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JaimeML
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snomed-entity-challenge

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train · 2.1k rows

text stringlengths 539 21.6k
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Past Medical History: - CAD, s/p stent ___ - Non-healing foot wound - Diabetes Mellitus , type II - Hypertension - Hyperlipidemia - anxiety ###RESPONSE: CAD {Coronary arteriosclerosis}, stent {Insertion of arterial stent}, Non-healing foot wound {Chronic ulcer of right foot}, Diabetes Mellitus , type II {Diabetes mellitus type 2}, Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, 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: Social History: ___ ###RESPONSE: EMPTY: No SNOMED annotations found in this fragment
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Family History: significant for CAD in father and diabetes mellitis, type II in mother Physical ___: Vital Signs: 98.3 79 150/79 18 98%/RA General: alert and oriented x 3, lying in bed in NAD HEENT: atraumatic, skin anicteric, MMM, no lymphadenopathy appreciated CV: RRR Pulm: breathing unlabored Abd: Soft, NT, ND Left groin puncture site: well approximated, soft, no ecchymosis, no drainage Extremities: Pulses: (___): R: P/ /D/faintly palpable L: P/ /D/D ###RESPONSE: CAD {Coronary arteriosclerosis}, diabetes mellitis, type II {Diabetes mellitus type 2}, Vital Signs {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, alert {Mentally alert}, oriented x 3 {Oriented to person, time and place}, lying in bed {Lying in bed}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, atraumatic {No injuries apparent}, skin anicteric {Normal color of skin}, MMM {Moist oral mucosa}, lymphadenopathy {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, Pulm {Examination of respiratory system}, unlabored {Breathing easily}, Abd {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, Left groin {Left inguinal region structure}, puncture site {Insertion site}, well approximated {Wound healing well}, soft {Abdomen soft}, ecchymosis {Ecchymosis}, drainage {Wound discharge}, Extremities {Examination of limb}, Pulses {Normal pulse}, palpable {Finding by palpation}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Pertinent Results: ___ 06:02AM BLOOD Hct-31.9* ___ 06:02AM BLOOD Creat-0.8 K-4.___ with PMH signifcant for CAD, s/p stenting in ___, HTN, DM, and HLD who presents with a 6 month history of a non-healing right heel ulcer. She was admitted on ___ for a right lower extremity angiogram. As a result of findings, a bare metal stent was placed in distal SFA/popliteal artery and at the end of the case, patient had dopplerable ___ signals bilaterally. For full details of the surgical procedure please see the dictated operative report. Patient tolerated the procedure well. She requested to stay over night which provided opportunity for continued monitoring of her groin puncture site. She did have some bleeding overnight which was quickly controlled with manual pressure. It continues to do well and on exam has no further drainage. Her diet was advanced to a house diet which she tolerated well. She was able to void on her own QS and was able to ambulate with her walker in her room. Paient had a bare metal stent placed in her distal SFA which will require a 30 day course of clopidogrel. Patient reports a history of clopidogrel use since placement of coronary stents in ___ but she reports she no longer requires it. She was advised to follow up with cardiology for further guidance on that. She should continue her daily ASA 81mg. Patient has a PMH of Diabetes Mellitus which was stable during admission. Her home medication, metformin was held and her blood sugars were addressed with SSI. Patient has a PMH of HTN, which was stable during admission, however, the patient had some confusion about which doses and medications she should be taking. The PCP office, Dr. ___, as well as the pharmacy, was contacted by this author and several discrepancies were found between patient's recollection and PCPs recommendations. ___ services have been arranged to follow the patient after discharge and a request was made to have the RN complete a medication reconciliation with the patient at home. The current medication list from this discharge is complete and accurate per the PCP ___. PCP ___ follow up with ___ findings at patient's follow up appt. Patient will also need to follow up with vascular surgery for a RLE duplex and office visit in approximately 1 month. Patient should continue to follow up with Podiatry for her right heel ulcer and should off-load the heel to assist with healing. Patient is discharged home with services in an improved and stable condition. ###RESPONSE: Hct {Hematocrit determination}, Creat {Creatinine measurement}, K {Blood potassium measurement}, CAD {Coronary arteriosclerosis}, stenting {Insertion of arterial stent}, HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, HLD {Hyperlipidemia}, non-healing right heel ulcer. {Chronic ulcer of right heel}, right lower extremity angiogram {Angiography of artery of right lower limb}, stent was placed {Placement of stent}, SFA/popliteal artery {Femoral and popliteal arteries (combined site)}, surgical procedure {Surgical procedure}, procedure {Procedure}, monitoring {Monitoring procedure}, groin {Inguinal region structure}, puncture site {Insertion site}, bleeding {Bleeding}, pressure {Application of dressing, pressure}, drainage {Wound discharge}, diet was advanced {Advance diet as tolerated}, diet {Dietary regime}, able to void {Normal micturition}, able to ambulate {Able to walk}, walker {Uses zimmer frame}, stent placed {Placement of stent}, SFA {Structure of superficial femoral artery}, placement of coronary stents {Placement of stent in coronary artery}, follow up with cardiology {Follow-up cardiac assessment}, Diabetes Mellitus {Diabetes mellitus}, stable {Patient's condition stable}, blood sugars {Blood sugar management}, SSI {Sliding scale insulin regime}, HTN {Hypertensive disorder, systemic arterial}, stable {Patient's condition stable}, PCP {Primary care management}, PCP {Primary care management}, medication reconciliation {Medication reconciliation}, PCP {Primary care management}, PCP {Primary care management}, vascular surgery {Vascular surgery procedure}, RLE {Structure of right lower limb}, duplex {Duplex ultrasonography of veins of lower limb}, right heel {Structure of right heel}, heel {Heel structure}, healing {Structure resulting from tissue repair process}, improved {Patient's condition improved}, 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. Aspirin 81 mg PO DAILY 2. amLODIPine 5 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 5. losartan 50 mg oral DAILY 6. MetFORMIN (Glucophage) 1000 mg PO TAKE 500MG IN AM AND 1000MG IN ___ 7. Omeprazole 20 mg PO DAILY 8. Pravastatin 10 mg PO QPM 9. RisperiDONE 1 mg PO DAILY 10. Collagenase Ointment 1 Appl TP DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Clopidogrel 75 mg PO DAILY Take for 30 days only RX clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:*0 3. amLODIPine 5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Collagenase Ointment 1 Appl TP DAILY 6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 7. Losartan Potassium 50 mg PO DAILY 8. losartan 50 mg oral DAILY 9. MetFORMIN (Glucophage) 1000 mg PO TAKE 500MG IN AM AND 1000MG IN ___ 10. Omeprazole 20 mg PO DAILY 11. Pravastatin 10 mg PO QPM 12. RisperiDONE 1 mg PO DAILY ###RESPONSE: EMPTY: No SNOMED annotations found in this fragment
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Peripheral vascular disease with non-healing ulcer Secondary: Diabetes Mellitus- type II, Hypertension, hyperlipidemia 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}, Peripheral vascular disease {Peripheral vascular disease}, healing ulcer {Healing ulcer}, Diabetes Mellitus- type II {Diabetes mellitus type 2}, Hypertension {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Discharge Instructions: Ms. ___, It was a pleasure taking care of you at ___ ___. You were admitted to the hospital after a peripheral angiogram. To do the test, a small puncture was made in one of your arteries. The puncture site heals on its own: there are no stitches to remove. You tolerated the procedure well and are now ready to be discharged from the hospital. Please follow the recommendations below to ensure a speedy and uneventful recovery. Peripheral Angiography Puncture Site Care For one week: Do not take a tub bath, go swimming or use a Jacuzzi or hot tub. Use only mild soap and water to gently clean the area around the puncture site. Gently pat the puncture site dry after showering. Do not use powders, lotions, or ointments in the area of the puncture site. You may remove the bandage and shower the day after the procedure. You may leave the bandage off. You may have a small bruise around the puncture site. This is normal and will go away one-two weeks. Activity For the first 48 hours: Do not drive for 48 hours after the procedure For the first week: Do not lift, push , pull or carry anything heavier than 10 pounds Do not do any exercises or activity that causes you to hold your breath or bear down with abdominal muscles. Take care not to put strain on your abdominal muscles when coughing, sneezing, or moving your bowels. After one week: You may go back to all your regular activities, including sexual activity. We suggest you begin your exercise program at half of your usual routine for the first few days. You may then gradually work back to your full routine. Medications: Before you leave the hospital, you will be given a list of all the medicine you should take at home. If a medication that you normally take is not on the list or a medication that you do not take is on the list please discuss it with the team! For Problems or Questions: Call ___ in an emergency such as: Sudden, brisk bleeding or swelling at the groin puncture site that does not stop after applying pressure for ___ minutes Bleeding that is associated with nausea, weakness, or fainting. Call the vascular surgery office (___) right away if you have any of the following. (Please note that someone is available 24 hours a day, 7 days a week) Swelling, bleeding, drainage, or discomfort at the puncture site that is new or increasing since discharge from the hospital Any change in sensation or temperature in your legs Fever of 101 or greater Any questions or concerns about recovery from your angiogram ###RESPONSE: angiogram {Angiography}, puncture {Puncture}, arteries {Arterial structure}, puncture site {Insertion site}, stitches {Removal of suture}, procedure {Procedure}, Peripheral Angiography {Angiography of peripheral vascular system}, Puncture Site {Insertion site}, puncture site {Insertion site}, puncture site {Insertion site}, puncture site {Insertion site}, shower {Functional activity education}, procedure {Procedure}, bruise {Contusion}, puncture site {Insertion site}, normal {No abnormality detected}, Activity {Functional activity education}, Do not drive {Recommendation to avoid activity of daily living}, procedure {Procedure}, lift {Does lift}, push {Does push}, pull {Does pull}, carry {Does carry}, exercises {Exercises}, activity {Functional activity education}, abdominal muscles {Entire skeletal muscle of abdomen}, strain {Muscle strain}, abdominal muscles {Entire skeletal muscle of abdomen}, coughing {Cough}, sneezing {Sneezing}, bowels {Intestinal structure}, activities {Functional activity education}, sexual activity {Finding relating to sexual behavior}, exercise {Exercises}, bleeding {Bleeding}, swelling {Swelling}, groin {Inguinal region structure}, puncture site {Insertion site}, pressure {Application of dressing, pressure}, Bleeding {Bleeding}, nausea {Nausea}, weakness {Asthenia}, fainting {Syncope}, Swelling {Swelling}, bleeding {Bleeding}, drainage {Wound discharge}, discomfort {Discomfort}, puncture site {Insertion site}, change in sensation {Altered sensation of skin}, temperature {Body temperature finding}, legs {Lower limb structure}, Fever {Fever}, angiogram {Angiography}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: Bactrim / Ampicillin / Sulfa (Sulfonamide Antibiotics) / cefuroxime / Gadolinium-Containing Contrast Media / gluten / nadolol / Pneumovax 23 Attending: ___ Chief Complaint: low grade fevers, abdominal pain Major Surgical or Invasive Procedure: ___ line placement ###RESPONSE: Ampicillin {Allergy to ampicillin}, Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, cefuroxime {Allergy to cefuroxime}, Contrast Media {Allergy to contrast media}, gluten {Allergy to gluten}, nadolol {Allergy to nadolol}, low grade fevers {Low grade pyrexia}, abdominal pain {Abdominal pain}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: History of Present Illness: Mrs. ___ is a ___ year-old lady with a history of cirrhosis due to PSC complicated by ascites, encephalopathy and varices being admitted directly from clinic due to low grade fevers and abdominal pain in the setting of recurrent ascending cholangitis. Mrs. ___ has been having chill and low grade fevers (100.0-100.4) with a peak temperature at 100.7 today. She has also been having RUQ discomfort, nausea requiring her to take her prn ondansetron. She also reports some mild arthralgias and fatigue that are typical for her when she has an episode of cholangitis. In clinic , initial vitals were: 98.5 \| 114/53 \| 84 \| 16 \| 99%RA Labs were notable for: CBC: 5.2 > 10.5/34.0 < 266 Na 140 \| K 4.3 \| Cl 101 \| HCO3 29 \| BUN 13 \| Cr 0.7 AST 51 \| ALT 46 \| AP 292 \| TB 1.1 \| INR 1.2 UA negative *1xBCx drawn Patient was directly admitted to ___ 10. Currently, she complains of mild nausea and abdominal discomfort. Does not feel feverish anymore. Denies recent gluten exposure although household not gluten-free, uses same pots and pans. ###RESPONSE: cirrhosis {Cirrhosis of liver}, PSC {Primary sclerosing cholangitis}, ascites {Ascites}, encephalopathy {Disorder of brain}, varices {Esophageal varices}, low grade fevers {Low grade pyrexia}, abdominal pain {Abdominal pain}, ascending cholangitis {Ascending cholangitis}, chill {Chill}, low grade fevers {Low grade pyrexia}, temperature {Body temperature finding}, RUQ {Right upper quadrant pain}, discomfort {Discomfort}, nausea {Nausea}, mild {Symptom mild}, arthralgias {Joint pain}, fatigue {Fatigue}, cholangitis {Cholangitis}, vitals {Vital signs finding}, RA {Breathing room air}, CBC {Complete blood count}, UA {Urinalysis}, negative {No abnormality detected}, mild {Symptom mild}, nausea {Nausea}, abdominal discomfort {Abdominal discomfort}, feel feverish {Feeling feverish}, gluten {Allergy to gluten}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: - Primary sclerosing cholangitis (PSC) - History of recurrent cholangitis requiring hospitalization and IV antibiotics - ___ Laparoscopic cholecystectomy with liver biopsy showing bile ductular proliferation and very focal early, incomplete nodule formation (stage ___ fibrosis) - Celiac sprue (diagnosed by biopsy, slightly elevated tTG) - Hypertension - GERD - Hypothyroidim - OSA previously on CPAP - negative on repeat testing - (?) IBD (Crohn disease diagnosed at ___ at the age of ___, but questionable diagnosis as no symptoms for over ___ ###RESPONSE: Primary sclerosing cholangitis {Primary sclerosing cholangitis}, recurrent cholangitis {Recurrent cholangitis}, IV antibiotics {Intravenous antibiotic therapy}, Laparoscopic cholecystectomy {Laparoscopic cholecystectomy}, liver biopsy {Biopsy of liver}, nodule {Nodule}, fibrosis {Fibrosis}, Celiac sprue {Celiac disease}, biopsy {Biopsy}, elevated {Measurement finding above reference range}, tTG {Serum tissue transglutaminase level}, Hypertension {Hypertensive disorder, systemic arterial}, GERD {Gastroesophageal reflux disease}, Hypothyroidim {Hypothyroidism}, OSA {Obstructive sleep apnea syndrome}, on CPAP {Dependence on continuous positive airway pressure ventilation}, negative {No abnormality detected}, IBD {Inflammatory bowel disease}, Crohn disease {Crohn's disease}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Social History: ___ ###RESPONSE: EMPTY: No SNOMED annotations found in this fragment
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Family History: Daughter has ___ disease. The patient denies a history of premature cardiac disease such as MI, arrhythmia or sudden cardiac death. No history of liver disease. Sister with endometrial cancer and thyroid condition. Other sister and a brother with thyroid condition. Father with CAD, DM. Mother with thyroid disease and peritoneal cancer. ###RESPONSE: cardiac disease {Heart disease}, MI {Myocardial infarction}, arrhythmia {Cardiac arrhythmia}, sudden cardiac death {Sudden cardiac death}, liver disease {Disorder of liver}, endometrial cancer {Endometrial carcinoma}, thyroid condition {Disorder of thyroid gland}, thyroid condition {Disorder of thyroid gland}, CAD {Coronary arteriosclerosis}, DM {Diabetes mellitus}, thyroid disease {Disorder of thyroid gland}, peritoneal cancer {Malignant tumor of peritoneum}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Physical Exam: ADMISSION EXAM: =============== VS: 98.7 \| 108/60 \| 76 \| 18 \| 98%RA General: Well-appearing, alert and oriented, no acute distress HEENT: No scleral icterus or conjunctival pallor, MMM Neck: No JVD, no LAD CV: RRR, no murmurs/rubs/gallops Lungs: Clear to auscultation bilaterally Abdomen: non-distended, soft, mild tenderness in RUQ, no rebound GU: no Foley Ext: WWP, 1+ bilateral lower extremity edema Neuro: AOx3, no asterixis, fluent speech, no focal deficits Skin: Tanned skin, no lesions DISCHARGE EXAM: =============== VS: 98.6 tm: 98.8 67 (64-72) 101/51 (95-108/46-58) 18 100RA General: Well-appearing, alert and oriented, no acute distress HEENT: No scleral icterus or conjunctival pallor, MMM Neck: No JVD, no LAD CV: RRR, ___ systolic ejection murmur, no rubs/gallops Lungs: Clear to auscultation bilaterally Abdomen: non-distended, soft, mild tenderness in RUQ, no rebound GU: no Foley Ext: WWP, 1+ bilateral lower extremity edema Neuro: AOx3 fluent speech, no focal deficits Skin: Tanned skin, no lesions ###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, Well-appearing {Well cared for appearance}, alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, scleral icterus {Scleral icterus}, conjunctival pallor {Pale conjunctiva}, MMM {Moist oral mucosa}, Neck {Physical examination procedure}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, Abdomen {Examination of abdomen}, non-distended {Normal abdominal contour}, soft {Abdomen soft}, mild {Symptom mild}, tenderness {Tenderness}, RUQ {Structure of right upper quadrant of abdomen}, rebound {Rebound tenderness}, GU {Examination of genitourinary system}, Foley {Urinary catheter in situ}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, edema {Edema}, Neuro {Neurological examination}, AOx3 {Oriented to person, time and place}, asterixis {Asterixis}, fluent speech {Finding of fluency of speech}, no focal deficits {Normal nervous system function}, Skin {Examination of skin}, lesions {Lesion}, VS {Vital signs finding}, General {General examination of patient}, Well-appearing {Well cared for appearance}, alert {Mentally alert}, oriented {Oriented to person}, distress {Distress}, scleral icterus {Scleral icterus}, conjunctival pallor {Pale conjunctiva}, MMM {Moist oral mucosa}, Neck {Neck structure}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, systolic ejection murmur {Systolic murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, mild {Symptom mild}, tenderness {Tenderness}, RUQ {Structure of right upper quadrant of abdomen}, rebound {Rebound tenderness}, GU {Examination of genitourinary system}, Foley {Urinary catheter in situ}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, bilateral lower extremity edema {Edema of bilateral lower limbs}, Neuro {Neurological examination}, AOx3 {Oriented to person, time and place}, fluent speech {Finding of fluency of speech}, no focal deficits {Normal nervous system function}, Skin {Examination of skin}, lesions {Skin lesion}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: =============== ___ 11:15AM BLOOD WBC-5.2 RBC-3.99 Hgb-10.5* Hct-34.0 MCV-85 MCH-26.3 MCHC-30.9* RDW-22.2* RDWSD-68.0* Plt ___ ___ 11:15AM BLOOD Neuts-67.0 Lymphs-12.8* Monos-15.3* Eos-3.9 Baso-0.8 Im ___ AbsNeut-3.45 AbsLymp-0.66* AbsMono-0.79 AbsEos-0.20 AbsBaso-0.04 ___ 11:15AM BLOOD ___ ___ 11:15AM BLOOD UreaN-13 Creat-0.7 Na-140 K-4.3 Cl-101 HCO3-29 AnGap-14 ___ 11:15AM BLOOD ALT-46* AST-51* AlkPhos-292* TotBili-1.1 ___ 11:15AM BLOOD Albumin-4.2 ___ 11:15AM BLOOD AFP-2.0 MICROBIOLOGY: ============== URINE CULTURE (Final ___: NO GROWTH. Blood culture x3: PENDING, NGTD DISCHARGE LABS: =============== ___ 06:24AM BLOOD WBC-3.4* RBC-3.57* Hgb-9.5* Hct-31.2* MCV-87 MCH-26.6 MCHC-30.4* RDW-22.3* RDWSD-71.2* Plt ___ ___ 06:24AM BLOOD ___ PTT-39.9* ___ ___ 06:24AM BLOOD Glucose-119* UreaN-9 Creat-0.5 Na-141 K-4.2 Cl-107 HCO3-26 AnGap-12 ___ 06:24AM BLOOD ALT-31 AST-30 AlkPhos-257* TotBili-0.6 ___ 06:24AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0 ###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}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, MICROBIOLOGY {Microbiology}, URINE CULTURE {Urine culture}, Blood culture {Blood culture}, 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}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Brief Hospital Course: Mrs. ___ is a ___ year-old woman with a history of cirrhosis due to PSC complicated by ascites, encephalopathy and varices being admitted directly from clinic due to low grade fevers and abdominal pain in the setting of history of recurrent ascending cholangitis. #FEVERS/RUQ tenderness: Low grade fever at home with RUQ discomfort and associated nausea. On presentation she was afebrile and hemodynamically stable. She was found to have no leukocytosis and her LFTS were at baseline, AST: 51, ALT: 46, AP: 292, Tb: 1.1. Lipase was WNL. MRCP was not done given her recent unchanged MRCP in ___. Given her history of recurrent ascending cholangitis with resistant organisms, treatment for presumed cholangitis was initiated. Blood cultures were sent, with no growth to date. Hepatology was consulted and she was initially started on meropenem per their recommendations. She was then switched to cefepime/flagyl which she tolerated well. Her pain and nausea improved and she continued to be afebrile and hemodynamically stable. A picc line was placed and she ultimately was switched to ertapenem on discharge for a total 14 day course. #PSC: There was low concern for new stenotic lesion given recent stable MRCP in ___. She was continued on her home ursodiol, cholestyramine and hydroxyzine. # CIRRHOSIS: Due to PSC. Childs class B. MELD 9. She was continued on rifaximin. Her home diuretics were held in the setting of infection. They were not resumed on discharge given soft blood pressures in the ___ range. * Transplant status: unclear * Hepatic encephalopathy: Cont rifaximin, only takes lactulose prn * Fluid status: holding diuretics * h/o SBP: no hx, protein 0.9 * Variceal status: 2x grade II varices s/p banding TRANSITIONAL ISSUES: ===================== - Lasix and spironolactone were held in the setting of infection, blood pressures lower than baseline thoughout admission without evidence of volume overload, please re-evaluate at follow-up appointment - f/u blood cx - receiving ertapenem 1G daily via ___ line with ___ services, will need PICC removed after last day of antibiotics on ___ ###RESPONSE: cirrhosis {Cirrhosis of liver}, PSC {Primary sclerosing cholangitis}, ascites {Ascites}, encephalopathy {Disorder of brain}, varices {Esophageal varices}, low grade fevers {Low grade pyrexia}, abdominal pain {Abdominal pain}, ascending cholangitis {Ascending cholangitis}, FEVERS {Fever}, RUQ tenderness {Tenderness of right upper quadrant of abdomen}, Low grade fever {Low grade pyrexia}, RUQ {Right upper quadrant pain}, discomfort {Discomfort}, nausea {Nausea}, afebrile {Temperature normal}, hemodynamically stable {Hemodynamically stable}, leukocytosis {Leukocytosis}, LFTS {Hepatic function panel}, baseline {Baseline state}, AST {Aspartate aminotransferase measurement}, ALT {Alanine aminotransferase measurement}, AP {Alkaline phosphatase measurement}, Tb {Finding of bilirubin level}, Lipase {Serum lipase measurement}, WNL {No abnormality detected}, MRCP {Magnetic resonance cholangiopancreatography}, MRCP {Magnetic resonance cholangiopancreatography}, ascending cholangitis {Ascending cholangitis}, cholangitis {Cholangitis}, Blood cultures {Blood culture}, pain {Abdominal pain}, nausea {Nausea}, improved {Patient's condition improved}, afebrile {Fever}, hemodynamically stable {Hemodynamically stable}, picc line was placed {Percutaneous transluminal insertion of peripherally inserted central catheter}, PSC {Primary sclerosing cholangitis}, stenotic lesion {Stenosis of bile duct}, MRCP {Magnetic resonance cholangiopancreatography}, CIRRHOSIS {Cirrhosis of liver}, PSC {Primary sclerosing cholangitis}, diuretics {Diuretic therapy}, infection {Infectious disease}, soft blood pressures {Low blood pressure}, Hepatic encephalopathy {Hepatic encephalopathy}, diuretics {Diuretic therapy}, SBP {Primary bacterial peritonitis}, varices {Esophageal varices}, banding {Banding}, infection {Infectious disease}, blood pressures lower than baseline {Low blood pressure}, volume overload {Hypervolemia}, blood cx {Blood culture}, PICC {Peripherally inserted central venous catheter in situ}, removed {Removal of catheter}, antibiotics {Antibiotic therapy}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO BID:PRN nausea 2. Cholestyramine 4 gm PO DAILY 3. Escitalopram Oxalate 20 mg PO DAILY 4. Furosemide 40 mg PO BID 5. HydrOXYzine 50 mg PO QHS:PRN itching 6. Lactulose 15 mL PO BID:PRN confusion 7. Levothyroxine Sodium 75 mcg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Rifaximin 550 mg PO BID 10. Spironolactone 100 mg PO BID 11. Temazepam 15 mg PO QHS:PRN insomnia 12. Ursodiol 300 mg PO TID 13. Ferrous Sulfate 325 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Ertapenem Sodium 1 g IV ONCE cholangitis Duration: 1 Dose Continue until last dose on ___. RX ertapenem [Invanz] 1 gram 1 gram IV daily Disp #12 Vial Refills:*0 2. Cholestyramine 4 gm PO DAILY 3. Escitalopram Oxalate 20 mg PO DAILY 4. HydrOXYzine 50 mg PO QHS:PRN itching 5. Lactulose 15 mL PO BID:PRN confusion 6. Levothyroxine Sodium 75 mcg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Rifaximin 550 mg PO BID 10. Temazepam 15 mg PO QHS:PRN insomnia 11. Ursodiol 300 mg PO TID 12. Ferrous Sulfate 325 mg PO DAILY 13. Ondansetron 4 mg PO BID:PRN nausea ###RESPONSE: EMPTY: No SNOMED annotations found in this fragment
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: CHOLANGITIS PSC SECONDARY DIAGNOSIS: Cirrhosis ___ PSC recurrent cholangitis 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}, CHOLANGITIS {Cholangitis}, PSC {Primary sclerosing cholangitis}, Cirrhosis {Cirrhosis of liver}, PSC {Primary sclerosing cholangitis}, recurrent cholangitis {Recurrent cholangitis}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Discharge Instructions: Dear Ms. ___, You came into the hospital because you were having low grade fevers and abdominal pain. You were treated with antibiotics for cholangitis and monitored in the hospital. Your pain improved on antibiotics. Your spironolactone and lasix were held because of your infection. You were given a PICC line and arranged to have antibiotics through the PICC line for a total course of 14 days. You were instructed to stop taking your lasix and spironolactone on discharge because your blood pressures have been lower than usual. The liver clinic will call you with a follow-up appointment with Dr. ___. It was a pleasure being involved in your care! Your ___ Team ###RESPONSE: low grade fevers {Low grade pyrexia}, abdominal pain {Abdominal pain}, treated with antibiotics {Antibiotic therapy}, cholangitis {Cholangitis}, pain {Pain}, improved {Patient's condition improved}, antibiotics {Antibiotic therapy}, lasix {Diuretic therapy}, infection {Infectious disease}, PICC line {Percutaneous transluminal insertion of peripherally inserted central catheter}, antibiotics {Antibiotic therapy}, PICC line {Peripherally inserted central venous catheter in situ}, lasix {Diuretic therapy}, blood pressures have been lower {Low blood pressure}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: 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: Compazine / Tree Nut Attending: ___ ___ Complaint: SOB, cough Major Surgical or Invasive Procedure: none ###RESPONSE: Compazine {Allergy to prochlorperazine}, Tree Nut {Allergy to tree nut}, SOB {Dyspnea}, cough {Cough}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: ___ hx of COPD, s/p trach x2, multiple intubations for resp failure who presents with worsening SOB for over a week. Pt had been completing prednisone taper however the past several days she noted increas in cough and sputum production. Also reports chest tightness which began yesterday which she describes as pleuritic, non-radiating and non-exertional States she has had similar symptoms in past with severe COPD flares. Denies abdominal pain or emesis although states she did have decreased appetite and nausea yesterday. No dysuria. States she was not having known fevers at home although does not appear to have been taking temperature. Did take a dose of PO levo today as well. Sick contacts include her mother who is currently hospitalized with a COPD exacerbation and possible pna. Had been using xopenex nebs at home. On arrival to the ED, VS: 102.0 ___ 28 100% 15L NRB. After nebs, VS: HR 160s 220/100. Pt started on nitroglycerin gtt. Also received CTX, azithro and 125 mg methylprednisone. Pt required ICU transfer given nonrebreather requirement. On the floor, VS: 98.7, 133/87, HR 119, 96% on 2L NC. Pt states her breathing is much improved. She does now have a headache. Chest tightness still present although has improved as respiratory status improving. Review of systems: (+) Per HPI (-) Denies recent weight loss or gain. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. ###RESPONSE: COPD {Chronic obstructive lung disease}, trach {Exteriorization of trachea}, intubations {Insertion of endotracheal tube}, resp failure {Respiratory failure}, worsening {Patient's condition worsened}, SOB {Dyspnea}, prednisone {Steroid therapy}, taper {Medication decreased}, cough {Cough}, sputum production {Sputum finding}, chest tightness {Tight chest}, pleuritic {Pleuritic pain}, radiating {Radiating pain}, exertional {Chest pain on exertion}, severe {Symptom severe}, COPD flares {Acute exacerbation of chronic obstructive airways disease}, abdominal pain {Abdominal pain}, emesis {Vomiting}, decreased appetite {Decrease in appetite}, nausea {Nausea}, dysuria {Dysuria}, fevers {Fever}, taking temperature {Temperature taking}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, VS {Vital signs finding}, NRB {Oxygen administration by mask}, VS {Vital signs finding}, HR {Finding of heart rate}, started {New medication added}, ICU transfer {Patient transfer to intensive care unit}, VS {Vital signs finding}, HR {Finding of heart rate}, 2L NC {Oxygen administration by nasal cannula}, breathing {Difficulty breathing}, improved {Patient's condition improved}, headache {Headache}, Chest tightness {Tight chest}, improved {Patient's condition improved}, respiratory {Respiratory function finding}, improving {Patient's condition improved}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, chest pain {Chest pain}, chest pressure {Tight chest}, palpitations {Palpitations}, weakness {Asthenia}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, changes in bowel habits {Altered bowel function}, dysuria {Dysuria}, frequency {Increased frequency of urination}, urgency {Urgent desire to urinate}, arthralgias {Joint pain}, myalgias {Muscle pain}, rashes {Eruption of skin}, skin changes {Skin appearance abnormal}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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, PFTs in ___ with FEV1 0.30 (13%), FVC 1.02 (34%) and FVC/FEV1 38% - on Home O2 at 3L NC, on chronic steroids, hx of prolonged intubation requiring trach for resp failure in ___, ___. She was recently taken off the lung transplant list at the ___ due to compression fractures. Has previous history of asthma per OMR 2. Hypertension 3. Anxiety 4. Leukocytosis of unknown etiology with negative BMBx. 5. Osteoporosis with compression fractures 6. Shoulder pain 7. History of positive PPD s/p 6mos of isoniazid 8. Mitral valve prolapse 9. Obstructive sleep apnea on BiPAP ___ every night) ###RESPONSE: COPD {Chronic obstructive lung disease}, PFTs {Measurement of respiratory function}, FEV {Finding of forced expired volume}, FVC {Finding of forced vital capacity}, Home O2 {Home oxygen therapy}, 3L NC {Oxygen administration by nasal cannula}, steroids {Steroid therapy}, intubation {Insertion of endotracheal tube}, trach {Exteriorization of trachea}, resp failure {Respiratory failure}, lung transplant {Transplant of lung}, compression fractures {Compression fracture}, asthma {Asthma}, Hypertension {Hypertensive disorder, systemic arterial}, Anxiety {Anxiety}, Leukocytosis {Leukocytosis}, negative {No pathologic diagnosis}, BMBx {Bone marrow sampling}, Osteoporosis {Osteoporosis}, compression fractures {Compression fracture}, Shoulder pain {Shoulder pain}, positive PPD {Mantoux: positive}, Mitral valve prolapse {Mitral valve prolapse}, Obstructive sleep apnea {Obstructive sleep apnea syndrome}, BiPAP {Bilevel positive airway pressure titration}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 had MI in ___, Maternal & Paternal GMs had CVAs in ___. ###RESPONSE: CVAs {Cerebrovascular accident}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.7, 133/87, HR 119, 96% on 2L NC. General: Alert, oriented, no acute distress, pursed lips breathing, no notable conversational dyspnea HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: decreased breath sounds bilaterally, unable to appreciate wheezing CV: tachy, normal S1 + S2, no murmurs, 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 DISCHARGE PHYSICAL EXAM: General: Alert, oriented, no acute distress, pursed lips breathing, no notable conversational dyspnea HEENT: Sclera anicteric, dry MM, oropharynx clear, no dental pain, no evidence of swelling/fullness of floor of mouth, no dilation of whartons duct Neck: supple, JVP not elevated, large soft mildly tender left cervical mass, unchanged from prior Lungs: decreased breath sounds bilaterally, unable to appreciate wheezing CV: tachy, normal S1 + S2, no murmurs, 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: PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, HR {Finding of heart rate}, NC {Normal head}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, pursed lips breathing {Pursed-lip breathing}, dyspnea {Dyspnea}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, dry MM {Mucous membrane dryness}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, decreased breath sounds {Decreased breath sounds}, wheezing {Wheezing}, CV {Cardiovascular physical examination}, tachy {Tachycardia}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, foley {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}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, pursed lips breathing {Pursed-lip breathing}, dyspnea {Dyspnea}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, dry MM {Mucous membrane dryness}, oropharynx clear {Pharynx normal}, dental pain {Toothache}, no evidence {No abnormality detected}, swelling {Swelling of oral cavity structure}, floor of mouth {Floor of mouth structure}, dilation of whartons duct {Dilation of Wharton's duct}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, soft {Mass of soft tissue}, tender {Tenderness of neck}, left {Structure of left half of neck}, cervical mass {Mass of neck}, Lungs {Examination of respiratory system}, decreased breath sounds {Decreased breath sounds}, wheezing {Wheezing}, CV {Cardiovascular physical examination}, tachy {Tachycardia}, normal S1 + S2 {Heart sounds normal}, murmurs {Heart murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound tenderness {Rebound tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, 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}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: ___ 09:59PM TYPE-ART PO2-289* PCO2-53* PH-7.44 TOTAL CO2-37* BASE XS-10 INTUBATED-NOT INTUBA ___ 09:59PM O2 SAT-99 ___ 09:43PM LACTATE-2.4* ___ 09:35PM GLUCOSE-138* UREA N-10 CREAT-0.7 SODIUM-136 POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-34* ANION GAP-11 ___ 09:35PM estGFR-Using this ___ 09:35PM cTropnT-<0.01 ___ 09:35PM CALCIUM-9.3 PHOSPHATE-2.1* MAGNESIUM-1.6 ___ 09:35PM WBC-16.2# RBC-4.39 HGB-13.2 HCT-39.9 MCV-91 MCH-30.0 MCHC-33.0 RDW-12.7 ___ 09:35PM NEUTS-86.9 LYMPHS-6.3* MONOS-6.2 EOS-0.4 BASOS-0.2 ___ 09:35PM PLT COUNT-358 ___ 09:35PM ___ PTT-26.9 ___ MICRO: BLOOD CX-NEG X2 ======= Final Report PORTABLE CHEST: ___. HISTORY: ___ female with respiratory distress. Question pneumonia. COMPARISON: ___. FINDINGS: Streaky linear opacities are again seen, similar to prior and may be due to atelectasis. There is no confluent consolidation. Costophrenic angles are sharp. The cardiomediastinal silhouette is within normal limits. Rounded calcific density overlying the anterior left seventh rib is compatible with calcification at the costochondral junction. No acute osseous abnormality is detected. IMPRESSION: No focal consolidations to suggest pneumonia. ======= Final Report CT NECK W/CONTRAST (EG:PAROTIDS) Study Date of ___ 1:45 ___ HISTORY: History of COPD with shortness of breath and 2new eft-sided tender neck mass. Rule out infection versus mass. COMPARISON: Prior neck soft tissue ultrasound from ___. TECHNIQUE: Routine enhanced MDCT study of the neck was performed with images obtained from the skullbase to the thoracic inlet using 3 mm thick sections. Coronal and sagittal reformations were performed. Total exam DLP: 394 mGy-cm. FINDINGS: Evaluation of the aerodigestive tract demonstrates no exophytic mucosal mass, there is no focal mass effect. There is mild mucosal thickening of the maxillary sinuses bilaterally and ethmoidal air cells, worse on the left. Evaluation of the cervical lymph chains demonstrate no pathologic lymphadenopathy by imaging criteria. The thyroid gland is normal. The left salivary gland appears slightly larger than the left however no focal abnormality is identified. Adjacent to the left salivary gland however, there is a heterogeneous soft tissue lesion similar in appearance to the left parotid gland, measuring 2 x 2 cm and demonstrating fat density. This lesion seems to connect to the parotid gland and could correlate to the lesion identified on prior ultrasound. There appears to be surrounding fat stranding and thickening of the adjacent tissues (5 b: 36, 04:39). There is however no definite enhancement to suggest abscess formation. Neck vessels enhance bilaterally without significant stenosis. IMPRESSION: 2 x 2 cm heterogeneous soft tissue lesion adjacent to the left salivary gland with apparent connection to the parotid gland, similar in appearance to parotid tissue, demonstrating fatty density and surrounding fat stranding could represent an extension of normal parotid tissue with possible early signs of inflammatory changes, given surrounding fat stranding. However, no definite enhancement is seen to suggest abscess formation. This lesion likely correlates to lesion seen on prior ultrasound. The study and the report were reviewed by the staff radiologist. ___. ___ ___. ___ ___: SAT ___ 5:10 ___ DISCHARGE LABS: ___ 04:59AM BLOOD WBC-11.4* RBC-4.42 Hgb-13.1 Hct-40.3 MCV-91 MCH-29.7 MCHC-32.6 RDW-12.9 Plt ___ ___ 04:59AM BLOOD Glucose-96 UreaN-12 Creat-0.7 Na-135 K-3.9 Cl-88* HCO3-41* AnGap-10 ___ 04:59AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.___ hx of COPD, s/p trach x2, multiple intubations for respiratory failure who presents with worsening SOB for over a week, now with cough, increased sputum production and fevers for 2 days. Patient was treated for COPD exacerbation #COPD exacerbation: Patient with history of debilitating COPD, on home oxygen. Patient received nebs, 125 mg methylpred, CTX and azithro in ED with improvement of respiratory status. In the ICU patient was treated with course of azithromycin and Prednisone 60mg daily. Patient with continued improvement in respiratory status with standing Albuterol and Tiotroprium nebs. Plan for *Prednisone taper for total 2 weeks (down from 60mg x 7 days): ___ - ___ => Prednisone 40mg daily; ___ => Prednisone 20mg daily; ___ => Prednisone 10mg daily. Then STOP ___. # Acute non-suppurative Parotitis: Patient with tender left neck swelling noted on ___, U/S and CT scan with possible early inflamation vs. extension of parotid tissue. No evidence of abcess or stones on imaging and no purulence on exam. Patient received several doses of IV clindamycin and was generally well appearing. Low suspicion of MRSA. Discussed with ENT who reviewed imaging, and agreed patient could be stepped down to PO antibiotics. Discharged on Augmentin 875mg BID x 10 days ending ___. Continue sialigogues (i.e. lemon wedges, lozenges every few hours to promote salivation). #HTN: Pt hypertensive to SBP 220 in ED after receiving nebs. Improved with nitro gtt. Stable (133/87) now on floor. Patient restarted on home dose of Verapamil with improvement in hypertension. Patient should follow up with outpatient PCP for consideration of additional antihypertensive. #Chest Tightness: Patient reports pleuritic CP which she has had in past during COPD exacerbations. Unlikely cardiac: non-exertional, non-radiating, troponins negative. Pain resolved while inpatient. #Anxiety: Patient with significant anxiety associated with tachycardia to 130s. Significant improvement with Lorazepam 0.5mg q4 hours. Switched to clonazepam at discharge. #Depression: Continued on home dose Lexapro while inpatient. TRANSITIONAL ISSUES - Patient is MRSA nasal swab positive. 1) COPD: Patient with end stage lung disease. Discharged to ___ and will require close outpatient follow up. 2) Hypertension: Patient hypertensive while hospitalized. Please consider addition of second antihypertensive as an outpatient. 3) Suspected mild Parotitis: Augmentin 875mg BID x 10 days ending ___. Broaden to IV antibiotics, add MRSA coverage, and obtain urgent ENT evaluation if patient has worsening parotitis symptoms including high fevers, purulence, redness tracking down the neck, or Trismus** 4) Prednisone taper as above. ###RESPONSE: ART {Arterial specimen collection for laboratory test}, PO2 {Oxygen measurement, partial pressure, arterial}, PCO2 {Measurement of arterial partial pressure of carbon dioxide}, PH {pH measurement}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, BASE XS {Delta base, blood}, O2 SAT {Oxygen saturation measurement}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, CALCIUM {Blood calcium measurement}, PHOSPHATE {Phosphate, total measurement}, MAGNESIUM {Blood magnesium 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}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}, BLOOD CX {Blood culture}, NEG {No abnormality detected}, PORTABLE {Portable X-ray}, CHEST {Plain chest X-ray}, respiratory distress {Respiratory distress}, pneumonia {Pneumonia}, opacities {Abnormally opaque structure}, atelectasis {Atelectasis}, consolidation {Lung consolidation}, Costophrenic angles {Structure of costophrenic angle}, cardiomediastinal {Mediastinal structure}, normal {No abnormality detected}, calcific {Pathologic calcification, calcified structure}, density {Abnormally opaque structure}, left {Bone structure of left rib}, seventh rib {Bone structure of seventh rib}, calcification {Pathologic calcification, calcified structure}, costochondral junction {Structure of seventh costochondral junction}, No acute {No abnormality detected}, osseous {Bone structure}, consolidations {Lung consolidation}, pneumonia {Pneumonia}, CT NECK W/CONTRAST {Computed tomography of neck with contrast}, PAROTIDS {Parotid gland structure}, Study {Evaluation procedure}, COPD {Chronic obstructive lung disease}, shortness of breath {Dyspnea}, eft-sided {Structure of left half of neck}, tender {Tenderness of neck}, neck mass {Mass of neck}, Rule out {Evaluation procedure}, infection {Infectious disease}, mass {Mass of body structure}, neck soft tissue ultrasound {Ultrasonography of mass of soft tissue of neck}, CT study of the neck {Computed tomography of neck}, skullbase {Base of skull structure}, thoracic inlet {Structure of thoracic inlet}, Evaluation {Evaluation procedure}, mass {Mass of body structure}, mild {Symptom mild}, mucosal {Mucous membrane structure}, thickening {Increased thickness}, maxillary sinuses {Maxillary sinus structure}, ethmoidal air cells {Ethmoid sinus structure}, worse {Patient's condition worsened}, left {Structure of left half of head}, Evaluation {Evaluation procedure}, cervical lymph chains {Cervical lymph node structure}, no pathologic {No pathologic diagnosis}, lymphadenopathy {Cervical lymphadenopathy}, imaging {Imaging}, thyroid gland {Thyroid structure}, normal {No abnormality detected}, left salivary gland {Structure of left salivary gland}, larger {Increased size}, no focal abnormality {No abnormality detected}, left salivary gland {Structure of left salivary gland}, soft tissue lesion {Soft tissue lesion}, left parotid gland {Structure of left parotid gland}, fat density {Lesion with fat containing (radiolucent) density}, lesion {Lesion}, parotid gland {Parotid gland structure}, lesion {Lesion}, ultrasound {Ultrasonography}, thickening {Increased thickness}, tissues {Body tissue structure}, abscess {Abscess}, Neck vessels {Vascular structure of neck}, stenosis {Stenosis}, soft tissue lesion {Soft tissue lesion}, left salivary gland {Structure of left salivary gland}, parotid gland {Parotid gland structure}, parotid tissue {Structure of interstitial tissue of parotid gland}, fatty density {Lesion with fat containing (radiolucent) density}, extension {Abnormal extension}, normal {No abnormality detected}, parotid tissue {Structure of interstitial tissue of parotid gland}, signs {Sign}, inflammatory {Inflammatory disorder}, abscess {Abscess}, lesion {Lesion}, lesion {Lesion}, ultrasound {Ultrasonography}, study {Evaluation procedure}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, 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}, COPD {Chronic obstructive lung disease}, trach {Exteriorization of trachea}, intubations {Insertion of endotracheal tube}, respiratory failure {Respiratory failure}, worsening {Patient's condition worsened}, SOB {Dyspnea}, cough {Cough}, increased {Patient's condition worsened}, sputum production {Sputum finding}, fevers {Fever}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD {Chronic obstructive lung disease}, home oxygen {Home oxygen therapy}, improvement {Patient's condition improved}, respiratory {Respiratory function finding}, ICU {Admission to intensive care unit}, azithromycin {Antibiotic therapy}, Prednisone {Steroid therapy}, improvement {Patient's condition improved}, respiratory {Respiratory function finding}, taper {Medication decreased}, Prednisone {Steroid therapy}, Prednisone {Steroid therapy}, Prednisone {Steroid therapy}, Parotitis {Parotitis}, tender {Tenderness of neck}, left {Structure of left half of neck}, neck swelling {Neck swelling}, U/S {Ultrasonography of mass of soft tissue of neck}, CT scan {Computed tomography of neck}, inflamation {Inflammatory disorder}, parotid tissue {Structure of interstitial tissue of parotid gland}, No evidence {No abnormality detected}, abcess {Abscess}, stones {Calculus}, imaging {Imaging}, purulence {Purulent discharge}, exam {Evaluation procedure}, IV clindamycin {Intravenous antibiotic therapy}, well appearing {Normal appearance}, MRSA {Methicillin resistant Staphylococcus aureus infection}, imaging {Imaging}, PO antibiotics {Oral antibiotic therapy}, Augmentin {Antibiotic therapy}, HTN {Hypertensive disorder, systemic arterial}, hypertensive {Finding of increased blood pressure}, SBP {Increased systolic arterial pressure}, nebs {Nebulizer therapy}, Improved {Patient's condition improved}, Stable {Patient's condition stable}, restarted {Restart of medication}, improvement {Patient's condition improved}, hypertension {Hypertensive disorder, systemic arterial}, PCP {Primary care management}, antihypertensive {Antihypertensive therapy}, Chest Tightness {Tight chest}, pleuritic CP {Pleuritic pain}, COPD exacerbations {Acute exacerbation of chronic obstructive airways disease}, cardiac {Heart disease}, exertional {Chest pain on exertion}, radiating {Radiating pain}, troponins {Troponin measurement}, negative {No abnormality detected}, Pain resolved {No present pain}, Anxiety {Anxiety}, anxiety {Anxiety}, tachycardia {Tachycardia}, improvement {Patient's condition improved}, Switched {Change of medication}, Depression {Depressive disorder}, MRSA {Methicillin resistant Staphylococcus aureus infection}, nasal swab {Taking nasal swab}, COPD {Chronic obstructive lung disease}, lung disease {Disorder of lung}, outpatient follow up {Outpatient care management}, Hypertension {Hypertensive disorder, systemic arterial}, hypertensive {Hypertensive disorder, systemic arterial}, antihypertensive {Antihypertensive therapy}, mild {Symptom mild}, Parotitis {Parotitis}, Augmentin {Antibiotic therapy}, IV antibiotics {Intravenous antibiotic therapy}, MRSA {Methicillin resistant Staphylococcus aureus infection}, ENT {Ear, nose and throat examination}, evaluation {Evaluation procedure}, worsening {Patient's condition worsened}, parotitis {Parotitis}, fevers {Fever}, purulence {Purulent discharge}, redness {Redness of skin over lesion}, neck {Neck structure}, Trismus {Trismus}, Prednisone {Steroid therapy}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Tiotropium Bromide 1 CAP IH DAILY 2. Benzonatate 100 mg PO TID 3. Verapamil SR 240 mg PO QAM 4. Verapamil SR 120 mg PO QHS 5. Ipratropium Bromide MDI 2 PUFF IH QID 6. Furosemide 20 mg PO ONCE 7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 8. Omeprazole 20 mg PO DAILY 9. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315mg-200 unit oral 2 tablets Qday 10. Levalbuterol Neb 0.63 mg/3 mL inhalation q4 hrs 11. Escitalopram Oxalate 10 mg PO DAILY 12. TraZODone 150 mg PO HS:PRN insomnia 13. Vitamin D 1000 UNIT PO DAILY 14. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea Discharge Medications: 1. Escitalopram Oxalate 10 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Levalbuterol Neb 1.26 mg INHALATION Q4H Wheezing, SOB 4. TraZODone 50 mg PO HS:PRN insomnia 5. Verapamil SR 240 mg PO QAM 6. Verapamil SR 120 mg PO QHS 7. Acetaminophen 650 mg PO Q6H:PRN pain 8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days 9. Cepastat (Phenol) Lozenge 1 LOZ PO Q2H:PRN Sore throat 10. Docusate Sodium 100 mg PO BID 11. Ipratropium Bromide Neb 1 NEB IH Q6H SOB 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Senna 1 TAB PO BID 14. Benzonatate 100 mg PO TID 15. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315mg-200 unit oral 2 tablets Qday 16. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 17. Omeprazole 20 mg PO DAILY 18. Vitamin D 1000 UNIT PO DAILY 19. PredniSONE 40 mg PO DAILY Duration: 1 Day Start: Tomorrow - ___, First Dose: First Routine Administration Time Total 2 week taper beginning ___ at 60mg 20. PredniSONE 20 mg PO DAILY Duration: 2 Days Start: After 40 mg tapered dose Total 2 week taper beginning ___ at 60mg 21. PredniSONE 10 mg PO DAILY Duration: 2 Days Start: After 20 mg tapered dose Total 2 week taper beginning ___ at 60mg 22. Lemon wedges Q4H to promote salivation while treating Parotid Gland infection 23. ClonazePAM 0.5 mg PO BID:PRN anxiety RX clonazepam 0.5 mg 1 tablet(s) by mouth twice a day as needed Disp #10 Tablet Refills:*0 ###RESPONSE: EMPTY: No SNOMED annotations found in this fragment
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: COPD exacerbation parotidis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. ###RESPONSE: COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, parotidis {Parotitis}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Discharge Instructions: Dear Ms. ___, it was a pleasure taking care of you during your stay at ___. You were admitted for a COPD exacerbation. You were treated with antibiotics, steroids and nebulizers. Your breathing improved. While you were here you developed an inflammation of your parotid gland. You should continue on antibiotics for this inflammation. ###RESPONSE: COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, treated with antibiotics {Antibiotic therapy}, steroids {Steroid therapy}, nebulizers {Nebulizer therapy}, breathing {Finding of respiration}, improved {Patient's condition improved}, inflammation {Inflammatory disorder}, parotid gland {Parotid gland structure}, antibiotics {Antibiotic therapy}, inflammation {Inflammatory disorder}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Followup Instructions: ___ ###RESPONSE: EMPTY: No SNOMED annotations found in this fragment
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: 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: Tetracyclines Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: none ###RESPONSE: Tetracyclines {Allergy to tetracycline}, 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: This is a ___ year-old female with a history of HTN who presents with chest pain. . For a couple weeks, pt has been feeling fatigued, generalized weakness, increased frequency of headaches. Her symptoms worsened 4 days ago. Her headache has been persistent the last 4 days despite motrin, tylenol, zanaflex, excedrin, and zonegran. She has had these headaches before. She describes a frontal headache, throbbing, currently ___. No photophobia, neck stiffness. She also noted chills, but have them with her hypothyeroidism. She also reports watery diarrhea over the weekend. No abdominal pain. She has her worsening nausea. No vomiting. No fevers. No sick contacts. . Over the years, she has had chest pain intermittently, associated with stress. The chest pain started 2 weeks ago but intensified over the weekend. She describes the pain as a heavy substernal pressure radiating down to her left arm. This pain started ___ and worsened until today, prompting her go to the ED. She feels the pain is worse when she bends over. It does not worsen with deep breaths. She was noted to be pale, diaphoretic today while at therapy. She has chronic nausea and palpitations. No dizziness, SOB. No recent exertion. . Of note, pt has had chronic nausea for the past ___ years and was evaluated by GI over the summer. EGD showed gastritis and grade 2 esophagitis; gastric emptying study was normal. . In the ED, initial vitals were T: 97.1 BP: 129/81 HR: 79 RR: 22 O2Sat: 98RA. EKG showed sinus bradycardia with HR of ___ without acute signs of ischemia. She received ASA, toradol x2, and SL NTG x2 with improvement of CP from 6->4. 2 sets of CEs neg. . Currently her CP is at a 6, improved from 10 this AM. She believes the NTG helped the most. Her HA has improved with Toradol. . ROS: The patient denies any orthopnea, PND, lower extremity oedema, cough, sinus problems, nasal congestion, sore throat, urinary frequency, urgency, dysuria, vision changes, focal weakness, rash. . ###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, chest pain {Chest pain}, fatigued {Fatigue}, weakness {Asthenia}, headaches {Headache}, worsened {Patient's condition worsened}, headache has been persistent {New daily persistent headache}, tylenol {Administration of analgesic}, headaches {Headache}, frontal headache {Frontal headache}, throbbing {Throbbing pain}, photophobia {Photophobia}, neck stiffness {Stiff neck}, chills {Chill}, hypothyeroidism {Hypothyroidism}, watery {Liquid stool}, diarrhea {Diarrhea}, abdominal pain {Abdominal pain}, worsening {Patient's condition worsened}, nausea {Nausea}, vomiting {Vomiting}, No fevers {Temperature normal}, chest pain {Chest pain}, stress {Stress}, chest pain {Chest pain}, pain {Chest pain}, substernal {Structure of substernal region}, pressure {Tight chest}, radiating down to her left arm {Pain radiating to left arm}, pain {Chest pain}, worsened {Increased pain}, pain {Chest pain}, worse {Increased pain}, worsen {Patient's condition worsened}, deep breaths {Deep breathing}, pale {Pale discoloration of entire skin of body}, diaphoretic {Excessive sweating}, therapy {Therapy}, chronic {Chronic disease}, nausea {Nausea}, palpitations {Palpitations}, dizziness {Dizziness}, SOB {Dyspnea}, chronic {Chronic disease}, nausea {Nausea}, evaluated {Evaluation procedure}, EGD {Esophagogastroduodenoscopy}, gastritis {Gastritis}, esophagitis {Esophagitis}, gastric emptying study {Gastric emptying study}, normal {No abnormality detected}, vitals {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2Sat {Oxygen saturation measurement}, RA {Breathing room air}, EKG {Electrocardiographic procedure}, sinus bradycardia {Sinus bradycardia}, HR {Finding of heart rate}, without acute signs of ischemia {Electrocardiogram normal}, ASA {Administration of aspirin}, NTG {Administration of prophylactic glyceryl trinitrate}, improvement {Patient's condition improved}, CP {Chest pain}, CEs neg {Cardiac enzymes within reference range}, CP {Chest pain}, improved {Patient's condition improved}, NTG {Administration of prophylactic glyceryl trinitrate}, HA {Headache}, improved {Patient's condition improved}, ROS {Review of systems}, orthopnea {Orthopnea}, PND {Paroxysmal nocturnal dyspnea}, lower extremity oedema {Edema of lower extremity}, cough {Cough}, sinus problems {Disorder of nasal sinus}, nasal congestion {Nasal congestion}, sore throat {Sore throat}, urinary frequency {Increased frequency of urination}, urgency {Urgent desire to urinate}, dysuria {Dysuria}, vision changes {Visual disturbance}, weakness {Asthenia}, rash {Eruption of skin}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Past Medical History: HTN Hypothyroidism Migraine and tension headaches MVP Complex partial seizures Sleep apnea, not tolerating CPAP at home Depression/Generalized anxiety disorder ADHD Asthma ###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, Hypothyroidism {Hypothyroidism}, Migraine {Migraine}, tension headaches {Tension-type headache}, partial seizures {Focal onset epileptic seizure}, Sleep apnea {Sleep apnea}, CPAP at home {Uses home continuous positive airway pressure ventilation supply}, Depression {Depressive disorder}, Generalized anxiety disorder {Generalized anxiety disorder}, ADHD {Attention deficit hyperactivity disorder}, Asthma {Asthma}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Social History: ___ ###RESPONSE: EMPTY: No SNOMED annotations found in this fragment
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Family History: Mother with colorectal cancer, pancreatitis. No h/o MI. Father died of MI at age of ___. ###RESPONSE: colorectal cancer {Malignant neoplasm of colon and/or rectum}, pancreatitis {Pancreatitis}, MI {Myocardial infarction}, died {Dead}, MI {Myocardial infarction}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Physical Exam: Vitals: T: 97.8, BP: 138/94, HR: 61, RR: 20, O2Sat: 100RA GEN: Well-appearing, obese female no acute distress HEENT: EOMI, sclera anicteric, MMM, OP Clear NECK: No JVD, no carotid bruits, no cervical lymphadenopathy, no meningismus COR: RRR, no M/G/R, normal S1 S2 PULM: Lungs CTAB, no W/R/R CHEST: tender to palpation over sternum, L side of chest and L arm ABD: Obese, soft, mildly tender in LLQ, no rebound, no guarding, ND, +BS EXT: No C/C/E, 2+ DP pulses ###RESPONSE: Vitals {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2Sat {Oxygen saturation measurement}, RA {Breathing room air}, GEN {General examination of patient}, Well-appearing {Well cared for appearance}, obese {Obese}, no acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, EOMI {Normal ocular motility}, sclera anicteric {White sclera}, MMM {Moist oral mucosa}, OP Clear {Pharynx normal}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, carotid bruits {Carotid bruit}, cervical lymphadenopathy {Cervical lymphadenopathy}, meningismus {Meningeal irritation}, COR {Cardiovascular physical examination}, RRR {Normal heart rate}, no M/G/R {Heart sounds abnormal}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, no W/R/R {Normal breath sounds}, CHEST {Examination of respiratory system}, tender {Abdominal tenderness}, palpation {Palpation}, sternum {Bone structure of sternum}, L side of chest {Structure of left half of chest wall}, L arm {Structure of left upper limb}, ABD {Examination of abdomen}, Obese {Obese}, soft {Abdomen soft}, tender {Abdominal tenderness}, LLQ {Structure of left lower quadrant of abdomen}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, ND {Swollen abdomen}, +BS {Normal bowel sounds}, EXT {Examination of limb}, No C/C/E {No abnormality detected}, 2+ DP pulses {Dorsalis pulse present}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Pertinent Results: troponins <0.01 x3 ###RESPONSE: troponins {Troponin 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: Assesment: This is a ___ year-old female with a history of HTN, hypothyroidism, GAD who presents with chest pain, fatigue, and headaches. . Chest pain: Likely MSK given reproducible pain on exam. ___ also be from esophagitis and gastritis, ? esophageal spasm as improved with NTG. Unlikely pericarditis since no EKG changes. Unlikely to be ACS given duration of symptoms without EKG changes or increased CEs. Also had normal stress test in ___. Patient had serial normal EKGs, CEs negative x3. . Headache: Pt reports it's consistent with her tension headaches except not being relieved. Has improved with Toradol. No meningimus, afebrile, no leukocytosis to suggest meninigitis. cont. toradol . # Nausea: Has been thoroughly worked up by GI. - start protonix - Compazine prn . # HTN: Well controlled. - cont. propranolol . # Hypothyroidism: TSH WNL on admission. - cont. levothyroxine. . # Complex partial seizures: - cont. Lamictal. . # Sleep apnea, not tolerating CPAP at home: - CPAP ordered . # Depression/Generalized anxiety disorder: - cont. . # ADHD - cont. Ritalin . # Asthma: Currently asymptomatic. - albuterol prn ###RESPONSE: Assesment {Evaluation procedure}, HTN {Hypertensive disorder, systemic arterial}, hypothyroidism {Hypothyroidism}, GAD {Generalized anxiety disorder}, chest pain {Chest pain}, fatigue {Fatigue}, headaches {Headache}, Chest pain {Chest pain}, MSK {Structure of musculoskeletal system}, pain {Pain}, exam {Physical examination procedure}, esophagitis {Esophagitis}, gastritis {Gastritis}, esophageal spasm {Diffuse spasm of esophagus}, improved {Patient's condition improved}, NTG {Administration of prophylactic glyceryl trinitrate}, pericarditis {Pericarditis}, no EKG changes {Electrocardiogram normal}, ACS {Acute coronary syndrome}, without EKG changes {Electrocardiogram normal}, increased CEs {Cardiac enzyme or marker above reference range}, normal {Electrocardiogram normal}, stress test {Cardiovascular stress testing}, normal EKGs {Electrocardiogram normal}, CEs negative {Cardiac enzymes within reference range}, Headache {Headache}, tension headaches {Tension-type headache}, improved {Patient's condition improved}, meningimus {Meningeal irritation}, afebrile {Temperature normal}, leukocytosis {Leukocytosis}, meninigitis {Meningitis}, Nausea {Nausea}, worked up {Evaluation procedure}, HTN {Hypertensive disorder, systemic arterial}, Well controlled {Disease condition determination, well controlled}, Hypothyroidism {Hypothyroidism}, TSH WNL {Serum thyroid stimulating hormone level within reference range}, partial seizures {Focal onset epileptic seizure}, Sleep apnea {Sleep apnea}, CPAP at home {Uses home continuous positive airway pressure ventilation supply}, CPAP {Continuous positive airway pressure ventilation treatment}, Depression {Depressive disorder}, Generalized anxiety disorder {Generalized anxiety disorder}, ADHD {Attention deficit hyperactivity disorder}, Asthma {Asthma}, asymptomatic {Asymptomatic}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 puffs by mouth every four (4) to six (6) hours as needed for cough/wheezing LAMOTRIGINE [LAMICTAL] - (Prescribed by Other Provider: ___ - 200 mg Tablet - 1 (One) Tablet(s) by mouth twice a day LEVOTHYROXINE SODIUM - 175MCG Tablet - ONE BY MOUTH EVERY DAY METHYLPHENIDATE [RITALIN LA] - (Prescribed by Other Provider: ___ - 30 mg Capsule, Multiphasic Rel.50-50 - 2 (Two) Capsule(s) by mouth once a day PRAMIPEXOLE [MIRAPEX] - 0.125 mg Tablet - 1 (One) Tablet(s) by mouth once a day 2 hours before sleep PRAZOSIN - (Prescribed by Other Provider: ___ - 1 mg Capsule - 1 (One) Capsule(s) by mouth three times a day PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth twice a day PROPRANOLOL - (Prescribed by Other Provider: ___ - 80 mg Capsule, Sust. Release 24 hr - 1 (One) Capsule(s) by mouth once a day TIZANIDINE [ZANAFLEX] - 4 mg Tablet - 1 Tablet(s) by mouth twice a day TRAZODONE - 100 mg Tablet - 2 Tablet(s) by mouth at bedtime ___ take additional tablet qhs prn sleeplessness ZONISAMIDE [ZONEGRAN] - 100 mg Capsule - 2 Capsule(s) by mouth at bedtime Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Methylphenidate 20 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO DAILY (Daily). 5. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qhs (). 6. Prazosin 1 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO twice a day as needed for nausea. 8. Propranolol 80 mg Capsule,Sustained Action 24 hr Sig: One (1) Capsule,Sustained Action 24 hr PO DAILY (Daily). 9. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 11. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). ###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: Atypical Chest pain Secondary: HTN Hypothyroid GAD Discharge Condition: stable ###RESPONSE: Atypical Chest pain {Atypical chest pain}, HTN {Hypertensive disorder, systemic arterial}, Hypothyroid {Hypothyroidism}, GAD {Generalized anxiety disorder}, stable {Patient's condition stable}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Discharge Instructions: You were admitted to the hospital with chest pain that was thought to NOT be of cardiac origin per blood tests and EKGS. Please take all medications as prescribed Please call your doctor or return to the hosptial if you have more chest pain, shortness of breath or any other concerning symptoms ###RESPONSE: chest pain {Chest pain}, cardiac {Heart structure}, blood tests {Blood test}, EKGS {Electrocardiographic procedure}, Please take all medications as prescribed {Patient medication education}, call your doctor {Informing doctor}, chest pain {Chest pain}, shortness of breath {Dyspnea}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Followup Instructions: ___ ###RESPONSE: EMPTY: No SNOMED annotations found in this fragment
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: 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: amlodipine Attending: ___. Chief Complaint: fever, dyspnea Major Surgical or Invasive Procedure: None ###RESPONSE: amlodipine {Allergy to amlodipine}, fever {Fever}, dyspnea {Dyspnea}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: History of Present Illness: ___ h/o severe COPD not on home O2, s/p endobronchial coil placement for stage 4 emphysema as part of a study on ___. Dc'd home began having fevers, went to ___ local ___, admitted ___ (discharged yesterday) after treatment for pneumonia, continued on PO levoquin. Presents today after speaking w/ study coordinator who recommended he present here for further evaluation if temp >100.4. Temp at home to 101. Increased dyspnea from baseline. Denies CP. No n/v. Soft stool this AM, no abd pain. In the ED initial vitals were: 99.4 102 146/74 18 100% RA. Pt spiked to 100.2 and received tylenol. - Labs were significant for no leukocytosis, normal lactate, INR 1.4. - CXR was pending. - EKG was unchanged. - Patient was given IV vanc and zosyn, tylenol, duonebs x2, and 1L NS. On the floor, patient is resting fairly comfortably with his wife at bedside. He reports that his breathing is still bad. He confirms the above history and also adds the following: While hospitalized at ___ in ___, his inpatient MDs were communicating with Dr. ___ for recommendations about his pulmonary management. He was started on levaquin ___, which he took for one day and then was changed to IV vanc/zosyn while in the hospital, but discharged again on levaquin after improvement. He says that initially after the coil embolization ___ he felt well for a few days. However, on the ___ following the procedure (___), he began feeling unwell. On ___ he developed a fever. Of note, his sputum after the procedure was initially white with streaks of BRB but then changed to a rust color after he got sick. Even with the antibiotics, he continued to feel unwell. His sputum changed to a yellow mucous. He went 2 days without fevers, was discharged, and then had another fever that night (last night). Denies flu like symptoms such as body aches, HA, n/v/d. Most importantly, he reports that since being unwell, his breathing really hasn't improved. He feels like he is not moving any air. No CP or leg swelling. No diarrhea or dysuria. Review of Systems: (+) per HPI. Remainder of 10 point ROS is negative. ###RESPONSE: severe COPD {Severe chronic obstructive pulmonary disease}, home O2 {Home oxygen therapy}, endobronchial coil placement {Endotracheal tube present}, emphysema {Emphysema}, study {Evaluation procedure}, fevers {Fever}, pneumonia {Pneumonia}, study {Evaluation procedure}, evaluation {Evaluation procedure}, temp {Body temperature finding}, Temp {Body temperature finding}, Increased {Patient's condition worsened}, dyspnea {Dyspnea}, baseline {Baseline state}, Soft stool {Soft stool}, abd pain {Abdominal pain}, vitals {Vital signs finding}, tylenol {Administration of analgesic}, Labs {Laboratory test}, leukocytosis {Leukocytosis}, normal {No abnormality detected}, lactate {Lactic acid measurement}, INR {Calculation of international normalized ratio}, CXR {Plain chest X-ray}, EKG {Electrocardiographic procedure}, unchanged {Patient condition unchanged}, vanc {Antibiotic therapy}, tylenol {Administration of analgesic}, comfortably {Breathing easily}, breathing {Difficulty breathing}, pulmonary {Pulmonary medicine service}, started {New medication added}, changed {Change of medication}, vanc {Antibiotic therapy}, improvement {Patient's condition improved}, embolization {Embolization procedure}, following the procedure {Postoperative state}, feeling unwell {Malaise}, fever {Fever}, sputum {Sputum finding}, procedure {Procedure}, changed {Change of medication}, color {Color finding}, antibiotics {Antibiotic therapy}, feel unwell {Malaise}, sputum {Sputum finding}, yellow {Yellow sputum}, fevers {Fever}, fever {Fever}, flu like symptoms {Influenza-like symptoms}, body aches {Generalized aches and pains}, n/v/d {Nausea, vomiting and diarrhea}, breathing {Difficulty breathing}, improved {Patient's condition improved}, leg swelling {Leg swelling symptom}, diarrhea {Diarrhea}, dysuria {Dysuria}, ROS {Review of systems}, negative {No pathologic diagnosis}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: - Severe COPD/emphysema. FEV1 23% in ___, with significant hyperinflation. Negative for A1AT deficiency. No history of respiratory failure. - s/p RUL endobronchial coil placement ___ - CAD s/p MI and PCI x2, in ___ - Hypertension - Nephrolithiasis, with lithotripsy, stenting, and nephrostomies in the past. - Hypothyroidism - Systolic HF with EF 40% on ___ ###RESPONSE: Severe COPD {Severe chronic obstructive pulmonary disease}, emphysema {Emphysema}, hyperinflation {Hyperdistention}, Negative {No pathologic diagnosis}, A1AT deficiency {Alpha-1-antitrypsin deficiency}, respiratory failure {Respiratory failure}, endobronchial coil placement {Endotracheal tube present}, CAD {Coronary arteriosclerosis}, PCI {Percutaneous coronary intervention}, Hypertension {Hypertensive disorder, systemic arterial}, Nephrolithiasis {Kidney stone}, lithotripsy {Lithotripsy}, stenting {Insertion of arterial stent}, Hypothyroidism {Hypothyroidism}, Systolic {Systolic heart failure}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Social History: ___ ###RESPONSE: EMPTY: No SNOMED annotations found in this fragment
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Family History: His grandfather had emphysema and asbestos exposure. ###RESPONSE: emphysema {Emphysema}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.3, 122/75, 80, 18, 97% on RA GENERAL: well nourished middle aged man lying in bed with O2 on for comfort, AAOx3, NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: no JVD CARDIAC: very difficult to auscultate, no murmurs, gallops, or rubs appreciated LUNG: mild RUL crackles, overall poor air movement. no wheezing. no use of accessory muscles. able to speak in full sentences. ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: Vitals: Tmax 98.6 Tc 97.8 122-133/78-79 HR ___ RR ___ 99% RA GEN: Well appearing, speaks in full sentences on room air Exam otherwise unchanged ###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, well nourished {Well nourished}, middle aged {Middle-age}, lying in bed {Lying in bed}, Ox3 {Oriented to person, time and place}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclera {White sclera}, pink conjunctiva {Conjunctival hyperemia}, MMM {Moist oral mucosa}, good dentition {Normal dentition}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, murmurs {Murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, LUNG {Examination of respiratory system}, mild {Symptom mild}, RUL {Structure of upper lobe of right lung}, crackles {Respiratory crackles}, poor air movement {Decreased breath sounds}, wheezing {Wheezing}, accessory muscles {Accessory skeletal muscle}, able to speak {Able to speak}, full sentences {Able to complete sentence in one breath}, ABDOMEN {Examination of abdomen}, nondistended {Normal abdominal contour}, nontender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, hepatosplenomegaly {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, cyanosis {Cyanosis}, clubbing {Clubbing}, edema {Edema}, moving all 4 extremities {Does move all four limbs}, NEURO {Neurological examination}, CN II-XII intact {Normal central nervous system}, SKIN {Examination of skin}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Lesion}, rashes {Eruption of skin}, Vitals {Vital signs finding}, RA {Breathing room air}, Well appearing {Well cared for appearance}, speaks {Does speak}, full sentences {Able to complete sentence in one breath}, on room air {Breathing room air}, Exam {Lung finding}, unchanged {Patient condition unchanged}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: ======= ___ 03:10PM GLUCOSE-140* UREA N-13 CREAT-1.0 SODIUM-138 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 ___ 03:10PM WBC-8.6 RBC-4.21* HGB-12.6* HCT-37.3* MCV-89 MCH-30.0 MCHC-33.9 RDW-12.8 ___ 03:10PM PLT COUNT-286 ___ 03:10PM ___ PTT-29.6 ___ ___ 12:30PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 12:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 12:30PM URINE RBC-7* WBC-5 BACTERIA-NONE YEAST-NONE EPI-0 ___ 12:30AM ___ COMMENTS-GREEN TOP ___ 12:30AM LACTATE-1.3 K+-4.1 ___ 12:20AM GLUCOSE-105* UREA N-15 CREAT-1.0 SODIUM-136 POTASSIUM-5.6* CHLORIDE-100 TOTAL CO2-24 ANION GAP-18 ___ 12:20AM WBC-11.0 RBC-4.42* HGB-13.5* HCT-38.9* MCV-88 MCH-30.5 MCHC-34.7 RDW-13.1 ___:20AM NEUTS-71.8* LYMPHS-13.6* MONOS-11.7* EOS-2.0 BASOS-0.8 ___ 12:20AM PLT COUNT-282 ___ 12:20AM ___ PTT-28.4 ___ ___ 05:59AM BLOOD WBC-8.8 RBC-4.22* Hgb-12.6* Hct-37.6* MCV-89 MCH-30.0 MCHC-33.6 RDW-12.9 Plt ___ ___ 05:59AM BLOOD Glucose-90 UreaN-20 Creat-1.1 Na-143 K-3.7 Cl-105 HCO3-28 AnGap-14 ___ 05:59AM BLOOD ALT-30 AST-16 AlkPhos-38* TotBili-0.3 MICRO: ======== ___ 11:45 am SPUTUM Site: EXPECTORATED Source: Expectorated. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): ___ 8:30 pm SPUTUM Source: Expectorated. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): MTB Direct Amplification (Final ___: M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT cannot rule out TB or other mycobacterial infection. NAAT results will be followed by confirmatory testing with conventional culture and DST methods. This TB NAAT method has not been approved by FDA for clinical diagnostic purposes. However, ___ ___ Institute (___) has established assay performance by in-house validation in accordance with ___ standards. TEST PERFORMED BY ___ LAB (___). ___ 11:36 am SPUTUM Source: Expectorated. GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. YEAST. SPARSE GROWTH. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): ___ 12:20 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 10:54 am BRONCHIAL WASHINGS RIGHT BRONCHIAL WASH. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final ___: ~4000/ML Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by ___ ___. MEROPENEM sensitivity testing performed by ___. ACHROMOBACTER SPECIES. 10,000-100,000 ORGANISMS/ML.. sensitivity testing performed by Microscan. MEROPENEM <= 1 MCG/ML. Cefepime >16 MCG/ML. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SECOND MORPHOLOGY. Piperacillin/Tazobactam sensitivity testing performed by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| ACHROMOBACTER SPECIES \| \| PSEUDOMONAS AERUGINOSA \| \| \| CEFEPIME-------------- 32 R R 2 S CEFTAZIDIME----------- =>64 R =>32 R 4 S CEFTRIAXONE----------- 32 I CIPROFLOXACIN--------- 2 I =>4 R 0.5 S GENTAMICIN------------ <=1 S 2 S <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- <=1 S MEROPENEM------------- R S <=0.25 S PIPERACILLIN/TAZO----- I <=8 S S TOBRAMYCIN------------ <=1 S 2 S <=1 S TRIMETHOPRIM/SULFA---- <=2 S ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): MYCOBACTERIUM AVIUM COMPLEX. Identified by ___ Laboratory ,REPORT DATE: ___. FUNGAL CULTURE (Final ___: EXOPHIALA SPECIES. 1 COLONY. IMAGING: ========= ___ Imaging CHEST (PA & LAT) 1. Large right upper lobe consolidation, concerning for pneumonia versus hemorrhage little change since ___. Concurrent peribronchial infiltration in the right middle and lower lobes has improved. ___ Cardiovascular ECG Sinus tachycardia. Borderline R wave progression. Borderline leftward axis. Compared to the previous tracing of ___ the rate is faster. The findings are otherwise similar. Intervals Axes Rate PR QRS QT/QTc P QRS T 103 140 88 ___ ___ with h/o severe COPD s/p right sided endobronchial coil placement on ___ admitted with fever, RUL infiltrate consistent with PNA. # RUL bacterial pneumonia: Pt developed fever and increased sputum production following last admission for endobronchial coil placement. He was started on levofloxacin as an outpatient and shortly after admitted to OSH where he received vanc/piperacillin-tazobactam for several days and was discharged home on levofloxacin. He experienced recurrent fever at home and was advised to present to ___ where CXR showed RUL consolidation infiltrate, most likely postobstructive PNA in area of coiling procedure given fevers, change in sputum production and temporary clinical improvement while on broad spectrum abx at OSH. He was initially treated with vanc/piperacillin-tazobactam /levofloxacin. Notably, BAL from ___ on last admission grew resistant pseudomonas. Patient at risk for developing further antibiotic resistance given interrupted courses of levofloxacin and vanc/zosyn in the week prior to presentation. However, given clinical improvement, antibiotics were narrowed to piperacillin-tazobactam in consultation with ID with plan for 14 day total course with close outpatient follow up. Sputum culture this admission grew commensal respiratory flora and sparse yeast, which may represent exophiala species felt to represent colonization on prior BAL. Endobronchial coil removal was discussed with IP and ID, but deferred given clinical improvement on antibiotics. # COPD: Severe with FEV1 23% and reduced DLCO s/p endobronchial coiling as above. Normally on prednisone 10mg daily, recently on prednisone taper following coiling procedure. Increased to 60mg on admission in case COPD symptoms were contributing to SOB. Treated with prednisone 60mg daily x 5 day burst (d1 = ___. Continued home advair, spiriva, zyrtec, montelukast. # ___: AFB cx from ___ BAL returned positive on ___. Patient had history of partially treated ___ in ___ per Parters records. Ruled out for active pulm TB with negative sputum AFB x 3. AFB cx from ___ sent to state lab and identified as ___. # Emergency Contact: ___ ___ (wife) TRANSITIONAL ISSUES: ==================== # RUL Pseudomonal PNA: Discharged on piperacillin-tazobactam for 14 day total course (last day ___. If worsens clinically, may require tobramycin given intermediate sensitivity of pseudomonas from BAL ___ to pip-tazo. Has ID followup on ___. Will need labs to include CBC with differential, Creatinine, LFTs in 5 days of discharge ___ or ___ given upcoming ___) faxed to Dr. ___ new ID provider ___ ___. # ___: Consider reattempting outpatient treatment, would require prolonged course. ___ have positive AFB culture on future BALs given known ___ infection. ###RESPONSE: GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, 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 COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}, URINE {Evaluation of urine specimen}, COLOR {Color finding}, PROTEIN {Measurement of protein in urine}, GLUCOSE-NEG {Urine glucose not detected}, KETONE-NEG {Urine ketones not detected}, BILIRUBIN {Bilirubin measurement, urine}, NEG {No abnormality detected}, UROBILNGN {Urobilinogen measurement, urine}, NEG {No abnormality detected}, PH {pH measurement}, LEUK-NEG {Urine leukocytes not detected}, URINE {Urinalysis}, RBC {Red blood cell count}, WBC {White blood cell count}, AST {Aspartate aminotransferase measurement}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, 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}, BASOS {Basophil count}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, SPUTUM {Microbial culture of sputum}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, CULTURE {Microbial culture}, SPUTUM {Microbial culture of sputum}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, CULTURE {Microbial culture}, TUBERCULOSIS {Tuberculosis}, negative {No pathologic diagnosis}, infection {Infectious disease}, culture {Microbial culture}, SPUTUM {Microbial culture of sputum}, GRAM STAIN {Gram stain method}, epithelial cells {Epithelial cells present}, NEGATIVE {No pathologic diagnosis}, RESPIRATORY CULTURE {Respiratory microbial culture}, YEAST {Yeast culture}, FUNGAL {Mycology culture}, CULTURE {Microbial culture}, YEAST {Yeast culture}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, CULTURE {Microbial culture}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, BRONCHIAL WASHINGS {Lavage of bronchus}, RIGHT {Right lung structure}, BRONCHIAL {Bronchial structure}, WASH {Bronchoscopic lavage}, GRAM STAIN {Gram stain method}, POLYMORPHONUCLEAR LEUKOCYTES {Polymorphonuclear leukocyte count}, NEGATIVE {No pathologic diagnosis}, RESPIRATORY CULTURE {Respiratory microbial culture}, sensitivity {Antimicrobial susceptibility test}, sensitivity {Antimicrobial susceptibility test}, sensitivity {Antimicrobial susceptibility test}, sensitivity {Antimicrobial susceptibility test}, SENSITIVITIES {Antimicrobial susceptibility test}, CIPROFLOXACIN {Antibiotic therapy}, LEVOFLOXACIN {Antibiotic therapy}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, CULTURE {Microbial culture}, Laboratory {Laboratory test}, FUNGAL {Mycology culture}, CULTURE {Mycology culture}, Imaging CHEST (PA & LAT {Diagnostic radiography of chest, combined posteroanterior and lateral}, right upper lobe {Structure of bronchus of right upper lobe}, consolidation {Lung consolidation}, pneumonia {Pneumonia}, hemorrhage {Hemorrhage}, infiltration {Infiltration}, right {Right lung structure}, middle {Structure of middle lobe of right lung}, lower lobes {Structure of lower lobe of right lung}, improved {Patient's condition improved}, ECG {Electrocardiographic procedure}, Sinus tachycardia {Sinus tachycardia}, R wave progression {Electrocardiographic R wave abnormal}, axis {Electrocardiographic axis finding}, rate {Finding of heart rate}, Rate {Finding of heart rate}, QRS {Finding of electrocardiogram QRS complex}, QRS {Finding of electrocardiogram QRS complex}, severe COPD {Severe chronic obstructive pulmonary disease}, right sided {Right lung structure}, endobronchial coil placement {Endotracheal tube present}, fever {Fever}, RUL {Structure of upper lobe of right lung}, infiltrate {Infiltration}, PNA {Pneumonia}, RUL {Structure of upper lobe of right lung}, bacterial pneumonia {Bacterial pneumonia}, fever {Fever}, increased {Patient's condition worsened}, sputum production {Productive cough}, placement {Implantation procedure}, started {New medication added}, levofloxacin {Antibiotic therapy}, vanc {Antibiotic therapy}, levofloxacin {Antibiotic therapy}, recurrent {Recurrent disease}, fever {Fever}, CXR {Plain chest X-ray}, RUL {Structure of upper lobe of right lung}, consolidation {Lung consolidation}, infiltrate {Infiltration}, PNA {Pneumonia}, procedure {Procedure}, fevers {Fever}, sputum production {Sputum finding}, improvement {Patient's condition improved}, vanc {Antibiotic therapy}, levofloxacin {Antibiotic therapy}, BAL {Bronchoscopy and bronchoalveolar lavage}, antibiotic {Antibiotic therapy}, levofloxacin {Antibiotic therapy}, vanc {Antibiotic therapy}, improvement {Patient's condition improved}, antibiotics {Antibiotic therapy}, consultation {Consultation}, outpatient follow up {Outpatient care management}, Sputum culture {Microbial culture of sputum}, yeast {Yeast detected}, BAL {Bronchoscopy and bronchoalveolar lavage}, Endobronchial coil removal {Removal of endotracheal tube}, improvement {Patient's condition improved}, antibiotics {Antibiotic therapy}, COPD: Severe {Severe chronic obstructive pulmonary disease}, prednisone {Steroid therapy}, prednisone {Steroid therapy}, taper {Medication decreased}, procedure {Procedure}, Increased {Medication increased}, COPD {Chronic obstructive lung disease}, SOB {Dyspnea}, prednisone {Steroid therapy}, BAL {Bronchoscopy and bronchoalveolar lavage}, r active pulm TB {Active tuberculosis}, negative {No pathologic diagnosis}, sputum {Microbial culture of sputum}, RUL {Structure of upper lobe of right lung}, Pseudomonal PNA {Pneumonia caused by Pseudomonas}, worsens {Patient's condition worsened}, sensitivity {Antimicrobial susceptibility test}, BAL {Bronchoscopy and bronchoalveolar lavage}, labs {Laboratory test}, CBC {Complete blood count}, differential {Differential white cell count within reference range}, Creatinine {Creatinine measurement}, LFTs {Hepatic function panel}, AFB culture {Acid fast bacilli culture}, infection {Infectious disease}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze 2. Cetirizine 10 mg PO DAILY 3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 4. Guaifenesin ER 600 mg PO Q12H 5. Levothyroxine Sodium 150 mcg PO DAILY 6. Lorazepam 1 mg PO BID 7. Montelukast 10 mg PO DAILY 8. Losartan Potassium 25 mg PO DAILY 9. Tiotropium Bromide 1 CAP IH DAILY 10. Aspirin 81 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Vitamin D 1000 UNIT PO DAILY 13. PredniSONE 10 mg PO DAILY Start: After 20 mg tapered dose 14. Levofloxacin 500 mg PO Q24H Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze 2. Aspirin 81 mg PO DAILY 3. Cetirizine 10 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 5. Guaifenesin ER 600 mg PO Q12H 6. Levothyroxine Sodium 150 mcg PO DAILY 7. Lorazepam 1 mg PO BID 8. Losartan Potassium 25 mg PO DAILY 9. Montelukast 10 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Tiotropium Bromide 1 CAP IH DAILY 12. Vitamin D 1000 UNIT PO DAILY 13. Piperacillin-Tazobactam 4.5 g IV Q6H RX piperacillin-tazobactam 4.5 gram 4.5 gram IV Every 6 hours Disp #44 Vial Refills:0 14. PredniSONE 60 mg PO DAILY Duration: 1 Dose Take on ___ and return to regular 10mg dosing after that. RX prednisone 20 mg 3 tablet(s) by mouth Once Disp #3 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 With Service Facility: ___ Discharge Diagnosis: Primary: Bacterial Pneumonia Secondary: COPD 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}, Bacterial Pneumonia {Bacterial pneumonia}, COPD {Chronic obstructive lung disease}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Discharge Instructions: Dear Mr. ___, It was a pleasure participating in your care at ___. You were admitted to the hospital for shortness of breath due to a pneumonia. You were treated with IV antibiotics and should continue to take them through your new ___ line for a total of 14 days (last day ___. You are scheduled to see Dr. ___ in the ___ Diseases clinic to discuss whether you will need additional antibiotics after that. Please follow up with the interventional pulmonary doctors as ___. We gave you high dose prednisone (60mg) in the hospital which you should also take tomorrow to complete 5 days. On ___, you may resume your normal dose of 10mg daily. ###RESPONSE: shortness of breath {Dyspnea}, pneumonia {Pneumonia}, IV antibiotics {Intravenous antibiotic therapy}, antibiotics {Antibiotic therapy}, follow up {Follow-up arranged}, pulmonary {Pulmonary medicine service}, prednisone {Steroid therapy}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Followup Instructions: ___ ###RESPONSE: EMPTY: No SNOMED annotations found in this fragment
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE ###RESPONSE: EMPTY: No SNOMED annotations found in this fragment
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Allergies: Penicillins / Latex Attending: ___. Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Thoracentesis (x2) Chest Tube Bronchoscopy ###RESPONSE: Penicillins {Allergy to penicillin}, Latex {Allergy to Hevea brasiliensis latex protein}, Shortness of Breath {Dyspnea}, Thoracentesis {Thoracentesis}, Chest Tube {Insertion of pleural tube drain}, Bronchoscopy {Bronchoscopy}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: History of Present Illness: ___ with newly diagnosed Stage IV NSCLC, rapidly progrsesive, presenting to clinic today with SOB. She was diagnosed on ___ after a ___ week history of cough following which the patient palpated a R supraclavicular node. One week ago the pt was seen by medical oncology and is now s/p a right supraclavicular node biopsy that revealed NSCLC. She presented for follow up PET/CT and subsequently to clinic today. and found be hypoxic (O2 sat ___ on RA). The patient was recently started on prednisone 80 mg daily by her PCP for the last 2 days without significant improvement. . Upon further ROS: The pt denies fevers, chills, headache, chest pain, nausea, vomitting, diarrhea, dysuria. The patient notes mild constipation when taking Vicoden. ###RESPONSE: Stage IV NSCLC {Non-small cell carcinoma of lung, TNM stage 4}, progrsesive {Patient's condition worsened}, clinic {Outpatient care management}, SOB {Dyspnea}, cough {Cough}, palpated {Palpation}, R supraclavicular node {Structure of right supraclavicular lymph node}, supraclavicular node biopsy {Supraclavicular lymph node biopsy}, NSCLC {Non-small cell lung cancer}, PET/CT {Positron emission tomography}, clinic {Outpatient care management}, hypoxic {Hypoxia}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, PCP {Primary care management}, improvement {Patient's condition improved}, fevers {Fever}, chills {Chill}, headache {Headache}, chest pain {Chest pain}, nausea {Nausea}, vomitting {Vomiting}, diarrhea {Diarrhea}, dysuria {Dysuria}, mild {Symptom mild}, constipation {Constipation}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 Oncology History: - Initial symptoms: cough, supraclavicular lymph node, nodular mass lower abdomen - CXR demonstrated R hilar mass. CT on ___ showed 3.5 X 3.7 cm R hilar mass with marked narrowing of the right upper lobe bronchus and apparent obstruction of the posterior bronchus to the right upper lobe. Bulky bilateral mediastinal lymphadenopathy was noted. The dominant lymph node mass in the right paratracheal region measured 2.9 x 2.7 cm, with a dominant conglomerate nodal mass in the precarinal lesion measuring 3.3 x 2.8 cm. Multiple lymph nodes were identified throughout the mediastinum including the prevascular space bilaterally, the posterior subcarinal space, and the right hilum. There was a moderate dependent right pleural effusion and a small left pleural effusion as well as a small pericardial effusion. Also noted was a 2.8 x 1.9 cm nodule within the periphery of the right upper lobe. Heterogeneous enhancement of the left adrenal gland was seen, measuring 1.9 x 1.8 cm. In addition, an enlarged left supraclavicular lymph node measured 1.4 x 1 cm. Several lucent vertebral body lesions were identified in the lower thoracic spine. - Excisional biopsy of the right supraclavicular lymph node on ___. - Pathology: poorly differentiated neuroendocrine carcinoma of pulmonary origin, probably best characterized as large cell type, although there is considerable variation in cell size. No e/o lymphoproliferative disorder. . ###RESPONSE: cough {Cough}, supraclavicular lymph node {Structure of supraclavicular lymph node}, nodular mass {Nodule}, lower abdomen {Lower abdomen structure}, CXR {Plain chest X-ray}, hilar mass {Mass of hilum}, CT {Computed tomography of abdomen}, hilar mass {Mass of hilum}, narrowing {Narrowing}, right upper lobe bronchus {Structure of bronchus of right upper lobe}, obstruction {Obstruction}, posterior bronchus to the right upper lobe {Structure of right upper lobe posterior segmental bronchus}, mediastinal lymphadenopathy {Mediastinal lymphadenopathy}, lymph node {Structure of lymph node}, mass {Mass}, right paratracheal {Structure of right paratracheal lymph node}, mass {Mass}, precarinal {Structure of pretracheal lymph node}, lesion {Lesion}, lymph nodes {Structure of lymph node}, mediastinum {Mediastinal lymph node structure}, prevascular {Structure of prevascular and/or retrotracheal lymph node}, subcarinal {Structure of subcarinal lymph node}, right hilum {Structure of hilum of right lung}, right {Right sphenoid sinus structure}, pleural effusion {Pleural effusion}, pleural effusion {Pleural effusion}, pericardial effusion {Pericardial effusion}, nodule {Nodule of lung}, right upper lobe {Structure of upper lobe of right lung}, enhancement {Adrenal hyperplasia}, left adrenal gland {Structure of left adrenal gland}, enlarged {Localized enlarged lymph nodes}, left supraclavicular lymph node {Structure of left supraclavicular lymph node}, vertebral body {Structure of body of vertebra}, lesions {Lesion}, thoracic spine {Structure of thoracic vertebral column}, Excisional biopsy {Excisional biopsy}, right supraclavicular lymph node {Structure of right supraclavicular lymph node}, Pathology {Abnormal histology findings}, poorly differentiated neuroendocrine carcinoma {Malignant poorly differentiated neuroendocrine carcinoma}, pulmonary {Examination of respiratory system}, large cell {Large cell carcinoma of lung}, variation in cell size {Cell size alteration}, lymphoproliferative disorder {Lymphoproliferative 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: Past Medical History: 1. L4/L5 spondylolisthesis with synovial cyst resected in ___. 2. Left piriformis syndrome. 3. Hypertension. 4. Status post hysterectomy in ___ for leiomyomata with foci of atypical hyperplasia of the endometrium, focally involving an endometrial polyp. ###RESPONSE: L4 {Bone structure of L4}, L5 {Bone structure of L5}, spondylolisthesis {Spondylolisthesis of lumbar vertebra}, synovial cyst resected {Excision of synovial cyst}, Left {Structure of left piriformis muscle}, piriformis syndrome {Piriformis syndrome}, Hypertension {Hypertensive disorder, systemic arterial}, Status post {Postoperative state}, hysterectomy {Hysterectomy}, leiomyomata {Leiomyoma}, atypical hyperplasia of the endometrium {Endometrioid intraepithelial neoplasia}, endometrial polyp {Polyp of endometrium}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: The patient's mother died at age ___ from squamous cell carcinoma of the oral cavity. Her father died of congestive heart failure at age ___. She has no siblings. Her paternal aunt was diagnosed with breast cancer in her ___. . ###RESPONSE: died {Dead}, squamous cell carcinoma {Squamous cell carcinoma}, oral cavity {Oral cavity structure}, died {Dead}, congestive heart failure {Congestive heart failure}, breast cancer {Malignant neoplasm of breast}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Physical Exam: Tc 97.3 BP 125/79 HR 95 RR 28 93% 3L NC Gen: Mild Distress, Sitting upright, AOx3 HEENT: PEERLA, EOMI, OP without exudates or erythema Neck: Supple Resp: Healing R supraclavicular bx site with palpable node, bilateral diffuse expiratory wheezes, no accessory muscle use, decreased BS at bases, coarse BS throughout. Card: Regular, S1S2 No MRG Abd: Palpable non-tender mobile 2cm nodule in LLQ, soft, slightly protuberant, non-tender, non-distended, BS+ Extr: Trace edema bilaterally, Bilateral mild ulnar deviation of the phalanges Neuro: AOx3, CNII-XII tested and intact. ___ strength and sensation in upper and lower extremities, normal finger to nose bilaterally. Psych: Patient visibly anxious but appropriate conversation. ###RESPONSE: BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, NC {Normal head}, Gen {General examination of patient}, Mild {Symptom mild}, Distress {Distress}, Sitting upright {Sitting upright}, AOx3 {Oriented to person, time and place}, HEENT {Physical examination procedure}, PEERLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, OP {Oropharyngeal structure}, exudates {Exudate}, erythema {Erythema}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Resp {Examination of respiratory system}, Healing {Structure resulting from tissue repair process}, R supraclavicular bx site with palpable node {Supraclavicular lymph node biopsy}, wheezes {Wheezing}, accessory muscle {Accessory skeletal muscle}, decreased BS {Decreased breath sounds}, bases {Structure of base of lung}, BS {Normal bowel sounds}, Card {Cardiovascular physical examination}, Regular {Normal heart rate}, S2 {Normal second heart sound, S>2<}, No MRG {Heart sounds normal}, Abd {Examination of abdomen}, Palpable {Finding by palpation}, non-tender {Abdominal tenderness}, nodule {Nodule}, LLQ {Structure of left lower quadrant of abdomen}, soft {Abdomen soft}, protuberant {Swollen abdomen}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, BS+ {Normal bowel sounds}, Extr {Examination of limb}, edema {Edema}, mild {Symptom mild}, ulnar deviation of the phalanges {Ulnar deviation of fingers}, Neuro {Neurological examination}, AOx3 {Oriented to person, time and place}, XII {Hypoglossal nerve structure}, intact {Normal sensation}, sensation {Normal sensation}, upper {Upper limb structure}, lower extremities {Lower limb structure}, normal {No abnormality detected}, nose {Nasal structure}, Psych {Psychological assessment}, anxious {Anxiety}, appropriate conversation {Conversation content appropriate}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Pertinent Results: Admission Labs: ___ 04:40PM WBC-25.2# RBC-4.08 HGB-12.0 HCT-35.7* MCV-88 MCH-29.5 MCHC-33.7 RDW-13.2 ___ 04:40PM NEUTS-86.9* LYMPHS-5.3* MONOS-5.6 EOS-2.0 BASOS-0.3 ___ 04:40PM PLT COUNT-570* ___ 04:40PM ___ PTT-35.1* ___ ___ 04:40PM CALCIUM-9.7 PHOSPHATE-3.3 MAGNESIUM-2.5 URIC ACID-4.5 ___ 04:40PM CK-MB-5 cTropnT-<0.01 proBNP-2531* ___ 04:40PM LIPASE-23 ___ 04:40PM ALT(SGPT)-26 AST(SGOT)-35 LD(LDH)-370* ALK PHOS-148* AMYLASE-59 TOT BILI-0.2 ___ 04:40PM GLUCOSE-69* UREA N-19 CREAT-0.7 SODIUM-130* POTASSIUM-4.2 CHLORIDE-85* TOTAL CO2-26 ANION GAP-23* . CT Head ___ IMPRESSION: There is no evidence of abnormal enhancement or evidence of focal or diffuse lesions. There is no evidence of intracranial hemorrhage, mass, or mass effect. No metastasic lesions are visulized, however CT with contrast is not able to provide the same anatomical detail comparable to MRI with and without contrast. . PET CT: ___ MPRESSION: 1. Widespread metastatic disease. 2. Malignant soft tissue nodule in the deep right breast is most likely a metastasis from lung cancer (given second subcutaneous deposit in the anterior abdominal wall), but the possibility of a second breast primary remains a remote consideration. 3. Suspicious focus in the pancreas is also likely a metastasis, but again, a primary malignancy would be difficult to entirely exclude. . ECHO: ___ The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60-70%). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. The main pulmonary artery is dilated. . There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There is brief right atrial as well as right ventricular free wall diastolic invagination. However, there is no major respirophasic variation of right or left ventriculart inflow. These findings suggest that increased pericardial pressure is present, without major impairment of ventricular filling or frank cardiac tamponade. Serial clinical and echocardiographic followup is recommended. . ECHO ___: Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. There is brief right atrial diastolic collapse. . Compared with the prior study (images reviewed) of ___, no right ventricular diastolic invagination is appreciated. The pericardial effusion appears slightly smaller. . ___: IMPRESSION: 1. No evidence of aortic dissection or pulmonary embolism to the subsegmental level. 2. Increased dense nonenhancing right lower lobe consolidation consistent with pneumonia, with additional increased predominantly ground-glass consolidation / post obstructive changes (due to right hilar mass / adenopathy) within the posterior portion of the left upper lobe and adjacent to the right pleural effusion, which are also presumably infectious in etiology. Please note reexpansion edema involving a portion of the right lower lobe may also have a similar appearance. 3. Increased enhancing atelectasis involving the left lower lobe with left pleural fluid noted to insinuate around regions of "drowned" lung. 4. No significant interval change in the degree of previously described adenopathy and a dominant right hilar mass, with stable mass effect on right upper lobe and bronchus intermedius bronchi. Stable mass effect on the right upper lobe pulmonary artery, which remains patent. 5. Unchanged soft tissue density within the deep right breast, which was noted to be FDG-avid. 6. Unchanged background emphysema and interstitial septal thickening, which is worrisome for lymphangitic carcinomatosis. 7. Stable lytic metastatic lesions and thickening of the left adrenal gland. . ___: Cytology ReportPLEURAL FLUIDProcedure Date of ___ REPORT APPROVED ___ SPECIMEN ___ ___ PLEURAL FLUID SPECIMEN DESCRIPTION: Received 1,300 ml of bloody fluid. Prepared 1 ThinPrep slide. CLINICAL DATA: 73 with metastatic NSCLA with R pleural effusion. PREVIOUS BIOPSIES: ___ PLEURAL FLUID ___ PERITONEAL WASHINGS REPORT ___. ___ ___: Pleural fluid: ATYPICAL. Clusters of atypical epithelioid cells on cell block (___) only. The cells are negative for ___ 31, B72.3, TTF-1 and CEA and cannot be further classified. DIAGNOSED BY: ___, CT(___) ___, M.D. (___) . ___: TTE Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. The mitral valve leaflets are mildly thickened. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. No right ventricular diastolic collapse is seen. There is brief right atrial diastolic collapse. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Compared with the prior study (images reviewed) of ___, the resting heart rate is faster and respiratory variation in mitral valve inflow is present (this may be secondary to other entities than impending tamponade such as volume depletion or lung disease). Left ventricular function is more vigorous. . ___: CXR FINDINGS: As compared to the previous examination, there is increasing consolidation and volume loss in the right upper lobe. The perihilar right lung areas, notably neighboring a hilar mass, are denser than on the previous examination. A pre-existing right-sided pleural effusion is unchanged, and the expansion of the right lower lobe is slightly improved as compared to the previous exam. No pathologic changes in the left lung. . Discharge Labs: ___ 06:40AM BLOOD WBC-4.6 RBC-3.37* Hgb-10.0* Hct-29.9* MCV-89 MCH-29.7 MCHC-33.5 RDW-13.0 Plt ___ ___ 06:40AM BLOOD Plt ___ ___ 07:10AM BLOOD ___ PTT-33.6 ___ ___ 06:40AM BLOOD Glucose-97 UreaN-23* Creat-0.7 Na-136 K-3.8 Cl-100 HCO3-29 AnGap-11 ___ 07:10AM BLOOD ALT-12 AST-15 LD(LDH)-168 AlkPhos-91 TotBili-0.6 ___ 06:40AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.___ with newly diagnosed metastatic NSCLC here with dyspnea and new 02 requirement. . # Dyspnea, Hypoxia: The patients initial differential included worsening atelectasis, bronchospasms, worsening effusions, post-obstructive PNA, anxiety, anemia. The patient was admitted on Prednsione 80mg PO Daily which was tapered down during her hospital course in addition to receiving nebs PRN. CXR revealed a large R sided effusion and the pt underwent thoracentesis on ___ during which 2.1L were removed. That evening the pt had an episode of desaturation requiring up to 10L with CXR evidence of re-expansion pulmonary edema, this improved somewhat with diuresis, but CT chest ___ showed marked worsening of effusions & dense consolodate of RLL with ground glass opacities surrounding. A second thoarcenetsis was then performed which was complcated by a PTX after which a chest tube was placed for 24 hrs without complication. The patient was placed on Levo/Flagyl for a questionable post-obstructive PNA. The chest tube was removed and ___ 48hrs the patient an the patients 02 requirement resolved. The patient was discharged on room air with home 02 PRN. . # Metastatic NSCLC: PET-CT revealed wide-spread metastatic disease. Pathology "poorly differentiated neuroendocrine carcinoma of pulmonary origin, probably best characterized as large cell type". Potentially the etiology of the patients SOB. The patient was initiated on her first cycle of Cabroplatin/Etoposide on ___ for 3 days. The patient tolerated the treatment during her hospital course without complications. . # Pericardial effusion: A pericardial effusion was noted on CT prior to admittion. TTE (details above) revealed early signs of tamponade on ___, this was improved on ___ echo. Care was taken during diureses not to drop the patients BP. (The patient tolerated doses of 20IV lasix, although 40IV lasix caused asymptomatic drops to the mid ___ systolically). The patient required no interventions and the patients TTE was repeated on ___ prior to d/c (details above). . # Anxiety: Continued anxiety over the past ___ weeks. Has been taking Ativan and Valium while at home.The patient was continued on Ativan 0.5-1mg as needed. . # HTN: BP controlled.The patients BP was exchanged (Toprol XL 50mg for Metoprolol 25mg PO BID) while in house. ###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, PTT {Partial thromboplastin time, activated}, CALCIUM {Blood calcium measurement}, cTropnT {Troponin T cardiac measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, LIPASE {Triacylglycerol lipase measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Lactate dehydrogenase measurement}, TOT BILI {Bilirubin, total measurement}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, no evidence {No abnormality detected}, enhancement {Refractive surgery enhancement}, lesions {Lesion}, no evidence {No abnormality detected}, intracranial hemorrhage {Intracranial hemorrhage}, mass {Mass}, mass {Mass}, metastasic {Metastatic malignant neoplasm}, lesions {Lesion}, MRI with {Magnetic resonance imaging of head with contrast}, without contrast {Magnetic resonance imaging without contrast}, disease {Disease}, Malignant soft tissue {Malignant neoplasm of soft tissue}, nodule {Nodule}, right breast {Metastatic malignant neoplasm to right breast}, metastasis from lung cancer {Primary malignant neoplasm of lung}, subcutaneous {Subcutaneous tissue structure of anterior abdominal wall}, deposit {Deposition}, anterior abdominal wall {Anterior abdominal wall structure}, breast primary {Primary malignant neoplasm of breast}, pancreas is also likely a metastasis {Metastatic malignant neoplasm to pancreas}, primary malignancy {Primary malignant neoplasm of pancreas}, ECHO {Echocardiography}, left atrium {Left atrial structure}, normal in size {Normal size}, Left ventricular wall {Left cardiac ventricular structure}, thicknesses are normal {Normal thickness}, left ventricular cavity {Structure of cavity of left cardiac ventricle}, size is normal {Normal size}, left ventricular systolic function {Normal left ventricular systolic function and wall motion}, normal {No abnormality detected}, Right ventricular chamber {Right cardiac ventricular structure}, wall motion are normal {Normal ventricular wall motion}, focal calcifications {Focal calcium deposition, calcified structure}, aortic arch {Aortic arch structure}, aortic valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve leaflets are mildly thickened {Thickened mitral leaflet}, mitral valve prolapse {Mitral valve prolapse}, Trivial mitral regurgitation {Mild mitral valve regurgitation}, mild {Mild mitral valve regurgitation}, pulmonary artery systolic hypertension {Pulmonary hypertensive arterial disease}, pulmonary artery is dilated {Dilatation of pulmonary artery}, pericardial effusion {Pericardial effusion}, effusion {Pericardial effusion}, right atrial {Right atrial structure}, right ventricular {Right cardiac ventricular structure}, wall {Cardiac wall structure}, invagination {Invagination}, right {Right cardiac ventricular structure}, left ventriculart {Left cardiac ventricular structure}, inflow {Abnormal cardiac flow}, pericardial {Pericardial structure}, pressure {Pressure}, impairment {Impairment}, ventricular {Cardiac ventricular structure}, filling {Abnormal cardiac flow}, cardiac tamponade {Cardiac tamponade}, echocardiographic {Echocardiography}, followup {Follow-up consultation}, left ventricular systolic function {Normal left ventricular systolic function and wall motion}, normal {No abnormality detected}, Right ventricular chamber {Right cardiac ventricular structure}, wall motion are normal {Normal ventricular wall motion}, aortic valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, mitral valve leaflets are mildly thickened {Thickened mitral leaflet}, pericardial effusion {Pericardial effusion}, effusion {Pericardial effusion}, echocardiographic {Echocardiography}, signs {Sign}, tamponade {Cardiac tamponade}, right atrial {Right atrial structure}, collapse {Collapse}, study {Evaluation procedure}, right ventricular {Right cardiac ventricular structure}, invagination {Invagination}, pericardial effusion {Pericardial effusion}, No evidence {No abnormality detected}, aortic dissection {Dissection of aorta}, pulmonary embolism {Pulmonary embolism}, right lower lobe {Structure of lower lobe of right lung}, consolidation {Lung consolidation}, pneumonia {Pneumonia}, ground-glass {Ground glass lung opacity}, consolidation {Lung consolidation}, obstructive {Obstruction}, hilar mass {Mass of hilum}, adenopathy {Lymphadenopathy}, left upper lobe {Structure of upper lobe of left lung}, right {Right sphenoid sinus structure}, pleural effusion {Pleural effusion}, infectious {Infectious disease}, edema {Edema}, right lower lobe {Structure of lower lobe of right lung}, atelectasis {Atelectasis}, left lower lobe {Structure of lower lobe of left lung}, pleural fluid {Pleural effusion}, lung {Lung structure}, adenopathy {Lymphadenopathy}, hilar mass {Mass of hilum}, stable {Symptom not changed}, mass {Nodule of lung}, right upper lobe {Structure of upper lobe of right lung}, bronchus {Structure of right bronchus}, Stable {Symptom not changed}, mass {Nodule of lung}, right upper lobe pulmonary {Structure of upper lobe of right lung}, soft tissue {Structure of soft tissue}, density {Abnormally opaque structure}, right breast {Right breast structure}, FDG {Positron emission tomography with computed tomography using fluorodeoxyglucose (18-F)}, emphysema {Emphysema}, septal {Cardiac septum structure}, thickening {Increased thickness}, lymphangitic carcinomatosis {Lymphangitis carcinomatosa}, Stable {Patient's condition stable}, lytic {Lysis}, metastatic {Metastatic malignant neoplasm}, lesions {Lesion}, thickening {Increased thickness}, left adrenal gland {Structure of left adrenal gland}, Cytology {Cytology examination - general}, PLEURAL FLUID {Pleural effusion}, SPECIMEN DESCRIPTION {Specimen description}, bloody fluid {Pleural fluid bloodstained}, metastatic {Metastatic malignant neoplasm}, NSCLA {Non-small cell lung cancer}, pleural effusion {Pleural effusion}, BIOPSIES {Biopsy}, PLEURAL FLUID {Pleural effusion}, Pleural fluid {Pleural effusion}, cells {Cell structure}, cell {Cell structure}, block {Obstruction}, cells {Cell structure}, negative {No abnormality detected}, TTE {Transthoracic echocardiography}, left ventricular systolic function {Normal left ventricular systolic function and wall motion}, normal {No abnormality detected}, Right ventricular chamber {Right cardiac ventricular structure}, wall motion are normal {Normal ventricular wall motion}, aortic valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, mitral valve leaflets are mildly thickened {Thickened mitral leaflet}, pericardial effusion {Pericardial effusion}, effusion {Pericardial effusion}, right ventricular {Right cardiac ventricular structure}, collapse {Collapse}, right atrial {Right atrial structure}, collapse {Collapse}, respiratory {Examination of respiratory system}, mitral {Mitral valve regurgitation}, tricuspid valve {Tricuspid valve structure}, inflows {Abnormal cardiac flow}, impaired {Impairment}, ventricular {Cardiac ventricular structure}, filling {Abnormal cardiac flow}, study {Evaluation procedure}, heart rate is faster {Tachycardia}, respiratory {Examination of respiratory system}, mitral valve {Mitral valve structure}, inflow {Abnormal cardiac flow}, tamponade {Cardiac tamponade}, volume depletion {Decreased blood volume}, lung disease {Disorder of lung}, Left ventricular {Left cardiac ventricular structure}, CXR {Plain chest X-ray}, consolidation {Consolidation}, volume loss {Decreased size}, right upper lobe {Structure of upper lobe of right lung}, perihilar right lung areas {Structure of perihilar region of right lung}, hilar mass {Mass of hilum}, right-sided {Right breast structure}, pleural effusion {Pleural effusion}, right lower lobe {Structure of lower lobe of right lung}, improved {Patient's condition improved}, exam {Examination of respiratory system}, left lung {Left lung structure}, 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}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, metastatic {Metastatic malignant neoplasm}, NSCLC {Non-small cell lung cancer}, dyspnea {Dyspnea}, Dyspnea {Dyspnea}, Hypoxia {Hypoxia}, worsening {Patient's condition worsened}, atelectasis {Atelectasis}, bronchospasms {Bronchospasm}, worsening {Patient's condition worsened}, effusions {Effusion}, post-obstructive PNA {Postobstructive pneumonia}, anxiety {Anxiety}, anemia {Anemia}, CXR {Plain chest X-ray}, R sided {Right pleura structure}, effusion {Pleural effusion}, thoracentesis {Thoracentesis}, removed {Drainage of pleural cavity}, desaturation {Oxygen saturation below reference range}, 10L {Oxygen therapy}, CXR {Plain chest X-ray}, pulmonary edema {Pulmonary edema}, improved {Patient's condition improved}, diuresis {Diuretic therapy}, CT chest {Computed tomography of chest}, worsening {Patient's condition worsened}, effusions {Pleural effusion}, RLL {Structure of lower lobe of right lung}, ground glass opacities {Ground glass lung opacity}, thoarcenetsis {Thoracentesis}, PTX {Pneumothorax}, chest tube was placed {Insertion of pleural tube drain}, on Levo/Flagyl {Antibiotic therapy}, post-obstructive PNA {Postobstructive pneumonia}, chest tube was removed {Intercostal drain removal}, resolved {Problem resolved}, on room air {Breathing room air}, 02 {Oxygen therapy}, Metastatic {Metastatic malignant neoplasm}, NSCLC {Non-small cell lung cancer}, PET-CT {Positron emission tomography}, wide-spread metastatic disease {Widespread metastatic malignant neoplastic disease}, Pathology {Abnormal histology findings}, poorly differentiated neuroendocrine carcinoma {Malignant poorly differentiated neuroendocrine carcinoma}, pulmonary {Primary malignant neoplasm of lung}, large cell {Large cell carcinoma of lung}, SOB {Dyspnea}, Cabroplatin/Etoposide {Chemotherapy}, Pericardial effusion {Pericardial effusion}, pericardial effusion {Pericardial effusion}, TTE {Transthoracic echocardiography}, signs {Sign}, tamponade {Cardiac tamponade}, improved {Patient's condition improved}, echo {Echocardiography}, diureses {Diuretic therapy}, drop the patients BP {Finding of decreased blood pressure}, lasix {Diuretic therapy}, lasix {Diuretic therapy}, asymptomatic {Asymptomatic}, drops {Finding of decreased blood pressure}, TTE {Transthoracic echocardiography}, Anxiety {Anxiety}, anxiety {Anxiety}, HTN {Hypertensive disorder, systemic arterial}, BP {Blood pressure finding}, BP {Blood pressure finding}, exchanged {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: Medications on Admission: HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - ___ Tablet(s) by mouth every six (6) hours as needed for pain LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - Tablet(s) by mouth METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg Tablet Sustained Release 24 hr - 1 (One) Tablet(s) by mouth qd - OTC ACETAMINOPHEN [TYLENOL ARTHRITIS] - (___) - 650 mg Tablet Sustained Release - Tablet(s) by mouth as needed for pain ASPIRIN [BABY ASPIRIN] - (OTC) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a day DOCUSATE SODIUM [DOCUSIL] - 100 mg Capsule - 1 Capsule(s) by mouth twice a day as needed for while on pain med HOLD if having diarrhea IBUPROFEN [MOTRIN] - (___) - 600 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for pain Discharge Medications: 1. Home O2 therapy ___ Patient requires home O2 for hypoxia with malignant pleural effusion 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days: to complete taper. Disp:4 Tablet(s) Refills:0 3. Percocet ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain: do not drive or drink alcohol with this medication. 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety: do not drink or drink alcohol with this medication. 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Tylenol ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain. 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. ###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 With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Community acquired pneumonia Pleural Effusion Pericardial effusion . Secondary Diagnosis: Non small cell lung cancer Anxiety Discharge Condition: Good, on RA. Desats to the high ___ when climbing stairs. At her mental baseline. ###RESPONSE: With Service {Home health aide service management}, Community acquired pneumonia {Community acquired pneumonia}, Pleural Effusion {Pleural effusion}, Pericardial effusion {Pericardial effusion}, Non small cell lung cancer {Non-small cell lung cancer}, Anxiety {Anxiety}, Good {Patient's condition satisfactory}, RA {Breathing room air}, climbing stairs {Difficulty walking up stairs}, mental {Mental state finding}, baseline {Baseline state}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Discharge Instructions: You were admitted with shortness of breath. You were found to have both a pneumonia and fluid in your lung (pleural effusion). You underwent a thoracentesis with removal of fluid in your lung. Your chest x rays have been stable since then, as well as your echocardiogram. . Please continue your home medications as before. You have completed a course of antibiotics for presumed pneumonia. Additionally, we are tapering your steroids starting by your primary physician. Please continue Prednisone 10mg daily for an additional 4 days and then stop. . Please follow up with Dr. ___ on ___ as scheduled, and follow up with Dr. ___ in 2 weeks to reassess your pericardial effusion . Please return to the hospital if you experience worsening shortness of breath, chest pain, high fever, or low blood pressure ###RESPONSE: shortness of breath {Dyspnea}, pneumonia {Pneumonia}, fluid in your lung {Pleural effusion}, pleural effusion {Pleural effusion}, thoracentesis {Thoracentesis}, removal {Removal}, fluid in your lung {Pleural effusion}, chest x rays {Plain chest X-ray}, stable {Patient's condition stable}, echocardiogram {Echocardiography}, medications {Administration of drug or medicament}, antibiotics {Antibiotic therapy}, pneumonia {Pneumonia}, steroids {Steroid therapy}, primary physician {Primary care management}, follow up {Follow-up arranged}, pericardial effusion {Pericardial effusion}, worsening {Patient's condition worsened}, shortness of breath {Dyspnea}, chest pain {Chest pain}, fever {Fever}, low blood pressure {Low blood pressure}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Followup Instructions: ___ ###RESPONSE: EMPTY: No SNOMED annotations found in this fragment
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE ###RESPONSE: EMPTY: No SNOMED annotations found in this fragment
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Allergies: Penicillins / Citalopram Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None ###RESPONSE: Penicillins {Allergy to penicillin}, 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: ___ woman with history of moderate COPD/asthma (FEV1 40% pred. in ___, CAD, diastolic CHF, and aortic aneurysm who presented to the emergency room overnight with several weeks of SOB and cough productive of yellow sputum. Pt reports that symptoms have been intermittent for several weeks; recently symptoms have become worse. She was seen by her PCP ___ who recommended that she keep her appointment with her pulmonologist ___ for consideration of initiation of daily low dose prednisone. Of note, in the past pt has had issues with noncompliance with meds. Pt reports that she has been using her nebs more frequently recently given her SOB. . Her initial vitals in the ED were 100.4, 86, 136/89, 16, and 94%. Labs notable for no white count, normal electrolytes and normal lactate (1.3). Chest x-ray notable for stable left lingular nodule and linear opacities in the right mid lung. There was no acute process. Nevertheless, the patient was treated for CAP in the ED with ceftriaxone and azithromycin. She was also treated with methylprednisolone and Combivent nebs for presumptive COPD exacerbation. Blood cultures were drawn prior to antibiotic administration. The patient was then admitted for further treatment. Vitals at time of admit: 97.9, 77, 157/83, 18, 100% RA. . Review of Systems: (+) Pt reports feeling nightsweats yesterday, nausea two days ago, intermittent headaches (recently changed from amitriptyline prn to daily), chronic constipation (-) Denies rhinorrhea, sore throat, chest pain, palpitations, abdominal pain ###RESPONSE: COPD {Chronic obstructive lung disease}, asthma {Asthma}, CAD {Coronary arteriosclerosis}, diastolic CHF {Heart failure with normal ejection fraction}, aortic aneurysm {Aortic aneurysm}, emergency {Emergency treatment management}, SOB {Dyspnea}, cough productive of yellow sputum {Productive cough-yellow sputum}, worse {Patient's condition worsened}, PCP {Primary care management}, prednisone {Steroid therapy}, noncompliance with meds {Non-compliance of drug therapy}, nebs {Nebulizer therapy}, SOB {Dyspnea}, vitals {Vital signs finding}, Labs {Laboratory test}, white count {White blood cell count outside reference range}, normal electrolytes {Electrolytes within reference range}, normal {No abnormality detected}, lactate {Lactic acid measurement}, Chest x-ray {Plain chest X-ray}, stable {Symptom not changed}, left {Left pleura structure}, lingular {Structure of lingular bronchus}, nodule {Nodule of lung}, opacities {Abnormally opaque structure}, right mid lung {Structure of middle lobe of right lung}, no acute {No abnormality detected}, CAP {Community acquired pneumonia}, azithromycin {Antibiotic therapy}, nebs {Nebulizer therapy}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, Blood cultures {Blood culture}, antibiotic {Antibiotic therapy}, Vitals {Vital signs finding}, Review of Systems {Review of systems}, nightsweats {Night sweats}, nausea {Nausea}, intermittent headaches {Intermittent headache}, changed {Change of medication}, chronic constipation {Chronic constipation}, rhinorrhea {Nasal discharge}, sore throat {Sore throat}, chest pain {Chest pain}, palpitations {Palpitations}, abdominal pain {Abdominal pain}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Past Medical History: - Chronic obstructive pulmonary disease - Asthma - Hypertension - Headaches - Duodenal and stomach ulcers, s/p partial gastrectomy - Aortic aneurysm - Cataracts - History of pulmonary nodule - Diastolic CHF ###RESPONSE: Chronic obstructive pulmonary disease {Chronic obstructive lung disease}, Asthma {Asthma}, Hypertension {Hypertensive disorder, systemic arterial}, Headaches {Headache}, Duodenal {Ulcer of duodenum}, stomach ulcers {Gastric ulcer}, partial gastrectomy {Subtotal gastrectomy}, Aortic aneurysm {Aortic aneurysm}, Cataracts {Cataract}, pulmonary nodule {Nodule of lung}, Diastolic CHF {Heart failure with normal ejection fraction}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: On admission: VS: 98.1 140/80 72 24 100%4L Gen: NAD. Alert and oriented x3. Mood and affect appropriate. Pleasant and cooperative. Resting in bed. HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP clear. Neck: Supple. JVP not elevated. CV: RRR. Normal S1, S2. No murmur, rubs, or gallops. Chest: Faint diffuse wheezes, decreased breath sounds diffusely, bibasilar crackles Abd: BS present. Soft, NT, ND. No HSM detected. Ext: WWP, no cyanosis or clubbing. Trace ___ edema. Digital cap refill <2 sec. Distal pulses DP 2+, ___ 2+. Neuro/Psych: CNs II-XII intact. ___ strength in U/L extremities ###RESPONSE: VS {Vital signs finding}, Gen {General examination of patient}, NAD {No abnormality detected}, Alert {Mentally alert}, oriented {Orientated}, Mood {Level of mood - normal}, affect {Mood finding}, cooperative {Cooperative mental state}, Resting in bed {Lying in bed}, HEENT {Physical examination procedure}, NC {Normal head}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, anicteric sclera {White sclera}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmur {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Chest {Examination of respiratory system}, wheezes {Wheezing}, decreased breath sounds {Decreased breath sounds}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, Abd {Examination of abdomen}, BS present {Normal bowel sounds}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, cyanosis {Cyanosis}, clubbing {Clubbing}, edema {Edema}, pulses {Pulse finding}, DP 2 {Dorsalis pulse present}, Neuro {Neurological examination}, CNs II-XII {Cranial nerve structure}, intact {No abnormality detected}, extremities {All extremities}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Pertinent Results: ADMISSION LABS -------------- ___ 01:00AM BLOOD WBC-4.1 RBC-4.26 Hgb-12.3 Hct-37.7 MCV-89 MCH-28.9 MCHC-32.6 RDW-14.0 Plt ___ ___ 01:00AM BLOOD Glucose-148* UreaN-14 Creat-0.8 Na-141 K-5.1 Cl-102 HCO3-31 AnGap-13 ___ 01:19AM BLOOD Lactate-1.3 ___ 1:00 am Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. . DISCHARGE LABS -------------- ___ 07:20AM BLOOD WBC-5.3 RBC-4.20 Hgb-12.4 Hct-38.0 MCV-90 MCH-29.5 MCHC-32.6 RDW-14.7 Plt ___ ___ 07:20AM BLOOD Glucose-112* UreaN-26* Creat-0.8 Na-144 K-3.5 Cl-105 HCO3-26 AnGap-17 ___ 07:20AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.0 . IMAGING ------- Chest (PA & LAT) ___: FRONTAL AND LATERAL VIEWS OF THE CHEST: Linear opacities in the right lung are again seen, unchanged since the prior study and likely relate to scarring/nonspecific fibrosis. The left lingular nodular opacity is not as discretely seen on this study but appears stable in size. There is no new pleural effusion or pneumothorax. Mild cardiomegaly is unchanged. The aorta remains tortuous. IMPRESSION: No acute intrathoracic process. Stable appearance of scarring/fibrosis over the right mid lung and lingular nodular density. . MICROBIOLOGY ------------ ___ 1:00 am BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ 5:54A ___. GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. . Blood culture ___: pending, no growth to date ###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Lactate {Lactic acid measurement}, Blood Culture {Blood culture}, NEGATIVE {No pathologic diagnosis}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, IMAGING {Imaging}, CHEST {Plain chest X-ray}, opacities {Abnormally opaque structure}, right lung {Right lung structure}, unchanged {Patient condition unchanged}, study {Evaluation procedure}, scarring {Scar}, fibrosis {Fibrosis}, left {Left pleura structure}, lingular {Structure of lingular bronchus}, nodular {Nodule of lung}, opacity {Abnormally opaque structure}, study {Evaluation procedure}, stable {Symptom not changed}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, cardiomegaly {Cardiomegaly}, unchanged {Patient condition unchanged}, aorta {Aortic structure}, tortuous {Tortuosity}, No acute intrathoracic process {No abnormality detected}, scarring {Scar}, fibrosis {Fibrosis}, right mid lung {Structure of middle lobe of right lung}, lingular {Structure of lingular bronchus}, nodular {Nodule of lung}, density {Abnormally opaque structure}, MICROBIOLOGY {Microbiology}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, NEGATIVE {No pathologic diagnosis}, SENSITIVITIES {Antimicrobial susceptibility test}, Gram Stain {Gram stain method}, Blood culture {Blood culture}, no growth {No organism isolated by microbiologic culture}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Brief Hospital Course: ___ woman with history of moderate obstructive lung disease presents with two weeks of shortness of breath and a couple days of sputum production, with low-grade fevers in the emergency room. . ACTIVE ISSUES ------------- # Shortness of breath, productive cough, low-grade fever: dyspnea likely secondary to COPD flare, possibly exacerbated by viral bronchitis given cough and low grade temperature. Chest X-ray did not show pneumonia. Patient was given standing nebulizers and prednisone 60mg x 7 days without a taper. She was also treated with azithromycin x 5 days. She was kept on her home oxygen of 4 liters with maintenance of oxygen saturations. . INACTIVE ISSUES --------------- # Diastolic CHF: Last TTE on ___ showed preserved ejection fraction, and no significant valvular disease. She appeared euvolemic on exam. Chest X-ray was without any large effusions. Patient was continued on her home dose of furosemide during hospitalization. . # Aortic aneurysm: CTA performed on ___ showing slightly enlarged aortic aneurysm measuring approximately 4.5 cm AP x 4.9 cm transversely (previously 4.2 cm in AP x 4.2 cm transverse). She should follow-up with her PCP as an outpatient further regarding this problem. . # Hypertension: patient was continued on her home dose of lasix and lisinopril. . # Headaches: patient was continued on her home dose of amitryptiline. . # Gastroesophageal reflux disease: patient was continued on home proton pump inhibitor. . TRANSITION OF CARE ------------------ # Follow-up: patient has pending blood cultures that should be followed up upon discharge. She will be scheduled by her primary care provider for ___ follow-up appointment. She will also be seen by Pulmonary soon after discharge for an initial assessment. . # Code status: patient is confirmed full code . # Communication: - Al (son): ___. - ___ (son): ___. ###RESPONSE: moderate obstructive lung disease {Moderate chronic obstructive pulmonary disease}, shortness of breath {Dyspnea}, sputum production {Productive cough}, low-grade fevers {Low grade pyrexia}, emergency {Emergency treatment management}, Shortness of breath {Dyspnea}, productive cough {Productive cough}, low-grade fever {Low grade pyrexia}, dyspnea {Dyspnea}, COPD flare {Acute exacerbation of chronic obstructive airways disease}, viral bronchitis {Viral bronchitis}, cough {Cough}, temperature {Body temperature above reference range}, Chest X-ray {Plain chest X-ray}, pneumonia {Pneumonia}, nebulizers {Nebulizer therapy}, prednisone {Steroid therapy}, taper {Medication decreased}, azithromycin {Antibiotic therapy}, home oxygen {Home oxygen therapy}, oxygen saturations {Finding of oxygen saturation}, Diastolic CHF {Heart failure with normal ejection fraction}, TTE {Transthoracic echocardiography}, valvular disease {Heart valve disorder}, euvolemic {Normal blood volume}, exam {Evaluation procedure}, Chest X-ray {Plain chest X-ray}, effusions {Pleural effusion}, Aortic aneurysm {Aortic aneurysm}, CTA {Computed tomography angiography with contrast}, enlarged {Enlargement}, aortic aneurysm {Aortic aneurysm}, PCP {Primary care management}, problem {Problem}, Hypertension {Hypertensive disorder, systemic arterial}, lasix {Diuretic therapy}, Headaches {Headache}, Gastroesophageal reflux disease {Gastroesophageal reflux disease}, proton pump inhibitor {Proton pump inhibitor therapy}, TRANSITION OF CARE {Transition of care}, blood cultures {Blood culture}, primary care {Primary care management}, Pulmonary {Pulmonary medicine service}, assessment {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: Medications on Admission: - albuterol 90 mcg HFA 2 puffs q6h prn - amitryptiline 50 mg once daily at night - budesonide 0.5 mg/2 mL solution for nebulizer bid - furosemide 40 mg every morning - ibuprofen 600 mg tid to qid prn - ipratropium-albuterol nebs up to three times daily - lactulose hs prn for constipation - lisinopril 40 mg qday - omeprazole 20 mg qday - oxygen 4L at night - acetaminophen prn - multivitamin Discharge Medications: 1. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 3 days. Disp:9 Tablet(s) Refills:0 8. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:1 Tablet(s) Refills:0 9. acetaminophen Oral 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 11. budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One (1) Inhalation twice a day. 12. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation three times a day as needed for shortness of breath or wheezing. 13. ibuprofen Oral ###RESPONSE: mg {Blood magnesium measurement}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Chronic obstructive pulmonary disease flare Bacteremia Secondary diagnosis: Diastolic congestive heart failure Hypertension Aortic aneurysm Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. ###RESPONSE: Chronic obstructive pulmonary disease flare {Acute exacerbation of chronic obstructive airways disease}, Bacteremia {Bacteremia}, Diastolic congestive heart failure {Heart failure with normal ejection fraction}, Hypertension {Hypertensive disorder, systemic arterial}, Aortic aneurysm {Aortic aneurysm}, Gastroesophageal reflux disease {Gastroesophageal reflux disease}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___. You came for further evaluation of shortness of breath. Further evaluation suggested that you had a flare-up of your chronic obstructive pulmonary disease. It is very important that you continue to take your medications as prescribed and follow up with your primary care provider after discharge. The following changes have been made to your medications: 1) Prednisone 60mg was started, which you should continue for three more days, starting tomorrow 2) Azithromycin 250mg was started, which you should continue for one more day, starting tomorrow ###RESPONSE: evaluation {Evaluation procedure}, shortness of breath {Dyspnea}, evaluation {Evaluation procedure}, flare-up of your chronic obstructive pulmonary disease {Acute exacerbation of chronic obstructive airways disease}, continue to take your medications as prescribed {Recommendation to continue with drug treatment}, primary care {Primary care management}, Prednisone {Steroid therapy}, started {New medication added}, Azithromycin {Antibiotic therapy}, started {New medication added}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None ###RESPONSE: Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, 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: Patient is an ___ year old female with PMH of moderate-to-severe COPD (on home 2L O2, no intubations/ICU stays) who presents from home with shortness of breath for 4 days. Patient was last in her usual state of health until 3 days prior to presentation when she developed insidious onset shortness of breath with cough. She had no fevers or chills and noted increased chest congestion but is unable to expectorate. She presented to her PCP's office 2 days PTA when she was prescribed prednisone and a z-pak. Then on the day prior to this admission she presented to the ___ ED for persistant SOB nad weakness. She was unable to eat large quantities because of the shortness of breath. In the ED she was treated with albuterol nebs and was discharged after performing well on a walk test around the ED. Then, on the day of presentation, patient's shortness of breath again became suddenly worse. She was speaking in short sentences and activities such as walking across the room or going to the bathroom caused her severe dyspnea. She called the ambulance and was taken back to the ED. . In the ED, initial vital signs were T95.6, HR98, BP175/96, RR28, O2sat99% 2L nasal prongs. Exam was significant for initially speaking in 2 word sentences, and poor air entry b/l with no wheezes/crackles. This improved with nebulizers and she was able to speak in full sentences. ECG showed sinus tachycardia with no acute ST-t wave changes. Troponin was <0.01. WBC count was normal, and patient received prednisone 60mg, ipratropium and albuterol nebs, and azithromycin 250mg. She had an episode of desaturation to 86% on nebs and was placed on NIPPV (FiO2: 100 PEEP: 5 PS: 10) with improvement of sats up to 96%. Unable to tolerate further bipap she was placed on 5LNC with O2sats 96%. She received 1mg of IV ativan for anxiety. Vital signs prior to transfer were T97.9 HR103 BP177/87 RR28 O2sat95% 5LNC. . On arrival to the MICU, intial VS were T98.1, HR99, BP152/90, RR29, O2sat94% 5LNC. She reports improvement in her SOB. She reports being hungry. She endorses a slight headache. She reports having some loose stool that corresponds to when she started azithromycin as an outpatient. ###RESPONSE: COPD {Chronic obstructive lung disease}, intubations {Intubation}, shortness of breath {Dyspnea}, cough {Cough}, fevers {Fever}, chills {Chill}, unable to expectorate {Unable to expectorate}, SOB {Dyspnea}, weakness {Asthenia}, unable to eat {Unable to eat}, shortness of breath {Dyspnea}, shortness of breath {Dyspnea}, dyspnea {Dyspnea}, wheezes {Wheezing}, crackles {Respiratory crackles}, improved {Patient's condition improved}, nebulizers {Nebulizer therapy}, able to speak {Able to speak}, ECG {Electrocardiographic procedure}, sinus tachycardia {Sinus tachycardia}, t wave changes {Electrocardiographic T wave abnormal}, Troponin {Troponin measurement}, WBC count was normal {White blood cell count within reference range}, bipap {Bilevel positive airway pressure titration}, anxiety {Anxiety}, SOB {Dyspnea}, hungry {Hungry}, headache {Headache}, loose stool {Loose stool}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Past Medical History: - Asthma - COPD - GERD - Anxiety - Osteopenia - S/p cataract surgery - White coat HTN (BPs at home 120s-130s/70s-80s) ###RESPONSE: Asthma {Asthma}, COPD {Chronic obstructive lung disease}, GERD {Gastroesophageal reflux disease}, Anxiety {Anxiety}, Osteopenia {Osteopenia}, cataract surgery {Cataract surgery}, White coat HTN {Labile hypertension due to being in a clinical environment}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 had angina. No other CAD, no cancers. Brother has ___. ###RESPONSE: angina {Angina}, CAD {Coronary arteriosclerosis}, cancers {Malignant neoplasm}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Physical Exam: ADMISSION EXAM: Vitals: T 98.1, HR 99, BP 152/90, RR 29, O2sat 94% 5LNC 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: Poor air movement bilaterally, diffuse rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: No foley Ext: Warm, well perfused, no edema or cyanosis Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred . DISCHARGE EXAM: VS: Tm 98.5, BP 164/82, P 70, R 18, 97-99% on 1L NC GENERAL: NAD, comfortable, speaking in full sentences HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK: Supple, no thyromegaly, no JVD HEART: RRR, nl S1-S2, no MRG LUNGS: Ronchorus BS throughout with diffuse expiratory wheezing though improved ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN: Scattered ecchymoses NEURO: Awake, A&Ox3, CNs II-XII grossly intact, strength and sensation grossly intact ###RESPONSE: Vitals {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, NC {Normal head}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx 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}, 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}, GU {Examination of genitourinary system}, foley {Urinary catheter in situ}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, edema {Edema}, cyanosis {Cyanosis}, Neuro {Neurological examination}, CNII {Optic nerve structure}, XII intact {Intact hypoglossal nerve}, upper {Upper limb structure}, lower extremities {Lower limb structure}, normal sensation {Normal sensation}, gait deferred {Abnormal gait}, VS {Vital signs finding}, BP {Blood pressure finding}, NC {Normal head}, GENERAL {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, sclerae anicteric {White sclera}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, thyromegaly {Goiter}, JVD {Jugular venous engorgement}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, no MRG {Heart sounds normal}, LUNGS {Examination of respiratory system}, Ronchorus {Wheeze - rhonchi}, wheezing {Wheezing}, improved {Patient's condition improved}, ABDOMEN {Examination of abdomen}, NABS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, 2+ peripheral pulses {Peripheral pulses normal}, radials {Normal radial pulse}, SKIN {Examination of skin}, ecchymoses {Ecchymosis}, NEURO {Neurological examination}, Awake {Awake}, A {Mentally alert}, Ox3 {Oriented to person, time and place}, CNs II {Optic nerve structure}, XII {Hypoglossal nerve structure}, grossly intact {Normal nervous system function}, sensation grossly intact {Normal sensation}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Pertinent Results: ADMISSION LABS: ___ 06:12PM BLOOD WBC-8.8 RBC-4.78 Hgb-14.1 Hct-42.5 MCV-89 MCH-29.6 MCHC-33.3 RDW-12.8 Plt ___ ___ 06:12PM BLOOD Neuts-91.7* Lymphs-6.7* Monos-1.4* Eos-0 Baso-0.2 ___ 06:12PM BLOOD Glucose-169* UreaN-18 Creat-0.9 Na-136 K-4.5 Cl-101 HCO3-23 AnGap-17 ___ 04:06AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.3 ___ 09:55AM BLOOD cTropnT-<0.01 ___ 04:00PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04:00PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-150 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ___ 04:00PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-1 . DISCHARGE LABS: ___ 08:00AM BLOOD WBC-11.9* RBC-4.66 Hgb-13.8 Hct-42.4 MCV-91 MCH-29.7 MCHC-32.6 RDW-12.6 Plt ___ ___ 08:00AM BLOOD Glucose-130* UreaN-27* Creat-0.9 Na-142 K-4.0 Cl-99 HCO3-34* AnGap-13 ___ 08:00AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.0 . MICRO: ___ Blood cultures: no growth to date ___ Urine culture: pending . IMAGING: ___ PA/LAT/OBLIQUE CXR: The heart is normal in size. The mediastinal and hilar contours appear unchanged. The aortic arch is calcified. Central pulmonary arteries are again prominent. The chest is hyperinflated. Bronchovascular markings are attenuated and irregular, particularly in the upper lungs, suggesting obstructive pulmonary disease. A hiatal hernia is probably small-to-moderate in size. No focal opacity is identified. There is no pleural effusion or pneumothorax. Mild degenerative changes are similar along the lower thoracic spine. IMPRESSION: Findings suggesting chronic obstructive pulmonary disease. No evidence of pneumonia. Small-to-moderate hiatal hernia. ###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, cTropnT {Troponin T cardiac measurement}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, RBC {Red blood cell count}, WBC {White blood cell count}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Blood cultures {Blood culture}, Urine culture {Urine culture}, PA {Plain x-ray of chest posteroanterior view}, LAT {Diagnostic radiography of chest, lateral}, CXR {Plain chest X-ray}, heart {Heart structure}, normal in size {Normal size}, mediastinal {Mediastinal structure}, hilar {Hilar lymphadenopathy}, aortic arch {Aortic arch structure}, calcified {Pathologic calcification, calcified structure}, Central pulmonary arteries {Structure of central pulmonary artery}, chest is hyperinflated {Chest over-expanded}, upper lungs {Structure of upper zone of lung}, pulmonary disease {Disorder of lung}, hiatal hernia {Hiatal hernia}, opacity {Abnormally opaque structure}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, thoracic spine {Structure of thoracic vertebral column}, chronic obstructive pulmonary disease {Chronic obstructive lung disease}, pneumonia {Pneumonia}, hiatal hernia {Hiatal hernia}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Brief Hospital Course: ___ year old female with PMH of moderate-to-severe COPD (FEV1 37% of predicted ___ on home O2 for exertion, who presented with SOB secondary to a COPD exacerbation. . ACTIVE ISSUES: # COPD exacerbation: Patient has moderate-severe COPD on 2LNC home oxygen only with exertion, otherwise on room air. She presented with 3 days of increasing shortness of breath improving with bronchodilators and at one point requiring NIPPV in the ED. She had a significant component of anxiety while in the ED, exacerbating the tachypnea in addition to her COPD flare, which has been the case in prior exacerbations as well per discussion with her PCP. Overnight in the ICU she was easily weaned to 91% oxygen on room air and was able to be transferred to the medical floor. Although there was no evidence of pneumonia on her CXR, she was continued on the azithromycin which had been started by her PCP and completed ___ 5-day course. She was also started on prednisone 60mg daily with plan for a slow taper. Her Advair, Spiriva, and albuterol were continued and she was treated with lorazepam prn for anxiety with good effect. Upon discharge she was breathing comfortably with O2 sats in the mid-90s on 1L NC and was ambulating. She is currently on prednisone 50mg daily with plan to taper as follows: 40mg (___), 30mg (___), 20mg (___), 10mg (___), and then stop. She will have outpatient pulmonary rehab and has f/u appointments scheduled with her PCP and pulmonologist. . # Hypertension: Patient's blood pressure was persistent elevated in the 150s-160s with several readings in the 170s. She denies a history of HTN and after discussing this with her PCP ___. ___ may be a component of white coat hypertension and anxiety. We elected not to treat it at this time. She has a f/u appointment with Dr. ___ at which time he will recheck her BP and decide whether to start an antihypertensive agent. . # UTI: Patient developed a mild leukocytosis (WBC 11.9) on the day of discharge. She has been afebrile but UA revealed a UTI. She states that she has a history of recurrent UTIs and has a prescription for ciprofloxacin 250mg at home which is not expired. She wishes to take her own medication at home and states that she will take 1 pill BID for the next 3 days. She understands warning signs that should prompt her to seek medical attention such as worsening abdominal pain, flank pain, or fevers. The urine culture is pending at the time of discharge. I will follow this up and contact the patient and her PCP should the organism return resistant to ciprofloxacin. . INACTIVE ISSUES: # Osteopenia: Continued Vitamin D supplementation. . TRANSITIONAL ISSUES: # Opacity on CXR: Patient had a small opacity in the costophrenic recess on the lateral view CXR. Unclear etiology but stable since ___. Radiology recommends non-emergent CT scan to evaluate. The patient is aware of this. ###RESPONSE: COPD {Chronic obstructive lung disease}, SOB {Dyspnea}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD {Chronic obstructive lung disease}, on room air {Breathing room air}, shortness of breath {Dyspnea}, anxiety {Anxiety}, tachypnea {Tachypnea}, COPD {Chronic obstructive lung disease}, on room air {Breathing room air}, pneumonia {Pneumonia}, CXR {Plain chest X-ray}, anxiety {Anxiety}, ambulating {Fully mobile}, Hypertension {Hypertensive disorder, systemic arterial}, blood pressure was persistent elevated {Finding of increased blood pressure}, HTN {Hypertensive disorder, systemic arterial}, white coat hypertension {Labile hypertension due to being in a clinical environment}, anxiety {Anxiety}, UTI {Urinary tract infectious disease}, leukocytosis {Leukocytosis}, afebrile {Fever}, UA {Urinalysis}, UTI {Urinary tract infectious disease}, recurrent UTIs {Recurrent urinary tract infection}, abdominal pain {Abdominal pain}, flank pain {Flank pain}, fevers {Fever}, urine culture {Urine culture}, Osteopenia {Osteopenia}, Opacity {Abnormally opaque structure}, CXR {Plain chest X-ray}, opacity {Abnormally opaque structure}, costophrenic recess {Structure of phrenicocostal sinus}, lateral view CXR {Diagnostic radiography of chest, lateral}, CT scan {Computed tomography}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Medications on Admission: 1. Aspirin 81 mg PO 4X/WEEK (___) Pt states she only takes it 4x/wk because of increased bruising with daily dosing 2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 3. Tiotropium Bromide 1 CAP IH DAILY 4. Vitamin D 800 UNIT PO DAILY 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 6. PredniSONE 40 mg PO DAILY Duration: 10 Days started ___ by PCP 7. Azithromycin 250 mg PO Q24H Duration: 4 Days Day 1 of z-pack was ___ from PCP ___: 1. Aspirin 81 mg PO 4X/WEEK (___) Pt states she only takes it 4x/wk because of increased bruising with daily dosing 2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 3. Tiotropium Bromide 1 CAP IH DAILY 4. Vitamin D 800 UNIT PO DAILY 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 6. Pulmonary rehab Patient requires outpatient pulmonary rehab. 7. PredniSONE 40 mg PO daily Duration: 2 Days Start: In am RX prednisone 10 mg see below tablet(s) by mouth daily Disp #20 Tablet Refills:*0 8. PredniSONE 30 mg PO daily Duration: 2 Days Start: After 40 mg tapered dose. 9. PredniSONE 20 mg PO daily Duration: 2 Days Start: After 30 mg tapered dose. 10. PredniSONE 10 mg PO daily Duration: 2 Days Start: After 20 mg tapered dose. ###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: COPD UTI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. ###RESPONSE: COPD {Chronic obstructive lung disease}, UTI {Urinary tract infectious disease}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: Discharge Instructions: Ms. ___, . It was a pleasure caring for you at ___ ___. You were admitted with shortness of breath due to an exacerbation of your COPD. We treated you with azithromycin and prednisone and your breathing improved. You should continue to use the oxygen at home while your breathing continues to get better. We have arranged for you to attend outpatient pulmonary rehab. . You were found to have a urinary tract infection on the day of discharge. You have a history of frequent UTIs and have ciprofloxacin 250mg at home which you would prefer to take. When you get home please take this medication twice daily for the next 3 days as we discussed. ###RESPONSE: shortness of breath {Dyspnea}, exacerbation of your COPD {Acute exacerbation of chronic obstructive airways disease}, improved {Patient's condition improved}, urinary tract infection {Urinary tract infectious disease}, frequent UTIs {Recurrent urinary tract infection}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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: codeine Attending: ___ Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: Right total hip arthroplasty on ___ ###RESPONSE: codeine {Allergy to codeine}, Right hip {Right hip region structure}, pain {Hip pain}, Right total hip arthroplasty {Total replacement of right hip joint}
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: History of Present Illness: Ms. ___ has been having right knee and hip pain for several months. The pain has progressively worsened. She has had cortisone injections, which did not provide significant relief in her knee. She has groin pain, thigh pain and buttock pain as well as knee pain. She does not use an assistive device. She has taken anti-inflammatory medications and had physical therapy. ###RESPONSE: right knee {Structure of right knee region}, hip pain {Hip pain}, pain {Pain}, worsened {Increased pain}, cortisone injections {Injection of cortisone}, knee {Knee region structure}, groin pain {Inguinal pain}, thigh pain {Thigh pain}, buttock pain {Pain in buttock}, knee pain {Pain of knee region}, physical therapy {Physical therapy procedure}