding this change in condition and thus
prognosis. The decision was made to make the patient CMO. His
PCP, oncologist and cardiologist were made aware of this change.
He was made comfortable with morphine, olanzapine, scopolomine,
and glycopyroate and died peacefully with his wife at the
bedside on the morning of ___.
###RESPONSE: metastatic {Metastatic malignant neoplasm}, esophageal cancer {Malignant tumor of esophagus}, nausea, vomiting {Nausea and vomiting}, dehydration {Dehydration}, hypercalcemia {Hypercalcemia}, failure
to thrive {Failure to thrive}, multifactorial
encephalopathy {Multifactorial encephalopathy}, toxic-metabolic encephalopathy {Toxic metabolic encephalopathy}, Hypercalcemia {Hypercalcemia}, elev alk phos {Alkaline phosphatase above reference range}, malignancy {Malignant neoplasm}, dehydration {Dehydration}, CAD {Disorder of coronary artery}, echo {Echocardiography}, SOB {Dyspnea}, rales {Respiratory crackles}, improved {Patient's condition improved}, IV {Intravenous therapy}, multifactorial encephalopathy {Multifactorial encephalopathy}, toxic metabolic {Toxic metabolic encephalopathy}, hypercalcemia {Hypercalcemia}, pain {Pain}, malignancy {Malignant neoplasm}, Metastatic {Metastatic malignant neoplasm}, Esophageal Cancer {Malignant tumor of esophagus}, bone {Bone structure}, lung {Metastatic malignant neoplasm to lung}, disease {Disease}, chemo {Chemotherapy}, chemo {Chemotherapy}, hospice care {Hospice care}, discharge to
nursing home {Discharge to nursing home}, prognosis {Determination of prognosis}, make the patient CMO {Comfort care only status}, died {Dead} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prochlorperazine 10 mg PO Q6H:PRN nausea
2. Lorazepam 1 mg PO Q6H:PRN nausea
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Atorvastatin 80 mg PO DAILY
6. Torsemide 40 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
8. Methadone 20 mg PO TID
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
10. Pantoprazole 40 mg PO Q12H
11. Citalopram 30 mg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
none, pt deceased
###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
Discharge Diagnosis:
metastatic esophageal cancer
hypercalcemia of malignancy
failure to thrive
malnutrition, moderate
cancer related pain
bone metastasis
Discharge Condition:
deceased
___ MD ___
Completed by: ___
###RESPONSE: metastatic {Metastatic malignant neoplasm}, esophageal cancer {Malignant tumor of esophagus}, hypercalcemia of malignancy {Humoral hypercalcemia of malignancy}, failure to thrive {Failure to thrive}, malnutrition {Nutritional disorder}, cancer related pain {Chronic pain due to malignant neoplastic disease}, bone {Bone structure}, metastasis {Metastatic malignant neoplasm}, deceased {Dead} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
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:
Spice Flavor / Children's Tylenol Plus / Bactrim
Attending: ___.
Chief Complaint:
Abscess
Major Surgical or Invasive Procedure:
Incision and drainage of abscess
###RESPONSE: Abscess {Abscess}, Incision and drainage of abscess {Incision and drainage of abscess} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 ___ yo man with PMHx sig. for developmental delay
and history of MRSA abscesses who presents with an axillary
abscess. The patient reports itchy rash under his arms
bilaterally for the past 2 weeks. He was seen in the office on
___, given antifungal creams and antihistamines, which have not
helped. A painful lump under his L arm worsened and several
small R pustules under the right arm. He reports that the
redness and itching is spreading to his chest. The patient
reports that he has felt febrile for one night, did not take
temperature. No chills, nightsweats.
The patient is a ___ and has been outside recently, has
sunburn on left arm, but has redness on his chest which patient
reports is not sunburn.
In the ED, initial VS were: 98.2 86 134/88 15 98% RA. Exam was
notable for L axilla with single large abscess 2.5x3.5cm and
surrounding erythema. This was I&D'ed and packed. Labs were
unremarkable. The patient received vancomycin, percocet.
Review of Systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain or tightness, palpitations. Denies cough,
shortness of breath. Denies nausea, vomiting, diarrhea,
constipation, or abdominal pain. No dysuria, urinary frequency.
Denies arthralgias or myalgias. All other review of systems
negative.
###RESPONSE: developmental delay {Developmental delay}, MRSA {Methicillin resistant Staphylococcus aureus infection}, abscesses {Abscess}, axillary
abscess {Abscess of axilla}, itchy {Itching}, rash {Eruption of skin}, arms {Upper limb structure}, painful {Pain}, lump {Mass}, L arm {Left upper arm structure}, pustules {Pustule}, right arm {Right upper arm structure}, redness {Redness of skin over lesion}, itching {Itching}, chest {Thoracic structure}, febrile {Fever}, chills {Chill}, nightsweats {Night sweats}, sunburn {Solar erythema}, left arm {Left upper arm structure}, redness {Redness of skin over lesion}, chest {Thoracic structure}, sunburn {Solar erythema}, VS {Vital signs finding}, RA {Breathing room air}, Exam {Physical examination procedure}, L axilla {Structure of left axillary region}, abscess {Abscess}, erythema {Erythema}, I&D {Incision AND drainage}, unremarkable {No abnormality detected}, headache {Headache}, sinus {Nasal sinus structure}, tenderness {Tenderness}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, Denies cough {Does not cough}, shortness of breath {Dyspnea}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, dysuria {Dysuria}, urinary frequency {Increased frequency of urination}, arthralgias {Joint pain}, myalgias {Muscle pain}, review of systems {Review of systems} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
ANEMIA (ICD-285.9)
CONSTIPATION (ICD-564.0)
CALCULUS, KIDNEY (ICD-592.0)
CELLULITIS/ABSCESS - MRSA (ICD-682.9)
RETARDATION, MENTAL NOS (ICD-319)
CARPAL TUNNEL SYNDROME, BILATERAL (ICD-354.0)
###RESPONSE: ANEMIA {Anemia}, CONSTIPATION {Constipation}, CALCULUS {Calculus}, KIDNEY {Kidney structure}, CELLULITIS {Cellulitis}, ABSCESS {Abscess}, MRSA {Methicillin resistant Staphylococcus aureus infection}, RETARDATION, MENTAL {Intellectual disability}, CARPAL TUNNEL SYNDROME {Carpal tunnel syndrome} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Mother with diabetes.
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Vitals: 98.1, 121/66, 58, 14. 97RA, ___ pain in L axilla
Gen: NAD, AOX3
HEENT: PER, EOMI, MMM, sclera anicteric, not injected
Neck: no LAD, no JVD
Cardiovascular: RRR normal s1, s2, no murmurs appreciated
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: normoactive bowel sounds, soft, non-tender, non distended
Extremities: No edema, 2+ DP pulses, R axilla erythematous with
scattered pustules, L axilla erythematous with I&D site
NEURO: PERRL, EOMI, face symmetric, no tongue deviation
Integument: Warm, moist; erythematous macular rash across chest
Psychiatric: appropriate, pleasant, not anxious
###RESPONSE: Vitals {Vital signs finding}, RA {Breathing room air}, pain {Pain}, L axilla {Structure of left axillary region}, Gen {General examination of patient}, NAD {No abnormality detected}, AOX3 {Oriented to person, time and place}, HEENT {Physical examination procedure}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, sclera anicteric {White sclera}, Neck {Physical examination procedure}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, Cardiovascular {Cardiovascular physical examination}, RRR {Normal heart rate}, normal s1, s2 {Heart sounds normal}, murmurs {Murmur}, Respiratory {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Abd {Examination of abdomen}, normoactive bowel sounds {Normal bowel sounds}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, distended {Swollen abdomen}, Extremities {Examination of limb}, edema {Edema}, 2+ DP pulses {Dorsalis pulse present}, R axilla {Structure of right axillary region}, erythema {Erythema}, pustules {Pustule}, L axilla {Structure of left axillary region}, erythema {Erythema}, I&D {Incision AND drainage}, NEURO {Neurological examination}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, face symmetric {Facial symmetry}, tongue {Tongue structure}, deviation {Displacement}, Integument {Structure of integumentary system}, Warm {Warm skin}, moist {Moist skin}, erythema {Erythema}, rash {Eruption of skin}, chest {Thoracic structure}, Psychiatric {Psychiatric symptom}, anxious {Anxiety} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ 06:45PM WBC-8.4 RBC-4.84 HGB-14.2 HCT-41.5 MCV-86
MCH-29.2 MCHC-34.2 RDW-13.6
___ 06:45PM NEUTS-55.7 ___ MONOS-4.0 EOS-4.1*
BASOS-1.8
___ 06:45PM PLT COUNT-368
___ 06:45PM GLUCOSE-111* UREA N-17 CREAT-0.9 SODIUM-140
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-29 ANION GAP-12
___ 06:45PM ___ PTT-26.1 ___
___ 06:52PM LACTATE-1.___. Abscess, left axilla: Patient has a history of MRSA skin
abscesses. This episode was treated with incision and drainage
followed by IV vancomycin then oral clindamicin. He has an
appointment with his PCP's office for the day after discharge.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, PTT {Partial thromboplastin time, activated}, Abscess {Abscess}, left axilla {Structure of left axillary region}, MRSA {Methicillin resistant Staphylococcus aureus infection}, skin
abscesses {Abscess of skin and/or subcutaneous tissue}, incision and drainage {Incision AND drainage}, IV {Administration of drug or medicament via intravenous route}, oral {Administration of drug or medicament via oral route}, PCP {Primary care management} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
OMEPRAZOLE 20 MG CPDR (OMEPRAZOLE) 1 tab po every day
VYTONE CRE 1% (IODOQUINOL-HC) APPLY BID TO AFFECTED AREAS
CLOTRIM ANTIFUNGAL CREA 1 % (CLOTRIMAZOLE) apply to affected
area bid
DIPHENHYDRAMINE HCL 25 MG CAPS (DIPHENHYDRAMINE HCL) ___ tabs PO
Q4-6H PRN
LORATADINE 10 MG TABS (LORATADINE) 1 tab po every day as needed
for itch
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for itching.
3. iodoquinol-HC ___ % Cream Sig: One (1) Topical twice a day.
4. clotrimazole 1 % Cream Sig: One (1) Topical twice a day.
5. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours for 6 days.
Disp:*18 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:
1. Abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Abscess {Abscess}, 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 with an abscess in your left axilla (armpit).
Please continue taking the prescribed antibiotics and follow-up
with the ___ on tomorrow (___).
###RESPONSE: abscess {Abscess}, left axilla {Structure of left axillary region}, armpit {Structure of axillary fossa}, 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: 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:
low BP
Major Surgical or Invasive Procedure:
none
###RESPONSE: low BP {Low blood pressure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ h/o Lupus, embolic strokes s/p recent stroke on coumadin,
metastatic colon cancer on chemotherapy s/p renal transplant on
PD admitted from clinic with hypotension. Patient presented to
___ today for INR check, but went to ___ clinic. She
noted that she was slightly dizzy with some blurred vision while
walking through the parking lot. In ___ clinic, they
checked her INR, and then decided to start her on cycle 1 of
erbitux. She was given benadryl as premedication.
.
Her blood pressure was then found to be low 70/40. The patient's
typically BP runs in SBP ___ and there is always difficulty
obtaining accurate BP's. Because of this the patient was kept in
clinic for gentle fluids with the goal of returning her SBP to
mid 80's. She was also given decadron in the chance that she was
having a reaction to erbitux. As her blood pressure did not
increase adequately, it was decided to admit her. In addition,
she was drowsy in clinic - ___ to Benadryl?, but was becoming
increasingly alert as the benadryl wore off.
.
The patient now states that her mental status is greatly
improved, at baseline, "feels normal". She also reports that she
has increased the amount of fluid she removes in PD in order to
dec peripheral edema. In addition, she missed her midodrine
doses today. She also notes that yesterday she had poor PO
intake secondary to the heat and mild nausea. Denies any
vomting, no chills, no fever, minimal diarrhea.
.
In ___, the patient was admitted with fever and hypotension.
She was found to have CDiff colitis in early ___, discharged
on vancomycin PO - which she has finished. Several days ago, she
was admitted to the neurology service for acute/subacute embolic
stroke. In the work up, she was found to have a filamentous
structure on the right atrial catheter c/w thrombus and was
started on anticoagulation.
.
Clinic course:
# VS: 4:45pm BP 76/58 P ___
# Meds/IVF: 1.5L NS slowly, benadryl as premedication with
erbitux
.
ROS:
(+) mild nausea, mild diarrhea, DOE but at baseline, +
peripheral edema but dec over the past week, + leg weakness when
climbing stairs (at baseline)
(-) no abominal pain, no lupus symptoms, no rash, no worsening
joint swelling, no hematochezia, no melena
###RESPONSE: Lupus {Lupus erythematosus}, embolic strokes {Embolic stroke}, stroke {Cerebrovascular accident}, metastatic colon cancer {Metastatic carcinoma to colon}, chemotherapy {Chemotherapy}, renal transplant {Transplant of kidney}, PD {Peritoneal dialysis}, hypotension {Low blood pressure}, dizzy {Dizziness}, blurred vision {Blurring of visual image}, blood pressure {Blood pressure finding}, low {Low blood pressure}, BP {Blood pressure finding}, fluids {Administration of intravenous fluids}, drowsy {Drowsy}, alert {Mentally alert}, improved {Patient's condition improved}, baseline {Baseline state}, PD {Peritoneal dialysis}, peripheral edema {Peripheral edema}, poor PO
intake {Inadequate oral intake}, nausea {Nausea}, vomting {Vomiting}, chills {Chill}, fever {Fever}, diarrhea {Diarrhea}, fever {Fever}, hypotension {Low blood pressure}, CDiff colitis {Clostridium difficile colitis}, embolic
stroke {Embolic stroke}, right atrial {Right atrial structure}, thrombus {Thrombus}, anticoagulation {Anticoagulant therapy}, VS {Vital signs finding}, BP {Blood pressure finding}, nausea {Nausea}, diarrhea {Diarrhea}, DOE {Dyspnea on exertion}, peripheral edema {Peripheral edema}, leg weakness {Monoparesis of lower limb}, abominal pain {Abdominal pain}, lupus {Lupus erythematosus}, rash {Eruption of skin}, joint swelling {Joint swelling}, hematochezia {Hematochezia}, melena {Melena} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
.
POncH
# Stage III metstatic colon adenocarcinoma (dx ___: LVI,
venous, perineural invasion; FDG-avid RUL, L adrenal gland mass
(___), brain mets
--s/p resection
--s/p irinotecan X2 doses dc'd ___ intractable diarrhea
--s/p capecitabine, oxaliplatin x3 cycles
--s/p fluorouracil, leucovorin, oxaliplatin (Folfox) ___
.
PMH
# ESRD s/p failed renal transplants x2 (___), on PD x3
daily, immunosuppressants d/c'd on ___ given increasing
creatinine and in setting of chemo treatment
# SLE on prednisone 5mg daily
# Hyperlipidemia
# Osteoporosis
# Mitral regurgitation
# Dyspepsia
# Seizure disorder s/p stroke (___)
###RESPONSE: Stage III {Carcinoma of colon, stage III}, metstatic colon {Metastatic carcinoma to colon}, adenocarcinoma {Adenocarcinoma}, LVI {Blood/lymphatic vessel invasion by tumor present (breast)}, venous {Venous (large vessel) invasion by tumor present}, perineural invasion {Perineural invasion by tumor present}, FDG-avid {Positron emission tomography with computed tomography using fluorodeoxyglucose (18-F)}, RUL {Structure of upper lobe of right lung}, L adrenal gland {Structure of left adrenal gland}, mass {Mass of adrenal gland}, brain mets {Metastatic malignant neoplasm to brain}, resection {Excision}, diarrhea {Diarrhea}, ESRD {End-stage renal disease}, failed renal transplants {Failed renal transplant}, PD {Peritoneal dialysis}, chemo {Chemotherapy}, SLE {Systemic lupus erythematosus}, Hyperlipidemia {Hyperlipidemia}, Osteoporosis {Osteoporosis}, Mitral regurgitation {Mitral valve regurgitation}, Dyspepsia {Indigestion}, Seizure disorder {Seizure disorder}, 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: 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:
This is largely unknown to the patient. There are multiple
cancers in the family.
###RESPONSE: multiple
cancers {Multiple malignancy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS: T 97.3, BP 95/78, HR 100, RR 20, O2sat 97 on RA
Gen: NAD
HEENT: NCAT, MMM, OP clear, neck supple, mildly dysarthric
speech, mild ___ flattening on the left
CV: RRR, S1S2, ___ murmur
Chest: coughing with deep inspiration, crackles ___ up on right
side posteriorly, no labored breathing
Abd: Soft, NT, distended, no rebound, no guarding; no TTP, NABS
Ext: 2+ pitting edema B
Neuro: AOx3, attention intact, strength ___ bilaterally, CN II-
XII intact
###RESPONSE: VS {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2sat {Oxygen saturation measurement}, RA {Breathing room air}, Gen {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, supple {Normal movement of neck}, dysarthric
speech {Dysarthria}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmur {Murmur}, Chest {Examination of respiratory system}, coughing {Cough}, crackles {Respiratory crackles}, right
side {Right lung structure}, labored breathing {Labored breathing}, Abd {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, distended {Swollen abdomen}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, TTP {Tenderness}, NABS {Normal bowel sounds}, Ext {Examination of limb}, edema {Edema}, Neuro {Neurological examination}, AOx3 {Oriented to person, time and place}, attention {Finding related to attentiveness}, CN II-
XII intact {Normal central nervous system} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 06:08PM BLOOD WBC-9.6 RBC-3.29* Hgb-10.6* Hct-32.4*
MCV-98 MCH-32.1* MCHC-32.7 RDW-17.7* Plt ___
___ 05:15AM BLOOD WBC-9.7 RBC-3.23* Hgb-10.4* Hct-32.1*
MCV-99* MCH-32.1* MCHC-32.3 RDW-17.7* Plt ___
___ 12:23PM BLOOD ___
___ 11:56AM BLOOD ___
___ 06:08PM BLOOD Glucose-145* UreaN-33* Creat-8.4* Na-134
K-4.1 Cl-100 HCO3-27 AnGap-11
___ 05:15AM BLOOD Glucose-141* UreaN-36* Creat-8.3* Na-134
K-3.7 Cl-100 HCO3-28 AnGap-10
___ 06:08PM BLOOD Calcium-7.4* Phos-3.4 Mg-2.0
___ 05:15AM BLOOD Calcium-7.3* Phos-3.2 Mg-2.___y the time the patient reached the floor, her BP had returned
to normal and she was feeling well. She was observed overnight,
restarted on Midodrine and seen by the renal team. The renal
team recomended reducing the amount of fluid removed at each
session. She had no further episodes of low BP. In addition, her
INR was monitored. On the day of discharge, it was 3.6 and she
was instructed to hold her evening dose. These instructions were
also communicated to the ___ anti-coagulation nurses; they will
call her with further instructions.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, 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}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, low BP {Low blood pressure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily) for ___ days.
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO MWF (___).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
5. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO DAILY
(Daily).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (___).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
take at 4pm at night.
Disp:*30 Tablet(s)* Refills:*2*
###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:
Low Blood Pressure
End Stage Renal Disease
Discharge Condition:
improved
###RESPONSE: Low Blood Pressure {Low blood pressure}, End Stage Renal Disease {End-stage renal disease}, improved {Patient's condition improved} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were admitted for low blood pressure. You were given fluids
and restarted on Midodrine. Your blood pressure improved. The
renal team also recomended taking off less fluid with dialysis
to avoid low blood pressures.
.
You should continued taking coumadin. Your INR was elevated
today. You should NOT take any warfarin (coumadin) tonight. The
___ clinic will call you to adjust the dose. You
will need to have your INR checked on ___.
.
If you have dizziness, light-headedness, fevers or chills, you
should return to the emergency room.
###RESPONSE: low blood pressure {Low blood pressure}, fluids {Administration of intravenous fluids}, blood pressure {Blood pressure finding}, improved {Patient's condition improved}, dialysis {Dialysis procedure}, low blood pressures {Low blood pressure}, dizziness {Dizziness}, light-headedness {Lightheadedness}, fevers {Fever}, chills {Chill} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Dizziness, Left arm weakness
Major Surgical or Invasive Procedure:
None
###RESPONSE: Dizziness {Dizziness}, Left arm {Structure of left upper limb} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ year old left handed woman presenting with dizziness and left
arm weakness. The patient reports starting a new medication,
donepezil, about 1 week ago. Following this period in time she
noted the onset of vertigo while standing up, which would
resolve upon sitting down. She also noted, though not
concurrently, that her left arm "felt weak." Onset of this
sensation was slow over days. She reports difficulty reaching up
to touch her forehead. There was no associated pain. She reports
difficulty with handwriting because the pen jerks around the
page. She does not have any hand weakness however, in that she
has no difficulty in opening doorknobs or jars. The pt denied
headache, loss of vision, blurred vision, diplopia, dysarthria,
dysphagia. tinnitus or hearing difficulty. Denied difficulties
producing or comprehending speech. No parasthesias. No bowel or
bladder incontinence or retention. Denied difficulty with gait.
In the emergency department, initial vitals: 13:54 0 97.9 72
128/95 18 98. Not orthostatic. No gait abnormality. EKG- new TWI
I, otherwise nonspecific change. CXR-atelectasis at RL base, no
pna or effusion, large dilated air filled viscous in upper
abdomen correlate clinically- no abd pain on exam. KUB given
findings on CXR- non specific bowel gas pattern, need f/u final
read. Cardiac enzymes- neg. WBC inc but U/A-neg and it appears
to be chronically elevated. CT Head-neg. Neuro consult- no acute
issue, no objective signs of weakness, symptoms may be related
to Aricept, can d/c medicatoin and then get in touch with PCP to
discuss--->per neuro added on Lithium level (mildly elevated).
200 cc NS and 8 mg of IV Zofran given. Admitted for syncope w/u.
On arrival to the floor, she states she is feeling somewhat
depressed with suicidal ideation but no intent/plan. She feels
safe now that she is hospitalized. She states that occasionally
when she walks, she feels worried that she is going to fall but
has not fallen as of yet. She has a mildly productive cough that
has developed in the past 10 minutes.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
###RESPONSE: left handed {Left handed}, dizziness {Dizziness}, left
arm {Structure of left upper limb}, vertigo {Vertigo}, standing {Orthostatic body position}, resolve {Problem resolved}, sitting {Sitting position}, left arm {Structure of left upper limb}, weak {Asthenia}, difficulty reaching {Difficulty reaching}, forehead {Forehead structure}, pain {Pain}, hand {Hand structure}, weakness {Asthenia}, headache {Headache}, loss of vision {Functional visual loss}, blurred vision {Blurring of visual image}, diplopia {Diplopia}, dysarthria {Dysarthria}, dysphagia {Dysphagia}, tinnitus {Tinnitus}, hearing difficulty {Hearing difficulty}, difficulties
producing or comprehending speech {Difficulty comprehending speech}, parasthesias {Paresthesia}, bowel {Incontinence of feces}, bladder incontinence {Urinary incontinence}, retention {Retention of urine}, difficulty with gait {Abnormal gait}, vitals {Vital signs finding}, orthostatic {Orthostatic body position}, gait abnormality {Abnormal gait}, EKG {Electrocardiographic procedure}, TWI {Inverted T wave}, CXR {Plain chest X-ray}, atelectasis {Atelectasis}, RL base {Structure of base of right lung}, pna {Pneumonia}, effusion {Pleural effusion}, dilated {Dilatation}, upper
abdomen {Upper abdomen structure}, abd pain {Abdominal pain}, exam {Physical examination procedure}, KUB {Radiography of kidney-ureter-bladder}, CXR {Plain chest X-ray}, bowel gas pattern {Finding of gastrointestinal tract gas}, Cardiac enzymes {Finding of cardiac enzyme levels}, WBC {White blood cell count}, U/A-neg {Urinalysis = no abnormality}, CT Head {Computed tomography of head}, Neuro {Neurology service}, signs {Sign}, weakness {Asthenia}, Lithium level {Finding of lithium level}, syncope {Syncope}, depressed {Depressed mood}, suicidal ideation {Suicidal thoughts}, intent {Suicidal intent}, walks {Difficulty walking}, worried {Worried}, fall {Falls}, fallen {Falls}, productive cough {Productive cough}, 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}, shortness of breath {Dyspnea}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, 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:
COPD--Pt does not use 02 at home
Hypothryoid
Hyperlipidemia
RLS
PSYCHIATRIC HISTORY: Per OMR, and patient interview:
Diagnosedwith schizoaffective disorder ___ years ago after having
her son. First hospitalization in ___ ___ after
SA
by cutting wrists. Several other SA, including OD, and
self-stabbing. Reports associated ___ with some of these SA,
but
reports no auditory hallucinations in ___ years. Pt relates that
last suicide attempt was ___ years ago, and that last psychiatric
hospitalization was ___ years ago prior to recent ___
admission
in ___ (5 days). Has had over 10 psychiatric
hospitalizations. Has gone to day program at ___ over
past ___ years.
Psychiatrist: ___, MD at ___ ___
Therapist: ___ at ___
___
###RESPONSE: COPD {Chronic obstructive lung disease}, Hypothryoid {Hypothyroidism}, Hyperlipidemia {Hyperlipidemia}, schizoaffective disorder {Schizoaffective disorder}, cutting wrists {Cutting own wrists}, self-stabbing {Stabbing self}, auditory hallucinations {Auditory hallucinations}, suicide attempt {Suicidal intent} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
None known.
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VITAL SIGNS: T 96.7 BP 110/62 HR 61 RR 18 O2 94% on RA
GENERAL: Pleasant, depressed appearing.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or ___. JVP not elevated.
LUNGS: Occasional rhonchi that clear w/ coughing, good air
movement biaterally.
ABDOMEN: Distended but NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. Babinski
equivocal. Normal coordination. Gait assessment deferred
PSYCH: Endorses suicidal ideation but no plan, + more depressed
recently about concern that her memory is failing her
###RESPONSE: VITAL SIGNS {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 {Finding of oxygen saturation}, RA {Breathing room air}, GENERAL {General examination of patient}, depressed {Depressed mood}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, conjunctival pallor {Pale conjunctiva}, scleral icterus {Scleral icterus}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, Supple {Normal movement of neck}, LAD {Lymphadenopathy}, thyromegaly {Goiter}, CARDIAC {Cardiovascular physical examination}, Regular rhythm {Normal sinus rhythm}, normal rate {Normal heart rate}, Normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, JVP not elevated {Normal jugular venous pressure}, LUNGS {Examination of respiratory system}, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, Distended {Swollen abdomen}, NABS {Normal bowel sounds}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, edema {Edema}, pain {Pain}, 2+ dorsalis pedis {Dorsalis pulse present}, posterior
tibial pulses {Posterior tibial pulse present}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, ecchymoses {Ecchymosis}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, Appropriate {Appropriate affect}, CN {Cranial nerve structure}, grossly intact {Normal nervous system function}, Preserved
sensation {Normal sensation}, Babinski {Flexor plantar response finding}, Normal coordination {Normal coordination}, Gait assessment {Gait evaluation}, PSYCH {Initial psychiatric evaluation}, suicidal ideation {Suicidal thoughts}, depressed {Depressed mood}, memory {Memory finding} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 03:00PM PLT COUNT-386
___ 03:00PM NEUTS-83.1* LYMPHS-11.6* MONOS-3.6 EOS-1.4
BASOS-0.2
___ 03:00PM WBC-16.9* RBC-4.82 HGB-14.3 HCT-43.0 MCV-89
MCH-29.8 MCHC-33.3 RDW-13.4
___ 03:00PM LITHIUM-1.6*
___ 03:00PM CALCIUM-11.4* PHOSPHATE-3.0 MAGNESIUM-2.1
___ 03:00PM CK-MB-NotDone
___ 03:00PM cTropnT-<0.01
___ 03:00PM CK(CPK)-67
___ 03:00PM estGFR-Using this
___ 03:00PM GLUCOSE-98 UREA N-15 CREAT-1.0 SODIUM-136
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13
___ 03:31PM ___ PTT-24.6 ___
___ 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
___ 06:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:18PM CK-MB-NotDone
___ 09:18PM cTropnT-<0.01
___ 09:18PM CK(CPK)-45
.
CT Head (___):
There is no hemorrhage, edema, mass effect, or acute
large vascular territory infarction. The gray-white matter
differentiation is preserved. There is mild asymmetric frontal
atrophy, but the ventricles and sulci are otherwise normal in
caliber and configuration. Basal cisterns are preserved. There
is no shift of normally midline structures. Calcifications are
seen involving the cavernous and supraclinoid internal carotid
arteries. The osseous structures demonstrate no fracture. There
are no suspicious lytic
or sclerotic lesions. The visualized paranasal sinuses and
mastoid air cells are normally pneumatized and clear.
.
IMPRESSION: No acute intracranial process.
###RESPONSE: PLT COUNT {Platelet count}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte 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}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, LITHIUM {Finding of lithium level}, CALCIUM {Blood calcium measurement}, PHOSPHATE {Phosphate, total measurement}, MAGNESIUM {Blood magnesium measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK(CPK {Creatine kinase measurement}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, PTT {Partial thromboplastin time, activated}, URINE {Urinalysis}, PROTEIN {Measurement of protein in urine}, GLUCOSE {Glucose measurement, urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, COLOR {Color finding}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK(CPK {Creatine kinase measurement}, hemorrhage {Hemorrhage}, edema {Edema}, mass {Mass}, vascular {Blood vessel structure}, infarction {Infarct}, white matter {Cerebral white matter structure}, frontal {Structure of cortex of frontal lobe}, atrophy {Atrophy}, ventricles {Brain ventricle structure}, sulci {Structure of sulcus of brain}, cisterns {Structure of subarachnoid cistern}, shift of normally midline structures {Midline shift of brain}, Calcifications {Pathologic calcification, calcified structure}, internal carotid
arteries {Internal carotid artery structure}, osseous structures {Bone structure}, fracture {Fracture}, lytic {Lysis}, sclerotic {Sclerosis}, lesions {Lesion}, paranasal sinuses {Nasal sinus structure}, mastoid air cells {Structure of mastoid cell}, intracranial {Intracranial structure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ y/o female with a h/o schizoaffective disorder and
hypothyroidism who presented with dizziness and was found to be
hypercalcemic. The following issues were investigated during
this hospitalization:
1. Dizziness: Onset of symptoms correlates with initiation of
Aricept for short-term memory loss and this medication has been
associated with dizziness. Patient received IVF upon arrival for
hypercalcemia but was never found to be orthostatic. Aricept was
held while in house with improvement in symptoms. Head CT
unremarkable as was neuro exam. Patient was discharged with home
___. She will not continue on Aricept.
2. Hypercalcemia: Patient with history of elevated PTH since
___ with intermittently elevated calcium values. Calcium > 11
on admission, but responsive to IVF. Calcium and vitamin D
supplements discontinued but bisphosphonate continued. Endocrine
consulted given concern for Lithium-induced hyperparathyroidism.
24 hour urine calcium was low and consistent with
Lithium-induced disease and not likely necessitating surgical
intervention. Still, further work-up was deferred to the
outpatient setting. Lithium was decreased, but maintained as the
endocrinopathies are generally not reversed with stopping
Lithium and mood-stabilization remains of concern. She will f/u
her lithium levels with her outpatient psychiatrist Dr. ___.
She will also f/u as an outpatient with endocrinology.
3. Diabetes Insipidus: Suggested by mildly elevated Na and
chloride, in the setting of endocrinopathies in a patient on
long-term Lithium. Patient was started on Amiloride at the
recommendation of the endocrinology consult, with improvement in
electrolyte derrangements. Patient was otherwise encouraged to
remain hydrated. She will be discharged on amiloride.
4. Schizoaffective d/o: Psychiatry was consulted given concern
for suicidal ideations and depression as well as for guidance
for Lithium. Patient was initially on a ___, requiring
that she remain hospitalized with intention to be transferred to
a psychiatric facility. However, as her hospitalization
continued and her metabolic derrangements were corrected, her
mood improved. The section was eventually lifted and the patient
was restarted on Lithium at a lower dose with outpatient
follow-up with her psychiatrist.
5. Dementia: Per patient's outpatient psychologist,
neuropsychological testing showed significant memory impairment
and MRI showed vascular disease, suggesting a possible etiology
of dementia. Patient had been started on Aricept as an
outpatient, but this was held given the complaint of
lightheadedness that started after initiation of medication.
6. Hypothyroidism: Patient was maintained on outpatient
Levothyroxine.
7. Osteoporosis: Calcium and Vitamin D were held given elevated
calcium and PTh on presentation, though Alendronate was
continued.
8. Hyperlipidemia: Patient was maintained on outpatient statin.
9. Leukocytosis: Chronic problem of unclear etiology. No obvious
source of infection. ___ trended down during this
hospitalization and thus work-up was not pursued.
Full code
She was discharged with outpatient endocrine and psychiatry
follow up.
###RESPONSE: schizoaffective disorder {Schizoaffective disorder}, hypothyroidism {Hypothyroidism}, dizziness {Dizziness}, hypercalcemic {Hypercalcemia}, Dizziness {Dizziness}, short-term memory loss {Poor short-term memory}, dizziness {Dizziness}, IVF {Administration of intravenous fluids}, hypercalcemia {Hypercalcemia}, orthostatic {Orthostatic hypotension}, Head CT {Computed tomography of head}, unremarkable {No abnormality detected}, neuro exam {Normal nervous system function}, Hypercalcemia {Hypercalcemia}, calcium {Blood calcium measurement}, Calcium {Blood calcium measurement}, IVF {Administration of intravenous fluids}, Lithium-induced hyperparathyroidism {Hyperparathyroidism caused by lithium therapy}, urine calcium {Calcium measurement, urine}, surgical
intervention {Surgical procedure}, work-up {Evaluation procedure}, lithium levels {Finding of lithium level}, psychiatrist {Psychiatric follow-up}, Diabetes Insipidus {Diabetes insipidus}, Schizoaffective {Schizoaffective disorder}, suicidal ideations {Suicidal thoughts}, depression {Depressive disorder}, mood improved {Improved mood}, on Lithium {On lithium}, outpatient
follow-up {Outpatient care management}, psychiatrist {Psychiatric follow-up}, Dementia {Dementia}, neuropsychological testing {Neuropsychological testing}, memory impairment {Memory impairment}, MRI {Magnetic resonance imaging}, vascular disease {Disorder of blood vessel}, dementia {Dementia}, lightheadedness {Lightheadedness}, Hypothyroidism {Hypothyroidism}, Osteoporosis {Osteoporosis}, elevated
calcium {Hypercalcemia}, PTh {Hyperparathyroidism}, Hyperlipidemia {Hyperlipidemia}, Leukocytosis {Leukocytosis}, infection {Infectious disease} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Aricept 5mg QHS (started 1 week ago)
Simvastatin 40 mg daily
levothyroxine 0.125 mg daily
aspirin 81 mg daily
iron daily
alendronate 70 mg every week
vitamin D 400 units b.i.d.
calcium 400 mg b.i.d.
lithium 300 mg ___ mg once qhs
Risperdal 4 mg b.i.d.
Seroquel 50 mg daily
lorazepam 1 mg daily
cilostazol 100 mg b.i.d.
citalopram daily (dose unknown)
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Risperidone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
___.
8. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. Amiloride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)).
Disp:*30 Capsule(s)* Refills:*2*
11. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Lightheadedness
Hyperparathyroidism
Nephrogenic Diabetes Inspidus
Secondary:
Schizoaffective disorder
Discharge Condition:
Stable
###RESPONSE: Home With Service {Home health aide service management}, Lightheadedness {Lightheadedness}, Hyperparathyroidism {Hyperparathyroidism}, Nephrogenic Diabetes Inspidus {Nephrogenic diabetes insipidus}, Schizoaffective disorder {Schizoaffective disorder}, Stable {Patient's condition stable} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were seen and evaluated for left hand weakness and
lightheadedness, which was felt to be due to a new medication
you started - Aricept. This medication has been stopped.
Additionally, you were noted to have an elevated calcium, which
was due to a hormone problem called hyperparathyroidism. This
hormone problem is likely due to Lithium, which you take and
NEED to continue to take to control your mood. However, your
Lithium dose has been decreased. Since your walking was unsteady
but improved when you were discharged, you will have home ___
care.
Take all of your medications as directed. Your Aricept, calcium
and vitamin D have been stopped and your Lithium has been
decreased. You were also started on a new medication, Amiloride,
to help control your sodium level. It is important to stay very
well hydrated.
Keep all of your follow-up appointments. They are listed below.
Once you are discharged, you have an appointment with endocrine
at 3PM today. It is very important that you keep this
appointment. You will also need to follow up with your
psychiatrist, Dr. ___, for management of your
Lithium. The psychiatry team here will contact him and will make
an appointment for you.
Call your doctor or go to the ER for any of the following: chest
pain, shortness of breath, fevers/chills,
nausea/vomiting/diarrhea, worsened lightheadedness or falls,
sudden slurred speech or weakness, headaches, vision changes,
extreme fatigue, confusion or any other concerning symptoms.
###RESPONSE: left hand weakness {Weakness of left hand}, lightheadedness {Lightheadedness}, elevated calcium {Hypercalcemia}, hyperparathyroidism {Hyperparathyroidism}, mood {Mood swings}, r walking was unsteady {Unsteady when walking}, improved {Patient's condition improved}, sodium level {Finding of sodium level}, psychiatrist {Psychiatric follow-up}, chest
pain {Chest pain}, shortness of breath {Dyspnea}, fevers {Fever}, chills {Chill}, nausea/vomiting/diarrhea {Nausea, vomiting and diarrhea}, lightheadedness {Lightheadedness}, falls {Falls}, slurred speech {Slurred speech}, weakness {Asthenia}, headaches {Headache}, vision changes {Visual disturbance}, fatigue {Fatigue}, confusion {Clouded consciousness} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
vancomycin / Zosyn
Attending: ___.
Chief Complaint:
fevers, lethargy
Reason for MICU transfer: concern for septic shock
Major Surgical or Invasive Procedure:
None
###RESPONSE: vancomycin {Allergy to vancomycin}, fevers {Fever}, lethargy {Lethargy}, MICU transfer {Patient transfer to intensive care unit}, septic shock {Septic shock} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 recent diagnosis of Graves' disease and longtime
diagnosis of Kawasaki's disease on warfarin, presenting to ED
with intermittent fevers and lethargy x 1 week and RLQ abdominal
pain x ___ days. Initially developed fever up to 102 and mild
sore throat 1 week ago, was found to have normal WBC with left
shift and mildly elevated TSH at ___, and was discharged
home with presumptive diagnosis of viral infection. However,
his fevers persisted as high as 102 with night sweats and
headaches, and was told by his endocrinologist Dr. ___ to
discontinue his methimazole (MMI). He then developed RLQ pain
and right groin pain especially on ambulation, and was sent to
ED following appointment with Dr. ___.
In the ED, his initial vitals were 98.3 77 58/34 18 98%. He was
given 4L fluids. Bedside ultrasound showed no free fluid or
tamponade with normal IVC and mildly diminished cardiac
contractility. Labs notable for WBC 12.8 with left shift, UA
with 93 WBC, CXR showed no pneumonia, two CT A/P were performed
that showed no appendicitis or bowel wall thickening but did
show right retroperitoneal stranding. Surgery was consulted and
recommended admission to medicine. Endocrinology was consulted
for concern of thyrotoxicosis or adrenal insufficiency, and
recommended discontinuation of steroids but further thyroid
studies. He had a R IJ placed, was started on levophed,
vanc/zosyn, and hydrocortisone.
In the MICU, his initial vitals were 101.4 117 108/70 35 93% 2L.
He reported feeling more energy.
###RESPONSE: Graves' disease {Graves' disease}, Kawasaki's disease {Acute febrile mucocutaneous lymph node syndrome}, intermittent fevers {Intermittent fever}, lethargy {Lethargy}, RLQ abdominal
pain {Right lower quadrant pain}, fever {Fever}, sore throat {Sore throat}, normal WBC {White blood cell count within reference range}, left
shift {Left shifted white blood cells}, elevated TSH {Thyroid stimulating hormone level above reference range}, viral infection {Viral disease}, fevers {Fever}, night sweats {Night sweats}, headaches {Headache}, RLQ pain {Right lower quadrant pain}, right groin pain {Right inguinal pain}, vitals {Vital signs finding}, fluids {Administration of fluid therapy}, ultrasound {Ultrasonography}, free fluid {Effusion}, tamponade {Cardiac tamponade}, IVC {Inferior vena cava structure}, cardiac {Heart structure}, left shift {Left shifted white blood cells}, UA {Urinalysis}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, CT A/P {Computed tomography of abdomen and pelvis}, appendicitis {Appendicitis}, bowel wall {Intestinal wall structure}, thickening {Increased thickness}, right {Structure of right half of body}, retroperitoneal {Retroperitoneal compartment structure}, Surgery was consulted {Medical consultation on hospital inpatient}, thyrotoxicosis {Thyrotoxicosis}, adrenal insufficiency {Adrenal cortical hypofunction}, steroids {Steroid therapy}, thyroid
studies {Examination of thyroid gland}, vitals {Vital signs finding} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
- ___' disease based on clinical presentation (duration of
symptoms, mild orbitopathy, lid lag, non tender mildly enlarged
thyroid gland). No RAIU. No TSI or TBII testing. Had elevated
TPO
ab 266 (reference range ___
- Kawasaki disease s/p MI (suggestive though not completely
diagnosed on cardiac cath in ___ now on coumadin
- asthma
- hyperlipidemia
- gout
###RESPONSE: disease {Disease}, mild {Symptom mild}, orbitopathy {Thyroid eye disease}, lid lag {Lid lag}, tender {Tenderness of thyroid}, enlarged
thyroid gland {Goiter}, RAIU {Radionuclide imaging of thyroid using iodine radioisotope}, TSI {Thyroid stimulating immunoglobulins measurement}, TBII {Thyrotropin binding inhibitory immunoglobulins measurement}, Kawasaki disease {Acute febrile mucocutaneous lymph node syndrome}, MI {Myocardial infarction}, cardiac cath {Cardiac catheterization}, asthma {Asthma}, hyperlipidemia {Hyperlipidemia}, gout {Inflammatory disorder due to increased blood urate level} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
His father died at age ___ with asbestosis. His mother is ___ and
is in assisted living. He has two brothers and a sister who are
healthy. His son age ___ was diagnosed as hypothyroid and his
daughter, age ___, is healthy.
###RESPONSE: died {Dead}, asbestosis {Asbestosis}, hypothyroid {Hypothyroidism} |
Subsets and Splits