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###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
The patient was admitted to Dr. ___ service with
hematuria. He underwent conservative management with CBI but
continued to have hematuria when the CBI was clamped. On HD3 he
underwent cystoscopy and bladder biopsy. No obvious bleeding
source was identified. No concerning intraoperative events
occurred; please see dictated operative note for details. The
patient received ___ antibiotic prophylaxis. On POD1
he underwent a voiding trial but failed and a foley was
replaced. The evening of POD1 he developed fevers and chills.
His WBC was elevated to 13. Urine and blood cultures were
obtained and are still pending. CXR was normal. He deferveced
on POD2 and his WBC count was decreasing. At discharge,
patient's pain well controlled with oral pain medications,
tolerating regular diet, ambulating without assistance, and
urine is clear yellow. He will be discharged with a total 3 week
course of cipro. He is given explicit instructions to call Dr.
___ follow-up next week to have the catheter removed.
###RESPONSE: hematuria {Blood in urine}, conservative management {Conservative therapy}, CBI {Irrigation of urinary bladder}, hematuria {Blood in urine}, CBI {Irrigation of urinary bladder}, clamped {Application of clamp}, cystoscopy and bladder biopsy {Cystoscopy and biopsy of bladder}, bleeding {Bleeding}, intraoperative {Intraoperative state}, operative {Surgical procedure}, antibiotic prophylaxis {Administration of prophylactic antibiotic}, voiding {Normal micturition}, foley {Catheterization of urinary bladder}, replaced {Catheterization of urinary bladder}, fevers {Fever}, chills {Chill}, WBC {White blood cell count}, Urine {Urine culture}, blood cultures {Blood culture}, CXR was normal {Standard chest X-ray normal}, WBC count {White blood cell count}, pain well controlled {Demonstrates adequate pain control}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, tolerating {Tolerating diet}, regular diet {Normal diet}, ambulating without assistance {Independent walking}, urine is clear yellow {Urine looks clear}, instructions {Recommendation to}, catheter removed {Removal of urinary system catheter} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
BIMATOPROST [LUMIGAN] - 0.03 % Drops - one drop each eye once a
day
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day
TADALAFIL [CIALIS] - 20 mg Tablet - one Tablet(s) by mouth 60
min
prior to intercourse Do not take more than once per day.
TERAZOSIN - 5 mg Capsule - 1 Capsule(s) by mouth once a day
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply after shower
every other day
ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC; record) -
Dosage
uncertain
GARLIC - (OTC) - Dosage uncertain
Discharge Medications:
1. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 16 days.
Disp:*32 Tablet(s)* Refills:*0*
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
5. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold if diarrhea.
Disp:*60 Capsule(s)* Refills:*2*
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
hematuria, BPH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: hematuria {Blood in urine}, BPH {Benign prostatic hyperplasia}, Mental Status {Neurological mental status determination}, Clear {Normal breath sounds}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
-No vigorous physical activity for 2 weeks.
-Expect to see occasional blood in your urine and to experience
urgency and frequecy over the next month.
-You may shower and bathe normally.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain >4.
Replace Tylenol with narcotic pain medication. Max daily
Tylenol dose is 4gm, note that narcotic pain medication also
contains Tylenol (acetaminophen)
-Do not drive or drink alcohol while taking narcotics
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication,
discontinue if loose stool or diarrhea develops.
-Resume all of your home medications, except hold NSAID
(aspirin, and ibuprofen containing products such as advil &
motrin,) until you see your urologist in follow-up
-Resume all of your home medications, but please avoid
aspirin/advil for one week.
- Ciprofloxacin has been prescribed. You will take a total of 3
week course.
-Call Dr. ___ (___) for follow-up AND if you
have any questions (page Dr. ___ at ___.
-If you have fevers > 101.5 F, vomiting, severe abdominal pain,
or inability to urinate, call your doctor or go to the nearest
emergency room.
###RESPONSE: activity {Functional activity education}, blood in your urine {Blood in urine}, urgency {Urgent desire to urinate}, frequecy {Increased frequency of urination}, may shower {Wound treatment education}, Tylenol {Administration of analgesic}, pain medication {Administration of analgesic}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, breakthough pain {Breakthrough pain}, Tylenol {Administration of analgesic}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, Tylenol {Administration of analgesic}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, Tylenol {Administration of analgesic}, Do not drive {Recommendation to avoid activity of daily living}, post surgical {Postoperative state}, constipation {Constipation}, constipation {Constipation}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, loose stool {Loose stool}, diarrhea {Diarrhea}, aspirin {Administration of aspirin}, aspirin {Administration of aspirin}, Ciprofloxacin {Antibiotic therapy}, fevers {Fever}, vomiting {Vomiting}, abdominal pain {Abdominal pain}, inability to urinate {Retention of urine}, call your doctor {Informing doctor}, emergency {Emergency treatment} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
charcot arthropathy
Major Surgical or Invasive Procedure:
___
1. Closed treatment right bimalleolar ankle fracture with
manipulation.
2. Tenotomy, right Achilles tendon.
3. Flexor hallucis longus tendon release.
4. Flexor digitorum longus release.
5. Posterior tibial tendon release.
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, charcot arthropathy {Charcot's arthropathy}, right {Structure of right ankle}, bimalleolar ankle fracture {Bimalleolar fracture of ankle}, manipulation {Manipulation}, Tenotomy {Tenotomy}, right Achilles tendon {Structure of right Achilles tendon}, Flexor hallucis longus tendon {Structure of flexor hallucis longus tendon}, release {Release}, Flexor digitorum longus {Flexor digitorum longus muscle structure}, release {Release}, Posterior tibial tendon {Tendon structure of posterior tibial muscle}, release {Release} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
I am seeing your patient today in the ___ clinic. I am
seeing this patient today for review. She has had unfortunately
a fall approximately one and half weeks ago. She had a twisting
injury. She has had pain in the ankle since that time.
She does not describe any changes in her health. Her past
medical history has been documented including diabetes.
I examined her today and found that she has some tenderness on
deep palpation of medial or lateral aspects of her ankle. No
complaints of any calf pain or calf swelling to suggest deep
vein
thrombosis or pulmonary embolus.
IMAGING: I reviewed her x-rays that show evidence of an acute
fracture involving her ankle joint, specifically a bimalleolar
ankle fracture. She does have underlying Charcot arthropathy.
ASSESSMENT AND PLAN: I had a discussion today with ___
regarding management. I am concerned regarding her new
fracture.
We have talked about treatment. We have talked about surgical
intervention to address her deformity; however, I am concerned
about adding additional hardware because of her history of
noncompliance and the risk of deep infection that may require
additional procedures including a possible below-knee
amputation.
We will go ahead and make the appropriate arrangements for her
to
have her procedure done to stabilize the ankle and again, we
will
try to avoid any hardware that would not be removed at a later
date. She also is aware of the possibility that she may require
a fusion type procedure as if she continues to have instability
involving the ankle.
I have answered all of her questions. She was given specific
instructions regarding followup. She is to remain
nonweightbearing. She understands signs and symptoms associated
with deep vein thrombosis and pulmonary embolus.
###RESPONSE: fall {Falls}, twisting
injury {Rotation injury}, pain in the ankle {Ankle pain}, tenderness {Tenderness}, deep palpation {Deep palpation}, medial {Structure of medial aspect of ankle}, lateral aspects {Structure of lateral aspect of ankle}, ankle {Ankle region structure}, No
complaints {No complaints}, calf pain {Pain in calf}, calf swelling {Swollen calf}, deep
vein
thrombosis {Deep venous thrombosis}, pulmonary embolus {Pulmonary embolism}, IMAGING {Imaging}, x-rays {Radiographic imaging procedure}, fracture {Fracture}, ankle joint {Ankle joint structure}, bimalleolar
ankle fracture {Bimalleolar fracture of ankle}, Charcot arthropathy {Charcot's arthropathy}, fracture {Fracture}, surgical
intervention {Surgical procedure}, deformity {Deformity}, infection {Infectious disease}, procedures {Procedure}, below-knee
amputation {Amputation of leg through tibia and fibula}, ankle {Ankle region structure}, fusion type procedure {Fusion procedure}, ankle {Ankle region structure}, signs {Sign}, deep vein thrombosis {Deep venous thrombosis}, pulmonary embolus {Pulmonary embolism} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PMH:
type 1 DM
alport syndrome
htn
hypercholesterolemia
PSH:
vp shunt
c-section
###RESPONSE: type 1 DM {Diabetes mellitus type 1}, alport syndrome {Alport syndrome}, htn {Hypertensive disorder, systemic arterial}, hypercholesterolemia {Hypercholesterolemia}, shunt {Surgical fistula}, c-section {Cesarean section} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
splint c/d/i
neurovascularly intact distally
foot wwp
###RESPONSE: splint {Application of splint}, neurovascularly intact {Normal peripheral neurovascular function}, foot {Foot 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:
none
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#1. The patient
received lovenox for DVT prophylaxis starting on the morning of
POD#1. The patient was seen daily by physical therapy.
At the time of discharge the patient was tolerating a regular
diet and feeling well. The patient was afebrile with stable
vital signs. The patient's pain was adequately controlled on
an oral regimen. The operative extremity was neurovascularly
intact. The patient is non-weight-bearing on the operative
lower extremity.
She is discharged to home in stable condition with prescriptions
for oxycodone and lovenox
###RESPONSE: surgery {Surgical procedure}, IV antibiotics {Intravenous antibiotic therapy}, pain {Pain}, PCA {Patient controlled analgesia}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, DVT prophylaxis {Prevention of deep vein thrombosis}, physical therapy {Physical therapy procedure}, regular
diet {Normal diet}, feeling well {Well in self}, afebrile {Fever}, stable
vital signs {Normal vital signs}, pain was adequately controlled {Demonstrates adequate pain control}, oral {Administration of drug or medicament via oral route}, regimen {Therapeutic regimen}, operative {Operative site}, extremity {Limb structure}, neurovascularly
intact {Normal peripheral neurovascular function}, non-weight-bearing {Non-weight-bearing}, operative {Operative site}, lower extremity {Lower limb structure}, stable condition {Patient's condition stable} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Medications - Prescription
AMLODIPINE - 10 mg Tablet - take 1 Tablet(s) by mouth once a day
ENALAPRIL MALEATE - 20 mg Tablet - take 1 Tablet(s) by mouth
twice a day
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - use as
directed twice a day
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - use as
directed
four times a day
PAROXETINE HCL [PAXIL] - 10 mg Tablet - take 1 Tablet(s) by
mouth
once a day
PRAVASTATIN - 40 mg Tablet - take 1 Tablet(s) by mouth at
bedtime
SULFAMETHOXAZOLE-TRIMETHOPRIM - 800 mg-160 mg Tablet - take 1
Tablet(s) by mouth twice a day
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - use
as
directed to measure blood glucose four times a day
INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE ULTRA-FINE] -
30
gauge X ___ Syringe - use as directed 8 times a day as needed
for glucose level
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. enalapril maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for Pain.
6. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous Q 24H (Every 24 Hours).
###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:
charcot arthropathy
Discharge Condition:
home. stable. alert and oriented x3.
###RESPONSE: charcot arthropathy {Charcot's arthropathy}, stable {Patient's condition stable}, alert {Mentally alert}, oriented x3 {Oriented to person, time and place} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. Please call your surgeon's office to schedule or confirm your
follow-up appointment in two (2) weeks.
6. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
7. ANTICOAGULATION: Please continue your lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots).
8. CAST CARE: Please keep your cast clean, dry and intact.
9. ACTIVITY: Non-weight bearing on the operative extremity
###RESPONSE: severe pain {Severe pain}, swelling {Swelling}, decreased
sensation {Hypesthesia}, difficulty with movement {Difficulty moving}, fevers {Fever}, shaking {Tremor}, chills {Chill}, redness {Redness of skin over lesion}, drainage {Wound discharge}, incision
site {Surgical incision wound}, chest pain {Chest pain}, shortness of breath {Dyspnea}, medications {Patient medication education}, medications {Patient medication education}, medications {Patient medication education}, pain control {Pain control}, drink alcohol {Current drinker of alcohol}, while
taking these medications {Patient medication education}, pain decreases {Sensation of pain reduced}, constipation {Constipation}, take a stool softener {Administration of laxative}, side effect {Medication side effects present}, medication so that it can be refilled {Medication prefill education}, medications {Patient medication education}, medication {Patient medication education}, non-steroidal anti-inflammatory
medications {Non-steroidal anti-inflammatory agent therapy}, ANTICOAGULATION {Anticoagulant therapy}, prevent deep vein thrombosis {Prevention of deep vein thrombosis}, blood clots {Blood clot}, CAST CARE {Cast care}, cast {Cast}, clean, dry and intact {Wound healing well}, ACTIVITY {Functional activity education}, Non-weight bearing {Non-weight-bearing}, operative {Operative site}, extremity {Limb structure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
Lincosamides / Penicillins
Attending: ___
Chief Complaint:
Presentation for TIPS procedure
Major Surgical or Invasive Procedure:
TIPS
###RESPONSE: Penicillins {Allergy to penicillin}, TIPS procedure {Transjugular intrahepatic portosystemic shunt}, TIPS {Transjugular intrahepatic portosystemic shunt} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ with a PMHx of ___ cirrhosis c/b refractory ascites and
esophageal varices who presents for direct admission to the ET
service for TIPS procedure given now weekly need for
paracenteses and abdominal pain. Pt dx with NASH in ___
following her gastric bypass and had no symptoms until ___ when
she started to have increased abdominal girth and abd pain. Pt
has had weekly paracentesis for refractory ascites, most
recently ___ where 9L was taken off. She has complaints today of
dull abd pain given length of time since last tap.
Pt had EGD on ___ which revealed two lower esophageal
varices. Had one episode of HE one month ago when she missed her
lactulose. Pt notes persistent issues with varying constipation
and diarrhea and requires lactulose for BM's. Had 3 BM's
yesterday, denies melena/ BRBPR/ hematemesis.
###RESPONSE: cirrhosis {Cirrhosis of liver}, refractory ascites {Refractory ascites}, esophageal varices {Esophageal varices}, TIPS procedure {Transjugular intrahepatic portosystemic shunt}, paracenteses {Abdominal paracentesis}, abdominal pain {Abdominal pain}, NASH {Nonalcoholic steatohepatitis}, gastric bypass {Bypass of stomach}, increased abdominal girth {Swollen abdomen}, abd pain {Abdominal pain}, paracentesis {Abdominal paracentesis}, refractory ascites {Refractory ascites}, dull {Dull pain}, abd pain {Abdominal pain}, tap {Abdominal paracentesis}, EGD {Esophagogastroduodenoscopy}, esophageal
varices {Esophageal varices}, HE {Hepatic encephalopathy}, constipation {Constipation}, diarrhea {Diarrhea}, BM {Defecation care}, BM {Finding of defecation}, melena {Melena}, BRBPR {Hematochezia}, hematemesis {Hematemesis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
NASH cirrhosis with portal hypertension c/b refractory ascites,
esophageal varices (EGD on ___
ITP
Obesity s/p gastric bypass surgery in ___
CCY in ___
C-section ___
###RESPONSE: NASH {Nonalcoholic steatohepatitis}, cirrhosis {Cirrhosis of liver}, portal hypertension {Portal hypertension}, refractory ascites {Refractory ascites}, esophageal varices {Esophageal varices}, EGD {Esophagogastroduodenoscopy}, ITP {Chronic idiopathic thrombocytopenic purpura}, Obesity {Obesity}, gastric bypass {Bypass of stomach}, surgery {Surgical procedure}, CCY {Cholecystectomy}, C-section {Cesarean section} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Great uncle died of "liver disease" at age ___, possible HCC
###RESPONSE: died {Dead}, liver disease {Disorder of liver}, HCC {Liver cell carcinoma} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Physical exam on admission:
Vitals- 97.9 118/64 83 18 99% RA
General: Alert, oriented, pleasant, sitting up in bed
HEENT: NCAT, PERRL, EOMI, MMM, oropharynx clear
Neck: supple, no JVD, no LAD
CV: RRR, nl S1 and S2, no m/r/g
Lungs: CTAB without wheeze or crackles
Abdomen: obese, distended with + fluid wave, non-tender, no
appreciable organomegaly
GU: no foley
Ext: Warm and dry, 2+ peripheral pulses, trace pedal edema, no
cyanosis
Neuro: AOx3, CN2-12 grossly intact, moves all extremities
freely
Skin: varicose veins noted on bilateral ___, no rash or lesions
On discharge:
Vitals: Tm 98.3 Tc 97.9 HR 88 BP 127/67 RR 20
###RESPONSE: Physical Exam {Physical examination procedure}, Vitals {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, sitting {Sitting position}, HEENT {Physical examination procedure}, NC {Normal head}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, no m/r/g {Heart sounds normal}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, wheeze {Wheezing}, crackles {Respiratory crackles}, Abdomen {Examination of abdomen}, obese {Obese abdomen}, distended {Swollen abdomen}, fluid {Effusion}, non-tender {Abdominal tenderness}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, Ext {Examination of limb}, Warm {Warm skin}, 2+ peripheral pulses {Peripheral pulses normal}, edema {Edema}, cyanosis {Cyanosis}, Neuro {Neurological examination}, AOx3 {Oriented to person, time and place}, 12 {Hypoglossal nerve structure}, grossly intact {Normal nervous system function}, all extremities {All extremities}, Skin {Examination of skin}, varicose veins {Venous varices}, rash {Eruption of skin}, lesions {Lesion}, Vitals {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Gen: WDWN, no acute distress, sitting in chair
HENT: no scleral icterus
CV: RRR, no m/r/g
Pulm: CTA in all fields, no wheezes or ronchi
Abd: obese, distended, mild tenderness to palpation in RUQ, hard
enlarged liver palpated. RUQ wound bandaged, clean dry and
intact.
Ext: 2+ DP pulses bilaterally
Neuro: A&Ox3, fine tremor but no asterixis
###RESPONSE: Physical Exam {Physical examination procedure}, Gen {General examination of patient}, WDWN {Well nourished}, no acute {No abnormality detected}, distress {Distress}, sitting {Sitting position}, HENT {Physical examination procedure}, scleral icterus {Scleral icterus}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, Pulm {Examination of respiratory system}, CTA {Normal breath sounds}, wheezes {Wheezing}, ronchi {Wheeze - rhonchi}, Abd {Examination of abdomen}, obese {Obese abdomen}, distended {Swollen abdomen}, mild {Symptom mild}, tenderness to palpation in RUQ {Tenderness of right upper quadrant of abdomen}, enlarged liver {Large liver}, palpated {Palpation of abdomen}, RUQ {Structure of right upper quadrant of abdomen}, wound {Surgical incision wound}, bandaged {Application of bandage}, clean dry and
intact {Wound healing well}, Ext {Examination of limb}, 2+ DP pulses {All pulses present in bilateral lower limbs}, Neuro {Neurological examination}, A&Ox3 {Oriented to person, time and place}, fine tremor {Fine tremor}, asterixis {Asterixis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
Pertinent labs on admission:
___ 05:11PM BLOOD WBC-3.4* RBC-3.61* Hgb-7.4* Hct-25.8*
MCV-72* MCH-20.5* MCHC-28.7* RDW-20.7* RDWSD-53.4* Plt Ct-77*
___ 05:11PM BLOOD ___ PTT-30.1 ___
___ 05:11PM BLOOD Glucose-127* UreaN-10 Creat-0.8 Na-132*
K-3.6 Cl-99 HCO3-23 AnGap-14
___ 05:11PM BLOOD ALT-15 AST-47* AlkPhos-226* TotBili-0.7
DirBili-0.3 IndBili-0.4
___ 05:11PM BLOOD Albumin-3.0* Calcium-9.0 Phos-3.5 Mg-1.7
___ 05:11PM BLOOD HCG-<5
Reports:
Hepatic ultrasound with doppler studies ___
FINDINGS:
Liver: The hepatic parenchyma is coarsened and nodular.
Nofocal liver
lesions are identified. There is a moderate amount of ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation.
The common
hepatic duct measures 2 mm.
Gallbladder: The gallbladder surgically absent.
Pancreas: The pancreas is largely obscured by overlying bowel
gas, with
imaged portions of the pancreas appearing within normal limits.
Spleen: The spleen is markedly enlarged, and measures greater
than 18.3 cm.
Kidneys: Limited sagittal views of the right kidney demonstrate
no evidence
of hydronephrosis.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate
direction. The
right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with
appropriate waveforms.
IMPRESSION:
1. Patent hepatic vasculature with appropriate direction of
flow.
2. Cirrhosis and sequela of portal hypertension including marked
splenomegaly
and a moderate amount of ascites.
3. Status post cholecystectomy.
Micro:
Pertinent labs on discharge:
___ 05:45PM BLOOD WBC-2.8* RBC-3.44* Hgb-7.4* Hct-25.6*
MCV-74* MCH-21.5* MCHC-28.9* RDW-20.5* RDWSD-53.5* Plt Ct-66*
___ 04:33AM BLOOD Glucose-133* UreaN-13 Creat-0.9 Na-129*
K-4.0 Cl-97 HCO3-23 AnGap-13
___ 04:33AM BLOOD ALT-100* AST-258* AlkPhos-212*
TotBili-1.4
___ 04:33AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
___ 04:50AM BLOOD Albumin-3.0* Calcium-9.0 Phos-3.9 Mg-1.___ female with ITP and NASH cirrhosis c/b portal HTN resulting
in refractory ascites requiring large volume (___) paracenteses
qWeek presenting for TIPS procedure.
#NASH cirrhosis c/b esophageal varicies, refractory ascites and
hepatic encephalopathy: Pt with persistent disease and symptoms
since ___. Has been previously evaluated for
transplant, however, it was decided to undergo TIPS given weekly
need for large volume paracenteses and abdominal pain.
#NASH cirrhosis c/b esophageal varicies, refractory ascites and
hepatic encephalopathy: Pt with persistent disease and symptoms
since ___. Has been previously evaluated for
transplant, however, it was decided to undergo TIPS given weekly
need for large volume paracenteses and abdominal pain.
Complicated TIPS completed ___. Specifically, right hepatic
vein to right portal vein TIPS placed, complicated by suspected
dissection of the portal vein and jailing of right PV posterior
branches. TIPS was extended into main PV with luminex stents,
dilated to 10 mm. post procedure gradient approx 15, similar to
preprocedure gradient. 5 L paracentesis. approx 470 cc contrast
used. Pt reported abd soreness "like punched" which improved
with oxycodone. LFTs and Cr bumped. Creatinine normalized with
500cc 5% albumin for suspected contrast-induced nephropathy vs
HRS. Will obtain f/u ultrasound in 1 week post-discharge and f/u
with hepatology as arranged. Pt was maintained on lactulose
without evidence of hepatic encephalopathy throughout her stay.
#Hypotension - likely secondary to cirrhosis. Held home lasix,
spironolactone, nadolol for labile blood pressure and optimizing
renal blood flow which may be restarted per hepatology as an
outpatient.
#Anemia - likely secondary to chronic liver disease
- required 1U pRBC during stay with Hg 6.7 and appropriate rise
in Hg to 7.4 prior to discharge.
# History of ITP:
-Stable during hospitalization. Plt ranged 66-103
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Hepatic ultrasound with doppler {Doppler ultrasonography of liver and portal system}, Liver {Liver structure}, hepatic parenchyma {Structure of parenchyma of liver}, nodular {Nodule}, liver
lesions {Lesion of liver}, ascites {Ascites}, Bile ducts {Bile duct structure}, intrahepatic biliary ductal {Intrahepatic biliary tract structure}, dilation {Dilatation}, common
hepatic duct {Structure of common hepatic duct}, Gallbladder {Gallbladder structure}, gallbladder surgically absent {Gallbladder not seen}, Pancreas {Pancreatic structure}, pancreas {Pancreatic structure}, bowel {Intestinal structure}, pancreas {Pancreatic structure}, Spleen {Splenic structure}, spleen is markedly enlarged {Splenomegaly}, Kidneys {Kidney structure}, right kidney {Right kidney structure}, no evidence {No abnormality detected}, hydronephrosis {Hydronephrosis}, evaluation {Evaluation procedure}, portal vein {Portal vein structure}, right {Structure of right main branch of portal vein}, left portal veins {Structure of left main branch of portal vein}, hepatic artery {Structure of hepatic artery}, Right {Structure of right main branch of portal vein}, middle {Structure of middle hepatic vein}, left hepatic veins {Structure of left hepatic vein}, hepatic vasculature {Vascular structure of liver}, Cirrhosis {Cirrhosis of liver}, portal hypertension {Portal hypertension}, splenomegaly {Splenomegaly}, ascites {Ascites}, Status post {Postoperative state}, cholecystectomy {Cholecystectomy}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, ITP {Chronic idiopathic thrombocytopenic purpura}, NASH {Nonalcoholic steatohepatitis}, cirrhosis {Cirrhosis of liver}, portal HTN {Portal hypertension}, refractory ascites {Refractory ascites}, paracenteses {Abdominal paracentesis}, TIPS procedure {Transjugular intrahepatic portosystemic shunt}, NASH {Nonalcoholic steatohepatitis}, cirrhosis {Cirrhosis of liver}, esophageal varicies {Esophageal varices}, refractory ascites {Refractory ascites}, hepatic encephalopathy {Hepatic encephalopathy}, disease {Disease}, transplant {Transplantation of liver}, TIPS {Transjugular intrahepatic portosystemic shunt}, paracenteses {Abdominal paracentesis}, abdominal pain {Abdominal pain}, NASH {Nonalcoholic steatohepatitis}, cirrhosis {Cirrhosis of liver}, esophageal varicies {Esophageal varices}, refractory ascites {Refractory ascites}, hepatic encephalopathy {Hepatic encephalopathy}, disease {Disease}, transplant {Transplantation of liver}, TIPS {Transjugular intrahepatic portosystemic shunt}, paracenteses {Abdominal paracentesis}, abdominal pain {Abdominal pain}, TIPS {Transjugular intrahepatic portosystemic shunt}, right hepatic
vein {Structure of right hepatic vein}, right portal vein {Structure of right main branch of portal vein}, TIPS {Transjugular intrahepatic portosystemic shunt}, placed {Implantation procedure}, dissection {Dissection procedure}, portal vein {Portal vein structure}, right PV {Structure of right main branch of portal vein}, TIPS {Transjugular intrahepatic portosystemic shunt}, PV {Pulmonary valve structure}, stents {Insertion of arterial stent}, dilated {Dilatation}, procedure {Procedure}, paracentesis {Abdominal paracentesis}, abd soreness {Abdominal pain}, improved {Patient's condition improved}, LFTs {Hepatic function panel}, Cr {Finding of creatinine level}, Creatinine normalized {Serum creatinine within reference range}, albumin {Administration of albumin}, contrast-induced nephropath {Acute kidney injury caused by contrast agent}, HRS {Hepatorenal syndrome}, ultrasound {Ultrasonography}, hepatic encephalopathy {Hepatic encephalopathy}, Hypotension {Low blood pressure}, cirrhosis {Cirrhosis of liver}, lasix {Diuretic therapy}, labile blood pressure {Labile blood pressure}, renal {Kidney structure}, restarted {Restart of medication}, Anemia {Anemia}, chronic liver disease {Chronic liver disease}, 1U pRBC {Transfusion of packed red blood cells}, ITP {Chronic idiopathic thrombocytopenic purpura}, Stable {Patient's condition stable} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Lactulose 30 mL PO TID
3. Nadolol 20 mg PO DAILY
4. Omeprazole 20 mg PO BID
5. Spironolactone 150 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO BID
2. Lactulose 30 mL PO TID
3. Vitamin D 400 UNIT PO DAILY
4. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six hours Disp #*5
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
NASH cirrhosis s/p TIPS procedure
Secondary diagnoses:
ITP
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: NASH {Nonalcoholic steatohepatitis}, cirrhosis {Cirrhosis of liver}, TIPS procedure {Transjugular intrahepatic portosystemic shunt}, ITP {Chronic idiopathic thrombocytopenic purpura}, Mental Status {Neurological mental status determination}, Clear {Normal breath sounds}, 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 part in your care during your recent
hospitalization at ___. You
were hospitalized for a TIPS procedure. Your blood pressure was
low at times during this admission so we stopped your blood
pressure medications including furosemide, nadolol, and
spironolactone. Please discuss with your liver doctor when to
restart these medications.
Please follow-up with all appointments listed below and take
your medications as prescribed.
Again, it was a pleasure taking part in your care-
-Your ___ Care Team
___ MD ___
Completed by: ___
###RESPONSE: TIPS procedure {Transjugular intrahepatic portosystemic shunt}, blood pressure {Blood pressure monitoring}, blood
pressure medications {Antihypertensive therapy}, liver {Liver structure}, medications {Administration of drug or medicament} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ y/o M with a past medical history of hypertension
NIDDM2, HLD, stable angina, hearing loss and metastatic
pancreatic cancer s/p ___ on palliative chemotherapy
presenting with 6 days of diarrhea and 2 days of nausea and
vomiting. He notes ___ episodes of watery, non-bloody diarrhea
every day for the past 6 days. He also complains of several days
of nausea and vomiting. He also complains of one episode of
night sweats and chills on day prior to admission. Notes he has
been unable to take POs and has been feeling dehydrated and
lightheaded. He denies abdominal pain,
fevers, bloody stools, chest pain and SOB. The patient had his
most recent session of chemotherapy on ___ and his prior
session was held in the setting of acute illness. He denies any
recent sick contacts.
Of note, he was recently hospitalized ___ for chest
pain when he was found to be febrile and have a UTI and GNR
bacteremia.
ED course:
In the ED, patient was noted to have nausea, vomiting and
diarrhea. He received 1L IVF, Zofran and morphine for pain
control. CT A/P showed mild proctitis so he was admitted for
further workup.
###RESPONSE: hypertension {Hypertensive disorder, systemic arterial}, NIDDM2 {Diabetes mellitus type 2}, HLD {Hyperlipidemia}, stable angina {Stable angina}, hearing loss {Hearing loss}, metastatic
pancreatic cancer {Metastatic carcinoma to head of pancreas}, palliative chemotherapy {Administration of palliative antineoplastic agent}, diarrhea {Diarrhea}, nausea and
vomiting {Nausea and vomiting}, bloody diarrhea {Hemorrhagic diarrhea}, nausea and vomiting {Nausea and vomiting}, night sweats {Night sweats}, chills {Chill}, dehydrated {Dehydration}, lightheaded {Lightheadedness}, abdominal pain {Abdominal pain}, fevers {Fever}, bloody stools {Hematochezia}, chest pain {Chest pain}, SOB {Dyspnea}, chemotherapy {Chemotherapy}, chest
pain {Chest pain}, febrile {Fever}, UTI {Urinary tract infectious disease}, GNR
bacteremia {Bacteremia caused by Gram-negative bacteria}, nausea, vomiting and
diarrhea {Nausea, vomiting and diarrhea}, IVF {Administration of intravenous fluids}, morphine {Allergy to morphine}, pain
control {Pain control}, CT A/P {Computed tomography of abdomen and pelvis}, mild {Symptom mild}, proctitis {Proctitis}, workup {Evaluation procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PAST MEDICAL HISTORY:
T2D,HLD,HTN,stable angina and hearing loss.
See OMR for detailed oncologic history: Briefly,
___: dx with pancreatic cancer ___ s/p Whipple
Adjuvant gemcitabine and Abraxane until ___
___- additional chemotherapy for metatastatic liver lesions
___- worsening metastatic liver lesions
PAST SURGICAL HISTORY:
___ ___
###RESPONSE: T2D {Diabetes mellitus type 2}, HLD {Hyperlipidemia}, HTN {Hypertensive disorder, systemic arterial}, stable angina {Stable angina}, hearing loss {Hearing loss}, pancreatic cancer {Carcinoma of pancreas}, chemotherapy {Chemotherapy}, metatastatic liver {Metastatic malignant neoplasm to liver}, metastatic liver {Metastatic malignant neoplasm to liver} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Father prostate cancer, brother liver cancer.
###RESPONSE: prostate cancer {Carcinoma of prostate}, liver cancer {Malignant neoplasm of liver} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: ___ 1126 Temp: 98.0 PO BP: 130/72 HR: 88 RR: 18 O2
sat: 99% O2 delivery: RA
General: Awake, cooperative, NAD.
HEENT: Pupils react normally to light. Oropharynx is clear.
Neck: Supple
Lungs: Clear with no wheezing, rhonchi or rales.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2 no
m/r/g.
Abdomen: soft, tender to palpation in epigastric area.
non-distended. periumbilical surgical scar. No suprapubic
tenderness. There is no
organomegaly or appreciable mass. Bowel sounds are hyperactive.
Back: No CVA tenderness.
Extremities: No edema, 2+ pedal pulses
Neurologic: Cranial nerves II through XII are intact. No focal
motor or sensory deficits are noted.
DISCHARGE PHYSICAL EXAM
Vitals: ___ 2314 Temp: 97.9 PO BP: 155/70 HR: 77 RR: 20 O2
sat: 98% O2 delivery: Ra
General: Awake, cooperative, NAD.
HEENT: Pupils react normally to light. Oropharynx is clear.
Neck: Supple
Lungs: Clear with no wheezing, rhonchi or rales.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2 no
m/r/g.
Abdomen: soft, non-tender, non-distended. periumbilical surgical
scar. No suprapubic tenderness. There is no
organomegaly or appreciable mass. normal bowel sounds.
Back: No CVA tenderness.
Extremities: No edema, 2+ pedal pulses
Neurologic: Cranial nerves II through XII are intact. No focal
motor or sensory deficits are noted.
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2
sat {Oxygen saturation measurement}, RA {Breathing room air}, General {General examination of patient}, Awake {Awake}, cooperative {Cooperative mental state}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, Pupils react normally to light {Pupil afferent light reaction normal}, Oropharynx is clear {Pharynx normal}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Lungs {Examination of respiratory system}, Clear {Normal breath sounds}, wheezing {Wheezing}, rhonchi {Wheeze - rhonchi}, rales {Respiratory crackles}, Cardiovascular {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<}, no
m/r/g {Heart sounds normal}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, tender {Abdominal tenderness}, palpation {Palpation}, epigastric {Epigastric region structure}, non-distended {Normal abdominal contour}, surgical scar {Surgical scar}, suprapubic {Hypogastric region structure}, tenderness {Tenderness}, organomegaly {Abdominal organomegaly}, mass {Abdominal mass}, Bowel sounds are hyperactive {Bowel sounds hyperactive}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, Extremities {Examination of limb}, edema {Edema}, 2+ pedal pulses {Normal foot pulse}, Neurologic {Neurological examination}, Cranial nerves II {Optic nerve structure}, XII {Hypoglossal nerve structure}, motor {Motor testing}, sensory {Sensory testing}, deficits {Neurological deficit}, PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2
sat {Oxygen saturation measurement}, Ra {Breathing room air}, General {General examination of patient}, Awake {Awake}, cooperative {Cooperative mental state}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, Pupils react normally to light {Pupil afferent light reaction normal}, Oropharynx is clear {Pharynx normal}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Lungs {Examination of respiratory system}, Clear {Normal breath sounds}, wheezing {Wheezing}, rhonchi {Wheeze - rhonchi}, rales {Respiratory crackles}, Cardiovascular {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<}, no
m/r/g {Heart sounds normal}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, surgical
scar {Surgical scar}, suprapubic {Hypogastric region structure}, tenderness {Tenderness}, organomegaly {Abdominal organomegaly}, mass {Abdominal mass}, normal bowel sounds {Normal bowel sounds}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, Extremities {Examination of limb}, edema {Edema}, 2+ pedal pulses {Normal foot pulse}, Neurologic {Neurological examination}, Cranial nerves II {Optic nerve structure}, XII {Hypoglossal nerve structure}, motor {Motor testing}, sensory {Sensory testing}, deficits {Neurological deficit} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS
___ 11:07PM BLOOD WBC-7.7 RBC-3.31* Hgb-9.8* Hct-32.9*
MCV-99* MCH-29.6 MCHC-29.8* RDW-16.3* RDWSD-60.0* Plt ___
___ 11:07PM BLOOD Neuts-87.0* Lymphs-10.4* Monos-1.3*
Eos-0.7* Baso-0.1 Im ___ AbsNeut-6.67* AbsLymp-0.80*
AbsMono-0.10* AbsEos-0.05 AbsBaso-0.01
___ 11:07PM BLOOD Glucose-195* UreaN-20 Creat-0.9 Na-132*
K-4.9 Cl-98 HCO3-21* AnGap-13
___ 11:07PM BLOOD ALT-37 AST-26 AlkPhos-859* TotBili-0.9
___ 11:07PM BLOOD Albumin-3.5
DISCHARGE LABS
___ 05:25AM BLOOD WBC-3.0* RBC-2.56* Hgb-7.5* Hct-23.8*
MCV-93 MCH-29.3 MCHC-31.5* RDW-15.8* RDWSD-53.8* Plt ___
___ 05:25AM BLOOD Neuts-70.2 ___ Monos-3.9*
Eos-0.7* Baso-0.4 AbsNeut-1.98 AbsLymp-0.68* AbsMono-0.11*
AbsEos-0.02* AbsBaso-0.01
___ 05:25AM BLOOD Glucose-134* UreaN-9 Creat-0.7 Na-139
K-3.6 Cl-104 HCO3-22 AnGap-13
___ 05:25AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.9
MICRO
___ 7:43 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 7:43 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
___ 7:43 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
___ 12:40 am BLOOD CULTURE Source: Line-Port.
Blood Culture, Routine (Pending): No growth to date.
___ 9:05 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
___ 9:21 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 6:13 pm BLOOD CULTURE Source: Line-POC.
Blood Culture, Routine (Pending): No growth to date.
___ 7:20 pm BLOOD CULTURE Source: Line-POC.
Blood Culture, Routine (Pending): No growth to date.
IMAGING
CT ABD/PELVIS ___
1. Likely mild proctitis without a perirectal abscess or bowel
obstruction.
2. The known metastatic lesion in the right hepatic lobe
measuring up to 6.6 cm, is slightly large in size since prior
exam from ___, when it measured up to 6.2 cm. The
adjacent hepatic parenchyma in segment VI and VII enhances
heterogeneously raising suspicion for satellite metastases.
Unchanged appearance of occluded right hepatic vein and right
branch of the portal vein.
3. Subacute healing pathologic fracture is again seen in the
left lateral
tenth rib. Unchanged compression deformities of the L3-L5
vertebrae.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, 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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, 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}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, CULTURE {Blood culture}, Blood Culture {Blood culture}, URINE CULTURE {Urine culture}, CULTURE {Blood culture}, Blood Culture {Blood culture}, CULTURE {Blood culture}, Blood Culture {Blood culture}, IMAGING {Imaging}, proctitis {Proctitis}, perirectal abscess {Perirectal abscess}, bowel
obstruction {Intestinal obstruction}, metastatic {Metastatic malignant neoplasm}, lesion {Lesion}, right hepatic lobe {Structure of right lobe of liver}, hepatic parenchyma {Structure of parenchyma of liver}, metastases {Metastatic malignant neoplasm}, occluded {Complete obstruction}, right hepatic vein {Structure of right hepatic vein}, right
branch of the portal vein {Structure of right main branch of portal vein}, healing {Structure resulting from tissue repair process}, pathologic fracture {Pathologic fracture}, tenth rib {Bone structure of tenth rib}, compression {Compression}, deformities {Deformity}, L3 {Bone structure of L3}, L5 {Bone structure of L5}, vertebrae {Bone structure of L3} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ y/o M with a past medical history of hypertension NIDDM2,
HLD, stable angina, hearing loss and metastatic pancreatic
cancer s/p Whipple on palliative chemotherapy, who presented
with 6 days of diarrhea and 2 days of nausea and
vomiting likely ___ recent chemotherapy and a urinary tract
infection.
ACUTE ISSUES
#Complicated urinary tract infection
Despite lack of symptoms, due to a history of recurrent urinary
infections and ongoing fevers, we sent for a UA and urine
culture. The patient was found to have a grossly positive UA and
culture grew pan-sensitive E. Coli. The patient was initially
placed on Zosyn and was discharged to complete a 7 day course of
Bactrim DS. Given recurrent urinary tract infections, urology
was consulted and they recommended continuing prophylactic
Bactrim SS indefinitely. He will be following up with urology
outpatient.
#Diarrhea, nausea, vomiting
#Poor PO intake
Patient with one week of diarrhea and several days of nausea and
vomiting. C4D1 of chemotherapy was ___. Diarrhea is a
common adverse effect of onivyde. Given patient had a 2 month
break from chemotherapy, it is possible that this was a rebound
effect in the setting of drug break. The patient was also
complaining of chills and sweats concerning for possible
infectious etiology. During his last admission, he had GNR
bacteremia and was treated with meropenem and discharged on
ertapenem with course finishing ___. On this admission, C.
Diff and Legionella were negative. Nausea and vomiting resolved
rapidly with symptomatic treatment. He was able to eat, but
continued to have diarrhea throughout hospital course. It
resolved prior to discharge with loperamide. Stool, blood and
urine cultures were all negative to date.
#Proctitis:
CT with mild proctitis. DDx included anal fissures/fistulas, C.
Diff, diverticulitis, infectious, IBD, traumatic. In this case,
it was likely due to inflammation from severe diarrhea.
#Hyponatremia:
This was noted on admission and believed to be likely hypotonic
hypovolemic in the setting of poor PO intake and less likely
SIADH. Na was noted to be 133 on ___ at appointment prior for
chemotherapy, and believed to be ___ poor PO intake. Na 138 on
___.
#Metastatic pancreatic cancer
Followed by oncologist Dr. ___. His current regimen is
___ which he recently received on ___ for
palliative chemotherapy. Palliative care was consulted to
discuss GOC and symptom management. Patient will follow closely
with Dr. ___ discharge to discuss next steps.
CHRONIC ISSUES
#Anemia
Baseline around ___ at recent admission. Patient remained around
baseline and did not require any transfusions.
#Hx of stable angina
EKG on admission with no evidence of ST segment changes.
Troponins negative x1.
#Hypertension:
He was continued on amlodipine, lisinopril. Metoprolol was held
during this admission as it was held on discharge at last
admission. Given blood pressures were slightly elevated while
inpatient, patient may benefit from restarting metoprolol.
#Diabetes:
Patient placed on insulin sliding scale while inpatient.
TRANSITIONAL ISSUES
[]Last day of Bactrim DS for UTI ___
[]Given recurrent UTIs, urology consulted and recommended
prophylactic Bactrim SS indefinitely, will need to follow
closely with urology outpatient
[]Patient has had numerous hospitalizations and poor tolerance
to chemo, would benefit from conversations with outpatient
oncologist Dr. ___ plan moving forward
[]Will need ongoing conversations regarding code status
[]Nausea, vomiting and diarrhea resolved with symptomatic
treatment but will likely require titration of symptomatic
medications to ensure doesn't become constipated; encourage
patient to take loperamide for symptomatic relief
[]Patient seems somewhat confused about medication regimen,
would benefit from clarification or help with medication
management
[]BPs mostly 140s/60s while inpatient but going up to SBPs 160s
prior to discharge on amlodipine and lisinopril. metoprolol was
held on discharge but patient would benefit from ongoing BP
monitoring and may need to restart metoprolol.
[]Patient would benefit from ongoing follow up with nutrition as
PO intake appears somewhat poor at baseline and albumin was 3.1.
___) ___
#CODE STATUS: FULL
###RESPONSE: hypertension {Hypertensive disorder, systemic arterial}, NIDDM2 {Diabetes mellitus type 2}, HLD {Hyperlipidemia}, stable angina {Stable angina}, hearing loss {Hearing loss}, metastatic pancreatic
cancer {Metastatic carcinoma to head of pancreas}, Whipple {Pancreaticoduodenectomy}, palliative chemotherapy {Administration of palliative antineoplastic agent}, diarrhea {Diarrhea}, nausea and
vomiting {Nausea and vomiting}, chemotherapy {Chemotherapy}, urinary tract
infection {Urinary tract infectious disease}, urinary tract infection {Urinary tract infectious disease}, urinary {Urinary tract infectious disease}, infections {Infectious disease}, fevers {Fever}, UA {Urinalysis}, urine
culture {Urine culture}, UA {Urinalysis}, culture {Microbial culture}, recurrent urinary tract infections {Recurrent urinary tract infection}, Diarrhea {Diarrhea}, nausea, vomiting {Nausea and vomiting}, Poor PO intake {Decrease in appetite}, diarrhea {Diarrhea}, nausea and
vomiting {Nausea and vomiting}, chemotherapy {Chemotherapy}, Diarrhea {Diarrhea}, chemotherapy {Chemotherapy}, rebound
effect {Medication rebound effect}, chills {Chill}, sweats {Sweating}, infectious {Infectious disease}, GNR
bacteremia {Bacteremia caused by Gram-negative bacteria}, Nausea and vomiting {Nausea and vomiting}, resolved {Problem resolved}, able to eat {Able to eat}, diarrhea {Diarrhea}, resolved {Problem resolved}, Stool {Hematochezia}, urine cultures {Urine culture}, CT {Computed tomography}, proctitis {Proctitis}, anal fissures {Anal fissure}, fistulas {Fistula}, diverticulitis {Diverticulitis}, infectious {Infectious disease}, IBD {Inflammatory bowel disease}, traumatic {Traumatic injury}, inflammation {Inflammatory disorder}, severe diarrhea {Severe diarrhea}, hypovolemic {Hypovolemia}, poor PO intake {Decrease in appetite}, SIADH {Syndrome of inappropriate vasopressin secretion}, chemotherapy {Chemotherapy}, poor PO intake {Decrease in appetite}, Metastatic pancreatic cancer {Metastatic carcinoma to pancreas}, regimen {Therapeutic regimen}, palliative chemotherapy {Administration of palliative antineoplastic agent}, symptom management {Symptom management}, Anemia {Anemia}, Baseline {Baseline state}, baseline {Baseline state}, transfusions {Transfusion}, stable angina {Stable angina}, EKG {Electrocardiographic procedure}, ST segment changes {Finding of electrocardiogram ST segment}, Troponins {Troponin measurement}, blood pressures {Blood pressure monitoring}, elevated {Finding of increased blood pressure}, insulin sliding scale {Sliding scale insulin regime}, UTI {Urinary tract infectious disease}, recurrent UTIs {Recurrent urinary tract infection}, chemo {Chemotherapy}, Nausea, vomiting and diarrhea {Nausea, vomiting and diarrhea}, resolved {Problem resolved}, medications {Prescription of drug}, constipated {Constipation}, medication {Prescription of drug}, regimen {Therapeutic regimen}, medication
management {Procedure related to management of drug administration}, BP
monitoring {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:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Creon 12 2 CAP PO QIDWMHS
5. Finasteride 5 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 17.2 mg PO BID
10. LOPERamide 2 mg PO QID:PRN diarrhea
11. Magnesium Oxide 400 mg PO DAILY
12. MetFORMIN (Glucophage) 850 mg PO DAILY
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Take this medication after you finish Bactrim DS to prevent
recurrent urinary infection
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth every day Disp #*30 Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Creon 12 2 CAP PO QIDWMHS
7. Finasteride 5 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide 2 mg 1 tablet by mouth every 6 hours Disp #*60
Capsule Refills:*0
11. MetFORMIN (Glucophage) 850 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 17.2 mg PO BID
15. HELD- Magnesium Oxide 400 mg PO DAILY This medication was
held. Do not restart Magnesium Oxide until your doctor tells you
to
16. HELD- Metoprolol Succinate XL 100 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until your doctor tells you to
###RESPONSE: mg {Blood magnesium 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: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Complicated urinary tract infection
Diarrhea
SECONDARY DIAGNOSES
metastatic pancreatic cancer
hyponatremia
proctitis
anemia
hypertension
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}, urinary tract infection {Urinary tract infectious disease}, Diarrhea {Diarrhea}, metastatic pancreatic cancer {Metastatic carcinoma to pancreas}, hyponatremia {Hyponatremia}, proctitis {Proctitis}, anemia {Anemia}, hypertension {Hypertensive disorder, systemic arterial}, Mental Status {Neurological mental status determination}, Clear {Normal breath sounds}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were nauseous and were
having diarrhea and vomiting all week.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We gave you lots of fluids through the IV and you felt better
- You were found to have a urinary infection and we gave you
antibiotics
- We gave you medications for your nausea and diarrhea and you
felt better
- You were able to eat and stopped having diarrhea so you were
discharged home
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Be sure to take the DOUBLE STRENGTH Bactrim until ___
after this switch to the SINGLE STRENGTH Bactrim and only take
one of those tablets daily until you talk to the urologists
- Continue to take all your medicines and keep your
appointments.
- Please come back to the hospital if you have any worsening of
your nausea, vomiting, diarrhea, dehydration or if you are
unable to eat and drink.
We wish you the best!
Sincerely,
Your ___ Team
###RESPONSE: nauseous {Nausea}, diarrhea and vomiting {Diarrhea and vomiting}, fluids {Administration of fluid therapy}, IV {Administration of drug or medicament via intravenous route}, urinary infection {Urinary tract infectious disease}, antibiotics {Antibiotic therapy}, medications {Prescription of drug}, nausea {Nausea}, diarrhea {Diarrhea}, able to eat {Able to eat}, diarrhea {Diarrhea}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, dehydration {Dehydration}, unable to eat {Unable to eat} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Morphine
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
###RESPONSE: Morphine {Allergy to morphine}, Chest pain {Chest pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
###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: History of Present Illness: ___ yo man with h/o "small heart
attack ___ years ago", ESRD (on HD for ___ years, urinates
3x/day), HTN, HLP, DM, presents with chest pain and SOB since
late afternoon today. He was sitting on his bed when he suddenly
developed ___ substernal chest heaviness, that may have
radiated to the back. This was associated with SOB, but no N/V,
sweats, dizziness, numbness or tingling. There was no
association of his pain with food, position, breathing, or
cough. He's never had this pain before. When he had the "mild
heart attack" ___ years ago, he cannot recal if this pain was
similar. He decided to present to the ED.
.
In the ED, initial vs were: 98 118/48 60 16 99%RA. Patient was
given . Vitals on transfer were 98.3 55 136/58 14 100%2LNC. ASA
325mg PO ONCE, morphine 4mg IV ONCE, 1gm tylenol PO ONCE
.
On the floor,
.
Review of sytems:
(+) 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
palpitations. Denied nausea, vomiting, diarrhea, constipation.
No recent change in bowel or bladder habits.
###RESPONSE: heart
attack {Myocardial infarction}, ESRD (on HD {End stage renal failure on dialysis}, urinates {Micturition finding}, HTN {Hypertensive disorder, systemic arterial}, HLP {Hyperlipidemia}, DM {Diabetes mellitus}, chest pain {Chest pain}, SOB {Dyspnea}, sitting {Sitting position}, substernal {Structure of substernal region}, chest heaviness {Tight chest}, radiated {Radiating pain}, back {Structure of back of trunk}, SOB {Dyspnea}, N/V {Nausea and vomiting}, sweats {Sweating}, dizziness {Dizziness}, numbness {Numbness}, tingling {Pins and needles}, pain {Pain}, food {Pain provoked by eating}, position {Pain provoked by movement}, breathing {Pain provoked by breathing}, cough {Pain provoked by coughing}, pain {Pain}, heart attack {Myocardial infarction}, pain {Pain}, Vitals {Vital signs finding}, ASA {Administration of aspirin}, tylenol {Administration of analgesic}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, headache {Headache}, sinus tenderness {Tenderness over frontal sinus}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, cough {Cough}, shortness of breath {Dyspnea}, palpitations {Palpitations}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, change in bowel {Altered bowel function}, bladder habits {Alteration in patterns of urinary elimination} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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) ESRD on HD for ___ years
2) "Mild heart attack" at ___ in ___
3) HTN
4) HLP
5) DM
6) ?Dementia
###RESPONSE: ESRD on HD {End stage renal failure on dialysis}, heart attack {Myocardial infarction}, HTN {Hypertensive disorder, systemic arterial}, HLP {Hyperlipidemia}, DM {Diabetes mellitus}, Dementia {Dementia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
###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:
Patient's father died of an MI in mid ___. No other personal or
family history of heart disease or blood clot.
###RESPONSE: died {Dead}, MI {Myocardial infarction}, heart disease {Heart disease}, blood clot {Blood clot} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: 96.5 150/68 66 18 100%2LNC
General: Alert, oriented x ___ (says he's in ___, can't recall
city, says he's in hospital can't recall name, says ___ can't
recall date) no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi except bibasilar rhales
CV: Regular rate and rhythm, normal S1 + S2, soft ___ SM at apex
no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
###RESPONSE: Vitals {Vital signs finding}, NC {Normal head}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, ronchi {Wheeze - rhonchi}, bibasilar {Structure of base of lung}, rhales {Respiratory crackles}, 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<}, soft {Abdomen soft}, apex {Structure of apex of heart}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, Ext {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, 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:
___ 02:25PM BLOOD WBC-8.0 RBC-3.74* Hgb-12.1* Hct-36.5*
MCV-98 MCH-32.4* MCHC-33.2 RDW-16.5* Plt ___
___ 02:25PM BLOOD Neuts-57.8 ___ Monos-5.9 Eos-2.5
Baso-0.7
___ 02:25PM BLOOD ___ PTT-22.1 ___
___ 02:25PM BLOOD Glucose-137* UreaN-45* Creat-6.4* Na-139
K-3.1* Cl-91* HCO3-36* AnGap-15
___ 02:25PM BLOOD ALT-4 AST-11 LD(LDH)-110 CK(CPK)-33*
AlkPhos-58 Amylase-74 TotBili-0.5
___ 02:25PM BLOOD proBNP-699*
___ 02:25PM BLOOD cTropnT-0.02*
___ 11:59PM BLOOD CK-MB-NotDone cTropnT-0.03*
___ 07:10AM BLOOD CK-MB-NotDone cTropnT-0.02*
___ 07:10AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.1
___ 02:25PM BLOOD Albumin-4.0
REPORTS:
___ Radiology CARDIAC PERFUSION PERSA Left
ventricular cavity size is normal. The end-diastolic volume is
129 ml.
Rest and stress perfusion images reveal a small region of
decreased tracer
uptake along the inferior wall of the left ventricle, although
this may be due to artifact generated by adjacent soft tissue.
There is no change in tracer uptake on stress versus rest
images.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 68 %.
No prior studies are available for comparison.
IMPRESSION: 1. No reversible myocardial perfusion defect. 2.
Focal decreased tracer uptake in the left ventricular inferior
wall is likely due to artifact from adjacent soft tissue;
alternatively this could represent a mild fixed perfusion
defect.
___ Cardiology STRESS ___: ___ yo
man with h/o HTN, HL and type II DM requiring
insulin; s/p "small heart attack" ___ years ago was referred to
evaluate
an atypical chest discomfort and shortness of breath. The
patient was
administered 0.142 mg/kg/min of Persantine over 4 minutes. No
chest,
back, neck or arm discomforts were reported by the patient
during the
procedure. No significant ST segment changes were noted. The
rhythm was
sinus with no ectopy noted. An appropriate heart rate and blood
pressure
response to the Persantine infusion was noted. Post-infusion,
the
patient was administered 125 mg Aminophylline IV.
IMPRESSION: No anginal symptoms or ischemic ST segment changes
to
Persantine. Appropriate heart rate and blood pressure response
to
Persantine infusion. Nuclear report sent separately.
___ Radiology CHEST (PA & LAT)
FINDINGS: Lung volumes are mildly diminished. Hazy subsegmental
atelectasis
is seen in both lung bases. No consolidation or edema is
evident. The
mediastinum is unremarkable. The cardiac silhouette is
borderline enlarged
even accounting for patient and technical factors. No effusion
or
pneumothorax is noted. The osseous structures are grossly
unremarkable.
IMPRESSION: Low lung volumes with hazy bibasilar atelectasis.
Otherwise, no
acute pulmonary process.
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-7.0 RBC-3.83* Hgb-12.5* Hct-37.1*
MCV-97 MCH-32.6* MCHC-33.6 RDW-15.5 Plt ___
___ 06:35AM BLOOD Glucose-103* UreaN-53* Creat-6.7*# Na-141
K-3.5 Cl-96 HCO3-31 AnGap-18
___ 06:35AM BLOOD Calcium-9.5 Phos-4.7* Mg-1.___ yo man with h/o "small heart attack ___ years ago", ESRD (on HD
for ___ years, urinates 3x/day), HTN, HLP, DM, presents with
chest pain and SOB since late afternoon today.
.
# Chest pain: Unclear etiology, ACS thought to be unlikely given
atypically pain, no EKG changes, negative enzymes, and negative
PMIBI results. LFTs including amylase/lipase were wnl. CXR
negative for any acute process. PE unlikely given lack of risk
factors, such as tachycardia, recent surgery/travel, hemoptysis,
DVT sx, h/o cancer or DVT/PE. Mild volume overload secondary to
ESRD was thought to be a possible cause, which was resolved
after HD. Pt was initially treated with ACS protocol with ASA
325mg PO daily, Plavix 75mg PO Daily, Atorvastatin 80mg PO
daily. We continued Metoprolol tartrate 200mg PO HS, Continue
Cozaar 50mg PO Daily. Once PMIBI was negative plavix was DC'd,
ASA dropped back to 81 and pt's original simvastatin 40 was
restarted.
.
# ESRD: On HD for ___ years. Continued HD ___, with
renal following.
.
# HTN: Continued BB and ___ per above
.
# HLP: Atorvastatin per above
.
# DM: Continued home Lantus 28 units plus SSI.
.
# Dementia: Continued carbidopa and levadopa.
###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}, Monos {Monocyte count}, Eos {Eosinophil 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}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Serum total lactate dehydrogenase measurement}, CK(CPK {Creatine kinase measurement}, AlkPhos {Alkaline phosphatase measurement}, Amylase {Amylase measurement}, TotBili {Bilirubin, total measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Albumin {Albumin measurement}, Radiology CARDIAC PERFUSION {Radionuclide myocardial perfusion study}, Left
ventricular cavity {Structure of cavity of left cardiac ventricle}, size is normal {Normal size}, stress perfusion images {Radionuclide myocardial perfusion stress study}, inferior wall {Structure of myocardium of diaphragmatic region}, left ventricle {Left cardiac ventricular structure}, artifact {Artifact}, soft tissue {Structure of soft tissue}, stress {Radionuclide myocardial perfusion stress study}, normal wall motion {Normal ventricular wall motion}, left ventricular {Structure of myocardium of left ventricle}, studies {Evaluation procedure}, reversible myocardial perfusion defect {Reversible myocardial perfusion defect}, left ventricular {Structure of myocardium of left ventricle}, inferior
wall {Structure of myocardium of diaphragmatic region}, artifact {Artifact}, soft tissue {Structure of soft tissue}, perfusion
defect {Myocardial perfusion defect}, HTN {Hypertensive disorder, systemic arterial}, HL {Hyperlipidemia}, type II DM {Diabetes mellitus type 2}, insulin {Insulin regime}, heart attack {Myocardial infarction}, evaluate {Evaluation procedure}, atypical {Atypical chest pain}, chest discomfort {Chest discomfort}, shortness of breath {Dyspnea}, chest {Thoracic structure}, back {Structure of back of trunk}, neck {Neck structure}, arm {Upper limb structure}, discomforts {Discomfort}, procedure {Procedure}, ST segment changes {Electrocardiographic ST segment changes}, rhythm was
sinus {Normal sinus rhythm}, heart rate {Finding of heart rate}, blood
pressure {Blood pressure finding}, infusion {Infusion}, infusion {Infusion}, anginal symptoms {Angina}, ischemic {Ischemia}, ST segment changes {Electrocardiographic ST segment changes}, heart rate {Finding of heart rate}, blood pressure {Blood pressure finding}, infusion {Infusion}, Radiology CHEST (PA & LAT) {Diagnostic radiography of chest, combined posteroanterior and lateral}, Lung volumes {Finding of respiratory volume}, atelectasis {Atelectasis}, lung bases {Structure of base of lung}, consolidation {Consolidation}, edema {Edema}, mediastinum {Mediastinal structure}, unremarkable {No abnormality detected}, cardiac {Heart structure}, enlarged {Enlargement}, effusion {Pleural effusion}, pneumothorax {Pneumothorax}, osseous structures {Bone structure}, unremarkable {No abnormality detected}, lung volumes {Finding of respiratory volume}, bibasilar {Structure of base of lung}, atelectasis {Atelectasis}, no
acute {No abnormality detected}, pulmonary {Lung structure}, 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}, 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}, heart attack {Myocardial infarction}, ESRD (on HD {End stage renal failure on dialysis}, urinates {Micturition finding}, HTN {Hypertensive disorder, systemic arterial}, HLP {Hyperlipidemia}, DM {Diabetes mellitus}, chest pain {Chest pain}, SOB {Dyspnea}, Chest pain {Chest pain}, ACS {Acute coronary syndrome}, atypically pain {Atypical chest pain}, no EKG changes {Electrocardiogram normal}, negative enzymes {Cardiac enzymes within reference range}, negative {No abnormality detected}, PMIBI {Radionuclide myocardial perfusion study}, LFTs {Hepatic function panel}, amylase {Amylase measurement}, lipase {Serum lipase measurement}, wnl {Liver function tests within reference range}, CXR {Plain chest X-ray}, PE {Pulmonary embolism}, tachycardia {Tachycardia}, surgery {Surgical procedure}, travel {Travel abroad}, hemoptysis {Hemoptysis}, DVT {Deep venous thrombosis}, cancer {Malignant neoplasm}, DVT {Deep venous thrombosis}, PE {Pulmonary embolism}, volume overload {Hypervolemia}, ESRD {End-stage renal disease}, resolved {Problem resolved}, HD {Hemodialysis}, ACS {Acute coronary syndrome}, ASA {Administration of aspirin}, PMIBI {Radionuclide myocardial perfusion study}, negative {No abnormality detected}, ASA {Administration of aspirin}, restarted {Restart of medication}, ESRD {End stage renal failure on dialysis}, HD {Hemodialysis}, HD {Hemodialysis}, HTN {Hypertensive disorder, systemic arterial}, HLP {Hyperlipidemia}, DM {Diabetes mellitus}, SSI {Sliding scale insulin regime}, Dementia {Dementia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
1) Aspirin 81mg PO daily
2) Simvastatin 40mg PO daily
3) Losartan 50mg PO daily
4) Nexium 40mg PO Daily
5) Sevelamer carbonate 800mg PO TID
6) Nephrocaps 1 cap PO Daily
7) Ambien 10mg PO HS
8) Trazadone 100mg PO HS
9) Insulin glargine 28 units daily
10) Sliding scale insulin
11) Carbidopa-Levodopa (___) 2 tab PO TID
12) Metoprolol XL 200mg PO HS
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Losartan 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Carbidopa-Levodopa ___ mg Tablet Sig: Two (2) Tablet PO
TID (3 times a day).
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO HS (at bedtime).
10. Insulin Glargine 100 unit/mL Solution Sig: ___ (28)
Units Subcutaneous once a day: Plus sliding scale. .
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet 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 With Service
Facility:
___
Discharge Diagnosis:
1) Atypical chest pain
2) Musculoskeletal chest pain
3) End stage renal disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: Home With Service {Home health aide service management}, Atypical chest pain {Atypical chest pain}, Musculoskeletal chest pain {Musculoskeletal chest pain}, End stage renal disease {End-stage renal 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}, walker {Uses zimmer frame}, cane {Uses single walking stick} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
It was a pleasure to take care of you here at ___. You were
admitted for chest pain. Fortunately, an stress test was
negative for any evidence of heart disease. Also, our testing
revealed that you did not have a heart attack. You will be
discharged home with physical therapy.
We have not made the any changes to your medications.
###RESPONSE: chest pain {Chest pain}, stress test {Radionuclide myocardial perfusion stress study}, negative {No abnormality detected}, heart disease {Heart disease}, heart attack {Myocardial infarction}, physical therapy {Physical therapy procedure}, changes to your medications {Change of medication} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: 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:
Keflex / Augmentin / Amoxicillin
Attending: ___.
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
None
###RESPONSE: Keflex {Allergy to cefalexin}, Augmentin {Antibiotic therapy}, Amoxicillin {Allergy to amoxicillin}, Shortness of breath {Dyspnea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Mrs. ___ is a ___ y.o. female with a past history of
COPD/Asthma, who reported increased dyspnea over approximately
one week. Apparently, her husband came home almost a week ago
with a "cold" and she then developed a non-productive cough,
malaise, dyspnea on exertion and eventually an inability to
sleep due to dyspnea. She denied the presence of fevers,
chills, or chest pain. Over the past 3 days her dyspnea
increased and today she appeared in significant distress. She
was brought to the ED. She has had several admissions in the
past for dyspnea/COPD exacerbation, has been on BiPAP, never
been intubated.
.
In the ED on arrival, VS: Temp 98.8; BP 129/61; HR 95; RR 28;
SpO2 80% on RA. She arrived ambulatory from home with family
(who reported cough productive with yellow sputum). Blood gases
after 3.5 L for 4 minutes revealed hypoxia with PO2 61 and PCO2
47. She received 3 combivent nebs with marked improvement. A
CXR was suggestive of pneumonia. She was given prednisone and
levofloxacin and admitted for COPD exacerbation/pneumonia. On
transfer to the floor, VS: Temp 98.8; BP 140/47; HR 102; RR 20;
SpO2 93% on 3L.
.
Currently, her dyspnea is much better. She denied chest pain,
or other symptoms. Her daughter, a nurse, was with her and able
to assist with much of the history, as the patient reproted her
memory was poor. Her daughter reported that the patient became
confused during previous admission.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria. She refuses to have a
mammogram or colonoscopy.
###RESPONSE: COPD {Chronic obstructive lung disease}, Asthma {Asthma}, increased {Patient's condition worsened}, dyspnea {Dyspnea}, cold {Common cold}, non-productive cough {Dry cough}, malaise {Malaise}, dyspnea on exertion {Dyspnea on exertion}, dyspnea {Dyspnea}, fevers {Fever}, chills {Chill}, chest pain {Chest pain}, dyspnea {Dyspnea}, increased {Patient's condition worsened}, distress {Distress}, dyspnea {Dyspnea}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, BiPAP {Bilevel positive airway pressure titration}, intubated {Insertion of endotracheal tube}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, SpO2 {Finding of oxygen saturation}, RA {Breathing room air}, cough productive {Productive cough}, yellow sputum {Yellow sputum}, Blood gases {Blood gas measurement}, hypoxia {Hypoxia}, PO2 {Measurement of venous partial pressure of oxygen}, PCO2 {Measurement of venous partial pressure of carbon dioxide}, nebs {Nebulizer therapy}, improvement {Patient's condition improved}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, prednisone {Steroid therapy}, levofloxacin {Antibiotic therapy}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, pneumonia {Pneumonia}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, SpO2 {Finding of oxygen saturation}, dyspnea {Dyspnea}, chest pain {Chest pain}, memory was poor. {Memory impairment}, confused {Clouded consciousness}, ROS {Review of systems}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, headache {Headache}, vision
changes {Visual disturbance}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, sore throat {Sore throat}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, BRBPR {Hematochezia}, melena {Melena}, hematochezia {Hematochezia}, dysuria {Dysuria}, hematuria {Blood in urine}, mammogram {Mammography}, colonoscopy {Colonoscopy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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. COPD/Ashtma
2. Hypertension
3. Hyperlipidemia
4. Type II Diabetes
5. Peripheral Neuropathy
6. s/p MRSA osteomyelitis in right foot with 3 surgical
debridements
7. s/p MRSA bacteremia in ___. ?Dementia (reported by daughter)
9. Bilateral cataract surgery
###RESPONSE: COPD {Chronic obstructive lung disease}, Ashtma {Asthma}, Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, Type II Diabetes {Diabetes mellitus type 2}, Peripheral Neuropathy {Peripheral nerve disease}, MRSA {Methicillin resistant Staphylococcus aureus infection}, surgical {Surgical procedure}, debridements {Debridement}, MRSA bacteremia {Bacteremia caused by Methicillin resistant Staphylococcus aureus}, Dementia {Dementia}, Bilateral cataract surgery {Surgery of cataract of bilateral eyes} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Her father was a smoker and exposed to asbestos, died of lung
cancer at age ___. Her mother died form with complications from
Alzheimer's at age ___. One sister survived breast CA.
###RESPONSE: smoker {Smoker}, died {Dead}, lung
cancer {Malignant tumor of lung}, died {Dead}, Alzheimer {Alzheimer's disease}, breast CA {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:
Vitals - T: 99.3; BP: 128/76; HR: 100; RR: 20; SpO2: 93% on 3L
GENERAL: Pleasant, female with mild respiratory distress.
Speaks in near full sentences, slight tachypnea.
HEENT: Normocephalic, atraumatic. Conjunctiva moist and pink. No
scleral icterus. PERRLA, EOMs intact. Mucosa pink and moist.
Neck Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, tachy rate. Normal S1, S2. No murmurs,
rubs or ___. No gross JVD.
LUNGS: Good, equal chest excursion. Lung sounds with rales and
rhonchi in right lower lobe, slight in left base. Scattered
expiratory wheezes throughout. No egophony.
ABDOMEN: Protuberant. Positive bowel sounds. Soft, non-tender
to palpation.
EXTREMITIES: No peripheral edema, positive pain in left calf, 2+
dorsalis pedis pulses. Noted deformed toenails and prior
surgery on right foot.
SKIN: Pink/hot/dry. No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate, seems slightly confused, refers many
answers to daughter. CN ___ grossly intact. Sensation and
moevement grossly intact in all extremities.
PSYCH: Listens and responds to questions appropriately,
pleasant.
###RESPONSE: Vitals {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, SpO2 {Finding of oxygen saturation}, GENERAL {General examination of patient}, distress {Distress}, Speaks {Does speak}, full sentences {Able to complete sentence in one breath}, tachypnea {Tachypnea}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, Conjunctiva moist and pink {Finding of moistness of eye}, scleral icterus {Scleral icterus}, PERRLA {Pupils equal, react to light and accommodation}, EOMs {Ophthalmic examination and evaluation}, intact {No abnormality detected}, Mucosa pink and moist {Moist oral mucosa}, Supple {Normal movement of neck}, LAD {Lymphadenopathy}, thyromegaly {Goiter}, CARDIAC {Cardiovascular physical examination}, Regular rhythm {Normal sinus rhythm}, tachy {Tachycardia}, rate {Finding of heart rate}, Normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, JVD {Jugular venous engorgement}, LUNGS {Examination of respiratory system}, Good {Normal breath sounds}, chest excursion {Finding of chest expansion}, Lung {Lung structure}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, right lower lobe {Structure of lower lobe of right lung}, left base {Structure of base of left lung}, wheezes {Wheezing}, egophony {Egophony}, ABDOMEN {Examination of abdomen}, Protuberant {Swollen abdomen}, Positive bowel sounds {Normal bowel sounds}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, palpation {Palpation}, EXTREMITIES {Examination of limb}, edema {Edema}, pain {Pain}, left calf {Structure of calf of left lower leg}, 2+
dorsalis pedis {Dorsalis pulse present}, pulses {Pulse finding}, right foot {Structure of soft tissue of dorsum of right foot}, SKIN {Examination of skin}, Pink {Pink skin}, hot {Hot skin}, dry {Xeroderma}, rashes {Eruption of skin}, lesions {Lesion}, ecchymoses {Ecchymosis}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, Appropriate {Appropriate affect}, confused {Clouded consciousness}, grossly intact {Normal nervous system function}, Sensation {Finding of sensation by site}, grossly intact {Normal nervous system function}, all extremities {All extremities}, PSYCH {Psychological 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: Pertinent Results:
IMAGING:
CXR ___ - IMPRESSION: Patchy airspace opacities, most
notable in the right lung base, but also in the right mid lung
and likely also left lower lung. Findings are concerning for
aspiration or pneumonia.
.
MICROBIOLOGY: Blood cultures ___ - pending
.
LAB DATA:
LABS ON ADMISSION:
___ 10:45AM BLOOD WBC-19.3* RBC-5.09 Hgb-14.9 Hct-44.3
MCV-87 MCH-29.3 MCHC-33.7 RDW-14.2 Plt ___
___ 10:45AM BLOOD Neuts-86.3* Lymphs-9.0* Monos-3.8 Eos-0.7
Baso-0.2
___ 10:45AM BLOOD Plt ___
___ 10:45AM BLOOD Glucose-170* UreaN-24* Creat-1.0 Na-139
K-4.6 Cl-99 HCO3-28 AnGap-17
___ 10:45AM BLOOD cTropnT-<0.01
___ 10:45AM BLOOD CK-MB-5
___ 10:50AM BLOOD Type-ART pO2-61* pCO2-47* pH-7.40
calTCO2-30 Base XS-2
___ 10:50AM BLOOD Lactate-1.0
.
LABS ON DISCHARGE:
###RESPONSE: IMAGING {Imaging}, CXR {Plain chest X-ray}, opacities {Abnormally opaque structure}, right lung base {Structure of base of right lung}, right mid lung {Structure of middle lobe of right lung}, left lower lung {Structure of lower lobe of left lung}, aspiration {Aspiration pneumonia}, pneumonia {Pneumonia}, MICROBIOLOGY {Microbiology}, Blood cultures {Blood culture}, 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}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, 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}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, ART {Arterial specimen collection for laboratory test}, pH {pH measurement}, calTCO2 {Blood total carbon dioxide (calculated)}, Base XS {Delta base, blood}, Lactate {Lactic acid measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ y.o. woman with a past history of COPD and asthma that
presented with increasing dyspnea and cough.
.
# Dyspnea: Likely due to COPD exacerbation with pneumonia
suggested by CXR. ___ have occured in the setting of a URI given
her husband's recent cold symptoms, but may also be due
COPD/asthma exacerbation alone. Respiratory status has improved
significantly since she presented to the ED. Infleunza was
negative Does not appear to be volume overloaded, making CHF
less likely. PE unlikely given her presentation and response to
bronchodilators. Given her baseline respiratory dysfunction, she
will likely need pulmonary rehab prior to returning home. She is
not a candidate for home oxygen because she continues to smoke.
If she can quit, she should start on nighttime home oxygen.
Smoking cessation was discussed. She had a nicotine patch and
was discharged on chantix. She plans not to smoke on this
medication and knows to watch for depression and altered dreams.
She was discharged with a steroid taper, plan to complete a 10
day course of antibiotics, and nebs for COPD/Asthma. She should
continue oxygen as needed.
.
Leukocytosis: Elevated WBC prior to steroids. Decreased during
admission. Likely related to pneumonia, as suggested by CXR.
This trended down.
.
# Hypertension: Well controlled with home medications. HCTZ,
metoprolol and norvasc were continued, BP remained stable.
.
# Type II Diabetes: Glucose checks qid, standing coverage with
70/30 and sliding scale. Her 70/30 was increased while on
prednisone and she was started on metformin.
.
# Hyperlipidemia: Continued her simvastatin.
.
# Peripheral Neuropathy: Continued with her gabapentin.
.
# ? Dementia: Patient is on aricept, she and her daughter
reported forgetfulness. Aricept was continued and she was
monitored closely for delerium.
.
# CODE: Remains FULL code at this time. Patient did express that
she may not want to be resuscitated/intubated, but further
discussion with patient and family is required. She does not
have a health care proxy.
.
# CONTACT: With patient and her daughter.
###RESPONSE: COPD {Chronic obstructive lung disease}, asthma {Asthma}, increasing {Patient's condition worsened}, dyspnea {Dyspnea}, cough {Cough}, Dyspnea {Dyspnea}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, pneumonia {Pneumonia}, CXR {Plain chest X-ray}, URI {Upper respiratory infection}, cold {Common cold}, COPD {Chronic obstructive lung disease}, asthma exacerbation {Exacerbation of asthma}, Respiratory status {Monitoring of respiration}, improved {Patient's condition improved}, Infleunza {Influenza}, negative {No pathologic diagnosis}, volume overloaded {Hypervolemia}, CHF {Congestive heart failure}, PE {Pulmonary embolism}, baseline {Baseline state}, respiratory {Respiratory function finding}, dysfunction {Functional disorder}, pulmonary rehab {Pulmonary rehabilitation}, home oxygen {Home oxygen therapy}, smoke {Smoker}, home oxygen {Home oxygen therapy}, Smoking cessation {Smoking cessation education}, smoke {Smoker}, medication {Administration of drug or medicament}, depression {Depressive disorder}, steroid {Steroid therapy}, taper {Medication decreased}, antibiotics {Antibiotic therapy}, nebs {Nebulizer therapy}, COPD {Chronic obstructive lung disease}, Asthma {Asthma}, oxygen {Oxygen therapy}, Leukocytosis {Leukocytosis}, Elevated WBC {White blood cell count outside reference range}, steroids {Steroid therapy}, pneumonia {Pneumonia}, CXR {Plain chest X-ray}, Hypertension {Hypertensive disorder, systemic arterial}, Well controlled {Disease condition determination, well controlled}, medications {Administration of drug or medicament}, stable {Stable blood pressure}, Type II Diabetes {Diabetes mellitus type 2}, Glucose {Glucose measurement, blood}, sliding scale {Sliding scale insulin regime}, increased {Increasing dosage of medication}, prednisone {Steroid therapy}, started {New medication added}, Hyperlipidemia {Hyperlipidemia}, Peripheral Neuropathy {Peripheral nerve disease}, Dementia {Dementia}, forgetfulness {Forgetful}, monitored {Monitoring procedure}, delerium {Delirium}, resuscitated {Resuscitation}, intubated {Insertion of endotracheal tube} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Albuterol - 90mcg aerosol prn
Citalopram - 10 mg PO daily
Fluticasone-Salmeterol (Advair) - 250 mcg-50 mcg inhaled bid
Gabapentin - 300 mg PO qhs
HCTZ - 25 mg PO daily
Metoprolol Succinatate - 150 mg PO daily
Simvastatin - 40 mg PO qhs
ASA - 81 mg PO daily
Norvasc - 5 mg PO daily
Aricept - 5 mg PO daily
Insulin NPH and Regular (Humulin 70/30) - 32 units, QAM and QPM
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day
for 12 days: 6 tabs for 2 days, then 4 tabs for 2 days, then 3
tabs for 2 days, then 2 tabs for 2 days, then 1 tab for 2 days
then ___ tab for 2 days.
Disp:*43 Tablet(s)* Refills:*0*
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
3. Chantix 0.5(11)-1(3X14) mg Tablets, Dose Pack Sig: ___
Tablets, Dose Packs PO as directed for 11 weeks: 0.5 mg daily
for 3 days, then 0.5 mg BID for 4 days, then 1 mg BID.
Disp:*1 Tablets, Dose Pack(s)* Refills:*0*
4. Citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: ___ (32) Subcutaneous twice a day: Take 40 units
twice daily for the next ___ days while on prednisone.
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inh Inhalation once a day.
Disp:*QS 1 month unit* Refills:*2*
15. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
16. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
17. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Priamry: COPD exacerbation, penumonia.
Secondary: Hypertension, Type II Diabetes, Hyperlipidemia,
Peripheral Neuropathy, Dementia:
Discharge Condition:
Stable
###RESPONSE: COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, penumonia {Pneumonia}, Hypertension {Hypertensive disorder, systemic arterial}, Type II Diabetes {Diabetes mellitus type 2}, Hyperlipidemia {Hyperlipidemia}, Peripheral Neuropathy {Peripheral nerve disease}, Dementia {Dementia}, Stable {Patient's condition stable} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were admitted for shortness of breath. You were treated a
COPD exacerbation and pneumonia and were given frequent
nebulizers, supplemental oxygen, oral steroids and antibiotics
with improvement in your breathing. You were also given a
nicotine patch and encouraged to stop or reduce your smoking,
which is likely contributing to your condition.
You were started on a new medication, chantix, to help with
smoking cessation. Please watch for depressed mood or strange
dreams on this medication and report these symptoms to your PCP.
You were started on Spireva for better COPD control as well as a
taper of prednisone. You were given increased insulin and
metformin to help control your blood sugars while on the
prednisone. You should comeplete a 10 day course of
antibiotics.
Please call your primary care physician or come to the emergency
room if you experience worsening breathing difficulties that do
not respond to inhalers, fevers, chills, chest pain, or other
concerning symptoms.
###RESPONSE: shortness of breath {Dyspnea}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, pneumonia {Pneumonia}, nebulizers {Nebulizer therapy}, supplemental oxygen {Oxygen therapy support}, oral {Administration of drug or medicament via oral route}, steroids {Steroid therapy}, antibiotics {Antibiotic therapy}, improvement {Patient's condition improved}, reduce your smoking {Smoking cessation education}, started {New medication added}, new medication {New medication commenced}, smoking cessation {Smoking cessation education}, depressed mood {Depressed mood}, medication {Administration of drug or medicament}, PCP {Primary care management}, started {New medication added}, COPD {Chronic obstructive lung disease}, taper {Medication decreased}, prednisone {Steroid therapy}, increased {Increasing dosage of medication}, insulin {Insulin regime}, metformin {Allergy to metformin}, blood sugars {Blood sugar management}, prednisone {Steroid therapy}, antibiotics {Antibiotic therapy}, primary care {Primary care management}, emergency {Emergency treatment management}, breathing difficulties {Difficulty breathing}, fevers {Fever}, chills {Chill}, chest pain {Chest pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: 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:
Aspirin / Penicillins / Codeine / Inderal / Isordil Titradose /
Iodine-Iodine Containing / Celexa / Glucophage / Atorvastatin /
Dilaudid (PF) / Vioxx / Levofloxacin / Hydralazine And
Derivatives / Ondansetron / Carbapenem / Lidocaine /
Nortriptyline / Fosfomycin / Morphine / Trimethoprim / Latex
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
###RESPONSE: Aspirin {Allergy to aspirin}, Penicillins {Allergy to penicillin}, Codeine {Allergy to codeine}, Iodine-Iodine {Allergy to iodine compound}, Atorvastatin {Allergy to atorvastatin}, Levofloxacin {Allergy to levofloxacin}, Morphine {Allergy to morphine}, Latex {Allergy to Hevea brasiliensis latex protein}, Chest pain {Chest pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Ms. ___ is a ___ year old female with CAD, HTN, Type II DM, CKD
and a history of bradycardia with Wenckebach rhythm, CVA, s/p
DVT with indwelling IVC filter w/o coumadin, presenting with
___ substernal chest pressure radiating to the left arm as well
as jaw while waiting for dermatology appointment.
In the ED, initial vitals were 98.6 76 150/82 16 98% 2L NC
Labs and imaging significant for clear CXR, Cr 1.2 (baseline),
troponin T <0.01
Patient started on nitro gtt, heparin bolus and gtt, started on
2L n/c and was transferred to floor for further w/u.
Vitals on transfer were 97.1, 73, 134/60, 24, 93% 2L
.
On arrival to the floor, patient denies CP, states has improved.
She only notes feeling of general malaise. Denies DOE, SOB,
cough, F/C/S. She notes that the pain had started at about
10:45, and remained constant until about 4pm when it improved.
.
Pt had admission for chest pain ___, was ruled out for MI
with echo and CE, felt to have large anxiety component to pain
at that time.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. She denies
recent fevers, chills or rigors. She denies exertional buttock
or calf pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
###RESPONSE: CAD {Coronary arteriosclerosis}, HTN {Hypertensive disorder, systemic arterial}, Type II DM {Diabetes mellitus type 2}, CKD {Chronic kidney disease}, bradycardia {Bradycardia}, rhythm {Irregular heart beat}, CVA {Cerebrovascular accident}, DVT {Deep venous thrombosis}, IVC filter {Inferior vena cava filter in situ}, coumadin {Anticoagulant therapy}, chest pressure {Tight chest}, radiating to the left arm {Pain radiating to left arm}, jaw {Pain radiating to jaw}, vitals {Vital signs finding}, NC {Oxygen administration by nasal cannula}, imaging {Imaging}, clear {Chest clear}, CXR {Plain chest X-ray}, baseline {Baseline state}, troponin {Troponin measurement}, heparin {Heparin therapy}, Vitals {Vital signs finding}, CP {Chest pain}, improved {Patient's condition improved}, malaise {Malaise}, DOE {Dyspnea on exertion}, SOB {Dyspnea}, cough {Cough}, F/C {Fever with chills}, pain {Chest pain}, constant {Constant pain}, improved {Patient's condition improved}, chest pain {Chest pain}, MI {Myocardial infarction}, echo {Echocardiography}, anxiety {Anxiety}, pain {Chest pain}, review of systems {Review of systems}, pulmonary
embolism {Pulmonary embolism}, bleeding {Bleeding}, surgery {Surgical procedure}, myalgias {Muscle pain}, joint
pains {Joint pain}, cough {Cough}, hemoptysis {Hemoptysis}, black stools {Dark stools}, red stools {Red stools}, fevers {Fever}, chills {Chill}, rigors {Rigor}, buttock {Pain in buttock}, calf pain {Pain in calf}, review of systems {Review of systems}, Cardiac {Heart disease}, review of systems {Review of systems}, dyspnea on
exertion {Dyspnea on exertion}, paroxysmal nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, ankle edema {Ankle edema}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
- CAD: Cardiac cath ___ showed 50% mid LAD, 50% OM1 lesions c/b
coronary aneurysm
- HTN
- Diabetes mellitus, type 2
- CRI: baseline creatinine 0.9-1.2
- Asymptomatic bradycardia w/ ___ rhythm in past
- s/p CVA with residual left sided weakness in ___
- h/o DVT in ___ post-op from back surgery, s/p IVC filter
- L1-2 discectomy, L5-S1 fusion, R sided L2-3 and L3-4 w/
residual right leg weakness, now wheelchair bound when going
outside but uses a walker at home
- Cervical stenosis on ___ MRI: mild stenosis C3-4, moderate
stenosis C4-5, C5-6
- Foraminotomy
- Recurrent UTIs, on chronic suppressive methenamine
- Arthritis
- Cervical spondylosis
- Osteoporosis
- GERD
- s/p: appendectomy, hysterectomy, tonsillectomy, lap
cholecystectomy in ___, cataract surgery x 2
###RESPONSE: CAD {Coronary arteriosclerosis}, Cardiac cath {Cardiac catheterization}, mid LAD {Structure of mid portion of anterior descending branch of left coronary artery}, OM1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, lesions {Lesion}, coronary aneurysm {Aneurysm of coronary vessels}, HTN {Hypertensive disorder, systemic arterial}, Diabetes mellitus, type 2 {Diabetes mellitus type 2}, CRI {Chronic renal insufficiency}, baseline {Baseline state}, creatinine {Creatinine measurement}, Asymptomatic bradycardia {Asymptomatic bradycardia}, rhythm {Irregular heart beat}, CVA {Cerebrovascular accident}, left sided weakness {Left hemiparesis}, DVT {Deep venous thrombosis}, post-op {Postoperative state}, surgery {Surgical procedure}, IVC filter {Inferior vena cava filter in situ}, discectomy {Chondrectomy of spine}, L5-S1 {Structure of intervertebral disc of L5 and S1}, fusion {Spinal arthrodesis}, right leg weakness {Right hemiparesis}, wheelchair bound {Does mobilize using wheelchair}, Cervical stenosis {Spinal stenosis in cervical region}, MRI {Magnetic resonance imaging}, stenosis {Stenosis}, stenosis {Stenosis}, Foraminotomy {Foraminotomy}, Recurrent UTIs {Recurrent urinary tract infection}, Arthritis {Arthritis}, Cervical spondylosis {Cervical spondylosis}, Osteoporosis {Osteoporosis}, GERD {Gastroesophageal reflux disease}, appendectomy {Excision of appendix}, hysterectomy {Hysterectomy}, tonsillectomy {Tonsillectomy}, lap
cholecystectomy {Laparoscopic cholecystectomy}, cataract surgery {Cataract surgery} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 at age ___ of CAD. Father died ___ CAD. 2 brothers
died at ___ of CAD. Sister: ___. Sister: lung cancer. 3
brothers: diabetes and CAD. 3 daughters: 1 with "hole in her
heart", 1 with learning disability, 1 died of melanoma ___ years
ago.
###RESPONSE: died {Dead}, CAD {Coronary arteriosclerosis}, died {Dead}, CAD {Coronary arteriosclerosis}, died {Dead}, CAD {Coronary arteriosclerosis}, lung cancer {Malignant tumor of lung}, CAD {Coronary arteriosclerosis}, "hole in her
heart" {Atrial septal defect}, learning disability {Developmental academic disorder}, died {Dead}, melanoma {Malignant melanoma 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: Physical Exam:
Admission PE:
GENERAL: ___ F in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
No Carotid Bruits.
NECK: Supple with JVP of 2 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Few crackles b/l at the
bases
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Discharge PE:
T 97.6 126/66 HR 78 RR 20 96% RA
GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
No Carotid Bruits.
NECK: Supple with JVP of 2 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Few crackles b/l at the
bases
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
###RESPONSE: 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}, pallor {Pallor of skin of face}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthalesma {Xanthelasma}, Carotid Bruits {Carotid bruit}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, intercostal space {Structure of intercostal space}, midclavicular
line {Midclavicular line}, RR {Finding of rate of respiration}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, No m/r/g {Heart sounds normal}, thrills {Thrill}, lifts {Does lift}, No S3 {Third heart sound, S>3<, inaudible}, LUNGS {Examination of respiratory system}, chest wall deformities {Deformity of chest wall}, scoliosis {Scoliosis deformity of spine}, kyphosis {Kyphosis deformity of spine}, Resp {Examination of respiratory system}, accessory muscle {Accessory skeletal muscle}, crackles {Respiratory crackles}, bases {Structure of base of lung}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, Abd {Examination of abdomen}, enlarged {Enlargement}, palpation {Palpation}, abdominial bruits {Abdominal bruit}, EXTREMITIES {Examination of limb}, femoral bruits {Femoral bruit}, SKIN {Examination of skin}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, Right {Right coronary artery structure}, Carotid {Carotid artery structure}, Femoral {Structure of femoral artery}, DP {Structure of dorsalis pedis artery}, Left {Structure of left carotid artery}, Carotid {Carotid artery structure}, Femoral {Structure of femoral artery}, DP {Structure of dorsalis pedis artery}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, WDWN {Well nourished}, NAD {Distress}, Oriented x3 {Oriented to person, time and place}, Mood {Level of mood - normal}, affect {Mood finding}, NCAT {Normal head}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva {Conjunctival structure}, pallor {Pallor of skin of face}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthalesma {Xanthelasma}, Carotid Bruits {Carotid bruit}, Supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, intercostal space {Structure of intercostal space}, midclavicular
line {Midclavicular line}, RR {Finding of rate of respiration}, normal S1, S2 {Heart sounds normal}, No m/r/g {Heart sounds normal}, thrills {Thrill}, lifts {Does lift}, No S3 {Third heart sound, S>3<, inaudible}, chest wall deformities {Deformity of chest wall}, scoliosis {Scoliosis deformity of spine}, kyphosis {Kyphosis deformity of spine}, Resp
were unlabored {Breathing easily}, accessory muscle {Accessory skeletal muscle}, crackles {Respiratory crackles}, bases {Structure of base of lung}, Soft {Abdomen soft}, NTND {Abdominal tenderness}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, Abd aorta {Abdominal aorta structure}, enlarged {Enlargement}, palpation {Palpation}, abdominial bruits {Abdominal bruit}, femoral bruits {Femoral bruit}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, Right {Right coronary artery structure}, Carotid {Carotid artery structure}, Femoral {Structure of femoral artery}, DP {Structure of dorsalis pedis artery}, Left {Structure of left carotid artery}, Carotid {Carotid artery structure}, Femoral {Structure of femoral artery}, DP {Structure of dorsalis pedis artery} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 11:45AM BLOOD WBC-6.1 RBC-3.45* Hgb-10.8* Hct-31.8*
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.7 Plt ___
___ 11:45AM BLOOD Neuts-60.5 ___ Monos-6.3 Eos-1.8
Baso-0.7
___ 11:45AM BLOOD ___ PTT-20.5* ___
___ 11:45AM BLOOD Glucose-277* UreaN-18 Creat-1.2* Na-140
K-4.5 Cl-104 HCO3-26 AnGap-15
___ 08:45PM BLOOD CK(CPK)-48
___ 11:45AM BLOOD cTropnT-<0.01
___ 08:45PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:13AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0
UA negative
___ CXR: No acute cardiopulmonary process
Discharge labs:
___ 06:13AM BLOOD WBC-6.0 RBC-3.30* Hgb-10.3* Hct-30.7*
MCV-93 MCH-31.3 MCHC-33.7 RDW-13.8 Plt ___
___ 06:13AM BLOOD ___ PTT-69.1* ___
___ 06:13AM BLOOD Plt ___
___ 06:13AM BLOOD Glucose-156* UreaN-15 Creat-1.1 Na-141
K-4.2 Cl-108 HCO___ AnGap-___ year old female with CAD, HTN, Type II DM, CKD and a history
of bradycardia with ___ rhythm, CVA, s/p DVT with
indwelling IVC filter w/o coumadin, presenting with ___ left
sided jaw, neck, chest, torso pain lasting for ___ hours.
# Atypical chest pain: Has long history of chest pain with
previous cath in ___ showing normal arteries and stress echo in
___ showing evidence of old infarct with no inducible
ischemia. CE negative x2. No acute changes on EKG. Has long
history of similar pain. Given history, ACS is possible and she
was ruled out with enzymes and seriel EKGs. Other possibilities
included anxiety/psychosomatic component which has been
documented in past. She has cervical stenosis which may have had
component. ___ have had musculoskeletal sprain/strain/pull. PE
was unlikely given no tachycardia, no pleuritic component, no
s/s DVT, s/p IVC filter. Pna unlikely given no infiltrate on
CXR, no cough, no F/C/S.
--On the floor she was weaned off nitro gtt with no return of
her pain, and stopped heparin. No events noted on telemetry.
ticlopidine was continued as pt allergic to asa. Simvastatin
was continued - patient had a documented allergy as "elevated
CPK" however pt has been on this medication at home for some
time without documented CPK elevations. No issues while in
house. Acetaminophen was used PRN for pain, further analgesic
options were limited given extensive allergy list. No beta
blocker was started as patient has documented allergy to
propanolol. Patient had a negative UA and UTI was unlikely
cause.
#nausea: was controlled with home prn compazine.
# Normocytic anemia: stable during admission
# Hypertension: patient not currently treated, has been on ACE-I
in past but blood pressures were controlled while in house.
# Diabetes Mellitus Type II- stable on sliding scale insulin in
house
# CKD - At baseline. Cr remained stable.
# H/o cerebrovascular accident - stable. continued ticlopidine.
# GERD - stable. continued home omeprazole.
.
FEN: Cardiac Heart Healthy
.
ACCESS: PIV's while in house
.
PROPHYLAXIS:
-DVT ppx with heparin gtt followed by sub cutaneous heparin.
-Pain management with tylenol
-Bowel regimen with senna/colace
.
CODE: full
Transitional issues:
-Atypical chest pain: Felt very unlikely to be cardiac.
Definitive diagnosis was difficult. She does have previously
diagnosed CAD, but does not tolerate beta blockers or aspirin.
-Social work/psych: ___ benefit from seeing a therapist
regarding anxiety. This has been broached with her in the past
and may be worth speaking to her about again.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, 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}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, UA {Urinalysis}, CXR {Plain chest X-ray}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, AnGap {Anion gap measurement}, CAD {Coronary arteriosclerosis}, HTN {Hypertensive disorder, systemic arterial}, Type II DM {Diabetes mellitus type 2}, CKD {Chronic kidney disease}, bradycardia {Bradycardia}, rhythm {Irregular heart beat}, CVA {Cerebrovascular accident}, DVT {Deep venous thrombosis}, IVC filter {Inferior vena cava filter in situ}, coumadin {Anticoagulant therapy}, jaw {Pain radiating to jaw}, neck {Neck pain}, chest {Chest pain}, torso {Trunk structure}, pain {Pain}, Atypical chest pain {Atypical chest pain}, chest pain {Chest pain}, cath {Cardiac catheterization}, arteries {Arterial structure}, stress echo {Stress echocardiography}, old infarct {Healed infarct}, ischemia {Ischemia}, EKG {Electrocardiographic procedure}, pain {Chest pain}, ACS {Acute coronary syndrome}, EKGs {Electrocardiographic procedure}, anxiety {Anxiety}, cervical stenosis {Spinal stenosis in cervical region}, musculoskeletal sprain/strain/pull {Muscle strain}, PE {Pulmonary embolism}, tachycardia {Tachycardia}, pleuritic {Pleuritic pain}, DVT {Deep venous thrombosis}, IVC filter {Inferior vena cava filter in situ}, Pna {Pneumonia}, infiltrate {Infiltration}, CXR {Plain chest X-ray}, cough {Cough}, F/C {Fever with chills}, pain {Chest pain}, heparin {Heparin therapy}, telemetry {Cardiac telemetry}, allergy {Allergic disposition}, "elevated
CPK" {Serum creatine kinase MB isoenzyme measurement}, pain {Pain}, allergy {Allergic disposition}, allergy to
propanolol {Allergy to propranolol}, UA {Urinalysis}, UTI {Urinary tract infectious disease}, nausea {Nausea}, Normocytic anemia {Normocytic anemia}, stable {Patient's condition stable}, Hypertension {Hypertensive disorder, systemic arterial}, blood pressures {Blood pressure monitoring}, Diabetes Mellitus Type II {Diabetes mellitus type 2}, sliding scale insulin {Sliding scale insulin regime}, CKD {Chronic kidney disease}, baseline {Baseline state}, stable {Patient's condition stable}, cerebrovascular accident {Cerebrovascular accident}, stable {Patient's condition stable}, GERD {Gastroesophageal reflux disease}, stable {Patient's condition stable}, Cardiac {Heart structure}, Heart {Heart structure}, PROPHYLAXIS {Preventive procedure}, DVT {Deep venous thrombosis}, ppx {Preventive procedure}, heparin {Heparin therapy}, cutaneous {Skin structure}, heparin {Heparin therapy}, Pain management {Pain management}, Bowel {Normal bowel habits}, regimen {Therapeutic regimen}, Atypical chest pain {Atypical chest pain}, cardiac {Heart disease}, CAD {Coronary arteriosclerosis}, anxiety {Anxiety} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
3. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for dizziness.
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO QID (4 times a day) as needed for heartburn.
8. ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Lantus 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime.
Discharge Medications:
1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime). Capsule(s)
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for Nausea.
5. ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea.
7. Lantus 100 unit/mL Solution Sig: Fifteen (15) Units
Subcutaneous At bedtime.
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Atypical chest pain with normal cardiac enzymes and no
electrocardiogram changes.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: Home With Service {Home health aide service management}, Atypical chest pain {Atypical chest pain}, cardiac enzymes {Finding of cardiac enzyme levels}, electrocardiogram {Electrocardiographic procedure}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, 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. ___,
It was a pleasure taking care of you in the hospital. You were
admitted for chest pain. The major concern was that this was
related to your heart. All the testing done, including lab work
and EKGs were very reassuring and it was unlikely this was
related to a problem with your heart. It may have been related
to your cervical stenosis or it may have been a muscle pull,
strain, or sprain. You should keep taking all of your
medications exactly as prescribed.
###RESPONSE: chest pain {Chest pain}, heart {Heart structure}, EKGs {Electrocardiographic procedure}, problem {Problem}, heart {Heart structure}, cervical stenosis {Spinal stenosis in cervical region}, strain {Muscle strain}, sprain {Sprain}, medications {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:
Bactrim / Claritin / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
###RESPONSE: Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, Claritin {Allergy to histamine H1 receptor antagonist}, Sulfa {Allergy to sulfonamide antibiotic}, Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, chest pain {Chest pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ CAD with NSTEMI in ___ s/p DES to LAD s/p in ___ DES
to LCX presenting with onset of rightsided cp (typical of his
angina equivilant). Pain started at rest around 1pm. resolved
s/p nitroX2. No CP since then. Pt denies SOB, n,v, diaphoresis,
dizziness, lightheaded. Of note, had a URI type illness ___
weeks ago that has resolved, but now has sporadic non-productive
cough.
In the ED, initial vitals were: 98.1 64 162/76 96RA
- Labs were significant for WBC 17. Initial trop<.01, MN trop
.02, and 02AM trop .03.
- Imaging revealed CXR with patchy R base opacity, most likely
atelectasis, but could be consistent with PNA in the right
clinical setting.
- The patient was given Asp 325,g, levofloxacin 750mg,
atorvastatin 80mg. Was started on heparin gtt.
Vitals prior to transfer were: 56 105/55 18 94% RA
Upon arrival to the floor, pt CP free. No SOB, dizziness,
lightheadedness.
###RESPONSE: CAD {Coronary arteriosclerosis}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, DES {Endovascular insertion of drug eluting stent}, LAD {Structure of anterior descending branch of left coronary artery}, DES {Endovascular insertion of drug eluting stent}, LCX {Structure of circumflex branch of left coronary artery}, angina {Angina}, Pain {Pain}, at rest {Chest pain at rest}, resolved {Problem resolved}, SOB {Dyspnea}, n,v {Nausea and vomiting}, diaphoresis {Excessive sweating}, dizziness {Dizziness}, lightheaded {Lightheadedness}, URI {Upper respiratory infection}, resolved {Problem resolved}, non-productive
cough {Dry cough}, vitals {Vital signs finding}, RA {Breathing room air}, Labs {Laboratory test}, WBC {White blood cell count}, trop {Troponin measurement}, trop {Troponin measurement}, trop {Troponin measurement}, Imaging {Imaging}, CXR {Plain chest X-ray}, R base {Structure of base of right lung}, opacity {Abnormally opaque structure}, atelectasis {Atelectasis}, PNA {Pneumonia}, levofloxacin {Antibiotic therapy}, started {New medication added}, heparin {Heparin therapy}, Vitals {Vital signs finding}, RA {Breathing room air}, CP {Chest pain}, SOB {Dyspnea}, dizziness {Dizziness}, lightheadedness {Lightheadedness} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
- Hypertension
- CAD with NSTEMI in ___ s/p DES to LAD s/p in ___ DES to
LCX
- COPD not on oxygen
- Chronic lymphocytic leukemia
- Prostate cancer
- DVT and PE in ___
- GERD
- Raynaud's syndrome
- Osteoarthritis of left knee
- Osteoporosis
- Spinal stenosis
- Attention deficit disorder
- Anxiety and depression
###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, CAD {Coronary arteriosclerosis}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, DES {Endovascular insertion of drug eluting stent}, LAD {Structure of anterior descending branch of left coronary artery}, DES {Endovascular insertion of drug eluting stent}, LCX {Structure of circumflex branch of left coronary artery}, COPD {Chronic obstructive lung disease}, oxygen {Oxygen therapy}, Chronic lymphocytic leukemia {Chronic lymphoid leukemia, disease}, Prostate cancer {Carcinoma of prostate}, DVT {Deep venous thrombosis}, GERD {Gastroesophageal reflux disease}, Raynaud's syndrome {Raynaud's disease}, Osteoarthritis of left knee {Osteoarthritis of left knee joint}, Osteoporosis {Osteoporosis}, Spinal stenosis {Spinal stenosis}, Attention deficit disorder {Attention deficit hyperactivity disorder, predominantly inattentive type}, Anxiety {Anxiety}, 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:
- Sister has a brain tumor.
- No family history of early MI, arrhythmia, cardiomyopathies,
or
sudden cardiac death; father had colon cancer
###RESPONSE: brain tumor {Neoplasm of brain}, MI {Myocardial infarction}, arrhythmia {Cardiac arrhythmia}, cardiomyopathies {Cardiomyopathy}, sudden cardiac death {Sudden cardiac death}, 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:
ADMISSION
Vitals: 98.1 131/73 58 18 94/1L Wt 86.5kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally
DISCHARGE
Vitals: t 98 BP 140/70 HR 58 RR 18 94/1L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: right base with rhonchi, no rales or wheezing. left lung
CTA.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
###RESPONSE: Vitals {Vital signs finding}, 1L {Oxygen therapy}, Wt {Weight finding}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, 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}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, GU {Examination of genitourinary system}, foley {Urinary catheter in situ}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, CNII-XII intact {Normal central nervous system}, upper {Upper limb structure}, lower extremities {Lower limb structure}, normal sensation {Normal sensation}, 2+ reflexes {Normal reflex}, Vitals {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, 1L {Oxygen therapy}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, 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}, Lungs {Examination of respiratory system}, right base {Structure of base of right lung}, rhonchi {Wheeze - rhonchi}, rales {Respiratory crackles}, wheezing {Wheezing}, left lung {Left lung structure}, CTA {Normal breath sounds}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, GU {Examination of genitourinary system}, foley {Urinary catheter in situ}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulse present}, 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:
=======================================================
LABS
ADMISSION
___ 06:10PM BLOOD WBC-17.0* RBC-5.11 Hgb-13.8 Hct-42.8
MCV-84 MCH-27.0 MCHC-32.2 RDW-18.4* RDWSD-53.7* Plt ___
___ 06:10PM BLOOD ___ PTT-30.3 ___
___ 06:10PM BLOOD Glucose-95 UreaN-32* Creat-1.2 Na-137
K-4.8 Cl-101 HCO3-24 AnGap-17
CARDIAC BIOMARKERS
___ 06:10PM BLOOD cTropnT-<0.01
___ 12:00AM BLOOD cTropnT-0.02*
___ 01:50AM BLOOD cTropnT-0.03*
___ 09:00AM BLOOD cTropnT-0.03*
___ 03:40PM BLOOD cTropnT-0.03*
___ 10:04PM BLOOD cTropnT-0.02*
___ 10:00AM BLOOD cTropnT-0.01
DISCHARGE
___ 10:00AM BLOOD WBC-15.8* RBC-5.37 Hgb-14.4 Hct-45.5
MCV-85 MCH-26.8 MCHC-31.6* RDW-19.1* RDWSD-55.3* Plt ___
___ 10:00AM BLOOD Glucose-145* UreaN-28* Creat-1.3* Na-139
K-4.2 Cl-101 HCO3-26 AnGap-16
=======================================================
MICRO
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTURE-FINALINPATIENT
No growth
=======================================================
IMAGING/STUDIES
___
Signnificant baseline artifact. Sinus rhythm. Diffuse
non-specific ST segment straightening throughout. Compared to
tracing #1 non-specific repolarization abnormalities are new and
suggest an ongoing pharmacologic metabolic process. Clinical
correlation is suggested. TRACING #2
Read ___
Intervals Axes
RatePRQRSQTQTc (___) ___
___
___ (PA & LAT)
Patchy right base opacity most likely due to atelectasis,
although infectious process is difficult to exclude in the
appropriate clinical setting.
___
Sinus rhythm. Tracing is within normal limits. Compared to the
previous
tracing of ___ the rate is minimally faster and no longer
technically
bradycardic. TRACING #1
Read ___
Intervals Axes
RatePRQRSQTQTc (___) ___
___
###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}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, CARDIAC {Heart structure}, 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}, 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}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, Culture {Blood culture}, CULTURE {Microbial culture}, No growth {No organism isolated by microbiologic culture}, IMAGING {Imaging}, STUDIES {Evaluation procedure}, baseline {Baseline state}, artifact {Artifact}, Sinus rhythm {Sinus rhythm}, non-specific ST segment straightening {Nonspecific ST-T abnormality on electrocardiogram}, abnormalities {Imaging result abnormal}, Intervals {Finding of electrocardiogram waveform}, (PA & LAT) {Diagnostic radiography of chest, combined posteroanterior and lateral}, right base {Structure of base of right lung}, opacity {Abnormally opaque structure}, atelectasis {Atelectasis}, infectious process {Infectious disease}, Sinus rhythm {Sinus rhythm}, normal {Electrocardiogram normal}, rate {Finding of heart rate}, bradycardic {Bradycardia}, Intervals {Finding of electrocardiogram waveform} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Mr. ___ is an ___ yo man with a history of NSTEMI s/p s/p
DES to LAD (___), LCX (___) who presented with right sided
light chest pressure at rest which was similar to his previous
NSTEMIs. Of note, he described holding his aspirin and
clopidogrel for a Dermatology procedure.
ACTIVE PROBLEMS
# NSTEMI
# Community acquired pneumonia
He was noted to have an NSTEMI with troponins peaking at 0.03.
His EKG was unremarkable for ischemic change, normal sinus
rhythm, TWI in V1, no STE, unchanged from prior. He was placed
on a heparin gtt with a plan for cardiac catheterization.
However, patient declined cardiac catheterization given his
desire for no invasive procedures. He also declines reversal of
code status from DNR/DNI for procedures. He is on Plavix,
aspirin, carvidilol, atorvastatin 80, and lisinopril-HCTZ at
home, and these were continued. Also, we counseled the patient
yesterday that he could NOT,
under any circumstances, discontinue his DAPT without a
cardiologist's permission.
In addition, he was noted to have a retrocardiac opacity,
leukocytosis, and a history of cough x2-3 weeks. He was started
on levofloxacin 750 mg x5 days with planned course from
___.
Unfortunately, before our team could prepare his discharge
paperwork, he walked to the nursing station dressed and shouted
that we had "no regard for patient care." I asked him to stay
for just a few minutes so that we could prepare the ___ and
homemaker services he had requested earlier, but he declined,
saying that we were just trying to "CYA." He did not leave with
his prescription for levofloxacin, or his ___ services
arranged. We forwarded this information to PCP and ___
in hopes they can assist with his follow-up care.
TRANSITIONAL ISSUES
- NSTEMI likely precipitated by holding DAPT - iterate in the
outpatient setting that he cannot discontinue these medications
- Levofloxacin 750 mg daily (___) for community acquired
PNA was prescribed but NOT completed, and he should be queried
specifically for PNA symptoms at next outpatient f/u
- Patient planned for cardiology appointment in ___ with
Dr. ___ would recommend follow up in the next month
with cardiology. Patient vocalized that he would make an
appointment within the next month to see cardiology.
###RESPONSE: NSTEMI {Acute non-ST segment elevation myocardial infarction}, DES {Endovascular insertion of drug eluting stent}, LAD {Structure of anterior descending branch of left coronary artery}, LCX {Structure of circumflex branch of left coronary artery}, right sided {Right thorax structure}, at rest {Chest pain at rest}, NSTEMIs {Acute non-ST segment elevation myocardial infarction}, aspirin {Administration of aspirin}, PROBLEMS {Problem}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, Community acquired pneumonia {Community acquired pneumonia}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, troponins {Troponin measurement}, EKG {Electrocardiographic procedure}, unremarkable {No abnormality detected}, ischemic change {Ischemia}, normal sinus
rhythm {Electrocardiogram: normal sinus rhythm}, TWI {Inverted T wave}, V1 {Lead site V1}, STE {ST segment elevation}, unchanged {Patient condition unchanged}, heparin {Heparin therapy}, cardiac catheterization {Cardiac catheterization}, cardiac catheterization {Cardiac catheterization}, procedures {Procedure}, DNR {Not for resuscitation}, procedures {Surgical procedure}, Plavix {Administration of prophylactic clopidogrel}, aspirin {Administration of aspirin}, could NOT,
under any circumstances, discontinue {Recommendation to continue with drug treatment}, opacity {Abnormally opaque structure}, leukocytosis {Leukocytosis}, cough {Cough}, started {New medication added}, levofloxacin {Antibiotic therapy}, walked {Does walk}, leave {Left against medical advice}, prescription {Prescription}, levofloxacin {Antibiotic therapy}, PCP {Primary care management}, follow-up care {Postoperative procedure education}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, cannot discontinue these medications {Recommendation to continue with drug treatment}, Levofloxacin {Antibiotic therapy}, community acquired
PNA {Community acquired pneumonia}, PNA {Pneumonia}, cardiology appointment {Cardiac care management}, follow up {Follow-up arranged}, cardiology {Cardiology service}, make an
appointment {Follow-up arranged}, cardiology {Cardiology service} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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. Aspirin 81 mg PO DAILY
3. BuPROPion (Sustained Release) 300 mg PO QAM
4. Clopidogrel 75 mg PO DAILY
5. DiphenhydrAMINE 25 mg PO QHS insomnia
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN
7. Lorazepam 1.5 mg PO QHS insomnia
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. AndroGel (testosterone) 1.25 gram/ actuation (1 %)
transdermal 5 pumps daily
11. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. Atorvastatin 80 mg PO QPM
14. Carvedilol 6.25 mg PO BID
15. Amphetamine-Dextroamphetamine 10 mg PO TID
16. glucosamine-chondroitin unknown strength oral 2 tablets PO
daily
17. Ascorbic Acid ___ mg PO DAILY
18. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram
oral with meals
19. azelastine 137 mcg (0.1 %) nasal 2 sprays NU BID as needed
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Amphetamine-Dextroamphetamine 10 mg PO TID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. BuPROPion (Sustained Release) 300 mg PO QAM
6. Clopidogrel 75 mg PO DAILY
7. DiphenhydrAMINE 25 mg PO QHS insomnia
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN
9. Lorazepam 1.5 mg PO QHS insomnia
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Carvedilol 6.25 mg PO BID
13. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
14. AndroGel (testosterone) 1.25 gram/ actuation (1 %)
transdermal 5 pumps daily
15. Ascorbic Acid ___ mg PO DAILY
16. azelastine 137 mcg (0.1 %) nasal 2 sprays NU BID as needed
17. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram
oral with meals
18. glucosamine-chondroitin 0 strength ORAL 2 TABLETS PO DAILY
19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
20. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
NSTEMI
community acquired PNA
Secondary:
CAD w/ NSTEMI s/p DES to LAD ___ DES to LCX (___)
COPD
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: NSTEMI {Acute non-ST segment elevation myocardial infarction}, community acquired PNA {Community acquired pneumonia}, CAD {Coronary arteriosclerosis}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, DES {Endovascular insertion of drug eluting stent}, LAD {Structure of anterior descending branch of left coronary artery}, DES {Endovascular insertion of drug eluting stent}, LCX {Structure of circumflex branch of left coronary artery}, COPD {Chronic obstructive lung disease}, HTN {Hypertensive disorder, systemic arterial}, 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 seen at ___ for the light chest
pressure you felt in your chest that was the same as you
experienced before with your heart attacks. You did have
elevation of troponins, which indicates a lack of blood flow to
your heart. This is concerning for ischemia, or the beginning of
a heart attack. We placed you on a medication called heparin to
prevent ischemia. Your troponins trended down, and your EKG was
normal. You were seen by our cardiology team, who felt that you
should have a cardiac catheterization to evaluate your heart
vessels and stents. You declined this procedure as it is not
within your goals of care.
In addition, you were noted to have a pneumonia, and we are
treating you with antibiotics. Please continue these until
___.
We are keeping you on your home medications. Please follow up
with your appointments that we have arranged. Please follow up
with your cardiologist Dr. ___ the next month as we
discussed.
It was a pleasure taking care of you.
Your ___ team
###RESPONSE: chest
pressure {Tight chest}, chest {Thoracic structure}, heart attacks {Myocardial infarction}, elevation {Measurement finding above reference range}, troponins {Troponin measurement}, lack of blood flow {Decreased vascular flow}, heart {Heart structure}, ischemia {Ischemia}, heart attack {Myocardial infarction}, medication {Administration of drug or medicament}, heparin {Heparin therapy}, prevent {Preventive procedure}, ischemia {Ischemia}, troponins {Troponin measurement}, EKG {Electrocardiographic procedure}, normal {Electrocardiogram normal}, cardiology {Cardiology service}, cardiac catheterization {Cardiac catheterization}, evaluate {Evaluation procedure}, heart
vessels {Coronary artery structure}, stents {Coronary stent patent}, procedure {Procedure}, pneumonia {Pneumonia}, antibiotics {Antibiotic therapy}, keeping {Recommendation to continue with drug treatment}, medications {Administration of drug or medicament}, follow up {Follow-up arranged}, follow up {Follow-up arranged} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
none
Major Surgical or Invasive Procedure:
None.
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ ___ speaking, with h/o dementia living in senior
apartment who presented with reported suicidal ideation. History
is gathered mainly from reports as pt poor historian. Per EMS a
family member at the scene stated that the pt was upset about
breaking up with her boyfriend and has had increased depression.
Tried to jump out of a window and family had to restrain her.
EMS found her calm, cooperative, and smiling.
.
In the ED, initial VS: 98.1 64 160/75 20 99%. She was noted to
only be oriented to person and needed a sitter for wandering
off, but was pleasant and cooperative. Through interpreter in
the ED, the only positive ROS was pain with urination. The ED
housestaff spoke to the son who stated he's having a hard time
taking care of her. Case management contacted in the ED --
because of her dementia she needs to have a guardian or HCP
assigned before she can placed and requires admission in the
meantime.
.
Psych saw the pt who noted her to be disoriented at baseline,
unable to provide any history or details of what happened, no SI
or HI; they note severe memory deficits and baseline is
wandering and getting lost, unable to recall family, unable to
feed or bathe self but can feed herself.
###RESPONSE: dementia {Dementia}, suicidal ideation {Suicidal thoughts}, poor historian {Poor historian}, upset {Feeling upset}, depression {Depressive disorder}, calm {Feeling calm}, cooperative {Cooperative mental state}, smiling {Smiling}, VS {Vital signs finding}, oriented to person {Oriented to person}, wandering {Wandering}, cooperative {Cooperative mental state}, ROS {Review of systems}, pain with urination {Dysuria}, dementia {Dementia}, memory deficits {Memory impairment}, wandering {Wandering}, getting lost {Getting lost}, bathe self {Unable to bath self}, can feed herself {Able to feed self} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 -> per husband patient has had this diagnosis for ___
years. She apparently does not remember family members names
intermittently, she gets lost, has a history of falls, per notes
with neuropsychologist Dr. ___ also has been having a long
history of word finding-difficulty. According to her husband,
her cognitive baseline is that she is alert & oriented to person
only. She cannot dress or bathe herself but she can eat
independently. She usually is talkative and understands commands
and conversations.
- Diabetes (Type 2)
- Psoriasis
- Hypertension
- Depression
- cholecystectomy
- hysterectomy
- Breast cancer status post lumpectomy, radiation, and CMF
chemotherapy. This was stage I invasive mucinous carcinoma of
the right breast diagnosed in ___.
###RESPONSE: Dementia {Dementia}, gets lost {Getting lost}, word finding-difficulty {Word finding difficulty}, alert {Mentally alert}, oriented to person {Oriented to person}, cannot dress {Unable to dress}, bathe {Unable to bath self}, can eat
independently {Able to feed self}, Diabetes (Type 2) {Diabetes mellitus type 2}, Psoriasis {Psoriasis}, Hypertension {Hypertensive disorder, systemic arterial}, Depression {Depressive disorder}, cholecystectomy {Cholecystectomy}, hysterectomy {Hysterectomy}, Breast cancer {Malignant neoplasm of breast}, status post {Postoperative state}, lumpectomy {Excision of mass}, radiation {Radiation oncology AND/OR radiotherapy}, chemotherapy {Chemotherapy}, mucinous carcinoma {Mucinous adenocarcinoma}, right breast {Right breast structure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |