text
stringlengths 539
21.6k
|
|---|
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ y.o. male with history of hypertrophic cardiomyopathy
presents from outside hospital with bilateral calcaneus
fractures. The patient reports that earlier today he was up on
a ladder, approximately 8 feet off of the ground. The bottom of
the ladder started to slide backwards, and the ladder fell to
the ground. He landed on his feet, and felt immediate heel pain
bilaterally. The patient denies head strike, LOC, or back pain.
He reports no other pain or injury. He was seen at ___
___ and had plain films of his bilateral ankle/feet which
revealed bilateral comminuted heel fractures. He was
transferred to ___ for further management.
He denies recent fever, cough, chest pain, shortness of breath,
n/v/d, and abodminal pain.
###RESPONSE: hypertrophic cardiomyopathy {Hypertrophic cardiomyopathy}, calcaneus
fractures {Fracture of calcaneus}, fell {Falls}, feet {Foot structure}, heel pain {Heel pain}, head strike {Injury of head}, LOC {Loss of consciousness}, back pain {Backache}, pain {Pain}, injury {Traumatic or non-traumatic injury}, plain films {Plain radiography}, bilateral ankle {Both ankles}, feet {Both feet}, comminuted {Fracture, comminuted}, heel fractures {Fracture of calcaneus}, fever {Fever}, cough {Cough}, chest pain {Chest pain}, shortness of breath {Dyspnea}, n/v/d {Nausea, vomiting and diarrhea}, abodminal pain {Abdominal 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:
(1) Hypertrophic Cardiomyopathy
(2) Depression
###RESPONSE: Hypertrophic Cardiomyopathy {Hypertrophic cardiomyopathy}, Depression {Depressive disorder} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
General Evaluation Exam
Sensorium: Awake (x) Awake impaired () Unconscious ()
Airway: Intubated () Not intubated (x)
Breathing: Stable (x) Unstable ()
Circulation: Stable (x) Unstable ()
Musculoskeletal Exam
Neck Normal (x) Abnormal () Comments:
Spine Normal (x) Abnormal () Comments:
Clavicle
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Shoulder
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Arm
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Elbow
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Forearm
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Wrist
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Hand
R Normal () Abnormal (x) Comments: superficial abrasions
over dorsum of right hand.
L Normal (x) Abnormal () Comments:
Pelvis
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Hip
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Thigh
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Knee
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Leg
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Ankle
R Normal () Abnormal (x) Comments: mild edema,
tenderness to palpation of the heel, plantar surface. No
palpable
deformity. 2+ ___ pulses. Normal sensation, normal capillary
refill.
L Normal () Abnormal (x) Comments: moderate edema,
tenderness to palpation of the heel, plantar surface. No
palpable
deformity. 2+ ___ pulses. Normal sensation, normal capillary
refill.
Foot
R Normal () Abnormal (x) Comments: see above
L Normal () Abnormal (x) Comments: see above
Vascular:
Radial R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
Ulnar R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
DP R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
___ R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
Neuro:
Deltoid R (5) L (5)
Biceps R (5) L (5)
Triceps R (5) L (5)
Wrist Flx R (5) L (5)
Wrist Ext R (5) L (5)
Finger Flx R (5) L (5)
Finger Ext R (5) L (5)
Thumb Ext R (5) L (5)
___ DIP R (5) L (5)
Index Abd R (5) L (5)
Thumd Add R (5) L (5)
Quad R (5) L (5)
Ant Tib R (5) L (5)
___ R ___ limited by pain) L ___, limited by pain)
Peroneal R ___ limited by pain) L ___ limited by pain)
___ R ___ limited by pain) L ___ limited by pain)
###RESPONSE: General {General examination of patient}, Sensorium {Structure of sensory nervous system}, Awake {Awake}, Awake {Awake}, Unconscious {Unconscious}, Airway {Airway structure}, Intubated {Intubation}, intubated {Intubation}, Breathing {Examination of respiratory system}, Stable {Patient's condition stable}, Unstable {Patient's condition unstable}, Circulation {Cardiovascular examination and evaluation}, Stable {Patient's condition stable}, Unstable {Patient's condition unstable}, Musculoskeletal Exam {Musculoskeletal system physical examination}, Spine {Structure of vertebral column}, Clavicle {Bone structure of clavicle}, Shoulder {Structure of right shoulder region}, R {Structure of right shoulder region}, L {Structure of left shoulder region}, Arm {Upper limb structure}, R {Right upper arm structure}, L {Left upper arm structure}, Elbow {Elbow region structure}, R {Right elbow region structure}, L {Left elbow region structure}, Forearm {Forearm structure}, R {Structure of right forearm}, L {Structure of left forearm}, Wrist {Structure of left wrist region}, R {Structure of right wrist region}, L {Structure of left wrist region}, Hand {Hand structure}, R {Structure of right hand}, superficial abrasions {Abrasion}, dorsum of right hand {Structure of dorsum of right hand}, L {Structure of left hand}, Pelvis {Structure of pelvis}, L {Structure of left half of pelvis}, Hip {Hip region structure}, R {Right hip region structure}, L {Left hip region structure}, Thigh {Thigh structure}, R {Structure of right thigh}, L {Structure of left thigh}, Knee {Structure of left knee region}, R {Structure of right knee region}, L {Structure of left knee region}, Leg {Lower limb structure}, R {Structure of right lower leg}, L {Structure of left lower leg}, Ankle {Ankle region structure}, R {Structure of right ankle}, mild {Symptom mild}, edema {Edema}, tenderness {Tenderness}, palpation {Palpation}, heel {Heel structure}, palpable {Finding by palpation}, deformity {Deformity}, pulses {Normal pulse}, Normal sensation {Normal sensation}, capillary
refill {Capillary refill}, L {Structure of left ankle}, moderate {Symptom moderate}, edema {Edema}, tenderness {Tenderness}, palpation {Palpation}, heel {Heel structure}, palpable {Finding by palpation}, deformity {Deformity}, pulses {Normal pulse}, Normal sensation {Normal sensation}, capillary
refill {Capillary refill}, Foot {Foot structure}, R {Structure of right foot}, L {Structure of left foot}, Radial {Structure of radial artery}, R {Structure of right radial artery}, Palpable {Finding by palpation}, palpable {Finding by palpation}, L {Structure of left radial artery}, Palpable {Finding by palpation}, palpable {Finding by palpation}, Ulnar {Structure of ulnar vessel}, R {Structure of right ulnar artery}, Palpable {Finding by palpation}, palpable {Finding by palpation}, L {Structure of left ulnar artery}, Palpable {Finding by palpation}, palpable {Finding by palpation}, R {Structure of right dorsalis pedis artery}, Palpable {Finding by palpation}, palpable {Finding by palpation}, L {Structure of left dorsalis pedis artery}, Palpable {Finding by palpation}, palpable {Finding by palpation}, Palpable {Finding by palpation}, palpable {Finding by palpation}, Neuro {Neurological examination}, Deltoid {Structure of deltoid muscle}, Biceps {Biceps brachii muscle structure}, R {Structure of right biceps brachii muscle}, L {Structure of left biceps brachii muscle}, Triceps {Triceps brachii muscle structure}, Wrist {Structure of left wrist region}, Flx {Structure of flexor of wrist joint}, Wrist {Structure of left wrist region}, Finger {Finger structure}, Finger {Finger structure}, Thumb {Thumb structure}, DIP {Structure of distal interphalangeal joint}, Index {Index finger structure}, Abd {Structure of adductor muscle}, Thumd {Thumb structure}, Add {Structure of adductor muscle}, Quad {Structure of quadriceps femoris muscle}, Ant Tib {Tibialis anterior muscle structure}, pain {Pain}, pain {Pain}, Peroneal {Structure of peroneal artery}, pain {Pain}, pain {Pain}, pain {Pain}, pain {Pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 06:40PM GLUCOSE-91 UREA N-11 CREAT-0.9 SODIUM-140
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-27 ANION GAP-17
___ 06:40PM WBC-10.2 RBC-4.39* HGB-14.0 HCT-40.1 MCV-91
MCH-31.8 MCHC-34.9 RDW-13.7
___ 06:40PM NEUTS-74.6* LYMPHS-16.6* MONOS-7.0 EOS-1.1
BASOS-0.7
###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}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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. ___ was evaluated in the emergency room by the
orthopaedic trauma service and found to have bilateral calcaneal
fractures. He was admitted to ortho for pain control and
bilateral bulky ___ casts were placed. He was evaluated by
physical therapy during his hospital stay.
On the floor he was given a regular diet with PO pain meds. At
the time of discharge he was afebrile with stable vital signs,
tolerating a regular diet, voiding spontaneously, and with his
pain well controled.
###RESPONSE: trauma {Traumatic injury}, calcaneal
fractures {Fracture of calcaneus}, pain control {Pain control}, casts {Cast}, placed {Implantation procedure}, evaluated by
physical therapy {Physical therapy management}, regular diet {Normal diet}, pain {Pain}, afebrile {Fever}, stable vital signs {Normal vital signs}, regular diet {Normal diet}, voiding spontaneously {Normal micturition}, pain well controled {Demonstrates adequate pain control} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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) Atenolol 50mg PO daily
(2) Paxil 20mg PO daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous once a day for 4 weeks.
Disp:*28 1* Refills:*0*
4. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours)
as needed for Pain.
Disp:*90 Tablet(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 With Service
Facility:
___
Discharge Diagnosis:
Bilateral calcaneal fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: calcaneal fractures {Fracture of calcaneus}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Wound Care:
- Keep Incision clean and dry.
- Do not soak the incision in a bath or pool.
Activity:
- Continue to be non-weight bearing on both of your legs.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours ___ through ___, 9am to
4pm) for refill of narcotic prescriptions, so plan ahead. There
will be no prescription refils on ___, or
holidays. You can either have them mailed to your home or pick
them up at the clinic located on ___. We are not allowed
to call in narcotic (oxycontin, oxycodone, percocet)
prescriptions to the pharmacy. In addition, we are only allowed
to write for pain medications for 90 days from the date of
surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
###RESPONSE: Wound Care {Wound care}, Incision {Incision}, soak {Soak}, incision {Incision}, Activity {Functional activity education}, non-weight bearing {Non-weight-bearing}, legs {Lower limb structure}, regular diet {Normal diet}, medications {Patient medication education}, medications {Patient medication education}, blood clots {Blood clot}, Medications {Patient medication education}, pain {Pain}, narcotic {Narcotherapy}, prescriptions {Prescription}, prescription {Prescription}, narcotic {Narcotherapy}, prescriptions {Prescription}, pain medications {Administration of analgesic}, surgery {Surgical procedure}, Narcotic {Narcotherapy}, pain medication {Administration of analgesic}, drowsiness {Drowsy}, Do not drink
alcohol {Education about alcohol consumption}, while taking narcotic {Narcotherapy}, medications {Patient medication education}, while taking narcotic {Narcotherapy}, pain
medications {Administration of analgesic}, breathing problems {Abnormal breathing}, signs {Sign} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Penicillins / Bactrim / Prochlorperazine / Sulfa (Sulfonamide
Antibiotics) / Quinolones / Pineapple / Erythromycin Base /
Metoclopramide
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
###RESPONSE: Penicillins {Allergy to penicillin}, Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, Prochlorperazine {Allergy to prochlorperazine}, Sulfonamide
Antibiotics {Allergy to sulfonamide antibiotic}, Pineapple {Allergy to pineapple}, Erythromycin {Allergy to erythromycin}, Metoclopramide {Allergy to metoclopramide}, Abdominal Pain {Abdominal pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Ms. ___ is a ___ year old female with a h/o kidney stones who
presents with several days of RUQ/flank pain and a distended
abdomen. The pain began ___ after eating when she started
having nausea and then vomited. Over the next few days she had
what she describes as a "belly ache" with some associated nausea
and one episode of emesis on ___. During the week she was
able to tolerate po's then noted an increase in urinary
frequency and thought she could feel a kidney stone passing, but
when the pain didn't improve she called her PCP's office on
___. She was seen by her PCP for evaluation of her
abdominal pain, who was concerned about a kidney stone vs.
gallbladder pathology so she had a noncontrast abdominal CT scan
done. The CT scan showed a 17mm likely cyst in her liver and two
kidney stones on the left, but since the cyst had increased in
size and she continued to have pain she was referred to the ER
for further evaluation.
.
In the ED, initial vs were: 98.6, 77, 125/80, 18, 100% on RA.
Patient was given morphine x 2 for pain, which improved her pain
but did not last that long, had an ultrasound of her abdomen
that showed a left sided 5mm non-obstructing kidney stone and
two likely liver hemangiomas. Labs showed all LFT's within
normal limits, lipase of 44, HCT of 34.2, u/a with a small
amount of blood, and was admitted for further work up of her
abdominal pain.
.
On the floor initial VS were: 96.2, 110/80, 88, 18, 99% on RA,
currently her pain is ___, improved to ___ with morphine.
Describes the belly pain as diffuse and dull, flank pain is
sharp.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation. No recent change in bowel habits. No dysuria.
Denied arthralgias or myalgias.
###RESPONSE: kidney stones {Kidney stone}, RUQ {Right upper quadrant pain}, flank pain {Flank pain}, distended
abdomen {Swollen abdomen}, pain {Abdominal pain}, nausea {Nausea}, vomited {Vomiting}, belly ache {Stomach ache}, nausea {Nausea}, emesis {Vomiting}, increase in urinary
frequency {Increased frequency of urination}, kidney stone {Kidney stone}, pain {Pain}, evaluation {Evaluation procedure}, abdominal pain {Abdominal pain}, kidney stone {Kidney stone}, gallbladder {Gallbladder structure}, noncontrast abdominal CT scan {Computed tomography of abdomen without contrast}, CT scan {Computed tomography of abdomen without contrast}, cyst in her liver {Cyst of liver}, kidney stones {Kidney stone}, left {Left kidney structure}, cyst {Cyst of liver}, pain {Pain}, evaluation {Evaluation procedure}, RA {Breathing room air}, improved {Patient's condition improved}, pain {Pain}, ultrasound of her abdomen {Ultrasonography of abdomen}, left {Left kidney structure}, kidney stone {Kidney stone}, liver hemangiomas {Hemangioma of liver}, LFT's within
normal limits {Liver function tests within reference range}, u/a {Urinalysis}, abdominal pain {Abdominal pain}, RA {Breathing room air}, pain {Abdominal pain}, improved {Patient's condition improved}, belly pain {Abdominal pain}, diffuse {Diffuse pain}, dull {Dull pain}, flank pain {Flank pain}, sharp {Sharp pain}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, headache {Headache}, sinus {Nasal sinus structure}, tenderness {Tenderness}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, cough {Cough}, shortness of breath {Dyspnea}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, nausea, vomiting {Nausea and vomiting}, diarrhea {Diarrhea}, constipation {Constipation}, change in bowel habits {Altered bowel function}, 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:
(per patient and atrius records)
Kidney Stones
Asthma
Anemia
Sickle cell trait
hx hematuria
endometriosis
Hx Abnormal Pap
###RESPONSE: Kidney Stones {Kidney stone}, Asthma {Asthma}, Anemia {Anemia}, Sickle cell trait {Sickle cell trait}, hematuria {Blood in urine}, endometriosis {Endometriosis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 HTN, DM, RA and interstitial cystitis
Two maternal aunts with breast cancer
One paternal aunt with colon cancer
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, RA {Rheumatoid arthritis}, interstitial cystitis {Chronic interstitial cystitis}, breast cancer {Malignant neoplasm of breast}, colon cancer {Malignant neoplasm of colon} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Vitals: T: 98 BP: 102/68 P: 77 (70-80s) R: 18 O2: 99% on RA
General: WDWN young AA female, appearing in mild discomfort
HEENT: NCAT, EOMI, MMM, OP clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly distended, TTP in epigastric region, RUQ
and RLQ, no rebound tenderness or guarding
Back: no spinal tenderness, +right CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
###RESPONSE: Vitals {Vital signs finding}, BP {Blood pressure finding}, RA {Breathing room air}, General {General examination of patient}, WDWN {Well nourished}, mild {Symptom mild}, discomfort {Discomfort}, HEENT {Physical examination procedure}, NC {Normal head}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, ronchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, distended {Swollen abdomen}, TTP {Tenderness}, epigastric region {Tenderness of epigastrium}, RUQ {Tenderness of right upper quadrant of abdomen}, RLQ {Tenderness of right lower quadrant of abdomen}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, spinal {Structure of vertebral column}, tenderness {Tenderness}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
Laboratory Findings
___ 08:33PM BLOOD WBC-5.4# RBC-3.95* Hgb-12.1 Hct-34.2*#
MCV-87 MCH-30.6 MCHC-35.3* RDW-13.0 Plt ___
___ 08:33PM BLOOD Neuts-48.5* ___ Monos-6.8
Eos-5.2* Baso-0.5
___ 08:33PM BLOOD Glucose-88 UreaN-10 Creat-0.6 Na-141
K-3.6 Cl-110* HCO3-23 AnGap-12
___ 08:33PM BLOOD ALT-15 AST-22 AlkPhos-58 TotBili-0.4
___ 08:33PM BLOOD Albumin-4.2
___ 10:05AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.8
___ 06:50AM BLOOD WBC-4.6 RBC-3.84* Hgb-11.9* Hct-33.3*
MCV-87 MCH-30.9 MCHC-35.7* RDW-12.7 Plt ___
___ 06:50AM BLOOD Glucose-84 UreaN-9 Creat-0.7 Na-139 K-3.7
Cl-107 HCO3-23 AnGap-13
----------------
Microbiology:
----------------
___ 08:33PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:33PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG
___ 08:33PM URINE ___ Bacteri-MOD Yeast-NONE
___
URINE CULTURE (Final ___: <10,000 organisms/ml. (final
report)
----------------
Imaging
----------------
Abdominal Ultrasound ___:
There is normal echogenicity of the liver. There is no extra- or
intra-hepatic biliary duct dilatation. There are two hyperechoic
lesions in the liver with no convincing vascularity, one
measuring 1.8 x 2.1 x 2 cm and second one measuring 8 x 8 x ___ile duct measures 3 mm. The portal vein is
patent. The left kidney measures 10.2 cm. There is a 5-mm
nonobstructing stone in the upper pole of the left kidney. The
right kidney measures 10 cm. There is no evidence of
hydronephrosis. There is no free fluid. The spleen is normal
measuring 7.3 cm. Evaluation of pancreas is slightly suboptimal
due to overlapping bowel gas; however, no gross abnormality of
the pancreatic head. Urinary bladder appears within normal
limits.
IMPRESSION:
1. Two hyperechoic liver lesions in the right liver lobe, with
no convincing vascularity, with imaging characteristics most
suggestive of liver hemangioma.
2. 5-mm nonobstructive stone in the upper pole of the left
kidney. No
hydronephrosis.
3. Patent main portal vein.
###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}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, liver {Liver structure}, intra-hepatic biliary duct {Intrahepatic biliary tract structure}, dilatation {Dilatation}, lesions {Lesion}, liver {Liver structure}, ile duct {Bile duct structure}, portal vein {Portal vein structure}, left kidney {Left kidney structure}, stone {Calculus}, upper pole of the left kidney {Structure of upper pole of left kidney}, right kidney {Right kidney structure}, no evidence {No abnormality detected}, hydronephrosis {Hydronephrosis}, free fluid {Effusion}, spleen {Splenic structure}, pancreas {Pancreatic structure}, no gross abnormality {No abnormality detected}, pancreatic head {Structure of head of pancreas}, Urinary bladder {Urinary bladder structure}, liver lesions {Lesion of liver}, right liver lobe {Structure of right lobe of liver}, liver hemangioma {Hemangioma of liver}, stone {Calculus}, upper pole of the left
kidney {Structure of upper pole of left kidney}, hydronephrosis {Hydronephrosis}, portal vein {Portal vein 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:
This is a ___ year old female with a history of kidney stones who
presents with a one week history of right sided crampy abdominal
pain, found to have a left-sided kidney stone and liver cyst on
abdominal ultrasound.
.
# Abdominal Pain: No clear etiology, but felt to be most likely
related to passage of a kidney stone on the right. The patient
described a crampy abdominal pain located on the right, and had
right and left CVA tenderness on examination. She was started
on tamsulosin given the presence of a 5mm stone on that side.
However, she experienced dizziness, so this medication was
stopped. Additionally, the patient mentioned experiencing a
painful big toe during a prior episode of passing a kidney
stone. While she did not pass a stone that could be collected
for laboratory evaluation, the possibility of hyperuricemia and
concurrent gout was considered, and the patient was given
information regarding a low uric acid diet. Her pain resolved
spontaneously during the admission, and she was able to tolerate
a regular diet at discharge. She was instructed to contact her
PCP regarding further workup for her kidney stones.
.
# Liver lesions: Outpatient CT records were obtained, which
noted growth of a liver lesion ___ 7 mm to 17 mm since ___.
The report did not specify whether this lesion was consistent
with a cyst or hemangioma, and suggested MRI for further
characterization. An ultrasound during admission identified
cysts consistent with hemangiomas. This lesion was felt to be
unrelated to her current episode of abdominal pain. The patient
preferred to undergo MRI as an outpatient, and was instructed to
contact her PCP regarding scheduling this test on discharge.
.
# Migraine HA: The patient reported a history of migraine
headaches, for which she had taken fioricet in the past,
although this had been discontinued by her PCP for unknown
reasons. While admitted, she did experience a migraine that was
partially relieved with acetaminophen and tramadol. She
requested a trial of motrin for headaches, and was discharged
with a prescription for several doses of Motrin 800 mg. She was
instructed to discuss this medication further with her PCP if
effective and she would like to continue.
.
# Asthma: The patient denied any asthmatic symptoms, and was
continued on her home dose of flovent and albuterol prn.
###RESPONSE: kidney stones {Kidney stone}, right sided {Right sided abdominal pain}, crampy {Stomach cramps}, abdominal
pain {Abdominal pain}, kidney stone {Kidney stone}, liver cyst {Cyst of liver}, abdominal ultrasound {Ultrasonography of abdomen}, Abdominal Pain {Abdominal pain}, kidney stone {Kidney stone}, right {Right kidney structure}, crampy {Stomach cramps}, abdominal pain {Abdominal pain}, right {Structure of right half of abdomen lateral to midsagittal plane}, CVA tenderness {Renal angle tenderness}, stone {Calculus}, dizziness {Dizziness}, painful {Pain in toe}, big toe {Great toe structure}, kidney
stone {Kidney stone}, stone {Calculus}, hyperuricemia {Hyperuricemia}, gout {Inflammatory disorder due to increased blood urate level}, pain resolved {No present pain}, regular diet {Normal diet}, workup {Evaluation procedure}, kidney stones {Kidney stone}, Liver lesions {Lesion of liver}, CT {Computed tomography of abdomen}, liver lesion {Lesion of liver}, lesion {Lesion}, cyst {Cyst}, hemangioma {Hemangioma}, MRI {Magnetic resonance imaging}, ultrasound {Ultrasonography}, cysts {Cyst}, hemangiomas {Hemangioma}, lesion {Lesion}, abdominal pain {Abdominal pain}, MRI {Magnetic resonance imaging}, Migraine HA {Migraine}, migraine
headaches {Migraine}, migraine {Migraine}, headaches {Headache}, Asthma {Asthma}, asthmatic {Asthma} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Flovent 2puffs daily
Albuterol PRN
Discharge Medications:
1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation DAILY (Daily).
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
3. Motrin 800 mg Tablet Sig: One (1) Tablet PO once a day as
needed for headache.
Disp:*10 Tablet(s)* Refills:*0*
4. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain, headache.
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Nephrolithiasis
Liver cysts
Migraine headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Nephrolithiasis {Kidney stone}, Liver cysts {Cyst of liver}, Migraine headaches {Migraine}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for severe abdominal pain.
You underwent an abdominal ultrasound that showed a cyst in your
liver and a kidney stone on the left. We think that you likely
passed a kidney stone on the right, which caused your pain. You
should call your PCP on ___ to discuss scheduling an MRI to
better evaluate your liver cyst.
We made the following changes to your medications:
-Start Motrin to use for headache for the next several days. If
you would like to continue with this medication, please discuss
it with your PCP.
###RESPONSE: abdominal pain {Abdominal pain}, abdominal ultrasound {Ultrasonography of abdomen}, cyst in your
liver {Cyst of liver}, kidney stone {Kidney stone}, left {Left kidney structure}, kidney stone {Kidney stone}, right {Right kidney structure}, pain {Abdominal pain}, MRI {Magnetic resonance imaging}, liver cyst {Cyst of liver}, 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: 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: NEUROLOGY
###RESPONSE: NEUROLOGY {Neurological examination} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
stroke
Major Surgical or Invasive Procedure:
None
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, 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: History of Present Illness:
Ms ___ is a lovely ___ yo woman with PMH significant for
Alzheimer dementia, HTN, HLD, and hypothyroid who presents after
subacute stroke was found on out patient MRI. The patient lives
in an assisted living in ___. She started acting "more
confused" this past ___ (10 days PTA). Most notable she
walked into several other apartments when she was looking for
her
own. She went to see his PCP on ___ and was found to have a
positive UA and was started on ___ (started on ___. Over
this weekend she was at a wedding with her daughter and kept
asking for someone to bring her food, while there was an
untouched plate sitting in front of her. on ___ she did the
same with a glass of juice. The patient's daughter asked her PCP
to order an MRI which was done and showed a subacute infarct on
the right.
On neuro ROS: the pt denies headache, loss of vision, blurred
vision, diplopia, oscilopsia, dysarthria, dysphagia, drop
attacks, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, paresthesias. No bowel
or bladder incontinence or retention. Denies difficulty with
gait.
On general ROS: the pt denies recent fever or chills. No night
sweats or recent weight loss or gain. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
###RESPONSE: Alzheimer dementia {Alzheimer's disease}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, hypothyroid {Hypothyroidism}, stroke {Cerebrovascular accident}, MRI {Magnetic resonance imaging of brain}, confused {Clouded consciousness}, positive {Detected by measurement}, UA {Urine examination}, MRI {Magnetic resonance imaging}, infarct {Infarct}, right {Structure of right half of body}, neuro {Neurological examination}, headache {Headache}, loss of vision {Functional visual loss}, blurred
vision {Blurring of visual image}, diplopia {Diplopia}, oscilopsia {Finding of movement of visual image}, dysarthria {Dysarthria}, dysphagia {Dysphagia}, drop
attacks {Drop attack}, lightheadedness {Lightheadedness}, vertigo {Vertigo}, tinnitus {Tinnitus}, hearing
difficulty {Hearing difficulty}, difficulties producing or comprehending
speech {Difficulty comprehending speech}, weakness {Asthenia}, numbness {Numbness}, paresthesias {Paresthesia}, bowel {Incontinence of feces}, bladder incontinence {Urinary incontinence}, retention {Retention}, difficulty with
gait {Abnormal gait}, general {General examination of patient}, fever {Fever}, chills {Chill}, night
sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, Denies cough {Does not cough}, 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}, rash {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:
Dementia
hypothyroidism
HTN
HLD
###RESPONSE: Dementia {Dementia}, hypothyroidism {Hypothyroidism}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
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:
ADMISSION PHYSICAL EXAM:
T: 97 HR: 84 BP: 158/80 RR: 18 Sat: 99%
GENERAL MEDICAL EXAMINATION:
General appearance: alert, in no apparent distress
HEENT: Neck is supple. Sclera are non-injected. Mucous membranes
are moist. No carotid bruit
CV: Heart rate is regular
Lungs: Clear to auscultation bilaterally without wheezing or
crackles.
Abdomen: soft, non-tender
Extremities: No evidence of deformities. No contractures.
Skin: No visible rashes. Warm and well perfused.
NEUROLOGICAL EXAMINATION:
Mental Status: Awake and alert. oriented to ___ and
___, location was "a place for head problems". she was able
to repeat that she was at ___ (where her
daughter works) but could not recall this moments later. She
could also not recall that she was here due to a stroke despite
several explanations. Inattentive with slow DOWB. Language is
fluent and appropriate with intact comprehension, repetition and
naming of both high and low frequency objects. Normal prosody.
There were no paraphasic errors. Speech was not dysarthric. Able
to follow both midline and appendicular commands. No neglect,
left/right confusion or finger agnosia. No apraxia for salute
or
brush your teeth. + palomental on left. no grasp.
Cranial Nerves:
I: not tested
II: dense homonymous hemianopsia on left. could not visualize
fundi.
III-IV-VI: pupils equally round, reactive to light - small.
Eyes were eso deviated. With both eyes open left eye did not
cross midline to the left. when tested separately EOMI. could
not
test saccads as patient had difficulty finding objects in space.
she denies diplopia.
V: Symmetric perception of LT in V1-3
VII: Face is symmetric at rest and with activation; symmetric
speed and excursion with smile.
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug and head rotation ___ bl
XII: No tongue deviation or fasciculations
Pt only describes the R side of the stroke cards. She lists
details in the scene (drawers, water, dish) but can not describe
the whole image at all. She seem to do the same when asked to
look at my face (eyes, neck, mouth, nose...) but does not seem
to
see my face. she has trouble locating objects in space both by
sight and sound, event when placed in her good field.
Motor: Normal muscle bulk and tone throughout. No pronator drift
or rebound
Strength:
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Toes are down going bilaterally.
Sensory: normal and symmetric perception of pinprick, light
touch, vibration and temperature. Proprioception is intact. No
agraphesthesia or astereognosis. No extinction to DSS.
Coordination: Finger to nose without dysmetria bilaterally. No
intention tremor. RAM were symmetric with regard to cadence and
speed, no dysdiadochokinesia noted.
Gait: not tested.
========================================================
DISCHARGE PHYSICAL EXAM:
NEUROLOGICAL EXAMINATION:
Mental Status: Awake and alert. Very hard of hearing. She cannot
say why she is in the hospital. Language is fluent and
appropriate with intact comprehension, repetition and naming of
both high and low frequency objects. Normal prosody. There were
no paraphasic errors. Speech was not dysarthric. Able to follow
both midline and appendicular commands. Left sided neglect.
Cranial Nerves:
I: not tested
II: dense homonymous hemianopsia on left. could not visualize
fundi.
III-IV-VI: pupils equally round, reactive to light, EOMI.
V: Symmetric perception of LT in V1-3
VII: Face is symmetric at rest and with activation; symmetric
speed and excursion with smile.
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug and head rotation ___ bl
XII: No tongue deviation or fasciculations
Motor: Normal muscle bulk and tone throughout. No pronator drift
or rebound
Strength:
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Toes are down going bilaterally.
Sensory: normal and symmetric perception of pinprick, light
touch, vibration and temperature. Proprioception is intact. No
agraphesthesia or astereognosis. No extinction to DSS.
Coordination: Finger to nose without dysmetria bilaterally.
Gait: not tested.
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, T {Body temperature finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, Sat {Finding of oxygen saturation}, General {General examination of patient}, appearance {Finding of general observation of appearance}, alert {Mentally alert}, distress {Distress}, HEENT {Physical examination procedure}, Neck {Neck structure}, supple {Normal movement of neck}, Sclera {Scleral structure}, Mucous membranes
are moist {Moist oral mucosa}, carotid bruit {Carotid bruit}, CV {Cardiovascular physical examination}, Heart rate is regular {Normal heart rate}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezing {Wheezing}, crackles {Respiratory crackles}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, Extremities {Examination of limb}, No evidence {No abnormality detected}, deformities {Deformity}, contractures {Contracture}, Skin {Examination of skin}, rashes {Eruption of skin}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, Mental Status {Neurological mental status determination}, Awake {Awake}, alert {Mentally alert}, oriented {Orientated}, head {Head structure}, problems {Problem}, stroke {Cerebrovascular accident}, fluent {Does speak fluently}, intact {Normal sensation}, comprehension {Does comprehend language}, repetition {Verbal repetition}, naming of both high and low frequency objects {Able to recognize objects}, Normal prosody {Able to use prosody in speech}, paraphasic {Paraphasia}, Speech {Speech finding}, dysarthric {Dysarthria}, neglect {Hemi-neglect}, left/right confusion {Right-left disorientation}, finger agnosia {Finger agnosia}, apraxia {Apraxia}, II {Optic nerve structure}, homonymous hemianopsia on left {Left homonymous hemianopsia}, could not visualize
fundi {Inadequate visualization of fundus of eye}, III {Oculomotor nerve structure}, IV {Trochlear nerve structure}, VI {Abducens nerve structure}, pupils equally round {Pupil size and shape normal}, reactive to light {Finding of pupil reaction to light}, small {Constricted pupil}, Eyes were eso deviated {Esotropia}, both eyes {Structure of both eyes}, left eye {Left eye structure}, EOMI {Normal ocular motility}, test saccads {Saccadic velocity test}, difficulty finding objects in space {Cognitive deficit in visuospatial function}, diplopia {Diplopia}, V {Trigeminal nerve structure}, Symmetric {Facial symmetry}, perception {Psychological finding of perception}, VII {Facial nerve structure}, Face {Face structure}, symmetric {Facial symmetry}, symmetric {Facial symmetry}, smile {Smiles}, VIII {Vestibulocochlear nerve structure}, Hearing intact {Hearing normal}, finger rub bl {Hearing examination}, IX {Glossopharyngeal nerve structure}, X {Vagus nerve structure}, Palate elevates {Does elevate soft palate}, XI {Accessory nerve structure}, Shoulder {Shoulder region structure}, head {Head structure}, XII {Hypoglossal nerve structure}, tongue {Tongue structure}, deviation {Displacement}, fasciculations {Fasciculation of tongue}, stroke {Cerebrovascular accident}, cards {Cardiology service}, trouble locating objects in space {Cognitive deficit in visuospatial function}, Motor {Motor testing}, Normal muscle bulk {Skeletal muscle size normal}, tone {Normal tone in skeletal muscle}, pronator drift {Downward drift of outstretched supinated arm}, rebound {Rebound tenderness}, Delt {Structure of deltoid muscle}, Bic {Biceps brachii muscle structure}, Tri {Triceps brachii muscle structure}, WrE {Structure of extensor of wrist joint}, FFl {Structure of flexor digitorum superficialis muscle of hand}, FE {Structure of extensor of interphalangeal joint of finger}, IO {Inferior oblique muscle structure}, IP {Interphalangeal joint structure}, Quad {Structure of quadriceps femoris muscle}, Ham {Posterior muscle of thigh structure}, TA {Tibialis anterior muscle structure}, Bi {Biceps brachii muscle structure}, Tri {Triceps brachii muscle structure}, Toes {Structure of all toes}, Sensory {Sensory testing}, normal {No abnormality detected}, symmetric {Facial symmetry}, perception {Psychological finding of perception}, pinprick {Normal pin prick discrimination}, light
touch {Light touch sensation present}, vibration {Finding of vibration sense}, temperature {Finding of temperature sense}, Proprioception is intact {Normal joint position sense}, agraphesthesia {Graphesthesia finding}, astereognosis {Tactile agnosia}, Coordination {Finding related to coordination / incoordination}, Finger to nose {Finger-to-nose test}, dysmetria {Dysmetria}, intention tremor {Intention tremor}, dysdiadochokinesia {Dysdiadochokinesis}, Gait {Gait normal}, NEUROLOGICAL EXAMINATION {Neurological examination}, Mental Status {Neurological mental status determination}, Awake {Awake}, alert {Mentally alert}, hard of hearing {Hearing loss}, fluent {Does speak fluently}, intact {Normal sensation}, comprehension {Able to comprehend language}, repetition {Verbal repetition}, naming of
both high and low frequency objects {Able to recognize objects}, Normal {No abnormality detected}, prosody {Able to use prosody in speech}, paraphasic {Paraphasia}, Speech {Speech finding}, dysarthric {Dysarthria}, Left sided neglect {Hemi-neglect}, Cranial Nerves {Cranial nerve structure}, I {Olfactory nerve structure}, II {Optic nerve structure}, homonymous hemianopsia on left {Left homonymous hemianopsia}, could not visualize
fundi {Inadequate visualization of fundus of eye}, III {Oculomotor nerve structure}, IV {Trochlear nerve structure}, VI {Abducens nerve structure}, pupils equally round {Pupil size and shape normal}, reactive to light {Finding of pupil reaction to light}, EOMI {Normal ocular motility}, V {Trigeminal nerve structure}, Symmetric {Facial symmetry}, perception {Psychological finding of perception}, VII {Facial nerve structure}, Face {Face structure}, symmetric {Facial symmetry}, symmetric {Facial symmetry}, smile {Smiles}, VIII {Vestibulocochlear nerve structure}, Hearing intact {Hearing normal}, finger rub bl {Hearing examination}, IX {Glossopharyngeal nerve structure}, X {Vagus nerve structure}, Palate elevates {Does elevate soft palate}, XI {Accessory nerve structure}, Shoulder {Structure of right shoulder region}, head {Head structure}, XII {Hypoglossal nerve structure}, tongue {Tongue structure}, deviation {Displacement}, fasciculations {Fasciculation of tongue}, Motor {Motor testing}, Normal muscle bulk {Skeletal muscle size normal}, tone {Normal tone in skeletal muscle}, pronator drift {Downward drift of outstretched supinated arm}, rebound {Rebound tenderness}, Strength {Examination of muscle power}, Delt {Structure of deltoid muscle}, Bic {Biceps brachii muscle structure}, Tri {Triceps brachii muscle structure}, WrE {Structure of extensor of wrist joint}, FFl {Structure of flexor digitorum superficialis muscle of hand}, FE {Structure of extensor of interphalangeal joint of finger}, IO {Inferior oblique muscle structure}, IP {Interphalangeal joint structure}, Quad {Structure of quadriceps femoris muscle}, Ham {Posterior muscle of thigh structure}, TA {Tibialis anterior muscle structure}, Reflexes {Reflex finding}, Bi {Biceps brachii muscle structure}, Tri {Triceps brachii muscle structure}, Toes {Structure of all toes}, Sensory {Sensory testing}, normal {No abnormality detected}, symmetric {Facial symmetry}, perception {Psychological finding of perception}, pinprick {Normal pin prick discrimination}, light
touch {Light touch sensation present}, vibration {Finding of vibration sense}, temperature {Finding of temperature sense}, Proprioception is intact {Normal joint position sense}, agraphesthesia {Graphesthesia finding}, astereognosis {Tactile agnosia}, Coordination {Finding related to coordination / incoordination}, Finger to nose {Finger-to-nose test}, dysmetria {Dysmetria}, Gait {Gait normal} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 07:00PM BLOOD WBC-5.7 RBC-4.37 Hgb-12.6 Hct-40.2 MCV-92
MCH-28.8 MCHC-31.3* RDW-13.6 RDWSD-46.2 Plt ___
___ 07:00PM BLOOD Neuts-58.6 ___ Monos-10.2 Eos-3.0
Baso-0.5 Im ___ AbsNeut-3.32 AbsLymp-1.55 AbsMono-0.58
AbsEos-0.17 AbsBaso-0.03
___ 07:00PM BLOOD ___ PTT-32.0 ___
___ 07:00PM BLOOD Glucose-93 UreaN-22* Creat-1.0 Na-141
K-5.4* Cl-104 HCO3-26 AnGap-16
___ 12:53PM BLOOD ALT-9 AST-16 AlkPhos-68 TotBili-1.0
___ 12:53PM BLOOD Albumin-4.4 Calcium-10.0 Phos-3.6 Mg-2.4
___ 12:53PM BLOOD %HbA1c-5.9 eAG-123
___ 12:53PM BLOOD TSH-3.6
IMAGING:
MRI BRAIN ___:
1. Moderate-sized acute infarction involving the right
parietotemporal
region, with associated small internal microhemorrhages.
2. Additional findings of moderate global cerebral atrophy and
small vessel ischemic disease.
3. A punctate susceptibility focus of the left occipital
parietal lobe, which may represent prior microhemorrhage.
CTA HEAD AND NECK ___ (PRELIM):
NCHCT: Hypodensity in the right temporoparietal lobe corresponds
to the areas of restricted diffusion on the patients recent MRI,
consistent with patients known infarction.
CTA: No definite vascular abnormalities identified in the region
of the known infarction in the right temporoparietal region. No
aneurysms identified.
TTE ___:
The left atrium is normal in size. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). There
is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Diastolic function could not be assessed. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. No cardiac source of
embolism identified. Mild symmetric left ventricular hypertrophy
with preserved regional/global systolic function. Mild aortic
regurgitation.
DISCHARGE LABS:
___ 12:53PM BLOOD WBC-6.2 RBC-4.63 Hgb-13.4 Hct-42.3 MCV-91
MCH-28.9 MCHC-31.7* RDW-13.6 RDWSD-45.4 Plt ___
___ 12:53PM BLOOD ___ PTT-33.9 ___
___ 12:53PM BLOOD Glucose-73 UreaN-18 Creat-1.1 Na-142
K-4.4 Cl-103 HCO3-26 AnGap-17
###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}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, eAG {Glucose measurement estimated from glycated hemoglobin}, TSH {Thyroid stimulating hormone measurement}, MRI BRAIN {Magnetic resonance imaging of brain}, Moderate {Symptom moderate}, infarction {Infarct}, right
parietotemporal
region {Right temporal and parietal lobes (combined site)}, small internal microhemorrhages {Silent micro-hemorrhage of brain}, moderate {Symptom moderate}, cerebral atrophy {Cerebral atrophy}, small vessel {Structure of small blood vessel (organ)}, ischemic disease {Ischemia}, left occipital
parietal lobe {Left parietal and occipital lobes (combined site)}, NCHCT {Computed tomography of head without contrast}, Hypodensity {Decreased radiologic density}, right temporoparietal lobe {Right temporal and parietal lobes (combined site)}, MRI {Magnetic resonance imaging of brain}, infarction {Infarct}, CTA {Computed tomography angiography of head with contrast}, vascular {Blood vessel structure}, abnormalities {No abnormality detected}, infarction {Infarct}, right temporoparietal region {Right temporal and parietal lobes (combined site)}, aneurysms {Aneurysm}, left atrium {Left atrial structure}, normal in size {Normal size}, left atrial {Left atrial structure}, mass {Mass}, thrombus {Thrombus}, transesophageal echocardiography {Transesophageal echocardiography}, 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}, Right ventricular
chamber {Right cardiac ventricular structure}, wall motion are normal {Normal ventricular wall motion}, aortic valve
leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, Mild (1+) aortic regurgitation {Mild mitral valve regurgitation}, mitral
valve leaflets are mildly thickened {Thickened mitral leaflet}, pulmonary
artery {Pulmonary artery structure}, systolic pressure is normal {Normal systolic arterial pressure}, pericardial
effusion {Pericardial effusion}, cardiac {Heart structure}, embolism {Embolism}, Mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, regional/global systolic function {Normal left ventricular systolic function and wall motion}, aortic
regurgitation {Aortic valve regurgitation}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, 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} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Ms ___ is an ___ yo woman with PMH significant for Alzheimer
dementia, HTN, HLD, and hypothyroidism who presented with left
sided neglect with acute right temporoparietal infarct.
# Right temporoparietal infarct: Patient presented with left
sided neglect and possible left sided field cut. She was placed
on aspirin 325mg and atorvastatin 40mg and MRI confirmed acute
infarction involving the right parietotemporal
region, with associated small internal microhemorrhages. CTA was
unremarkable. She was monitored on telemetry but there were no
episodes of atrial fibrillation to account for stroke. HbA1C and
lipid panel were within normal limits. TTE did not show any
evidence of left atrial thrombus or PFO. Given her age and
mental status, it was decided not to pursue long term cardiac
monitoring for evaluation of atrial fibrillation. Patient had
difficulty tolerating telemetry monitors while hospitalized and
it would not change management as the team decided they would
not start anti-coagulation in this patient even if atrial
fibrillation was found. She will continue on aspirin as an
outpatient and follow-up with stroke neurology as ab outpatient.
# UTI: Patient was found to have a UTI on admission and treated
with 3 days of Ciprofloxacin HCl 250 mg PO/NG Q12H.
# Hypothyroidism: She was continued on Levothyroxine Sodium 75
mcg PO/NG DAILY.
# HTN: She was continued on Lisinopril 5 mg PO/NG DAILY.
Transitional issues:
-continue on aspirin 81mg
-HCP: ___ (daughter) ___
-currently Full code, continue to address goals of care
###RESPONSE: Alzheimer
dementia {Alzheimer's disease}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, hypothyroidism {Hypothyroidism}, left
sided neglect {Hemi-neglect}, right temporoparietal {Right temporal and parietal lobes (combined site)}, infarct {Infarct}, Right temporoparietal {Right temporal and parietal lobes (combined site)}, infarct {Infarct}, left
sided neglect {Hemi-neglect}, left sided field cut {Visual field defect of left eye}, aspirin {Administration of aspirin}, MRI {Magnetic resonance imaging of brain}, infarction {Infarct}, right parietotemporal
region {Right temporal and parietal lobes (combined site)}, small internal microhemorrhages {Silent micro-hemorrhage of brain}, CTA {Computed tomography angiography with contrast}, unremarkable {No abnormality detected}, monitored {Monitoring procedure}, telemetry {Electroencephalogram telemetry}, atrial fibrillation {Atrial fibrillation}, stroke {Cerebrovascular accident}, within normal limits {Measurement finding within reference range}, TTE {Transthoracic echocardiography}, left atrial thrombus {Thrombus of left atrium}, PFO {Patent foramen ovale}, mental status {Altered mental status}, cardiac
monitoring {Cardiac monitoring}, evaluation {Evaluation procedure}, atrial fibrillation {Atrial fibrillation}, telemetry monitors {Telehealth monitoring}, anti-coagulation {Anticoagulant therapy}, atrial
fibrillation {Atrial fibrillation}, stroke {Cerebrovascular accident}, neurology {Neurological examination}, UTI {Urinary tract infectious disease}, UTI {Urinary tract infectious disease}, Hypothyroidism {Hypothyroidism}, HTN {Hypertensive disorder, systemic arterial} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. melatonin 3 mg oral QHS:PRN insomnia
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Lovastatin 40 mg oral QHS
Discharge Medications:
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. melatonin 3 mg oral QHS:PRN insomnia
4. Lovastatin 40 mg ORAL QHS
5. Aspirin 325 mg PO DAILY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnosis:
Right parietotemporal stroke
Secondary diagnosis:
Urinary Tract Infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: Right parietotemporal {Right temporal and parietal lobes (combined site)}, stroke {Cerebrovascular accident}, Urinary Tract Infection {Urinary tract infectious disease}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with a stroke. Your heart rhythm was
monitored but there was no evidence of an abnormal rhythm
causing the stroke. You did not have any evidence of clot in
your heart on ultrasound so the cause of your stroke remains
unclear. You should continue to take aspirin and you will
follow-up with neurology at the appointments scheduled below.
It was a pleasure taking care of you,
Your ___ Neurologists
###RESPONSE: stroke {Cerebrovascular accident}, heart rhythm {Finding of heart rhythm}, no evidence {No abnormality detected}, abnormal rhythm {Cardiac arrhythmia}, stroke {Cerebrovascular accident}, clot {Blood clot}, heart {Heart structure}, ultrasound {Ultrasonography}, stroke {Cerebrovascular accident}, follow-up with neurology {Follow-up neurological assessment} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
###RESPONSE: chest pain {Chest pain}, cardiac catheterization {Cardiac catheterization} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Mr. ___ is a ___ with h/o diabetes, HTN, HLD, DM who
presented to OSH for chest pain and was transferred for trop
elevation .08.
Mr. ___ in normal state of health until 1 week prior to
presentation when he started experiencing recurrent episodes of
chest pain. Pain is typically on the left side of his chest and
sometimes radiates to his neck, left arm and back. Described as
a tightness or squeezing. Pain sometimes goes away after ___
minutes but most recently has been persistent for ___ hours. He
endorses significant fatigue over the past week as well, night
sweats for the past 2 days, prominent cough of 7 days' duration
and loose stools for the past ___ days. He endorses one episode
of nausea/emesis on ___. Denies diaphoresis. He has not been
very active over the past week though notes no relation to
exertion. 2 weeks ago he was able to play hockey as he often
does with no issue. Also with some DOE. Reports if was cutting
the lawn would have to take breaks.
He presented to ___, where he was found to have elevated
trop at 0.08. Otherwise, labs were unremarkable and chest X-ray
showed no abnormality. He had CTA chest that showed no PE and no
dissection. He was treated with aspirin (325) and was
transferred for consideration for cath.
In the ED here, he had stable vital signs. His troponin here was
negative. EKG showed normal sinus rhythm at 66bpm, normal axis
and intervals, early R wave progression, without any ST
elevations/depressions, T wave inversions, or Q waves. He was
given sublingual nitro with no resolution of symptoms. He was
also given 12.5mg metoprolol tartrate, atorvastatin 80mg, and
started on a heparin gtt.
On arrival to the cardiology ward, patient corroborates the
above history. He currently is experiencing ___ chest pain and
notes no relief of his last dose of sublingual nitrogen. He is
no longer having sweats or shortness of breath but it does
endorse increased frequency of stool.
###RESPONSE: diabetes {Diabetes mellitus}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, chest pain {Chest pain}, trop {Troponin measurement}, elevation {Measurement finding above reference range}, recurrent {Recurrent disease}, chest pain {Chest pain}, Pain {Pain}, left side of his chest {Structure of left half of chest wall}, radiates {Radiating pain}, neck {Pain radiating to neck}, left arm {Pain radiating to left arm}, tightness {Tight chest}, squeezing {Squeezing chest pain}, Pain {Pain}, fatigue {Fatigue}, night
sweats {Night sweats}, cough {Cough}, loose stools {Loose stool}, nausea {Nausea}, emesis {Vomiting}, diaphoresis {Excessive sweating}, not been
very active {Physical deconditioning}, exertion {Finding related to exertion}, play hockey {Physically active}, DOE {Dyspnea on exertion}, elevated
trop {Troponin I above reference range}, labs {Laboratory test}, unremarkable {No abnormality detected}, chest X-ray {Plain chest X-ray}, no abnormality {Imaging result normal}, CTA chest {Computed tomography angiography of chest with contrast}, PE {Pulmonary embolism}, dissection {Dissection of aorta}, aspirin {Administration of aspirin}, cath {Cardiac catheterization}, stable vital signs {Normal vital signs}, troponin {Troponin measurement}, negative {No pathologic diagnosis}, EKG {Electrocardiographic procedure}, normal sinus rhythm {Electrocardiogram: normal sinus rhythm}, normal {Electrocardiogram normal}, axis {Electrocardiographic axis finding}, intervals {Finding of electrocardiogram waveform}, R wave progression {Electrocardiographic R wave abnormal}, ST
elevations {ST segment elevation}, depressions {ST segment depression}, T wave inversions {Inverted T wave}, Q waves {Finding of electrocardiogram Q wave}, no resolution of symptoms {Symptom not changed}, started {New medication added}, cardiology {Cardiology service}, chest pain {Chest pain}, relief {Pain relief}, last dose {Evaluation of response to medications}, sweats {Sweating}, shortness of breath {Dyspnea}, increased frequency of stool {Increased frequency of defecation} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CAD - mid 50% LAD - no intervention
3. OTHER PAST MEDICAL HISTORY
- Appendectomy
- Diverticulitis
###RESPONSE: CARDIAC RISK FACTORS {Assessment for risk of cardiovascular disease}, Diabetes {Diabetes mellitus}, Hypertension {Hypertensive disorder, systemic arterial}, Dyslipidemia {Dyslipidemia}, CAD {Coronary arteriosclerosis}, LAD {Structure of anterior descending branch of left coronary artery}, Appendectomy {Excision of appendix}, Diverticulitis {Diverticulitis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
FatherAliveHad an ' irrgeular heart rate and had ICD or
pacemaker placed'
MotherAliveNo Significant Medical History
SisterAliveNo Significant Medical History
###RESPONSE: irrgeular heart rate {Pulse irregular}, ICD {Implantation of automatic cardiac defibrillator}, pacemaker placed {Implantation of cardiac pacemaker} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 EXAMINATION:
=====================
VS: Temp 98.0 BP 139 / 87 HR 68 RR 17SaO2 96%Ra
GENERAL: NAD, well appearin man in NAD. Ruddy complexion
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs. JVD < 10 cm at 90
degrees
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES:trace edema b/l, at baseline per patient
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Exam:
GENERAL: NAD, well appearing man in NAD. Ruddy complexion
HEENT: AT/NC, anicteric sclera
NECK: supple, no LAD, no elevated JVD
CV: RRR, S1/S2, no murmurs, gallops, or rubs.
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender, no hepatosplenomegaly
EXTREMITIES: no edema b/l, right arm with dressing over cath
site without strike through, bruit, and with perfusion of distal
extremities, no evidence hematoma
Neuro: sensation to light touch in right hand, strength ___ in
B/l hands, movement of bilateral fingers with intention.
###RESPONSE: PHYSICAL EXAMINATION {Physical examination procedure}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, GENERAL {General examination of patient}, NAD {No abnormality detected}, well appearin {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, anicteric sclera {White sclera}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, JVD {Jugular venous engorgement}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, breathing comfortably {Breathing easily}, accessory muscles {Accessory skeletal muscle}, GI {Examination of digestive system}, soft {Abdomen soft}, nondistended {Normal abdominal contour}, nontender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, hepatosplenomegaly {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, edema {Edema}, baseline {Baseline state}, radial pulses {Radial pulse present}, NEURO {Neurological examination}, Alert {Mentally alert}, moving all 4 extremities {Does move all four limbs}, face
symmetric {Facial symmetry}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Lesion}, rashes {Eruption of skin}, GENERAL {General examination of patient}, NAD {No abnormality detected}, well appearing {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, anicteric sclera {White sclera}, NECK {Physical examination procedure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, breathing comfortably {Breathing easily}, accessory muscles {Accessory skeletal muscle}, GI {Examination of digestive system}, soft {Abdomen soft}, nondistended {Normal abdominal contour}, nontender {Abdominal tenderness}, hepatosplenomegaly {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, edema {Edema}, right arm {Structure of right upper limb}, cath
site {Vascular catheter insertion site}, bruit {Bruit}, perfusion {Normal tissue perfusion}, distal
extremities {Structure of distal lower limb artery}, no evidence {No abnormality detected}, hematoma {Hematoma}, Neuro {Neurological examination}, sensation to light touch {Light touch sensation present}, right hand {Structure of right hand}, B/l hands {Both hands}, bilateral {Both hands}, fingers {Finger 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: Pertinent Results:
ADMISSION
___ 11:20PM WBC-5.6 RBC-4.45* HGB-14.8 HCT-41.5 MCV-93
MCH-33.3* MCHC-35.7 RDW-12.1 RDWSD-41.4
___ 11:20PM NEUTS-41.7 ___ MONOS-11.2 EOS-1.8
BASOS-1.1* AbsNeut-2.35 AbsLymp-2.49 AbsMono-0.63 AbsEos-0.10
AbsBaso-0.06
___ 11:20PM ___ PTT-27.1 ___
___ 11:20PM GLUCOSE-98 UREA N-12 CREAT-1.0 SODIUM-139
POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-21* ANION GAP-15
___ 11:20PM ALT(SGPT)-42* AST(SGOT)-34 CK(CPK)-72 ALK
PHOS-63 TOT BILI-0.5
___ 11:20PM LIPASE-44
___ 11:20PM cTropnT-<0.01
___ 11:20PM CK-MB-<1
___ 11:20PM ALBUMIN-3.9
___ 10:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:45PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
PERTINENT STUDIES:
___ CATH
Coronary Anatomy
Right dominant
LM: No disease.
LAD: Focal 50% eccentric stenosis in mid vessel.
LCx: No significant disease.
RCA: No significant disease.
Impressions:
Intermediate mid LAD disease.
Recommendations
Med Rx. If patient has persistent angina or evidence of
ischemia, could do mid LAD PCI in future.
Discharge Labs:
___ 06:33AM BLOOD WBC-6.6 RBC-4.86 Hgb-15.7 Hct-45.6 MCV-94
MCH-32.3* MCHC-34.4 RDW-12.1 RDWSD-42.3 Plt ___
___ 06:33AM BLOOD Plt ___
___ 06:33AM BLOOD Glucose-123* UreaN-15 Creat-1.1 Na-141
K-4.8 Cl-102 HCO3-28 AnGap-11
___ 06:33AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.___ year old man with PMHx DM2, HTN, HLD, who presented with
chest pain at rest and found to have NSTEMI with moderate
coronary artery disease on cardiac catheterization, not thought
to be contributing to chest pain and no intervention was done.
Patient was started on aspirin, high dose atorvastatin and PRN
sublingual nitroglycerin and discharged with Cardiology follow
up.
Active Issues
# NSTEMI:
Presented with chest pain at rest concern for unstable angina.
Etiology unclear as underwent coronary angiogram and had only
moderate 50% mid LAD disease not thought to be responsible for
his chest pain. Patient started on ___, high dose statin and
PRN SL NTG and discharged with Cardiology follow up.
Chronic Issues
# HTN: continued home felodipine
# HLD: increased atorvastatin
# Depression: continued home citalopram
# Anxiety: continued home lorazepam
Transitional Issues:
[ ] new diagnosis of CAD: started on ASA 81, high dose
atorvastatin, PRN SL NTG
[ ] please obtain TTE as outpatient
###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}, RDWSD {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PTT {Partial thromboplastin time, activated}, 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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, CK(CPK {Creatine kinase measurement}, ALK
PHOS {Alkaline phosphatase measurement}, TOT BILI {Bilirubin, total measurement}, LIPASE {Triacylglycerol lipase measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, ALBUMIN {Albumin measurement}, COLOR {Color finding}, APPEAR-Clear {Urine looks clear}, NEG {No abnormality detected}, PROTEIN {Measurement of protein in urine}, GLUCOSE-NEG {Urine glucose not detected}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, NEG {No abnormality detected}, UROBILNGN {Urobilinogen measurement, urine}, NEG {No abnormality detected}, PH {pH measurement}, LEUK-NEG {Urine leukocytes not detected}, URINE {Evaluation of urine specimen}, RBC {Red blood cell count}, WBC {White blood cell count}, AST {Aspartate aminotransferase measurement}, CATH {Cardiac catheterization}, Coronary Anatomy {Coronary artery finding}, Right dominant {Right dominant coronary system}, No disease {No abnormality detected}, LAD {Structure of anterior descending branch of left coronary artery}, stenosis {Stenosis of mid portion of anterior descending branch of left coronary artery}, mid vessel {Structure of mid portion of anterior descending branch of left coronary artery}, No significant disease {No abnormality detected}, RCA {Right coronary artery structure}, No significant disease {No abnormality detected}, mid LAD disease {Stenosis of mid portion of anterior descending branch of left coronary artery}, angina {Angina}, ischemia {Ischemia}, mid LAD {Structure of mid portion of anterior descending branch of left coronary artery}, PCI {Percutaneous coronary intervention}, 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}, RDWSD {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, DM2 {Diabetes mellitus type 2}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, chest pain at rest {Chest pain at rest}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, moderate {Symptom moderate}, coronary artery disease {Coronary arteriosclerosis}, cardiac catheterization {Cardiac catheterization}, chest pain {Chest pain}, started {New medication added}, aspirin {Administration of aspirin}, nitroglycerin {Administration of prophylactic glyceryl trinitrate}, Cardiology {Cardiology service}, follow
up {Follow-up arranged}, chest pain at rest {Chest pain at rest}, unstable angina {Preinfarction syndrome}, coronary angiogram {Angiography of coronary artery}, mid LAD disease {Stenosis of mid portion of anterior descending branch of left coronary artery}, chest pain {Chest pain}, started {New medication added}, NTG {Administration of prophylactic glyceryl trinitrate}, Cardiology {Cardiology service}, follow up {Follow-up arranged}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, increased {Increasing dosage of medication}, Depression {Depressive disorder}, Anxiety {Anxiety}, CAD {Coronary arteriosclerosis}, started {New medication added}, ASA {Administration of aspirin}, NTG {Administration of prophylactic glyceryl trinitrate}, TTE {Transthoracic echocardiography} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Zolpidem Tartrate 10 mg PO QHS:PRN Insomnia
5. LORazepam 1 mg PO BID:PRN Anxiety
6. Felodipine 10 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually Q5minutes Disp
#*25 Tablet Refills:*0
3. Atorvastatin 80 mg PO QPM
4. Citalopram 20 mg PO DAILY
5. Felodipine 10 mg PO DAILY
6. LORazepam 1 mg PO BID:PRN Anxiety
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. Zolpidem Tartrate 10 mg PO QHS:PRN Insomnia
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
# Coronary artery disease
# Non-ST elevation myocardial infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Coronary artery disease {Coronary arteriosclerosis}, Non-ST elevation myocardial infarction {Acute non-ST segment elevation myocardial infarction}, 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:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had chest pain
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were admitted to the hospital because you had chest pain.
You were found to have had a heart attack. Your heart arteries
were examined (cardiac catheterization) which showed a blockage
of one of the arteries. This blockage was not enough to limit
the flow in your artery and was not thought to be the reason for
your pain.
- We increased your home medications to take the stress off the
heart
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please take your medications as prescribed
- Please follow up with your primary care doctor
- Please return to hospital if you have chest pain that does not
go away or gets worse when you are being active.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
###RESPONSE: chest pain {Chest pain}, chest pain {Chest pain}, heart attack {Myocardial infarction}, heart arteries {Coronary artery structure}, cardiac catheterization {Cardiac catheterization}, blockage {Coronary artery stenosis}, arteries {Coronary artery structure}, blockage {Coronary artery stenosis}, artery {Structure of intracranial artery}, pain {Pain}, increased {Increased pain}, medications {Administration of drug or medicament}, heart {Heart structure}, take your medications as prescribed {Recommendation to continue with drug treatment}, follow up {Follow-up arranged}, primary care {Primary care management}, chest pain {Chest pain}, worse {Increased pain}, active {Physically active} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain, dizziness
Major Surgical or Invasive Procedure:
none
###RESPONSE: chest pain {Chest pain}, dizziness {Dizziness} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ year old woman with a history of HTN who presents with one
week of chest pain. She describes the chest pain as a constant,
___, left-sided burning sensation that radiates to the back.
Pain has been progressively worsening over the week. It is worst
in the mornings, when pain is associated with weakness and
fatigue. It is also worse when she exerts her left arm (e.g.
cutting vegtables), but not with generalized exertion. She
states current pain is distinct from heartburn symptoms which
she had experienced in the past. Associated symptoms include
general weakness, fatigue, and mild DOE throughout the week. She
denies nausea, or diaphoresis. No fevers, sweats or rigors but
did have some chills today.
.
She went to see her PCP today due to her ongoing symptoms. At
the PCP's office SL NG was administered with almost immediate
relief within seconds. She also recieved Aspirin 325mg. She was
referred to the ED for further workup.
.
Of note: Patient has prior history of admission to ___ ___ years
ago with chest pain similar to current pain. At the time, pain
developed acutely while was shoveling snow and was stronger than
current complaints but similar in distribution and quality. She
says she spent several days in the hospital and was told her
heart was "damaged". No PTCA was done. She says she had a second
admission to ___ ___ years ago for difficult to control HTN. She
takes her BP meds regularly.
.
In the ED, initial Vitals: 99.2 66 185/88 18 99% 2L. Labs were
notable for absence of leukocytosis and Hct 33. The patient was
ruled out for MI by cardiac enzymes x 2 and EKG. The patient
underwent CXR that showed left basilar atelectasis versus
infiltrate. CTA chest ruled out aortic dissection and
demonstrated extensive bronchiectasis in the right middle lobe
and bilateral lower lobes. Levoquin was administered prior to
admission for possible infiltrate. Prior to transfer, VS: 97.8,
180/70, 57, 17, 98% ra.
.
On the floor, patient feels well. She states her pain had
resolved completley after NG at ___'s office. She has no further
complaints. She denies any recent or past known aspiration
events. She had no recent travel, no sick or animal exposures
and denies any history of TB or industrial exposures.
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, chest pain {Chest pain}, chest pain {Chest pain}, constant {Constant pain}, left-sided {Left sided chest pain}, burning sensation {Burning sensation}, radiates {Radiating pain}, Pain {Pain}, worsening {Increased pain}, pain {Pain}, weakness {Asthenia}, fatigue {Fatigue}, worse {Patient's condition worsened}, left arm {Left upper arm structure}, exertion {Chest pain on exertion}, pain {Pain}, heartburn {Heartburn}, general weakness {Asthenia}, fatigue {Fatigue}, mild {Symptom mild}, DOE {Dyspnea on exertion}, nausea {Nausea}, diaphoresis {Excessive sweating}, No fevers {Temperature normal}, sweats {Sweating}, rigors {Rigor}, chills {Chill}, PCP {Primary care management}, PCP {Primary care management}, relief {Pain relief}, Aspirin {Administration of aspirin}, referred to the ED {Referral to accident and emergency service}, workup {Evaluation procedure}, chest pain {Chest pain}, pain {Pain}, pain {Pain}, heart {Heart structure}, PTCA {Percutaneous transluminal coronary angioplasty}, difficult to control HTN {Poor hypertension control}, Vitals {Vital signs finding}, Labs {Laboratory test}, leukocytosis {Leukocytosis}, cardiac enzymes {Finding of cardiac enzyme levels}, EKG {Electrocardiographic procedure}, CXR {Plain chest X-ray}, left basilar {Structure of lower lobe of left lung}, atelectasis {Atelectasis}, infiltrate {Infiltration}, CTA chest {Computed tomography of chest}, aortic dissection {Dissection of aorta}, bronchiectasis {Bronchiectasis}, right middle lobe {Structure of middle lobe of right lung}, bilateral {Both lungs}, lower lobes {Structure of lower lobe of lung}, infiltrate {Infiltration}, patient feels well {Patient feels well}, pain {Pain}, resolved {Problem resolved}, aspiration {Aspiration}, travel {Travel abroad} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
- HTN
- Pneumonia ___ years ago treated as out patient
- ? of cardiac "event" - see HPI.
- s/p left salpingectomy > ___ years ago.
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, Pneumonia {Pneumonia}, cardiac {Heart disease}, left salpingectomy {Left salpingectomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 died of "heart attack" at age ___
- Father had MI at age ___
- no siblings or biological children
###RESPONSE: died {Dead}, heart attack {Myocardial infarction} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Admission
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS - Temp 96.1 F, 161/79 BP , HR 57 , R 18 , 97 O2-sat % RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
CHEST: some reproducible pain in left paravertebral area, mild
scoliosis
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI is hyperdynamic but not displaced, RRR, no MRG, a
third heart sound is heard possibly S4.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact.
.
Discharge Physical Exam:
VS: 97.3 136/74 55 18 97%RA
GENERAL - well-appearing in NAD, comfortable
NECK - supple, no JVD, no carotid bruits
CHEST: non-tender to palpation
LUNGS - mild dry crackles in bases, good air movement, resp
unlabored
HEART - RRR, no MRG
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact.
###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}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, comfortable {Comfortable appearance}, HEENT {Physical examination procedure}, NC {Normal head}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, sclerae anicteric {White sclera}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, NECK {Physical examination procedure}, supple {Normal movement of neck}, thyromegaly {Goiter}, JVD {Jugular venous engorgement}, carotid bruits {Carotid bruit}, pain {Pain}, left {Structure of left half of chest wall}, paravertebral {Structure of paravertebral region}, mild {Symptom mild}, scoliosis {Scoliosis deformity of spine}, LUNGS {Examination of respiratory system}, CTA {Normal breath sounds}, rh/wh {Wheeze - rhonchi}, good air movement {Breath normal}, resp
unlabored {Breathing easily}, accessory muscle {Accessory skeletal muscle}, HEART {Cardiovascular physical examination}, PMI {Finding of apex beat}, hyperdynamic {Hyperdynamic circulation}, displaced {Apex beat displaced}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, third heart sound {Third heart sound}, ABDOMEN {Examination of abdomen}, NABS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, no c/c/e {No abnormality detected}, 2+ peripheral pulses {Peripheral pulse present}, radials {Radial pulse present}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, cervical {Cervical lymphadenopathy}, axillary {Axillary lymphadenopathy}, LAD {Lymphadenopathy}, NEURO {Neurological examination}, awake {Awake}, Ox3 {Oriented to person, time and place}, grossly intact {Normal nervous system function}, muscle strength {Normal muscle function}, sensation grossly intact {Normal sensation}, DTRs 2 {Normal tendon reflex}, exam {Physical examination procedure}, Physical Exam {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, comfortable {Comfortable appearance}, NECK {Physical examination procedure}, supple {Normal movement of neck}, JVD {Jugular venous engorgement}, carotid bruits {Carotid bruit}, non-tender {Abdominal tenderness}, palpation {Palpation}, LUNGS {Examination of respiratory system}, mild {Symptom mild}, crackles {Respiratory crackles}, bases {Structure of base of lung}, good air movement {Breath normal}, resp
unlabored {Breathing easily}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, ABDOMEN {Examination of abdomen}, NABS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, no c/c/e {No abnormality detected}, 2+ peripheral pulses {Peripheral pulse present}, radials {Radial pulse present}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, cervical {Cervical lymphadenopathy}, axillary {Axillary lymphadenopathy}, LAD {Lymphadenopathy}, NEURO {Neurological examination}, awake {Awake}, Ox3 {Oriented to person, time and place}, grossly intact {Normal nervous system function}, muscle strength {Normal muscle function}, sensation grossly intact {Normal sensation}, DTRs 2 {Normal tendon reflex}, exam {Physical examination procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
Admission Labs:
___ 07:06PM BLOOD WBC-5.4 RBC-3.72* Hgb-11.2* Hct-33.6*
MCV-90 MCH-30.0 MCHC-33.3 RDW-13.2 Plt ___
___ 04:32PM BLOOD Glucose-125* UreaN-20 Creat-1.1 Na-141
K-4.0 Cl-104 HCO3-26 AnGap-15
___ 04:32PM BLOOD LD(LDH)-186
___ 10:45PM BLOOD Cholest-204*
___ 10:45PM BLOOD Triglyc-67 HDL-63 CHOL/HD-3.2 LDLcalc-128
___ 04:32PM BLOOD %HbA1c-5.5 eAG-111
___ 07:20PM BLOOD Lactate-1.0
.
Discharge Labs:
___ 06:25AM BLOOD WBC-5.6 RBC-3.65* Hgb-11.1* Hct-32.8*
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.1 Plt ___
___ 06:25AM BLOOD Glucose-94 UreaN-32* Creat-1.1 Na-144
K-3.5 Cl-108 HCO3-28 AnGap-12
___ 06:25AM BLOOD Calcium-9.2 Phos-4.4 Mg-1.8
.
Cardiac Enzyme trend:
___ 04:32PM BLOOD cTropnT-<0.01
___ 10:45PM BLOOD cTropnT-<0.01
___ 06:25AM BLOOD CK-MB-2 cTropnT-<0.01
.
Urine:
___ 04:33PM URINE Color-Straw Appear-Clear Sp ___
___ 04:33PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 4:33 pm URINE CULTURE (Final ___: NO GROWTH.
.
CXR ___:
Findings: PA and lateral view of the chest, no prior. There is
subtle left
basilar opacity, potentially atelectasis, however, infiltrate is
not excluded. In addition, there is a 7-mm nodular opacity
projecting in the suprahilar region on the left. Elsewhere, the
lungs are grossly clear, costophrenic angles are sharp. The
cardiomediastinal silhouette is within normal limits. Osseous
and soft tissue structures are unremarkable.
IMPRESSION: Left basilar atelectasis versus infiltrate. Possible
left
suprahilar nodule. These findings can be followed up on the
upcoming chest
CT, which has been ordered.
.
CTA chest/abdomen/pelvis ___:
1. No evidence of aortic dissection.
2. Bilateral adrenal nodules measuring 10 mm on the left and 8
mm on the
right, incompletely characterized on this single phase study.
Further
evaluation could be performed with an adrenal protocol CT or MR.
3. Extensive bronchiectasis with associated reticulation and
ground glass
opacity in the basilar aspects of the right middle lobe and both
lower lobes, possibly secondary to chronic aspiration or prior
infection, although an intrinsic lung process, such as
non-specific interstitial fibrosis, cannot be excluded.
4. Right renal simple cyst. Additional left renal tiny
hypodensities are too small to characterize, but are
statistically simple cysts.
5. Small quantity of free fluid in the dependent portion of the
pelvis is a nonspecific finding, but not typically seen in a
female patient of this age.
6. Moderate lumbar spinal stenosis at L3-L4 and L4-L5.
.
Cardiac Perfusion Persantine ___:
The image quality is adequate but limited due to soft tissue and
breast
attenuation. There is activity adjacent to the heart in the
stress images.
Left ventricular cavity size is normal. Rest and stress
perfusion images reveal uniform tracer uptake throughout the
left ventricular myocardium.
Gated images reveal normal wall motion. The calculated left
ventricular ejection fraction is 57% with an EDV of 102 ml.
.
Stress Portion ___: No anginal type symptoms or ischemic ECG
changes.
.
MRI head ___:
1. There is no evidence of acute or subacute intracranial
pathology.
2. A few foci of high signal intensity are identified in the
subcortical
white matter of the right frontal region, which are nonspecific
and may
represent chronic microvascular ischemic changes.
###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}, 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}, LDH {Lactate dehydrogenase measurement}, Cholest {Cholesterol measurement}, Triglyc {Triglycerides measurement}, HDL {High density lipoprotein measurement}, CHOL/HD {Cholesterol/High density lipoprotein ratio measurement}, LDLcalc {Calculated low density lipoprotein cholesterol level}, HbA1c {Hemoglobin A1c measurement}, eAG {Glucose measurement estimated from glycated hemoglobin}, Lactate {Lactic acid measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, 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}, Cardiac Enzyme {Cardiac enzymes/isoenzymes measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, Urine {Urinalysis}, URINE Color-Straw {Normal urine color}, Appear-Clear {Urine looks clear}, URINE Blood {Urine blood test}, NEG {No abnormality detected}, Nitrite-NEG {Nitrite not detected in urine}, Protein-NEG {Urine protein not detected}, Glucose-NEG {Urine glucose not detected}, Ketone-NEG {Urine ketones not detected}, NEG {No abnormality detected}, Urobiln-NEG {Urine urobilinogen not detected}, pH {pH measurement}, Leuks-NEG {Urine leukocytes not detected}, URINE CULTURE {Urine culture}, NO GROWTH {No organism isolated by microbiologic culture}, CXR {Plain chest X-ray}, PA and lateral view of the chest {Plain chest X-ray}, left
basilar {Structure of lower lobe of left lung}, opacity {Abnormally opaque structure}, atelectasis {Atelectasis}, infiltrate {Infiltration}, nodular {Nodule of lung}, opacity {Abnormally opaque structure}, region on the left {Structure of hilar lymph node}, lungs {Lung structure}, clear {Normal lung}, costophrenic angles {Structure of costophrenic angle}, cardiomediastinal {Mediastinal structure}, normal {No abnormality detected}, Osseous {Bone structure}, soft tissue {Structure of soft tissue}, unremarkable {Imaging result normal}, Left basilar {Structure of lower lobe of left lung}, atelectasis {Atelectasis}, infiltrate {Infiltration}, left {Left lung structure}, nodule {Nodule}, abdomen/pelvis {Computed tomography of abdomen and pelvis}, No evidence {No abnormality detected}, aortic dissection {Dissection of aorta}, Bilateral adrenal {Bilateral adrenal glands}, nodules {Nodule}, left {Structure of left adrenal gland}, right {Structure of right adrenal gland}, study {Evaluation procedure}, evaluation {Evaluation procedure}, bronchiectasis {Bronchiectasis}, opacity {Abnormally opaque structure}, basilar {Structure of base of lung}, right middle lobe {Structure of middle lobe of right lung}, lower lobes {Structure of lower lobe of lung}, chronic {Chronic disease}, aspiration {Aspiration pneumonia}, infection {Infectious disease}, lung {Lung structure}, interstitial fibrosis {Interstitial fibrosis}, Right {Right kidney structure}, renal {Kidney structure}, simple cyst {Simple cyst}, left renal {Left kidney structure}, simple cysts {Simple cyst}, free fluid {Effusion}, pelvis {Structure of pelvis}, Moderate {Symptom moderate}, lumbar spinal stenosis {Spinal stenosis of lumbar region}, L4-L5 {Intervertebral disc structure of fourth lumbar vertebra}, soft tissue {Structure of soft tissue}, breast {Breast structure}, heart {Heart structure}, stress {Radionuclide myocardial perfusion stress study}, Left ventricular cavity {Structure of cavity of left cardiac ventricle}, size is normal {Normal size}, stress
perfusion images {Radionuclide myocardial perfusion stress study}, left ventricular myocardium {Structure of myocardium of left ventricle}, normal wall motion {Normal ventricular wall motion}, left
ventricular {Left cardiac ventricular structure}, Stress {Radionuclide myocardial perfusion stress study}, anginal {Angina}, ischemic {Ischemia}, ECG {Electrocardiographic procedure}, MRI head {Magnetic resonance imaging of head}, no evidence {No abnormality detected}, intracranial {Intracranial structure}, white matter {Cerebral white matter structure}, right frontal region {Right frontal lobe structure}, chronic {Chronic disease}, microvascular {Structure of small blood vessel (organ)}, ischemic changes {Ischemia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ year old woman with a history of HTN admitted with 1 week of
chest pain, hospitalization complicated by dizziness.
.
# Chest pain: Patient presented to the emergency department with
a week of left-sided stabbing, burning chest pain that radiates
to the back. In the emergency department, she was ruled out for
myocardial infarction by enzymes and EKG. She underwent CTA
chest/abdomen/pelvis, that did not show evidence of pulmonary
embolism or aortic dissection. Stress test was performed given
the patient's risk factors that showed normal myocardial
perfusion and function, and absence of cardiac symptoms with
stress. CT did show extensive bronchiectasis and ground glass
opacities, likely representing ___ syndrome in the
context of the patient's chest pain, associated with fatigue and
malaise. Given absence of fevers and cough, there is no
indication for antibiotic therapy. The patient should undergo
follow-up CT in 3 months to evaluate for evolving ground glass
opacities.
.
# Dizziness: During admission, patient endorsed 2 weeks of
dizziness that occurred with sudden onset. She had no focal
neurologic deficits on exam. MRI brain did not show evidence of
an acute cerebral process. Orthostatics were negative and the
patient was not bradycardic. However, given the patient's
description of symptoms and borderline-low blood pressure,
labetalol was decreased to 200 mg BID. The patient was seen by
physical therapy, and was found to be safe to discharge home.
.
# Bilateral adrenal nodules: Incidental finding on CT. ___ be of
concern given history of difficult-to-control hypertension. The
patient will need dedicated adrenal imaging as an outpatient.
___ consider functional adrenal studies to evaluate for cause of
poorly-controlled hypertension.
.
# normocytic anemia: Patient admitted with mild normocytic
anemia without known baseline. Anemia remained stable
throughout admission. No evidence of bleed. The patient should
follow up with her primary care physician regarding her anemia.
.
# HTN: chronic. The patient was normotensive to mildly
hypotensive during admission on home regimen of lisinopril and
labetalol. Prior to discharge, the patient's labetalol was
decreased to 200 mg BID. She remained normotensive. She should
follow up with her PCP for ___ blood pressure check on discharge.
.
# CODE: full code
================================================================
TRANSITIONAL ISSUES:
# Patient should undergo repeat CT chest in 3 months (___) to
evaluate ground glass opacities
# Patient should undergo dedicated adrenal imaging to evaluate
bilateral adrenal nodules. ___ consider functional studies of
nodules.
# Patient should follow up with PCP for BP check, as labetalol
was decreased on admission.
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, chest pain {Chest pain}, dizziness {Dizziness}, Chest pain {Chest pain}, emergency {Emergency treatment management}, left-sided {Left sided chest pain}, stabbing {Stabbing pain}, burning chest pain {Burning chest pain}, radiates {Radiating pain}, emergency {Emergency treatment management}, myocardial infarction {Myocardial infarction}, EKG {Electrocardiographic procedure}, CTA
chest {Computed tomography angiography of chest with contrast}, abdomen/pelvis {Computed tomography of abdomen and pelvis}, pulmonary
embolism {Pulmonary embolism}, aortic dissection {Dissection of aorta}, Stress test {Radionuclide myocardial perfusion stress study}, normal myocardial
perfusion {Myocardial perfusion normal}, cardiac {Heart structure}, stress {Radionuclide myocardial perfusion stress study}, bronchiectasis {Bronchiectasis}, ground glass
opacities {Ground glass lung opacity}, syndrome {Disease}, chest pain {Chest pain}, fatigue {Fatigue}, malaise {Malaise}, fevers {Fever}, cough {Cough}, antibiotic therapy {Antibiotic therapy}, follow-up {Follow-up arranged}, evaluate {Evaluation procedure}, ground glass
opacities {Ground glass lung opacity}, Dizziness {Dizziness}, dizziness {Dizziness}, neurologic deficits {Neurological deficit}, exam {Evaluation procedure}, MRI brain {Magnetic resonance imaging of brain}, Orthostatics {Orthostatic hypotension}, negative {No pathologic diagnosis}, bradycardic {Bradycardia}, low blood pressure {Low blood pressure}, physical therapy {Physical therapy procedure}, Bilateral adrenal {Bilateral adrenal glands}, nodules {Nodule}, difficult-to-control hypertension {Poor hypertension control}, adrenal imaging {Adrenal imaging}, studies {Evaluation procedure}, evaluate {Evaluation procedure}, poorly-controlled hypertension. {Poor hypertension control}, normocytic anemia {Normocytic anemia}, mild {Symptom mild}, normocytic
anemia {Normocytic anemia}, baseline {Baseline state}, Anemia {Anemia}, stable {Patient's condition stable}, No evidence {No abnormality detected}, bleed {Hemorrhage}, follow up {Follow-up arranged}, primary care {Primary care management}, anemia {Anemia}, HTN {Hypertensive disorder, systemic arterial}, chronic {Chronic disease}, normotensive {Normal blood pressure}, hypotensive {Low blood pressure}, regimen {Therapeutic regimen}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, normotensive {Normal blood pressure}, follow up {Follow-up arranged}, PCP {Primary care management}, blood pressure {Finding of increased blood pressure}, CT chest {Computed tomography of chest}, evaluate {Evaluation procedure}, ground glass opacities {Ground glass lung opacity}, adrenal imaging {Adrenal imaging}, evaluate {Evaluation procedure}, bilateral adrenal {Bilateral adrenal glands}, nodules {Nodule}, studies {Evaluation procedure}, nodules {Thyroid nodule}, follow up {Follow-up arranged}, PCP {Primary care management}, BP check {Blood pressure monitoring} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
1. Lisinopril 40mg daily
2. Labetolol 400mg BOD
3. Aspirin 81mg daily
Discharge Medications:
1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
2. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*180 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: atypical chest pain, dizziness
SECONDARY DIAGNOSIS: Hypertension, bilateral adrenal nodules,
normocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: atypical chest pain {Atypical chest pain}, dizziness {Dizziness}, Hypertension {Hypertensive disorder, systemic arterial}, bilateral adrena {Bilateral adrenal glands}, nodules {Nodule}, normocytic anemia {Normocytic anemia}, 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:
Ms. ___,
.
You were admitted to the hospital with two weeks of left-sided
chest pain. On CT scan, you were found to have changes in your
lung, concerning for an infection that does not need treatment
with antibiotics at this time. You were also found to have
small nodules in your adrenal glands. Your chest pain resolved.
You should follow up with your primary care physician for ___
repeat CT scan in 3 months to evaluate for changes in your lung
findings and adrenal glands. You had a stress test that showed
no acute problems with your heart. During your hospitalization,
you were also noted to have dizziness and a feeling of weakness
in your left leg. We did not note any weakness on physical
exam. You underwent an MRI that showed no evidence of acute
stroke. You were seen by physical therapy who recommended that
you walk with a walker (given to you during admission) at all
times. You should follow up with your PCP on discharge.
.
Medications changed this admission:
DECREASE labetalol to 200 mg twice daily
###RESPONSE: left-sided
chest pain {Left sided chest pain}, CT scan {Computed tomography}, lung {Lung structure}, infection {Infectious disease}, antibiotics {Antibiotic therapy}, nodules {Nodule}, adrenal glands {Bilateral adrenal glands}, chest {Chest pain}, pain resolved {No present pain}, primary care {Primary care management}, CT scan {Computed tomography}, evaluate {Evaluation procedure}, lung
findings {Lung finding}, adrenal glands {Bilateral adrenal glands}, stress test {Cardiovascular stress testing}, no acute {No abnormality detected}, problems {Problem}, heart {Heart structure}, dizziness {Dizziness}, weakness {Asthenia}, left leg {Structure of left lower limb}, weakness {Asthenia}, physical
exam {Physical examination procedure}, MRI {Magnetic resonance imaging of head}, no evidence {No abnormality detected}, stroke {Cerebrovascular accident}, physical therapy {Physical therapy procedure}, walker {Uses zimmer frame}, PCP {Primary care management}, Medications changed {Change of medication}, DECREASE {Medication decreased} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with two DES ___
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Chest pain {Chest pain}, Cardiac catheterization {Cardiac catheterization} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Ms. ___ is ___ ___ with history of HTN, HLD p/w exertional
chest pain.
She first noticed central chest burning with walking 2 weeks
ago. Since then she has had chest burning with exertion almost
every day. No associated dyspnea, diaphoresis, nausea. She was
evaluated at ___'s office today and was found to have new ECG
changes (poor R wave progression, T wave flattening V4,5,6). She
received got full dose ASA and was sent to ED for further
evaluation.
Of not she has no previous history of chest pain. No recent
fevers/chills, abdominal pain, or dyspnea.
In the ED, intial vitals were: 98.3 67 135/94 16 98% RA
Labs/studies notable for: Trop 0.02
UA notable for leukocytosis with 17 WBCs. Normal CBC and
electrolytes. Guaiac negative.
Atrius on call cardiology was consulted from the ED. Per their
recommendations, she was started on heparin drip and admitted to
cardiology for unstable angina, consideration of cardiac
catheterization.
Of note, she is followed by Dr. ___. Previous ECG in
___ showed LVH and small inferior Q waves. She had stress
echo ___ with exercise duration of 9:27 without angina (beta
blocker was held by patient for the test). ECG response was
non-diagnostic without ischemia. Mild LVH was noted.
On the floor she reported no chest pain.
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, exertional
chest pain. {Chest pain on exertion}, chest burning {Burning chest pain}, chest burning {Burning chest pain}, dyspnea {Dyspnea}, diaphoresis {Excessive sweating}, nausea {Nausea}, evaluation {Evaluation procedure}, chest pain {Chest pain}, fevers {Fever}, chills {Chill}, abdominal pain {Abdominal pain}, dyspnea {Dyspnea}, UA {Urinalysis}, leukocytosis {Leukocytosis}, unstable angina {Preinfarction syndrome}, cardiac
catheterization {Cardiac catheterization}, stress
echo ___ {Stress echocardiography}, exercise {Exercises}, angina {Angina}, ischemia {Ischemia}, 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: Past Medical History:
HTN
h/o diverticulitis
Glaucoma
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, diverticulitis {Diverticulitis}, Glaucoma {Glaucoma} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Diabetes mother, father.
Maternal grandmother CAD/PVD; Diabetes - Unknown Type;
Hyperlipidemia; Hypertension; Stroke
Sister breast cancer
###RESPONSE: Diabetes {Diabetes mellitus}, CAD {Coronary arteriosclerosis}, Diabetes {Diabetes mellitus}, Hyperlipidemia {Hyperlipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, Stroke {Cerebrovascular accident}, breast cancer {Malignant neoplasm of breast} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 EXAMINATION:
VS: 98.2 160/90 74 18 99%ra wt 71kg
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: no elev JVP
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAMINATION:
VS: 99.4 98.7 113/68 80 20 98RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: no elev JVP
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
###RESPONSE: PHYSICAL EXAMINATION {Physical examination procedure}, VS {Vital signs finding}, GENERAL {General examination of patient}, 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 {Conjunctival structure}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthelasma {Xanthelasma}, NECK {Physical examination procedure}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, intercostal space {Structure of intercostal space}, midclavicular
line {Midclavicular line}, RR {Finding of rate of respiration}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, thrills {Thrill}, 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}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, EXTREMITIES {Examination of limb}, femoral bruits {Femoral bruit}, SKIN {Examination of skin}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, pulses {Normal pulse}, PHYSICAL EXAMINATION {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, 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 {Conjunctival structure}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthelasma {Xanthelasma}, NECK {Physical examination procedure}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, intercostal space {Structure of intercostal space}, midclavicular
line {Midclavicular line}, RR {Finding of rate of respiration}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, thrills {Thrill}, 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}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, EXTREMITIES {Examination of limb}, femoral bruits {Femoral bruit}, SKIN {Examination of skin}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, pulses {Normal pulse} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
SELECTED LABORATORY TESTS:
___ 04:56PM BLOOD WBC-5.0 RBC-4.67 Hgb-13.0 Hct-38.9 MCV-83
MCH-27.9 MCHC-33.4 RDW-13.8 Plt ___
___ 05:10AM BLOOD WBC-5.3 RBC-4.41 Hgb-12.2 Hct-36.3 MCV-82
MCH-27.7 MCHC-33.6 RDW-13.4 Plt ___
___ 04:56PM BLOOD Neuts-30.4* Lymphs-61.4* Monos-4.8
Eos-2.5 Baso-0.9
___ 04:56PM BLOOD ___ PTT-29.8 ___
___ 04:56PM BLOOD Glucose-162* UreaN-14 Creat-0.9 Na-142
K-3.9 Cl-103 HCO3-25 AnGap-18
___ 05:10AM BLOOD Glucose-102* UreaN-19 Creat-0.9 Na-141
K-4.0 Cl-105 HCO3-26 AnGap-14
___ 05:10AM BLOOD CK(CPK)-131
___ 04:56PM BLOOD cTropnT-0.02*
___ 05:10AM BLOOD CK-MB-2 cTropnT-0.02*
___ 11:00AM BLOOD cTropnT-0.01
___ 07:15PM BLOOD CK-MB-6 cTropnT-0.08*
___ 05:05AM BLOOD CK-MB-25* MB Indx-8.5* cTropnT-0.17*
___ 11:00AM BLOOD CK-MB-21* MB Indx-6.8* cTropnT-0.19*
___ 05:10AM BLOOD CK-MB-7 cTropnT-0.23*
___ 05:10AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.1
CXR ___: No acute cardiopulmonary abnormality
###RESPONSE: LABORATORY TESTS {Laboratory test}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, CXR {Plain chest X-ray} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Ms. ___ is ___ ___ with history of HTN, HLD now presenting with
exertional chest pain.
She had increasing frequency of exertional chest pain, with
office EKG showing T wave flattening. Troponin 0.02 in ED. She
underwent cardiac catheterization on ___. She was noted to have
proximal RCA 100% focal stenosis, (3.8x18 DES) and mid RCA 80%
tubular stenosis (3x30 DES). Catheterization also demonstrated
LAD ___ proximal stenosis, first diagonal 50-60% proximal
stenosis. She was subsequently continued on clopidogrel,
aspirin, atorvastatin, and atenolol. Troponin and CK-MB was
elevated in the post-procedural setting with subsequent
normalization of CK-MB suggesting resolving cardiac injury.
TRANSITION ISSUES:
- She will need close followup in the post-procedural setting
for unstable angina
- She will benefit from cardiac rehabilitation
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, exertional chest pain {Chest pain on exertion}, exertional chest pain {Chest pain on exertion}, cardiac catheterization {Cardiac catheterization}, stenosis {Stenosis}, stenosis {Stenosis}, Catheterization {Catheterization}, LAD {Structure of anterior descending branch of left coronary artery}, stenosis {Stenosis}, stenosis {Stenosis}, injury {Traumatic or non-traumatic injury}, unstable angina {Preinfarction syndrome}, cardiac rehabilitation {Cardiac rehabilitation} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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. Amlodipine 2.5 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth Once every evening
Disp #*30 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
5. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Unstable angina, complete occlusion of RCA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Unstable angina {Preinfarction syndrome}, occlusion {Complete obstruction}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Ms. ___,
It was a pleasure being part of your care at ___. You were
admitted to the hospital due to chest pain and concerning
findings on EKG. You had cardiac catheterization which showed
blockage of the blood vessels in the heart. A stent was placed.
You were monitored after the procedure and were found to be safe
for discharge.
After discharge please follow up with your outpatient providers
as described below.
###RESPONSE: chest pain {Chest pain}, cardiac catheterization {Cardiac catheterization}, blood vessels {Blood vessel structure}, heart {Heart structure}, procedure {Procedure}, follow up {Follow-up status} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Penicillins / Darvon / lisinopril
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
###RESPONSE: Penicillins {Allergy to penicillin}, Darvon {Allergy to dextropropoxyphene}, lisinopril {Non-allergic hypersensitivity to angiotensin-converting enzyme inhibitor}, Dyspnea {Dyspnea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ with PMHx of COPD, OSA on CPAP, current smoker, and HTN
presenting with increasing shortness of breath, cough, and chest
tightness similar to prior COPD exacerbations.
Patient was in her USOH until a couple of weeks ago when she
developed a cold (rhinorrhea, cough, sinus pressure, etc.). She
reports that at that time she also started to have some
worsening dyspnea and whezzing. She called her pulmonologist
(Dr. ___ and was prescribed a short course of prednisone. She
got slightly better when she again noticed the return of her
symptoms over the last week. She also noted that her cough which
is usually dry or productive of clear/white sputum had become
productive of yellow/green sputum. She also developed worsening
wheezing and chest tightness. Compounding her issues, she ran
out of her home nebulizer treatments which she thought had been
helping to keep her symptoms at bay. Denied fevers, abdominal
pain, vomiting, diarrhea, constipation, or myalgias. Reports
mild chills and nausea. She then decided to come into the ___
ED for evaluation.
In the ED:
Initial vital signs were notable for T 98.9, HR 86, BP 142/96,
RR 40, O2 92% on RA.
Labs were notable for:
- WBC 12.9, Hbg 10.6
- VBG pH 7.39, pCO2 51, O2sat 95
- Chemistries, renal function wnl, troponin neg x 1 CXR showed a
subtle increase in opacity at the right lung base, which could
be due to overlapping structures, but could not exclude definite
consolidation.
Patient was given:
- 500mg IV azithromycin
- 40mg PO prednisone
- Duonebs
The pt triggered in the ED for tachypnea and chest tightness,
with respiratory rates in the ___. Both the pt's tachypnea and
symptoms improved after administration of duonebs. She was
admitted to the medicine service for further management.
Upon arrival to the floor, the patient was breathing comfortably
and said that her SOB seemed to have improved after the
nebulizer treatments in the ED. She was hungry and requested
dinner.
Regarding the pt's relevant pulmonary history, recent pulmonary
function tests demonstrate features of moderate obstruction. She
has an FEV1 of 42% predicted with an FVC of 53% predicted ratio
62%. She continues to smoke cigarettes daily but is down to
about one cig every other day.
###RESPONSE: COPD {Chronic obstructive lung disease}, OSA {Obstructive sleep apnea syndrome}, CPAP {Continuous positive airway pressure ventilation treatment}, current smoker {Smoker}, HTN {Hypertensive disorder, systemic arterial}, increasing {Patient's condition worsened}, shortness of breath {Dyspnea}, cough {Cough}, chest
tightness {Tight chest}, COPD exacerbations {Acute exacerbation of chronic obstructive airways disease}, cold {Common cold}, rhinorrhea {Nasal discharge}, cough {Cough}, sinus pressure {Sensation of nasal sinus pressure}, worsening {Patient's condition worsened}, dyspnea {Dyspnea}, whezzing {Wheezing}, called {Informing doctor}, cough {Cough}, dry {Dry cough}, clear {Productive cough -clear sputum}, white sputum {White sputum}, yellow {Productive cough-yellow sputum}, green sputum {Productive cough -green sputum}, worsening {Patient's condition worsened}, wheezing {Wheezing}, chest tightness {Tight chest}, nebulizer treatments {Nebulizer therapy}, fevers {Fever}, abdominal
pain {Abdominal pain}, vomiting {Vomiting}, diarrhea {Diarrhea}, constipation {Constipation}, myalgias {Muscle pain}, mild {Symptom mild}, chills {Chill}, nausea {Nausea}, evaluation {Evaluation procedure}, vital signs {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, O2 {Oxygen saturation measurement}, RA {Breathing room air}, WBC {White blood cell count}, Hbg {Measurement of total hemoglobin concentration}, VBG {Blood gases, venous measurement}, pH {pH measurement}, pCO2 {Measurement of venous partial pressure of carbon dioxide}, O2sat {Venous oxygen saturation measurement}, renal function wnl {Renal function tests within reference range}, troponin {Troponin measurement}, neg {No abnormality detected}, CXR {Plain chest X-ray}, opacity {Abnormally opaque structure}, right lung base {Structure of base of right lung}, overlapping structures {Overriding structures}, consolidation {Lung consolidation}, azithromycin {Antibiotic therapy}, tachypnea {Tachypnea}, chest tightness {Tight chest}, respiratory rates {Finding of rate of respiration}, tachypnea {Tachypnea}, improved {Patient's condition improved}, breathing comfortably {Breathing easily}, SOB {Dyspnea}, improved {Patient's condition improved}, nebulizer treatments {Nebulizer therapy}, hungry {Hungry}, pulmonary {Respiratory tract structure}, pulmonary
function tests {Measurement of respiratory function}, moderate {Symptom moderate}, obstruction {Finding of respiratory obstruction}, smoke {Smoker} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
- DMII
- HTN
- COPD
- Asthma
- Anxiety/Depression
- Osteoarthritis
- IBS
- Seasonal allergies
- Hx of EtOH use disorder
- Obesity
- OSA
- Thyroid mass
###RESPONSE: DMII {Diabetes mellitus type 2}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, Asthma {Asthma}, Anxiety/Depression {Mixed anxiety and depressive disorder}, Osteoarthritis {Osteoarthritis}, IBS {Irritable bowel syndrome}, Seasonal allergies {Seasonal allergy}, EtOH use disorder {Alcoholism}, Obesity {Obesity}, OSA {Obstructive sleep apnea syndrome}, Thyroid mass {Mass of thyroid gland} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 T2DM
- Father with T2DM
- Sister with HTN
- Unknown cancers in grandparents on both sides
###RESPONSE: T2DM {Diabetes mellitus type 2}, T2DM {Diabetes mellitus type 2}, HTN {Hypertensive disorder, systemic arterial}, cancers {Malignant neoplasm of colon} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.1 137 / 85 76 18 96 2L nc
GENERAL: Pleasant F in NAD. At times w/ some dyspnea while
speaking during interview
HEENT: NCAT, MMM
CARDIAC: Heart sounds distant, RRR, no m/r/g
LUNGS: Decreased breath sounds throughout, no significant
wheezing
ABDOMEN: Obese, soft, NT/ND, BS+
EXTREMITIES: WWP, no c/c/e
NEUROLOGIC: AAOx3, grossly intact
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: Sitting on edge of bed in NAD
HEENT: NCAT, MMM, R lobe of thyroid enlarged
CARDIAC: RRR, no m/r/g
LUNGS: coarse breath sounds b/l, no wheezes, breathing
comfortably on room air
ABDOMEN: obese, soft, NT/ND, BS+
EXTREMITIES: WWP, bilateral 2+ nonpitting edema L>R
NEUROLOGIC: AAOx3, no focal deficits
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VITALS {Vital signs finding}, 2L nc {Oxygen administration by nasal cannula}, GENERAL {General examination of patient}, NAD {No abnormality detected}, dyspnea {Dyspnea}, HEENT {Physical examination procedure}, NC {Normal head}, MMM {Moist oral mucosa}, CARDIAC {Cardiovascular physical examination}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, LUNGS {Examination of respiratory system}, Decreased breath sounds {Decreased breath sounds}, wheezing {Wheezing}, ABDOMEN {Examination of abdomen}, Obese {Obese}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, BS+ {Normal bowel sounds}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, no c/c/e {No abnormality detected}, NEURO {Neurological examination}, GI {Examination of digestive system}, Ox3 {Oriented to person, time and place}, grossly intact {Normal nervous system function}, RA {Breathing room air}, Sitting {Sitting position}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NCAT {Normal head}, MMM {Moist oral mucosa}, R lobe {Structure of right lobe of thyroid gland}, thyroid enlarged {Goiter}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, LUNGS {Examination of respiratory system}, breath sounds {Finding of breath sounds}, wheezes {Wheezing}, breathing
comfortably on room air {Breathing easily}, ABDOMEN {Examination of abdomen}, obese {Obese}, soft {Abdomen soft}, BS+ {Normal bowel sounds}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, bilateral {Edema of bilateral lower limbs}, edema {Edema}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, no focal deficits {Normal nervous system function} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS:
===============
___ 04:49PM BLOOD WBC-12.9* RBC-4.36 Hgb-10.6* Hct-36.8
MCV-84 MCH-24.3* MCHC-28.8* RDW-16.7* RDWSD-51.1* Plt ___
___ 04:49PM BLOOD Neuts-68.6 ___ Monos-7.8 Eos-2.6
Baso-0.3 Im ___ AbsNeut-8.84* AbsLymp-2.59 AbsMono-1.01*
AbsEos-0.34 AbsBaso-0.04
___ 04:49PM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-143 K-5.0
Cl-103 HCO3-29 AnGap-11
___ 04:49PM BLOOD cTropnT-<0.01
___ 04:59PM BLOOD ___ pO2-132* pCO2-51* pH-7.39
calTCO2-32* Base XS-5
___ 04:59PM BLOOD O2 Sat-95
PERTINENT LABS:
===============
___ 08:31AM BLOOD proBNP-35
IMAGING:
========
___ CXR Portable
IMPRESSION:
Subtle increase in opacity at the right lung base may be due to
overlap of
structures, but underlying consolidation is difficult to
exclude. Consider
dedicated PA and lateral views if/when patient able, for better
evaluation.
___ CXR PA/Lateral
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. On the
prior study, there was suggestion of an opacity at the right
base; however, on today's study, this is not present. There is
mild prominence of the pulmonary interstitial markings
suggestive of mild pulmonary edema. No definite consolidation
or pneumothoraces are seen.
___ LENIs
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity veins. No evidence of medial popliteal fossa (___)
cyst.
___ Thyroid Ultrasound
IMPRESSION:
1. Numerous confluent nodules in the right lobe suggest an
overall stable
appearance although specific measurements are difficult to
obtain due to
differences in scanning technique.
2. Two left lobe nodules are minimally increased in size
compared to the prior ultrasound. No new worrisome nodule is
identified within the thyroid gland.
MICRO:
======
___ BCx x2: NGTD
DISCHARGE LABS:
===============
___ 05:30AM BLOOD WBC-16.8* RBC-3.92 Hgb-9.4* Hct-33.1*
MCV-84 MCH-24.0* MCHC-28.4* RDW-16.9* RDWSD-51.9* Plt ___
___ 05:30AM BLOOD Glucose-157* UreaN-19 Creat-0.8 Na-141
K-4.6 Cl-102 HCO3-30 AnGap-9*
___ 05:30AM BLOOD Calcium-10.7* Phos-3.5 Mg-2.1
###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}, RDWSD {Red cell distribution width determination}, Plt {Platelet count}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, pO2 {Measurement of partial pressure of oxygen in blood}, pCO2 {Measurement of partial pressure of carbon dioxide in blood}, pH {pH measurement}, calTCO2 {Blood total carbon dioxide (calculated)}, Base XS {Delta base, blood}, O2 Sat {Oxygen saturation measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, CXR {Plain chest X-ray}, Portable {Portable X-ray}, opacity {Abnormally opaque structure}, right lung base {Structure of base of right lung}, consolidation {Lung consolidation}, lateral {Diagnostic radiography of chest, lateral}, evaluation {Evaluation procedure}, CXR PA/Lateral {Diagnostic radiography of chest, combined posteroanterior and lateral}, Cardiomediastinal {Mediastinal structure}, normal {Normal appearance}, study {Evaluation procedure}, opacity {Abnormally opaque structure}, right
base {Structure of base of right lung}, study {Evaluation procedure}, mild {Symptom mild}, pulmonary {Lung structure}, mild {Symptom mild}, pulmonary edema {Pulmonary edema}, consolidation {Lung consolidation}, pneumothoraces {Pneumothorax}, No evidence {No abnormality detected}, deep venous thrombosis {Deep venous thrombosis}, right {Structure of vein of right lower limb}, left lower
extremity veins {Structure of vein of left lower limb}, No evidence {No abnormality detected}, medial {Structure of medial aspect of knee}, popliteal fossa {Popliteal fossa structure}, cyst {Cyst}, Thyroid Ultrasound {Ultrasound scan of thyroid}, nodules {Thyroid nodule}, right lobe {Structure of right lobe of thyroid gland}, stable
appearance {Patient's condition stable}, measurements {Measurement procedure}, left lobe {Structure of left lobe of thyroid gland}, nodules {Thyroid nodule}, increased in size {Increased size}, ultrasound {Ultrasonography}, nodule {Thyroid nodule}, thyroid gland {Thyroid structure}, BCx {Blood culture}, NGTD {No abnormality detected}, 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}, RDWSD {Red cell distribution width determination}, Plt {Platelet count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of COPD, OSA
on CPAP, current smoking, and HTN who presented with increasing
shortness of breath, cough, and chest tightness similar to prior
COPD exacerbations.
ACUTE ISSUES:
==============
#COPD EXACERBATION:
Ms. ___ presented with dyspnea, cough with changes in
sputum production, and chest tightness consistent with her prior
COPD exacerbations. This episode was likely triggered by a
recent URI and unfortunately exacerbated by her running out of
her home nebulizer treatments. CXR PA/lateral did not
demonstrate overlying pneumonia and flu swab was negative. She
was initiated on a 5 day course of PO prednisone 40mg and
azithromycin (___), treated with duonebs and albuterol, and
managed symptomatically for her cough.
#LOWER EXTREMITY EDEMA:
Ms. ___ also endorsed bilateral non-pitting edema, left
worse than right, for one week. LENIs were negative for DVT or
popliteal fossa cyst. There were no other signs of volume
overload on exam, and her BNP was 35. The edema could be an
amlodipine side effect, though would not expect asymmetry and
she has been on this medication (at the same dosage) for
multiple years.
STABLE ISSUES:
===============
#THYROID MASS:
Previously noted to be benign per biopsy results at ___, however
increasing in size per review of OMR. Ms. ___ was due to
have repeat thyroid U/S roughly 6 months ago, but had yet to
receive it in the outpatient setting. Therefore the study was
performed while the patient was admitted. This demonstrated
"Numerous confluent nodules in the right lobe suggest an overall
stable appearance although specific measurements are difficult
to obtain due to differences in scanning technique. Two left
lobe nodules are minimally increased in size compared to the
prior ultrasound. No new worrisome nodule is identified within
the thyroid gland." Patient to follow up with PCP regarding
these findings.
#CODE: Full (presumed)
#CONTACT: ___ (sister) - ___
TRANSITIONAL ISSUES:
=====================
[ ] Requires PCP ___ of thyroid ultrasound findings
[ ] Can consider discontinuing amlodipine to see if lower
extremity edema resolves.
###RESPONSE: COPD {Chronic obstructive lung disease}, OSA {Obstructive sleep apnea syndrome}, CPAP {Continuous positive airway pressure ventilation treatment}, smoking {Smoker}, HTN {Hypertensive disorder, systemic arterial}, increasing {Patient's condition worsened}, shortness of breath {Dyspnea}, cough {Cough}, chest tightness {Tight chest}, COPD exacerbations {Acute exacerbation of chronic obstructive airways disease}, COPD EXACERBATION {Acute exacerbation of chronic obstructive airways disease}, dyspnea {Dyspnea}, cough {Cough}, sputum production {Productive cough}, chest tightness {Tight chest}, COPD exacerbations {Acute exacerbation of chronic obstructive airways disease}, URI {Upper respiratory infection}, nebulizer treatments {Nebulizer therapy}, CXR PA/lateral {Diagnostic radiography of chest, combined posteroanterior and lateral}, pneumonia {Pneumonia}, negative {No pathologic diagnosis}, azithromycin {Antibiotic therapy}, cough {Cough}, bilateral {Edema of bilateral lower limbs}, non-pitting edema {Non-pitting edema}, left {Structure of left lower limb}, worse {Patient's condition worsened}, right {Structure of right lower limb}, negative {No pathologic diagnosis}, DVT {Deep venous thrombosis}, popliteal fossa {Popliteal fossa structure}, cyst {Cyst}, signs {Sign}, volume
overload {Hypervolemia}, exam {Cardiovascular investigation}, BNP {Brain natriuretic peptide measurement}, edema {Edema}, side effect {Medication side effects present}, medication {Administration of drug or medicament}, benign {Benign neoplasm of thyroid gland}, biopsy {Biopsy of thyroid}, increasing in size {Increased size}, thyroid U/S {Ultrasound scan of thyroid}, study {Evaluation procedure}, nodules {Thyroid nodule}, right lobe {Structure of right lobe of thyroid gland}, stable appearance {Patient's condition stable}, measurements {Measurement procedure}, left
lobe {Structure of left lobe of thyroid gland}, nodules {Thyroid nodule}, increased in size {Increased size}, ultrasound {Ultrasound scan of thyroid}, nodule {Thyroid nodule}, thyroid gland {Thyroid structure}, PCP {Primary care management}, thyroid {Ultrasound scan of thyroid}, ultrasound findings {Ultrasound scan finding}, lower
extremity edema {Edema of lower extremity}, resolves {Problem resolved} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheeze
5. Losartan Potassium 100 mg PO DAILY
6. Sertraline 125 mg PO DAILY
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough/wheezing
8. ammonium lactate 12 % topical DAILY
9. BuPROPion XL (Once Daily) 150 mg PO DAILY
10. diclofenac sodium 1 % topical BID
11. Gabapentin 300 mg PO TID
12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN Cough
RX *benzonatate 100 mg 1 capsule(s) by mouth Three times per day
Disp #*45 Capsule Refills:*0
2. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN Cough
RX *dextromethorphan-guaifenesin [Adult Cough Formula DM Max]
200 mg-10 mg/5 mL 5 mL by mouth Every 6 hours as needed Disp #*1
Bottle Refills:*0
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough/wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs IH every 4
to 6 hours Disp #*1 Inhaler Refills:*0
4. Amlodipine 10 mg PO DAILY
5. ammonium lactate 12 % topical DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. BuPROPion XL (Once Daily) 150 mg PO DAILY
9. diclofenac sodium 1 % topical BID
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. Gabapentin 300 mg PO TID
12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheeze
13. Losartan Potassium 100 mg PO DAILY
14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
15. Sertraline 125 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
###RESPONSE: mg {Blood magnesium measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
#Chronic Obstructive Pulmonary Disease Exacerbation
Secondary Diagnosis:
#Thyroid Mass
#Bilateral Lower Extremity Edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Chronic Obstructive Pulmonary Disease Exacerbation {Acute exacerbation of chronic obstructive airways disease}, Thyroid Mass {Mass of thyroid gland}, Bilateral Lower Extremity Edema {Edema of bilateral lower limbs}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you were having a cough and
shortness of breath.
What did you receive in the hospital?
- You were treated for a COPD exacerbation with steroids and
antibiotics.
- You had an ultrasound of your thyroid which did not show any
new worrisome nodules.
What should you do once you leave the hospital?
- Please take all of your medications as prescribed and attend
all of your follow up appointments as scheduled.
We wish you all the best!
- Your ___ Care Team
###RESPONSE: cough {Cough}, shortness of breath {Dyspnea}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, steroids {Steroid therapy}, antibiotics {Antibiotic therapy}, ultrasound of your thyroid {Ultrasound scan of thyroid}, nodules {Thyroid nodule}, take all of your medications as prescribed {Patient medication education} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
Levofloxacin / gabapentin
Attending: ___.
Chief Complaint:
cough, dyspnea
Major Surgical or Invasive Procedure:
None
###RESPONSE: Levofloxacin {Allergy to levofloxacin}, gabapentin {Allergy to gabapentin}, cough {Cough}, dyspnea {Dyspnea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Mr. ___ is an ___ y/o M with a PMHx of COPD not on home O2,
CKD baseline Cr 2.8, CAD, heart block with pacemaker placement,
BPH and NIDDM who p/w with shortness of breath for ___ days.
Patient notes a productive cough with greenish sputum as well as
malaise. At baseline he is able to ambulate long distances but
recently, has been slowly getting short of breath, which got
worse on day of admission when even getting to the bathroom was
taxing. He reports chills but no fever or rigors. He checked his
temperature at home which was not elevated. He denies chest
pain, abdominal pain, dysuria, rhinorrhea, myalgias or
headaches. In the ED, initial VS were 98.9 75 183/70 18 100% RA.
Exam significant for diffuse wheezing with good air movement and
oxygen saturations in 97-100% on 3L. Labs significant for K 5.4,
Cr 3.1 (baseline 2.8), WBC 9.6, H/H 12.3/36.8. Flu A/B PCR
positive for Influenza A. CXR significant for possible
superimposed consolidation at the right lung base. The patient
received albuterol/ipatropium nebs, ceftriaxone 1 g IV,
azithromycin 500 mg PO, and 60 mg PO prednisone. On transfer to
the floor, patient was febrile to 100.6 80 185/75 18 98% 2L
Nasal Cannula. On arrival to the floor, his dyspnea is improved
after breathing treatments. Patient reports significant cough
even at rest. He reports getting winded just talking for long
periods of time.
###RESPONSE: COPD {Chronic obstructive lung disease}, home O2 {Home oxygen therapy}, CKD {Chronic kidney disease}, baseline {Baseline state}, Cr {Creatine measurement}, CAD {Coronary arteriosclerosis}, heart block {Heart block}, pacemaker placement {Implantation of cardiac pacemaker}, BPH {Benign prostatic hyperplasia}, NIDDM {Diabetes mellitus type 2}, shortness of breath {Dyspnea}, productive cough {Productive cough}, greenish sputum {Productive cough -green sputum}, malaise {Malaise}, baseline {Baseline state}, able to ambulate {Able to walk}, short of breath {Dyspnea}, worse {Patient's condition worsened}, chills {Chill}, no fever {Temperature normal}, rigors {Rigor}, checked his
temperature {Monitoring of patient temperature}, not elevated {Temperature normal}, chest
pain {Chest pain}, abdominal pain {Abdominal pain}, dysuria {Dysuria}, rhinorrhea {Nasal discharge}, myalgias {Muscle pain}, headaches {Headache}, Exam {Physical examination procedure}, wheezing {Wheezing}, good air movement {Breath normal}, oxygen saturations {Finding of oxygen saturation}, Labs {Laboratory test}, K {Blood potassium measurement}, Cr {Creatine measurement}, baseline {Baseline state}, WBC {White blood cell count}, H/H {Measurement of total hemoglobin concentration and hematocrit}, Flu A/B PCR {Analysis using quantitative fluorescent polymerase chain reaction technique}, Influenza A {Influenza A virus present}, CXR {Plain chest X-ray}, consolidation {Lung consolidation}, right lung base {Structure of base of right lung}, nebs {Nebulizer therapy}, azithromycin {Antibiotic therapy}, prednisone {Steroid therapy}, febrile {Fever}, Nasal Cannula {Oxygen administration by nasal cannula}, dyspnea {Dyspnea}, improved {Patient's condition improved}, breathing treatments {Inhalation therapy procedure}, cough {Cough}, at rest {Cough at rest}, winded {Winded} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
DM (diabetes mellitus), type 2, uncontrolled, with renal
complications
Abdominal aortic aneurysm
Back pain
Hypertension
Pacemaker for heart block
Vitamin B 12 deficiency
Chronic kidney disease (CKD), stage IV (severe)
SPINAL STENOSIS, UNSPEC SITE
CORONARY ARTERY DISEASE, UNSPEC VESSEL TYPE
COPD
BPH
GERD
Hypercholesterolemia
Asbestosis
Macular degeneration
Iron deficiency anemia
s/p left TKR
s/p carotid endarterectomy
###RESPONSE: DM (diabetes mellitus), type 2, uncontrolled {Type II diabetes mellitus uncontrolled}, renal
complications {Renal disorder due to type 2 diabetes mellitus}, Abdominal aortic aneurysm {Abdominal aortic aneurysm}, Back pain {Backache}, Hypertension {Hypertensive disorder, systemic arterial}, Pacemaker {Implantation of cardiac pacemaker}, heart block {Heart block}, Vitamin B 12 deficiency {Cobalamin deficiency}, Chronic kidney disease {Chronic kidney disease}, CKD), stage IV {Chronic kidney disease stage 4}, SPINAL STENOSIS {Spinal stenosis}, CORONARY ARTERY DISEASE {Coronary arteriosclerosis}, COPD {Chronic obstructive lung disease}, BPH {Benign prostatic hyperplasia}, GERD {Gastroesophageal reflux disease}, Hypercholesterolemia {Hypercholesterolemia}, Asbestosis {Asbestosis}, Macular degeneration {Degenerative disorder of macula}, Iron deficiency anemia {Iron deficiency anemia}, left TKR {Total replacement of left knee joint}, carotid endarterectomy {Carotid endarterectomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
ADMISSION PHYSICAL EXAM:
VS - 98.0 165/63 (165-183/63-79) 71 22 98% 2L NC
I/O: -500mL
GENERAL: Alert and oriented x 3. NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Faint expiratory wheezes with good air entry. Decreased
breath sounds in right lung base.
ABDOMEN: obese, nontender, nondistended, normoactive BS
EXTREMITIES: 1+ pretibial edema. moving all extremities well, no
cyanosis,or clubbing PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Objective:
VS - 98.3 70 18 161/76 96 on 0.5%
BG ___ 181
Wt 92.9<-92.9
___
GENERAL: Alert and oriented x 3. NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB. No wheezes, rhonchi.
ABDOMEN: obese, nontender, nondistended, normoactive BS
EXTREMITIES: 2+ pitting edema to ankles; moving all extremities
well, no cyanosis,or clubbing
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, NC {Normal head}, I/O {Measuring intake and output}, GENERAL {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclerae {White sclera}, pink conjunctivae {Conjunctiva normal}, nares {Structure of anterior naris}, MMM {Moist oral mucosa}, good dentition {Normal dentition}, nontender {Abdominal tenderness}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, LUNG {Examination of respiratory system}, wheezes {Wheezing}, good {Normal breath sounds}, air entry {Audible inspiration}, Decreased
breath sounds {Decreased breath sounds}, right lung base {Structure of base of right lung}, ABDOMEN {Examination of abdomen}, obese {Obese}, nontender {Abdominal tenderness}, nondistended {Normal abdominal contour}, normoactive BS {Normal bowel sounds}, EXTREMITIES {Examination of limb}, edema {Edema}, all extremities {All extremities}, cyanosis {Cyanosis}, clubbing {Clubbing}, PULSES {Pulse finding}, 2+ DP pulses {Dorsalis pulse present}, NEURO {Neurological examination}, CN II-XII intact {Normal central nervous system}, SKIN {Examination of skin}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Lesion}, rashes {Eruption of skin}, VS {Vital signs finding}, RA {Breathing room air}, Alert {Mentally alert}, oriented x 3 {Oriented to person, time and place}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, AT/NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclerae {White sclera}, pink conjunctivae {Conjunctiva normal}, nares {Structure of anterior naris}, MMM {Moist oral mucosa}, good dentition {Normal dentition}, nontender {Tenderness of neck}, supple neck {Normal movement of neck}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, S1/S2 {Heart sounds normal}, murmurs {Heart murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, LUNG {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, obese {Obese}, nontender {Abdominal tenderness}, nondistended {Normal abdominal contour}, normoactive BS {Normal bowel sounds}, EXTREMITIES {Examination of limb}, edema {Edema}, ankles {Ankle edema}, moving all extremities {Does move all four limbs}, cyanosis {Cyanosis}, clubbing {Clubbing}, PULSES {Pulse finding}, 2+ DP pulses {Dorsalis pulse present}, NEURO {Neurological examination}, CN II-XII intact {Normal central nervous system}, SKIN {Examination of skin}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Skin lesion}, rashes {Eruption of skin} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 02:55PM BLOOD WBC-9.6 RBC-4.05* Hgb-12.3* Hct-36.8*
MCV-91 MCH-30.5 MCHC-33.6 RDW-14.3 Plt ___
___ 02:55PM BLOOD Neuts-91.8* Lymphs-3.3* Monos-2.6 Eos-2.0
Baso-0.2
___ 02:55PM BLOOD Glucose-164* UreaN-45* Creat-3.1* Na-142
K-5.4* Cl-107 HCO3-24 AnGap-16
___ 07:30AM BLOOD proBNP-3750*
___ 07:30AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.8
IMAGING:
___ CXR
Calcified pleural plaques. Although there is no prior to assess
for interval change, there is suspected superimposed
consolidation at the right lung base which could represent
pneumonia. Correlation with prior exams would be helpful to
assess for interval change. Followup will be necessary.
EKG ___ per Atrius
Underlying sinus rhythm with 1st degree AV block
PFTS ___
FEV1/FVC .62 (87% predicted)
___ RENAL ULTRASOUND: IMPRESSION: Preliminary
Report:Slightly increased parenchymal echogenicity bilaterally
may be seen in the setting of chronic renal disease. No
hydronephrosis.
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-7.1 RBC-3.85* Hgb-11.8* Hct-34.4*
MCV-89 MCH-30.5 MCHC-34.2 RDW-14.0 Plt ___
___ 06:20AM BLOOD Glucose-127* UreaN-70* Creat-3.7* Na-139
K-4.5 Cl-105 HCO3-23 AnGap-16
___ 06:20AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.___ year old male with hx of COPD p/w with increased shortness of
breath. He was found to have influenza, COPD exacerbation, ___
on CKD and lower extremity edema. He was treated with
oseltamivir, prednisone, and azithromcyin. He left against
medical advice one day prior to planned discharge.
# Influenza/pneumonia: Patient presented with fever, cough with
green sputum and flu positivity with CXR suggesting right lung
consolidation. Patient received ceftriaxone and azithromycin in
the ED for bacterial pneumonia/COPD exacerbation and was started
on Oseltamivir for influenza. Given that patient appeared
clinically well without elevated wbc, ceftriaxone was
discontinued (as bacterial pneumonia was less suspected). His
cough improved with treatment. He was unable to be weaned off of
supplemental O2 (ambulatory saturation on discharge 86%) and he
was discharged with supplemental O2. Lingering O2 requirment
likely due to infection in setting of COPD.
# Acute on chronic kidney injury: Most likely due to obstruction
secondary to BPH. Admission creatinine was 3.1, up from a
baseline of 2.8. FeNA was 11%, consistent with obstruction.
Patient had good urine output, so he did not have foley placed.
Renal ultrasound showed no hydronephrosis. Cr continued to
uptrend and stabilized at 3.7. FeUrea on day of discharge was
53%, suggestive of more of an intrinsic pathology - likely ATN
secondary to obstructive acute kidney injury. He also had
increased UOP, suggestive of post-ATN diuresis.
# Lower extremity edema: Patient presented with 3+ pitting
edema to the knees bilaterally. He does not have a history of
congestive heart failure but BNP was elevated to 3750, which is
consistent with heart failure diagnosis. Patient received IVFs
on admission which may have further exacerbated the issue. No
evidence to suggest heart failure causing his dyspnea symptoms.
No lasix was given due to ___, however, patient autodiuresed and
swelling was minimal on discharge. He should have outpatient
echocardiogram.
# Nausea: Patient had onset of nausea and difficulty tolerating
PO. He reported that this sometimes occurs at home. He was given
reglan and a GI cocktail with little effect. Most likely due to
oseltamivir side effect vs, less likely, gastroparesis. Patient
was tolerating clears when he left against medical advice.
# COPD with acute exacerbation: Patient has a history of COPD
not on home O2. His presentation was also consistent with a COPD
exacerbation. He received steroids and azithromycin in the ED.
He continued PO prednisone for a planned 5 day total course. He
was unable to be weaned off of supplemental O2 (ambulatory
saturation on discharge 86%) and he was discharged with
supplemental O2. Lingering O2 requirment likely due to infection
in setting of COPD.
# Hyperkalemia: Likely from CKD. This was within normal limits
on discharge.
# Type 2 DM (diabetes mellitus), noninsulin dependent: Last
HbA1C 6.5 in ___. Patient on glimepiride at home.
Glimepiride was held on admission but restarted on discharge.
# Hypertension: He continued home labetalol and amlodipine.
# CAD: He continued home aspirin and statin.
# BPH: He continued home finasteride and tamsulosin
TRANSITIONAL ISSUES:
-Discharge weight: 92.9 kg
-Needs TTE to evaluate new CHF
-Patient will continue prednisone 40mg, azithromycin and
oseltamivir until ___ need to increase Tamsulosin given symptoms of BPH causing
___
-Patient's blood glucoses elevated while on prednisone
-Patient was started on preventative COPD medications
-Patient will need oxygen on discharge given drop in sats while
ambulating.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Plt {Platelet count}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, CXR {Plain chest X-ray}, Calcified {Pathologic calcification, calcified structure}, pleural plaques {Pleural plaque}, consolidation {Lung consolidation}, right lung base {Structure of base of right lung}, pneumonia {Pneumonia}, exams {Evaluation procedure}, EKG {Electrocardiographic procedure}, sinus rhythm {Sinus rhythm}, 1st degree AV block {First degree atrioventricular block}, PFTS {Measurement of respiratory function}, FVC {Finding of forced vital capacity}, RENAL ULTRASOUND {Echography of kidney}, chronic renal disease {Chronic kidney disease}, hydronephrosis {Hydronephrosis}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Plt {Platelet count}, 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}, COPD {Chronic obstructive lung disease}, increased {Patient's condition worsened}, shortness of
breath {Dyspnea}, influenza {Influenza}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, CKD {Chronic kidney disease}, lower extremity edema {Edema of lower extremity}, prednisone {Steroid therapy}, azithromcyin {Antibiotic therapy}, left against
medical advice {Left against medical advice}, Influenza {Influenza}, pneumonia {Pneumonia}, fever {Fever}, cough {Productive cough}, green sputum {Productive cough -green sputum}, CXR {Plain chest X-ray}, right {Right lung structure}, lung
consolidation {Lung consolidation}, azithromycin {Antibiotic therapy}, bacterial pneumonia {Bacterial pneumonia}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, started {New medication added}, influenza {Influenza}, elevated wbc {White blood cell count outside reference range}, discontinued {Recommendation to stop drug treatment}, bacterial pneumonia {Bacterial pneumonia}, cough {Cough}, improved with treatment {Good therapeutic response}, O2 {Oxygen therapy}, saturation {Finding of oxygen saturation}, O2 {Oxygen therapy}, infection {Infectious disease}, COPD {Chronic obstructive lung disease}, Acute on chronic kidney injury {Acute-on-chronic renal failure}, obstruction {Urinary tract obstruction}, BPH {Benign prostatic hyperplasia}, creatinine {Creatinine measurement}, baseline {Baseline state}, FeNA {Measurement of fractional excretion of sodium}, obstruction {Urinary tract obstruction}, good urine output {Increased urine output}, foley placed {Catheterization of urinary bladder}, Renal ultrasound {Echography of kidney}, hydronephrosis {Hydronephrosis}, Cr {Creatine measurement}, uptrend {Serum creatinine above reference range}, ATN {Acute tubular necrosis}, obstructive {Urinary tract obstruction}, acute kidney injury {Acute kidney injury}, increased UOP {Increased urine output}, ATN {Acute tubular necrosis}, diuresis {Diuresis}, Lower extremity edema {Edema of lower extremity}, 3+ pitting
edema {3+ pitting edema}, knees {Edema of knee}, congestive heart failure {Congestive heart failure}, BNP {Brain natriuretic peptide measurement}, elevated {Complement level above reference range}, heart failure {Heart failure}, IVFs {Administration of intravenous fluids}, No
evidence {No abnormality detected}, heart failure {Heart failure}, dyspnea {Dyspnea}, lasix {Diuretic therapy}, autodiuresed {Increased urine output}, swelling {Swelling}, minimal {Symptom mild}, echocardiogram {Echocardiography}, Nausea {Nausea}, nausea {Nausea}, tolerating {Tolerating diet}, side effect {Medication side effects present}, gastroparesis {Gastroparesis}, tolerating clears {Tolerating oral fluid}, left against medical advice {Left against medical advice}, COPD {Chronic obstructive lung disease}, acute exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD {Chronic obstructive lung disease}, home O2 {Home oxygen therapy}, COPD
exacerbation {Acute exacerbation of chronic obstructive airways disease}, steroids {Steroid therapy}, azithromycin {Antibiotic therapy}, prednisone {Steroid therapy}, O2 {Oxygen therapy}, saturation {Finding of oxygen saturation}, O2 {Oxygen therapy}, infection {Infectious disease}, COPD {Chronic obstructive lung disease}, Hyperkalemia {Hyperkalemia}, CKD {Chronic kidney disease}, normal {Serum potassium level within reference range}, Type 2 DM (diabetes mellitus) {Diabetes mellitus type 2}, HbA1C {Hemoglobin A1c measurement}, held {Recommendation to stop drug treatment}, restarted {Restart of medication}, Hypertension {Hypertensive disorder, systemic arterial}, CAD {Coronary arteriosclerosis}, aspirin {Administration of aspirin}, statin {Administration of prophylactic statin}, BPH {Benign prostatic hyperplasia}, weight {Weight finding}, TTE {Transthoracic echocardiography}, evaluate {Evaluation procedure}, CHF {Congestive heart failure}, prednisone {Steroid therapy}, azithromycin {Antibiotic therapy}, BPH {Benign prostatic hyperplasia}, blood glucoses elevated {Glucose in blood specimen above reference range}, prednisone {Steroid therapy}, started {New medication added}, COPD {Chronic obstructive lung disease}, drop in sats {Oxygen saturation below reference range}, ambulating {Fully mobile} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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. Calcitriol 0.25 mcg PO EVERY OTHER DAY
2. Labetalol 200 mg PO BID
3. Pantoprazole 40 mg PO Q12H
4. Pravastatin 40 mg PO QPM
5. Amlodipine 5 mg PO DAILY
6. Tamsulosin 0.4 mg PO DAILY
7. glimepiride 1 mg oral BID
8. Finasteride 5 mg PO DAILY
9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain
10. Cyanocobalamin 1000 mcg PO DAILY
11. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral daily
12. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Labetalol 200 mg PO BID
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain
8. Pantoprazole 40 mg PO Q12H
9. Pravastatin 40 mg PO QPM
10. Tamsulosin 0.4 mg PO DAILY
11. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
12. OSELTAMivir 30 mg PO Q24H Duration: 4 Days
RX *oseltamivir [Tamiflu] 30 mg 1 capsule(s) by mouth daily Disp
#*1 Capsule Refills:*0
13. PredniSONE 40 mg PO DAILY Duration: 4 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
14. Tessalon Perles (benzonatate) 100 mg ORAL TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth TID PRN Disp #*30
Capsule Refills:*0
15. glimepiride 1 mg ORAL BID
16. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral daily
17. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
RX *budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/actuation
1 160 mcg-4.5 mcg inhaled twice a day Disp #*1 Inhaler
Refills:*0
18. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath,
wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inhaled Q4H
PRN Disp #*1 Inhaler Refills:*0
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Influenza
Pneumonia
Secondary diagnosis:
___ on CKD
Lower extremity edema
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}, Influenza {Influenza}, Pneumonia {Pneumonia}, CKD {Chronic kidney disease}, Lower extremity edema {Edema of lower extremity}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with shortness of breath and cough
and found to have the flu with superimposed pneumonia. You also
had a COPD exacerbation. You were treated for these and your
symptoms improved. You also had acute kidney injury which was
thought to be from your enlarged prostate.
Given the swelling in your legs, there is concern for a
condition in your heart called congestive heart failure. You
should talk to your primary care doctor about the next steps in
treatment. You may need to get an ultrasound of your heart to
get a better look at your heart.
It is very important that you finish taking all of your
medications and follow-up with your primary care doctor on ___.
Despite our recommendation to stay an extra night in the
hospital, you left ___ against our medical advice.
It was a pleasure taking care of you,
Your ___ Doctors
___ Instructions:
___
###RESPONSE: shortness of breath {Dyspnea}, cough {Cough}, pneumonia {Pneumonia}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, improved {Patient's condition improved}, acute kidney injury {Acute kidney injury}, enlarged prostate {Large prostate}, swelling {Edema of lower extremity}, legs {Lower limb structure}, heart {Heart structure}, congestive heart failure {Congestive heart failure}, primary care {Primary care management}, ultrasound of your heart {Echocardiography}, heart {Heart structure}, finish taking all of your
medications {Patient medication education}, follow-up {Follow-up arranged}, primary care {Primary care management}, recommendation to {Recommendation to continue with treatment}, against our medical advice {Left against medical advice} |