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:
1. adjustment disorder
2. atrial fibrillation (cardiologist - Dr. ___,
___
3. anxiety and depression
4. vitamin B12 deficiency
5. breast cancer (T1N0M0 invasive lobular adenocarcinoma
s/p RTX/implant/tamoxifen for ___ years)
6. colonic polyps (___)
7. constipation
8. hypertension
9. osteopenia
10. seasonal affective disorder
11. gastric bypass 01
12. SBO s/p exploratory laparotomy and small bowel resection
(___)
###RESPONSE: adjustment disorder {Adjustment disorder}, atrial fibrillation {Atrial fibrillation}, anxiety {Anxiety}, depression {Depressive disorder}, vitamin B12 deficiency {Cobalamin deficiency}, breast cancer {Malignant neoplasm of breast}, lobular adenocarcinoma {Lobular carcinoma}, colonic polyps {Polyp of colon}, constipation {Constipation}, hypertension {Hypertensive disorder, systemic arterial}, osteopenia {Osteopenia}, seasonal affective disorder {Seasonal affective disorder}, gastric bypass {Bypass of stomach}, SBO {Small bowel obstruction}, exploratory laparotomy {Exploratory laparotomy}, small bowel resection {Small intestine excision} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 deceased from recurrent non-Hodgkin's lymphoma. Multiple
family members with ovarian and breast ca at early ages (mother
with ovarian ca in her ___, 2 aunts with breast ca)
###RESPONSE: deceased {Dead}, recurrent {Recurrent disease}, non-Hodgkin's lymphoma {Non-Hodgkin's lymphoma}, ovarian {Malignant tumor of ovary}, breast ca {Malignant neoplasm of breast}, ovarian ca {Malignant tumor of ovary}, breast ca {Malignant neoplasm of breast} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
###RESPONSE: Well appearing {Well cared for appearance}, distress {Distress}, Afebrile {Temperature normal}, stable vital signs {Normal vital signs}, Pain well-controlled {Demonstrates adequate pain control}, Respiratory {Examination of respiratory system}, CTAB {Normal breath sounds}, Cardiovascular {Cardiovascular physical examination}, RRR {Normal heart rate}, Gastrointestinal {Examination of digestive system}, NT {Abdominal tenderness}, ND {Swollen abdomen}, Gen {General examination of patient}, Voiding independently {Normal micturition}, Neurologic {Neurological examination}, Intact {Normal sensation}, no focal deficits {Normal nervous system function}, O x3 {Oriented to person, time and place}, Musculoskeletal {Musculoskeletal system physical examination}, Lower Extremity {Lower limb structure}, Incision {Surgical incision wound}, healing well {Wound healing well}, staples {Closure by staple}, serosanguinous drainage {Serosanguineous discharge from wound}, Thigh {Thigh structure}, soft {Abdomen soft}, tenderness {Tenderness}, SILT {Light touch sensation present}, NVI distally {Normal peripheral neurovascular function}, Toes {Structure of all toes}, warm {Warm skin} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 05:58AM BLOOD WBC-12.0* RBC-2.48* Hgb-8.0* Hct-25.3*
MCV-102* MCH-32.3* MCHC-31.6* RDW-13.1 RDWSD-49.3* Plt ___
___ 06:35AM BLOOD WBC-10.9* RBC-2.46* Hgb-7.9* Hct-25.1*
MCV-102* MCH-32.1* MCHC-31.5* RDW-13.2 RDWSD-49.2* Plt ___
___ 05:48AM BLOOD WBC-9.8 RBC-2.68* Hgb-8.6* Hct-27.8*
MCV-104* MCH-32.1* MCHC-30.9* RDW-13.2 RDWSD-49.9* Plt ___
___ 06:25AM BLOOD WBC-7.4 RBC-2.46* Hgb-8.0* Hct-25.5*
MCV-104* MCH-32.5* MCHC-31.4* RDW-13.2 RDWSD-49.7* Plt ___
___ 05:48AM BLOOD WBC-7.7 RBC-2.94* Hgb-9.5* Hct-30.7*
MCV-104* MCH-32.3* MCHC-30.9* RDW-13.0 RDWSD-49.6* Plt ___
___ 05:58AM BLOOD Plt ___
___ 06:35AM BLOOD Plt ___
___ 05:48AM BLOOD Plt ___
___ 06:25AM BLOOD Plt ___
___ 05:48AM BLOOD Plt ___
___ 05:58AM BLOOD Glucose-90 UreaN-21* Creat-0.7 Na-138
K-3.7 Cl-101 HCO3-24 AnGap-17
___ 06:35AM BLOOD Glucose-92 UreaN-22* Creat-0.7 Na-138
K-4.3 Cl-101 HCO3-26 AnGap-15
___ 09:15AM BLOOD Glucose-111* UreaN-22* Creat-0.7 Na-135
K-4.4 Cl-99 HCO3-26 AnGap-14
___ 06:25AM BLOOD Glucose-94 UreaN-23* Creat-0.9 Na-139
K-4.9 Cl-103 HCO3-26 AnGap-15
___ 05:48AM BLOOD Glucose-107* UreaN-26* Creat-0.9 Na-134
K-5.0 Cl-99 HCO3-28 AnGap-12
___ 09:15AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:58AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.7
___ 06:35AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.8
___ 09:15AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.0
___ 06:25AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.2
___ 05:48AM BLOOD Calcium-8.3* Phos-4.5 Mg-1.7
___ 06:35AM BLOOD TSH-0.57
___ 10:20AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:20AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-SM Urobiln->12 pH-6.5 Leuks-SM
___ 10:20AM URINE RBC-3* WBC-9* Bacteri-FEW Yeast-NONE
Epi-12 TransE-<1
___ 10:20AM URINE AmorphX-OCC
___ 10:20AM URINE Mucous-RARE
___ 10:20AM URINE
###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}, 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}, 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}, 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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, TSH {Thyroid stimulating hormone measurement}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, RBC {Red blood cell count}, WBC {White blood cell count} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
The patient was admitted to the orthopedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
Overnight on POD#0, the patient was given a 500 mL bolus for low
urine output. She was unable to void and had to be straight
cath'ed x1. After that, she was able to void independently
thereafter. On POD 3, patient became acutely delirious. EKG
demonstrated Afib with Rvr. Rate was controlled with metoprolol.
Medicine was consulted who recommended continuing the metoprolol
for rate control. CXR and KUB were obtained. U/A were obtained.
Imaging did not demonstrate acute findings other than
atelectasis. Troponins negative. On POD#4 she became agitated
and the patient's family was contacted to assist. On POD#5
patient was noted to have leukocytosis with WBC 12.0 and urinary
frequency with discomfort, u/a was consistent with infection,
she was started on Ciprofloxacin for 7 days. Upon discharge her
mental status was clear, alert, oriented, and cooperative.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received lovenox for DVT
prophylaxis starting on the morning of POD#1. The surgical
dressing was changed and the Silverlon dressing was removed on
POD#2. The surgical incision was found to be clean and intact
without erythema or abnormal drainage. The patient was seen
daily by physical therapy. Labs were checked throughout the
hospital course and repleted accordingly. At the time of
discharge the patient was tolerating a regular diet and feeling
well. The patient was afebrile with stable vital signs. The
patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen. The operative extremity was
neurovascularly intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with posterior precautions.
Walker or two crutches at all times for 6 weeks.
Ms. ___ discharged to rehab in stable condition.
###RESPONSE: procedure {Procedure}, surgery {Surgical procedure}, IV antibiotics {Intravenous antibiotic therapy}, low
urine output {Decreased urine output}, unable to void {Retention of urine}, cath {Catheterization of urinary bladder}, able to void {Normal micturition}, delirious {Delirious}, EKG {Electrocardiographic procedure}, Afib with Rvr {Atrial fibrillation with rapid ventricular response}, CXR {Plain chest X-ray}, KUB {Radiography of kidney-ureter-bladder}, Imaging {Imaging}, atelectasis {Atelectasis}, Troponins {Troponin measurement}, negative {No abnormality detected}, agitated {Feeling agitated}, leukocytosis {Leukocytosis}, urinary
frequency {Increased frequency of urination}, discomfort {Discomfort}, infection {Infectious disease}, mental status {Neurological mental status determination}, clear {Normal state of mind}, alert {Mentally alert}, oriented {Orientated}, cooperative {Cooperative mental state}, pain was controlled {Pain control}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, DVT
prophylaxis {Prevention of deep vein thrombosis}, surgical
dressing was changed {Change of dressing}, dressing was removed {Removal of dressing}, surgical incision {Surgical incision wound}, clean and intact {Wound healing well}, erythema {Erythema}, drainage {Wound discharge}, physical therapy {Physical therapy assessment}, Labs {Laboratory test}, feeling
well {Well in self}, afebrile {Fever}, stable vital signs {Normal vital signs}, hematocrit was acceptable {Stable hematocrit}, pain was adequately
controlled {Demonstrates adequate pain control}, operative {Operative site}, extremity {Limb structure}, neurovascularly intact {Normal peripheral neurovascular function}, weight bearing {Weight-bearing}, operative {Operative site}, extremity {Limb structure}, precautions {Safety precautions}, Walker {Uses zimmer frame}, two crutches {Uses two crutches for walking}, stable condition {Patient's condition stable} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
1. ALPRAZolam 0.5 mg PO BID:PRN anxiety
2. Anastrozole 1 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Mirtazapine 15 mg PO QHS:PRN insomnia
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QD
4. Metoprolol Tartrate 25 mg PO Q6H
Please increase dosage to 37.5mg q6H if HR > 110 consistently
5. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
- Moderate
6. Senna 8.6 mg PO BID
7. ALPRAZolam 0.5 mg PO BID:PRN anxiety
8. Anastrozole 1 mg PO DAILY
9. Citalopram 20 mg PO DAILY
10. Mirtazapine 15 mg PO QHS:PRN insomnia
11. Omeprazole 20 mg PO BID
12. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until SBP > 140
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right total hip arthroplasty
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: Right total hip arthroplasty {Total replacement of right hip joint}, 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}, walker {Uses zimmer frame}, cane {Uses single walking stick} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking Aspirin prior to your surgery, please hold this
medication until you have completed your one-month course of
anticoagulation medication or unless cleared by your physician.
9. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in two (2) weeks.
10. ___ (once at home): Home ___, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
11. ACTIVITY: Weight bearing as tolerated with walker or 2
crutches at all times for six weeks. Posterior precautions. No
strenuous exercise or heavy lifting until follow up appointment.
Mobilize frequently.
Physical Therapy:
WBAT RLE
Posterior hip precautions x 3 months post-operatively
Assistive device x 6 weeks post-op (i.e., 2 crutches, walker)
Mobilize frequently
Treatments Frequency:
daily dressing changes as needed for drainage
wound checks daily
ice
staple removal and replace with steri-strips on POD ___ by
___
###RESPONSE: severe pain {Severe pain}, medication, increased {Medication increased}, swelling {Swelling}, decreased
sensation {Abnormal sensation}, difficulty with movement {Difficulty moving}, fevers {Fever}, shaking {Tremor}, chills {Chill}, redness {Redness of skin over lesion}, drainage {Wound discharge}, incision
site {Surgical incision wound}, chest pain {Chest pain}, shortness of breath {Dyspnea}, primary physician {Primary care management}, pain control {Pain control}, pain decreases {Sensation of pain reduced}, constipation {Constipation}, drink plenty of water {Fluid intake encouragement}, take a stool softener {Administration of laxative}, prevent
this side effect {Prevention of constipation}, medication so that it can be refilled {Medication prefill education}, SWELLING {Swelling}, operative joint {Operative site}, physical therapy {Physical therapy procedure}, skin {Skin structure}, ANTICOAGULATION {Anticoagulant therapy}, prevent deep vein thrombosis {Prevention of deep vein thrombosis}, blood clots {Blood clot}, anticoagulation {Anticoagulant therapy}, WOUND CARE {Wound care}, place a dry sterile dressing {Application of dressing}, wound {Wound}, drainage {Wound discharge}, Check wound {Wound assessment}, signs of infection {Monitoring for signs and symptoms of infection}, redness {Redness of skin over lesion}, drainage {Wound discharge}, Staples will be removed {Removal of staples}, dressing changes {Change of dressing}, wound checks {Wound assessment}, staple removal {Removal of staples}, Weight bearing {Weight-bearing}, walker {Uses zimmer frame}, 2
crutches {Uses two crutches for walking}, precautions {Safety precautions}, WBAT {Weight-bearing gait training}, RLE {Structure of right lower limb}, precautions {Safety precautions}, 2 crutches {Uses two crutches for walking}, walker {Uses zimmer frame}, dressing changes {Change of dressing}, drainage {Wound discharge}, wound checks {Wound assessment}, staple removal {Removal of staples}, steri-strips {Application of adhesive skin closure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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: SURGERY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending: ___.
Chief Complaint:
s/p Fall from bicycle, major blunt chest trauma
Major Surgical or Invasive Procedure:
None
###RESPONSE: Fall {Falls}, blunt chest trauma {Blunt injury of thorax} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ male helmeted bicyclist s/p fall from bicycle, flipping and
hitting back on pole. He was transported to ___ for further
care.
###RESPONSE: fall {Falls} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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
Pneumonia
###RESPONSE: Asthma {Asthma}, Pneumonia {Pneumonia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
Noncontributory
###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: Pertinent Results:
___ 11:59AM GLUCOSE-148* UREA N-14 CREAT-1.0 SODIUM-141
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
___ 11:59AM estGFR-Using this
___ 11:59AM WBC-7.3 RBC-5.57 HGB-14.5 HCT-43.3 MCV-78*
MCH-26.1* MCHC-33.6 RDW-13.3
___ 11:59AM NEUTS-60.3 ___ MONOS-3.5 EOS-2.3
BASOS-0.8
___ 11:59AM PLT COUNT-247
CT Chest ___
IMPRESSION:
1. Numerous right-sided rib fractures, with fractures involving
multiple
sites within the ribs, placing the patient at risk for flail
chest. Associated moderate right hemothorax with pulmonary
contusion and small right pneumothorax with locules of air in
the right epicardial fat.
2. Comminuted right scapular fracture.
Chest xray ___
IMPRESSION: Newly apparent tiny right apical pneumothorax.
Blunting of the
right costophrenic sulcus consistent with a small effusion.
Increased density in the lower right chest consistent with
contusion probably unchanged.
Subsegmental atelectasis left base. Multiple rib fractures and
possible
fracture right scapula.
###RESPONSE: GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, right-sided {Bone structure of right rib}, rib fractures {Fracture of rib}, fractures involving
multiple
sites within the ribs {Fracture of multiple ribs}, flail
chest {Flail chest}, right {Right lung structure}, hemothorax {Hemothorax}, pulmonary
contusion {Contusion of lung}, pneumothorax {Pneumothorax}, right {Right lung structure}, Comminuted {Fracture, comminuted}, scapular fracture. {Fracture of scapula}, Chest xray {Plain chest X-ray}, right apical {Structure of apex of right lung}, pneumothorax {Pneumothorax}, right {Right lung structure}, costophrenic sulcus {Structure of costophrenic angle}, effusion {Pleural effusion}, Increased density {Density above reference range}, right chest {Right thorax structure}, contusion {Contusion}, atelectasis {Atelectasis}, left base {Structure of base of left lung}, Multiple rib fractures {Fracture of multiple ribs}, fracture right scapula {Fracture of scapula} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
He was admitted to the Trauma service for pain control and
pulmonary management related to his rib fractures. He was
initially placed on PCA and later changed over to oral
narcotics. Epidural analgesia was discussed with him for which
he declined. His oxygen saturations on room air were in the high
90's and he had little to no oxygen requirements.
His right scapula fracture was managed non operatively and he
will follow up in Orthopedics clinic in 2 weeks.
Adjunct pain therapy treatments were also implemented; around
the clock Tylenol, prn NSAID's and a Lidoderm patch were all
started. This regimen appeared to be effective as he was better
able to ambulate, use the incentive spirometer, cough and deep
breathe. A bowel regimen was also initiated.
He was discharged to home with his wife on hospital day 4 with
instructions for follow up.
###RESPONSE: pain control {Pain control}, rib fractures {Fracture of multiple ribs}, PCA {Patient controlled analgesia}, oral
narcotics {Administration of drug or medicament via oral route}, Epidural analgesia {Epidural anesthesia}, oxygen saturations {Finding of oxygen saturation}, on room air {Breathing room air}, scapula fracture {Fracture of scapula}, follow up {Follow-up arranged}, pain {Pain}, therapy {Therapy}, able to ambulate {Able to walk}, cough and deep
breathe {Deep breathing and coughing exercises}, bowel {Intestinal structure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Albuterol
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for pain.
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. Hydromorphone 4 mg Tablet Sig: ___ - 2 Tablet PO Q3H (every
3 hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): take with food.
Disp:*120 Tablet(s)* Refills:*1*
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to right chest wall region. Remove old patch first.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1*
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as
needed for constipation.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. 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.
Disp:*1 * Refills:*1*
###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:
s/p Fall from bicycle
Right communicated scapula fracture
Multiple right rib fractures (posterior & lateral)
Right hemothorax
Small right apical pneumothorax
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
###RESPONSE: Fall {Falls}, Right {Bone structure of right scapula}, communicated {Fracture, comminuted}, Multiple right rib fractures {Fracture of multiple ribs}, Right {Right lung structure}, hemothorax {Hemothorax}, right apical {Structure of apex of right lung}, pneumothorax {Pneumothorax}, Hemodynamically stable {Hemodynamically stable}, tolerating {Tolerating diet}, regular diet {Normal diet}, pain
adequately controlled {Demonstrates adequate pain control} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Return to the Emergency room if you develop any fevers, chills,
headaches, productive cough, shortness of breath, increased rib
pain not relieved with the medication prescribed, nausea,
vomiting, diarrhea and/or any other symptoms that are concerning
to you.
It is important that you cough, deep breathe and use the
incentive spirometer every hour that you are awake in order to
minmize developing pneumonia which is commonly associated with
rib fractures.
Take the pain medication as prescribed and continue the bowel
regimen while you are on narcotics in order to prevent
constipation.
###RESPONSE: fevers {Fever}, chills {Chill}, headaches {Headache}, productive cough {Productive cough}, shortness of breath {Dyspnea}, rib
pain {Rib pain}, nausea,
vomiting, diarrhea {Nausea, vomiting and diarrhea}, cough {Cough}, awake {Awake}, pneumonia {Pneumonia}, rib fractures {Fracture of multiple ribs}, pain medication {Administration of analgesic}, bowel {Intestinal structure}, narcotics {Narcotherapy}, 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: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending: ___.
Chief Complaint:
Chest pain, headache.
Major Surgical or Invasive Procedure:
Stress MIBI.
###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, Chest pain {Chest pain}, headache {Headache}, Stress {Electrocardiogram with exercise test} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 ___ yof with hx of Stroke, DM II diet controlled, HTN,
Hypercholesterolemia, Cervical Radiculopathy who presents from
home chest pain. Patient reports she had an episdode of ___
"chest pressure" today while she was reading a magazine. The
episode lasted for about 45 minutes and was not relieved with
NTG given by EMS. +nausea but no vomiting. She denies SOB,
palpitations or radiating pain with this episode. She has had 2
similar episodes in the last two weeks. She has history of GERD
in the past and stopped her Protonix because she was feeling
better. She started the Protonix because she had similar
episodes of chest pain a few years ago. The only difference is
the her current episodes are more severe. She denies any recent
chest burning, nightime cough but she does have an occasional
sour taste in her mouth. She also reports an episode of 'shaking
chills' today along with a ___ frontal headache. Headache was
associated with some body weakness and patient was worred she
was having another stroke. EMS was called and she came to ___ ED.
She denies any recent fevers, sweats, cough, abdominal pain,
diarrhea, dysuria, urinary frequency or hematuria. While in the
ED, the patient was noted to have gait difficulty. No vision
complaints. Neurology was consulted and symptoms resolved on
their examination. CT Head was performed and was similar to
prior dated ___. The patient and her daughter report that she
gets right sided weakness occasionally as a result of her prior
CVA. Currently, she denies any weakness or numbness.
In the ED: Temp 98.3, BP 132/63, HR 102, RR 20, 100% NRB. She
was given ASA 325mg x 1 and NS 1 Liter bolus. Neurology was
consulted as above for transient right sided weakness. She was
admitted for ___.
###RESPONSE: Stroke {Cerebrovascular accident}, DM II diet controlled {Type 2 diabetes mellitus controlled by diet}, HTN {Hypertensive disorder, systemic arterial}, Hypercholesterolemia {Hypercholesterolemia}, Cervical Radiculopathy {Cervical radiculopathy}, chest pain {Chest pain}, chest pressure {Tight chest}, nausea {Nausea}, vomiting {Vomiting}, SOB {Dyspnea}, palpitations {Palpitations}, radiating pain {Radiating pain}, GERD {Gastroesophageal reflux disease}, feeling
better {Patient's condition improved}, chest pain {Chest pain}, chest burning {Burning chest pain}, cough {Cough}, sour taste {Unpleasant taste in mouth}, mouth {Mouth region structure}, shaking {Tremor}, chills {Chill}, frontal headache {Frontal headache}, Headache {Headache}, weakness {Asthenia}, stroke {Cerebrovascular accident}, fevers {Fever}, sweats {Sweating}, cough {Cough}, abdominal pain {Abdominal pain}, diarrhea {Diarrhea}, dysuria {Dysuria}, urinary frequency {Increased frequency of urination}, hematuria {Blood in urine}, gait difficulty {Abnormal gait}, No vision
complaints {Normal vision}, Neurology was consulted {Seen by neurologist}, resolved {Problem resolved}, CT Head {Computed tomography of head}, right sided weakness {Right hemiparesis}, CVA {Cerebrovascular accident}, weakness {Asthenia}, numbness {Numbness}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, NRB {Oxygen administration by mask}, Neurology was
consulted {Seen by neurologist}, right sided weakness {Right hemiparesis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
CVA x 4 with residual mild right sided weakness
Diabetes Mellitus Type II, diet controlled
Hypertension
Hypercholesterolemia
Gastroesophageal Reflux Disease
Cervical radiculopathy
Diverticulitis
###RESPONSE: CVA {Cerebrovascular accident}, right sided weakness {Right hemiparesis}, Diabetes Mellitus Type II, diet controlled {Type 2 diabetes mellitus controlled by diet}, Hypertension {Hypertensive disorder, systemic arterial}, Hypercholesterolemia {Hypercholesterolemia}, Gastroesophageal Reflux Disease {Gastroesophageal reflux disease}, Cervical radiculopathy {Cervical radiculopathy}, Diverticulitis {Diverticulitis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
1. brother - died late ___ w/ CVA
2. brother - died lung ca (smoker)
No hx of MI in first degree relative
Mother with HTN
###RESPONSE: died {Dead}, CVA {Cerebrovascular accident}, died {Dead}, lung ca {Malignant tumor of lung}, smoker {Smoker}, MI {Myocardial infarction}, HTN {Hypertensive disorder, systemic arterial} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS: Temp 97.3, BP 108/61, HR 76, RR 20, 97% RA
GEN: Elderly in NAD, awake, alert
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP
moist and without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND
EXT: No c/c/e
SKIN: No rash
Neuro: CN II-XII intact, ___ strenght right arm extension, ___
strenght right leg extension, ___ strenght remaining
extremities, sensation intact, +brisk patellar reflex, other
reflexes normal, Gait unstable on right side on walking, no
pronator drift, no intention tremor, no ataxia
###RESPONSE: VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, GEN {General examination of patient}, NAD {No abnormality detected}, awake {Awake}, alert {Mentally alert}, HEENT {Physical examination procedure}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, sclera anicteric {White sclera}, conjunctivae clear {Conjunctiva normal}, OP
moist {Moist oral mucosa}, lesion {Lesion}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, JVD {Jugular venous engorgement}, CV {Cardiovascular physical examination}, Reg rate {Pulse regular}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, No m/r/g {Heart sounds normal}, CHEST {Thoracic structure}, Resp {Examination of respiratory system}, accessory muscle {Accessory skeletal muscle}, CTAB {Normal breath sounds}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABD {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, No c/c/e {No abnormality detected}, SKIN {Examination of skin}, rash {Eruption of skin}, Neuro {Neurological examination}, CN II-XII {Normal central nervous system}, intact {Normal central nervous system}, strenght {Finding of power of skeletal muscle}, right arm {Structure of right upper limb}, extension {Abnormal extension}, strenght {Finding of power of skeletal muscle}, right leg {Structure of right lower limb}, extension {Abnormal extension}, strenght {Finding of power of skeletal muscle}, extremities {All extremities}, sensation intact {Normal sensation}, brisk patellar reflex {Knee reflex brisk}, reflexes normal {Normal reflex}, Gait unstable {Unsteady when walking}, right side {Structure of right half of body}, walking {Does walk}, pronator drift {Downward drift of outstretched supinated arm}, intention tremor {Intention tremor}, ataxia {Ataxia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
On Admission:
___ 03:20PM WBC-11.6* RBC-4.47 HGB-12.6 HCT-37.4 MCV-84
MCH-28.3 MCHC-33.8 RDW-14.6
___ 03:20PM NEUTS-91.7* LYMPHS-6.5* MONOS-0.7* EOS-0.8
BASOS-0.2
___ 03:20PM PLT COUNT-279
___ 03:20PM GLUCOSE-116* UREA N-16 CREAT-1.2* SODIUM-140
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
___ 03:20PM CK(CPK)-81
___:20PM CK-MB-NotDone
___ 03:20PM cTropnT-0.02*
___ 03:20PM ___ PTT-25.2 ___
___ 08:40PM URINE ___ BACTERIA-MOD YEAST-NONE
___ 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
___ 08:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
.
CT head ___:
No intracranial hemorrhage or evidence of acute major vascular
territorial infarct. Chronic microvascular ischemic changes
reidentified in the periventricular white matter.
.
Stress MIBIL:
Limited exercise tolerance. No anginal type symptoms or ischemic
ECG changes seen at workload achieved. Nuclear report sent
separately.
1. Normal myocardial perfusion. 2. Calculated LVEF is 63%.
###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}, 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}, PTT {Partial thromboplastin time, activated}, URINE {Urine culture}, AST {Aspartate aminotransferase measurement}, PROTEIN {Measurement of protein in urine}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, URINE {Evaluation of urine specimen}, COLOR {Color finding}, intracranial hemorrhage {Intracranial hemorrhage}, vascular {Blood vessel structure}, infarct {Infarct}, Chronic {Chronic disease}, ischemic {Ischemia}, periventricular white matter {Structure of periventricular white matter}, Limited exercise tolerance {Impaired exercise tolerance}, anginal {Angina}, ischemic {Ischemia}, ECG changes {Finding present on electrocardiogram}, Normal myocardial perfusion {Myocardial perfusion normal} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ yof with hx of Stroke, DM II diet controlled, HTN,
Hypercholesterolemia, Cervical Radiculopathy who presents from
home with chest pain associated with shaking chills and
headache.
.
# Chest Pain: Chest pain was concerning for ACS as she felt
"chest pressure" along with nausea and it lasted for 45 minutes.
Patient had negative cardiac enzymes x3 and serial ECG without
any changes. Patient was continued on her PPI for history of
GERD. Due to the concern with multiple risk factors and history,
patient had a stress MIBI that showed good HR of 137 (93% of
max) with product of ___, which does not suggest active
ischemia. However, her prognostic value was poor with 6:30 on a
Gervino protocol with ___ MTS. Patient did not have any
abnormalities on telemetry and is on tripple anti-platelet
therapy with aggrenox and plavix for her stroke that will
decrease her cardiovascular risk as well. Patient was continued
in her outpatient statin and ___. Will recommend starting
beta-blocker as outaptient; it was not started in house to
assess her neurologic status in the question of acute stroke and
severe headache.
.
# Right Sided Weakness: Patient with prior history of CVA.
Patient had transient weakness today and was evaluated by Neuro
in the ED. CT Head was negative and symptoms have now resolved.
Patient and daughter report occasional right sided fatigue s/p
her prior CVA. She uses a can at baseline for ambulation. Due to
her prior strokes patient is in an atypical regimen with
aggrenox and plavix suggested by neurology.
.
# Headache: Patient had episode of Headache today along with her
chest pain and weakness. She has history of headaches similar to
this. Most likely etiology is her cervical spine disease.
Conservative measurements with ice-packs, soft collar and
tylenol were done.
.
# Shaking chills: Patient with episode of shaking chills.
Afebrile since arrival but she does have a slightly elevated WBC
at 11.6. No signs of infection by history or exam. UA with Mod
bacteria but without pyuria. She was treated with a 3-day course
of ciprofloxacin to complete at home.
.
# HTN: cont home Diovan; meeting ___-7 criteria while in
hospital.
.
# DM II: diet controlled. Patient was put in ISS with minimal
requirements and blood sugars 100-200 range.
.
# Depression: cont home sertraline.
.
# FEN: Cardiac, diabetic diet.
.
# Access: PIV.
.
# PPx: heparin SC, bowel regimen.
.
# Code: FULL CODE.
.
# Dispo: Home with PCP follow up.
.
# Comm: With patient.
###RESPONSE: Stroke {Cerebrovascular accident}, DM II diet controlled {Type 2 diabetes mellitus controlled by diet}, HTN {Hypertensive disorder, systemic arterial}, Hypercholesterolemia {Hypercholesterolemia}, Cervical Radiculopathy {Cervical radiculopathy}, chest pain {Chest pain}, shaking {Tremor}, chills {Chill}, headache {Headache}, Chest Pain {Chest pain}, Chest pain {Chest pain}, ACS {Acute coronary syndrome}, chest pressure {Tight chest}, nausea {Nausea}, negative cardiac enzymes {Cardiac enzymes within reference range}, ECG {Electrocardiographic procedure}, GERD {Gastroesophageal reflux disease}, stress {Electrocardiogram with exercise test}, HR {Finding of heart rate}, ischemia {Ischemia}, did not have any
abnormalities {No abnormality detected}, telemetry {Cardiac telemetry}, anti-platelet
therapy {Anticoagulant therapy}, stroke {Cerebrovascular accident}, decrease {Finding of decreased risk level}, cardiovascular {Cerebrovascular accident}, statin {Administration of prophylactic statin}, outaptient {Outpatient care management}, assess her neurologic status {Neurological examination}, stroke {Cerebrovascular accident}, headache {Headache}, Right Sided Weakness {Right hemiparesis}, CVA {Cerebrovascular accident}, weakness {Asthenia}, evaluated {Evaluation procedure}, Neuro {Neurology service}, CT Head {Computed tomography of head}, resolved {Problem resolved}, right sided {Structure of right half of body}, fatigue {Fatigue}, CVA {Cerebrovascular accident}, uses a can {Dependence on walking stick}, baseline {Baseline state}, strokes {Cerebrovascular accident}, regimen {Therapeutic regimen}, Headache {Headache}, Headache {Headache}, chest pain {Chest pain}, weakness {Asthenia}, headaches {Headache}, cervical spine disease {Disorder of cervical spine}, Conservative measurements {Conservative therapy}, ice {Application of ice}, collar {Application of cervical collar}, tylenol {Administration of analgesic}, Shaking {Tremor}, chills {Chill}, shaking {Tremor}, chills {Chill}, elevated WBC {White blood cell count outside reference range}, signs of infection {Monitoring for signs and symptoms of infection}, exam {Physical examination procedure}, UA {Urinalysis}, bacteria {Bacteriuria}, pyuria {Pyuria}, ciprofloxacin {Antibiotic therapy}, HTN {Hypertensive disorder, systemic arterial}, DM II {Diabetes mellitus type 2}, diet controlled {Type 2 diabetes mellitus controlled by diet}, ISS {Sliding scale insulin regime}, blood sugars {Glucose measurement, blood}, Depression {Depressive disorder}, FEN {Nutrition management}, Cardiac {Heart disease}, diabetic diet {Diabetic diet}, PIV {Peripheral intravenous catheter care}, PPx {Preventive procedure}, heparin SC {Subcutaneous injection of heparin}, bowel {Normal bowel habits}, regimen {Therapeutic regimen}, Dispo {Patient disposition}, PCP {Primary care management}, follow up {Follow-up arranged} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Plavix 75mg daily
Aggrenox 25mg-200mg cap BID
Folic Acid
Crestor 40mg qHS
Sertraline 25mg daily
Diovan 80mg BID
Calcium/Vit D
Protonix 40mg daily
Vit B12
Colace
Fish Oil
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Four (4)
Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Cyanocobalamin 500 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
12. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
13. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Stable Coronary Artery Disease
Cervicalgia
.
Secondary Diagnsis:
CVA x 4 with residual mild right sided weakness
Diabetes Mellitus Type II, diet controlled
Hypertension
Hypercholesterolemia
Gastroesophageal Reflux Disease
Discharge Condition:
Stable, pain free, walking, tolerating diet.
###RESPONSE: Stable {Patient's condition stable}, Coronary Artery Disease {Coronary arteriosclerosis}, Cervicalgia {Neck pain}, CVA {Cerebrovascular accident}, mild {Symptom mild}, right sided weakness {Right hemiparesis}, Diabetes Mellitus Type II, diet controlled {Type 2 diabetes mellitus controlled by diet}, Hypertension {Hypertensive disorder, systemic arterial}, Hypercholesterolemia {Hypercholesterolemia}, Gastroesophageal Reflux Disease {Gastroesophageal reflux disease}, Stable {Patient's condition stable}, pain {Pain}, walking {Does walk}, tolerating diet {Tolerating diet} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were seen at ___ for chest pain. We were concern about
your heart and did some blood test, serial ECGs, heart monitor
(telemetry) and stress test that were all negative. This rules
you out as having an acute heart attack and puts you at low risk
from having one soon. We are sending you home with follow up
with your PCP.
.
You also have a headache and because of that you were seen by
the neurology stroke service who did not think you were having a
stroke. You had a CT scan that did not show any bleeding. Your
signs and symptoms are compatible with your cervical lessions
and we recommend conservative management with cold and pain
medication (Tylenol) as well as PCP follow up.
.
You were found to have a urinary tract infection and will need
to complete 3 days of antibiotics (ciprofloxacin). See attached
prescription.
.
Your medications were left unchanged.
.
If you notice any worsening in your weakness, new problems while
talking, facial droop, worsening of your chest pain or that it
last more than 15 minutes associated with sweating, bleeding or
anything else that concerns you please come back to the ER ASAP.
.
Please follow up as below.
###RESPONSE: chest pain {Chest pain}, heart {Heart structure}, blood test {Blood test}, ECG {Electrocardiographic procedure}, heart monitor {Cardiac monitoring}, telemetry {Cardiac telemetry}, stress test {Electrocardiogram with exercise test}, negative {No abnormality detected}, acute heart attack {Acute myocardial infarction}, follow up {Follow-up arranged}, PCP {Primary care management}, headache {Headache}, seen by
the neurology stroke service {Seen by stroke service}, stroke {Cerebrovascular accident}, CT scan {Computed tomography}, bleeding {Bleeding}, signs {Sign}, cervical {Bone structure of cervical vertebra}, lessions {Lesion}, conservative management {Conservative therapy}, cold {Cryoanalgesia}, pain
medication {Administration of analgesic}, PCP {Primary care management}, follow up {Follow-up arranged}, urinary tract infection {Urinary tract infectious disease}, antibiotics {Antibiotic therapy}, prescription {Prescription}, medications {Prescription of drug}, weakness {Asthenia}, problems {Problem}, talking {Speech problem}, facial {Face structure}, chest pain {Chest pain}, sweating {Sweating}, bleeding {Bleeding}, ER {Emergency treatment management} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p Multiple gunshot wounds
Major Surgical or Invasive Procedure:
___ EXPLORATORY LAPAROTOMY
###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, gunshot wounds {Gunshot wound}, EXPLORATORY LAPAROTOMY {Exploratory laparotomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ year old male who is s/p multiple gunshot wounds to abdomen
and left hand. He was transported from ___
for further managemnt of his injuries.
###RESPONSE: gunshot wounds {Gunshot wound}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, left hand {Structure of left hand}, injuries {Traumatic injury} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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, ?depression/ anxiety, ETOH use per family, h/o assault
###RESPONSE: Asthma {Asthma}, depression {Depressive disorder}, anxiety {Anxiety}, ETOH {Finding relating to alcohol drinking behavior} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Noncontributory
###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:
Upon presentation to ___:
HR: 70 BP: 100/p Resp: bagged O(2)Sat: 100 Normal
Constitutional: intubated, sedated
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
ETT in place
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry, GSW to L chest, LLQ x2, R flank, L hip,
R back, L thigh x 2, L thumb
Neuro: intubated, sedated
Psych: intubated, sedated
___: No petechiae
###RESPONSE: HR {Finding of heart rate}, BP {Blood pressure finding}, Resp {Examination of respiratory system}, bagged {Respiratory assist, manual}, intubated {Insertion of endotracheal tube}, sedated {Sedated}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, Pupils equal, round and
reactive to light {Pupils equal and reacting to light}, ETT in place {Endotracheal tube present}, Chest {Examination of respiratory system}, Clear to auscultation {Normal breath sounds}, Cardiovascular {Cardiovascular physical examination}, Regular Rate and Rhythm {Normal heart rate}, Normal first and
second heart sounds {Heart sounds normal}, Abd {Examination of abdomen}, Soft {Abdomen soft}, distended {Swollen abdomen}, GU {Examination of genitourinary system}, Flank {Flank structure}, tenderness {Tenderness}, Extr {Examination of limb}, Back {Structure of back of trunk}, cyanosis {Cyanosis}, clubbing {Clubbing}, edema {Edema}, Skin {Examination of skin}, Warm {Warm skin}, dry {Xeroderma}, GSW {Gunshot wound}, L chest {Structure of left half of chest wall}, LLQ {Structure of left lower quadrant of abdomen}, flank {Flank structure}, hip {Left hip region structure}, back {Structure of back of trunk}, L thigh {Structure of left thigh}, L thumb {Structure of left thumb}, Neuro {Neurological examination}, intubated {Insertion of endotracheal tube}, sedated {Sedated}, Psych {Neurological mental status determination}, intubated {Insertion of endotracheal tube}, sedated {Sedated}, petechiae {Petechia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ 09:20AM GLUCOSE-111* UREA N-7 CREAT-0.7 SODIUM-143
POTASSIUM-3.0* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18
___ 09:20AM CALCIUM-7.8* PHOSPHATE-3.3 MAGNESIUM-1.5*
___ 09:20AM WBC-6.2 RBC-3.94* HGB-12.3* HCT-34.3* MCV-87
MCH-31.2 MCHC-35.9* RDW-13.5
___ 09:20AM ___ PTT-25.3 ___
___ 09:20AM PLT COUNT-130*
___ 07:13AM GLUCOSE-88 LACTATE-3.2* K+-2.9* CL--109*
IMAGING:
___: Femur AP: Known lucency in the left iliac bone. No
evidence of bullet fragments. The left femur shows normal
cortical borders, no evidence of cortical disruption suggesting
fracture. No soft tissue abnormalities.
___: CXR: no evidence of larger parenchymal abnormalities and
no pneumothorax. The abnormalities seen on the outside CT torso
from ___, 4:48 a.m., are not depicted on the chest
radiograph. Only the dorsal right 11th rib fracture is visible
on the edge-enhanced image.
___: AP chest and pelvis: A focal lucency within the left iliac
bone corresponds to a traumatic injury seen on the reference CT
torso examination from 4:48 a.m. No bullet fragments are
detected. A Foley catheter resides within the bladder, which is
opacified with contrast.
___: Hand: comminuted fracture at the head of the first
proximal phalanx is seen, with extension to the IP joint.
###RESPONSE: GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, CALCIUM {Blood calcium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, GLUCOSE {Glucose measurement, blood}, CL {Chloride measurement, blood}, IMAGING {Imaging}, Femur {Bone structure of femur}, AP {Diagnostic radiography, anteroposterior}, left iliac bone {Bone structure of left ilium}, No
evidence {No abnormality detected}, left femur {Structure of left femur}, no evidence {No abnormality detected}, disruption {Disruption}, fracture {Fracture}, soft tissue {Structure of soft tissue of thigh}, abnormalities {No abnormality detected}, CXR {Plain chest X-ray}, no evidence {No abnormality detected}, abnormalities {No abnormality detected}, pneumothorax {Pneumothorax}, abnormalities {Imaging result abnormal}, torso {Trunk structure}, chest
radiograph {Plain chest X-ray}, right {Bone structure of right rib}, rib fracture {Fracture of rib}, AP chest {Plain x-ray of chest anteroposterior view}, pelvis {Plain X-ray of pelvis, anteroposterior view}, left iliac
bone {Bone structure of left ilium}, traumatic injury {Traumatic injury}, torso {Trunk structure}, Foley catheter {Urinary catheter in situ}, bladder {Urinary bladder structure}, Hand {Hand structure}, comminuted fracture {Fracture, comminuted}, head {Structure of head of phalanx}, proximal phalanx {Bone structure of proximal phalanx of hand}, IP joint {Interphalangeal joint structure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
He was admitted to the Acute Care Surgery team was taken from
the ED to the OR for exploratory laparotomy. He was transferred
to the Trauma SICU postoperatively for close monitoring. He
remained hemodynamically stable and continued to have palpable
lower extremity pulses. He was extubated without difficulty and
was alert and responsive. Hand surgery was consulted for the
left open thumb fracture for which he was fitted with a spica
cast. Ultimately he will follow up as an outpatient with Hand
Surgery to discuss operative repair. His pain was controlled
with IV narcotics initially. On the ___ postoperative day his
diet was advanced. His wounds were closely monitored for signs
of infection and they remained clean. His vital signs were
stable and his urine output was adequate; he was then
transferred out of the ICU to the floor on POD 1.
Once transferred to the floor he progressed slowly primarily
limited by pain. His narcotics required several adjustments.
Toradol was added to his regimen which was helpful. At time of
discharge his pain is well controlled with Oxycodone and
Baclofen both prn.
He was seen by Social work due to the nature of his trauma and
also due to +blood alcohol level. He was provided with
information pertaining to reactions to trauma.
###RESPONSE: exploratory laparotomy {Exploratory laparotomy}, transferred
to the Trauma SICU {Patient transfer to intensive care unit}, postoperatively {Postoperative state}, monitoring {Monitoring response to treatment}, hemodynamically stable {Hemodynamically stable}, lower extremity pulses {Lower limb pulse present}, extubated {Removal of endotracheal tube}, alert {Mentally alert}, Hand surgery was consulted {Referral to hand surgery service}, left {Structure of left thumb}, thumb {Structure of left thumb}, fracture {Open fracture of hand}, fitted with a spica
cast {Application of thumb spica plaster cast}, Hand
Surgery {Referral to hand surgery service}, operative {Surgical procedure}, repair {Repair of finger}, pain was controlled {Pain control}, IV {Administration of drug or medicament via intravenous route}, narcotics {Narcotherapy}, postoperative {Postoperative state}, diet was advanced {Advance diet as tolerated}, wounds {Wound}, signs
of infection {Monitoring for signs and symptoms of infection}, remained clean {Wound healing well}, vital signs were
stable {Normal vital signs}, urine output {Finding of measures of urine output}, transferred out of the ICU {Discharge from intensive care service}, pain {Pain}, narcotics {Narcotherapy}, adjustments {Procedure related to management of drug administration}, regimen {Therapeutic regimen}, pain is well controlled {Demonstrates adequate pain control}, seen by Social work {Seen by social worker}, trauma {Traumatic injury}, blood alcohol level {Blood ethanol measurement}, trauma {Traumatic injury} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Denies
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Baclofen 10 mg PO TID
RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp
#*21 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours as
needed Disp #*60 Tablet Refills:*0
5. Senna 1 TAB PO BID:PRN constipation
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
s/p Multiple Gunshot wounds to abdomen & left hand
Injuires:
Comminuted fracture of the left thumb proximal phalanx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Gunshot wounds {Gunshot wound}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, left hand
Injuires {Injury of left hand}, Comminuted fracture {Fracture, comminuted}, left thumb {Structure of left thumb}, proximal phalanx {Bone structure of proximal phalanx of hand}, 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:
You were admitted to the hopstial after sustaining multiple
gunshot wounds to your adbominal region and your left hand. You
underwent an operation to explore your abomen for internal organ
injuries and none were identified. You did sustain an open
fracture of your left thumb and was placed in a special cast.
You will need to follow up with the Orthopedic hand surgeon in
the next couple of weeks to discuss possible surgery. You have
staples along the incision in your abdomen and these will be
reomoved inthe next ___ days when you return for your
appointment in the Acute Care Surgery clinic.
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
###RESPONSE: gunshot wounds {Gunshot wound}, adbominal {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, left hand {Structure of left hand}, operation {Surgical procedure}, explore your abomen {Exploratory laparotomy}, internal organ
injuries {Internal injury of abdominal organ}, open
fracture {Open fracture of hand}, left thumb {Structure of left thumb}, cast {Application of thumb spica plaster cast}, Orthopedic hand surgeon {Seen by orthopedic surgeon}, surgery {Surgical procedure}, incision {Abdomen incision}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, medications {Prescription of drug}, pain {Pain}, operation {Surgical procedure}, medications {Administration of analgesic}, drowsy {Drowsy}, impair your ability to drive a motor vehicle or operate
machinery safely {Patient should not drive or operate machinery}, activities {Functional activity education}, while
taking these medications {Patient medication education}, call your doctor {Informing doctor}, return to the emergency {Emergency treatment education}, chest pain {Chest pain}, pressure {Tight chest}, squeezing {Squeezing chest pain}, tightness {Tight chest}, cough {Cough}, wheezing {Wheezing}, vomiting {Vomiting}, cannot keep in fluids or your
medications {Nausea and vomiting}, dehydrated {Dehydration}, vomiting {Vomiting}, diarrhea {Diarrhea}, Signs {Sign}, dehydration {Dehydration}, dry
mouth {Xerostomia}, rapid heartbeat {Tachycardia}, dizzy {Dizziness}, faint {Feeling faint}, standing {Orthostatic body position}, blood or dark/black material when you vomit {Vomit contains blood}, bowel movement {Hematochezia}, shaking {Tremor}, chills {Chill}, fever {Fever}, resume all regular home medications {Patient medication education}, lifting {Does lift}, moderate
exercise {Physical activity target moderate exercise}, abdominal exercises {Abdominal exercises}, may shower {Wound treatment education}, drainage {Wound discharge}, incisions {Surgical incision wound}, cover with
clean, dry gauze {Application of dressing}, increased pain {Increased pain}, swelling {Swelling}, redness {Redness of skin over lesion}, drainage {Wound discharge}, incision sites {Surgical incision wound} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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: SURGERY
###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:
Iodine; Iodine Containing / Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain and RLE claudication
Major Surgical or Invasive Procedure:
Angiogram x 2, celiac and SMA angioplasty
###RESPONSE: Iodine; Iodine {Allergy to iodine compound}, Penicillins {Allergy to penicillin}, Abdominal pain {Abdominal pain}, RLE {Structure of right lower limb}, claudication {Intermittent claudication}, Angiogram {Angiography}, celiac {Angioplasty of celiac artery}, SMA angioplasty {Angioplasty of superior mesenteric artery} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ with bilateral PVD presents with ___ abdominal pain
which has become unbearable and worsening RLE claudication which
has been controlled on oral pain medications. He underwent an
arteriogram in ___ that showed occluded SFA with runoff via
the peroneal and ___, the AT was occluded. Plans were made to
bring him back for a Left Fem to AK-pop bypass, but he failed to
keep his follow up appointments. He now presents with worsening
claudication in his right leg. He can only walk a few steps now
and then he gets pain in his calf and thigh. Resting and
percocet alleviate the pain. This is much worse than it was a
few months ago. He does get pain in his left leg too, but his
right leg is more severe. He does not have rest pain. He
denies
fevers, chills, nausea, emesis, paresthesias in his feet, and
weakness. He has no lesions on his feet. He quit smoking ___
years ago but does have ___ cigs to calm his nerves. His feet
have never been cold or turned blue.
###RESPONSE: PVD {Peripheral vascular disease}, abdominal pain {Abdominal pain}, RLE {Structure of right lower limb}, claudication {Intermittent claudication}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, arteriogram {Angiography of artery}, SFA {Structure of superficial femoral artery}, peroneal {Structure of peroneal artery}, AT {Structure of anterior tibial artery}, Fem to AK-pop bypass {Femoral-popliteal artery bypass graft}, claudication {Intermittent claudication}, right leg {Structure of right lower leg}, walk {Does walk}, pain {Pain}, calf {Structure of calf of leg}, thigh {Structure of left thigh}, pain {Pain}, pain {Pain}, left leg {Structure of left lower limb}, right leg {Structure of right lower leg}, rest pain {Pain provoked by rest}, fevers {Fever}, chills {Chill}, nausea {Nausea}, emesis {Vomiting}, paresthesias {Paresthesia}, feet {Foot structure}, weakness {Weakness of foot}, lesions {Skin lesion}, feet {Foot structure}, quit smoking {Ex-smoker}, calm {Feeling calm}, feet {Foot structure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
1. HTN
2. CAD, s/p CABG ___
3. Hyperlipidemia
4. Carotid artery disease, s/p L CEA approximately ___
5. Taxus drug-eluting stent and a 2.0mm MiniVision stent
6. PTCA & stenting Cypher ___ 3, LMA into ostial LAD, ___
7. S/p CVA x 2 in ___, R-sided weakness & expressive aphasia,
(now
improved)
8. s/p Fall / foot trauma ___, no surgery, wheelchair bound 6
months
9. GERD
10. Depression
11. DJD
12. Chronic kidney disease
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, Hyperlipidemia {Hyperlipidemia}, Carotid artery disease {Disorder of carotid artery}, L {Structure of left carotid artery}, CEA {Carotid endarterectomy}, drug-eluting stent {Endovascular insertion of drug eluting stent}, stent {Placement of stent}, PTCA {Percutaneous transluminal coronary angioplasty}, stenting {Insertion of arterial stent}, LMA {Structure of left coronary artery main stem}, LAD {Structure of anterior descending branch of left coronary artery}, CVA {Cerebrovascular accident}, R-sided weakness {Right hemiparesis}, expressive aphasia {Expressive dysphasia}, improved {Patient's condition improved}, Fall {Falls}, foot {Foot structure}, trauma {Traumatic injury}, surgery {Surgical procedure}, wheelchair bound {Does mobilize using wheelchair}, GERD {Gastroesophageal reflux disease}, Depression {Depressive disorder}, DJD {Osteoarthritis}, Chronic kidney disease {Chronic kidney 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:
Father died at age ___ of unknown cause. Mother died in her ___
of Influenza.
###RESPONSE: died {Dead}, died {Dead}, Influenza {Influenza} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
At time of discharge:
AVSS
A&O X 3, NAD
PERRL, EOMI
RRR
CTAB
Abdomen soft, nondistended, mild generalized tenderness, no
rebound or guarding
___ warm
Pulses: b/l fem 2+, pop, DP and ___ all dopplerable
###RESPONSE: AVSS {Vital signs finding}, A {Mentally alert}, O X 3 {Oriented to person, time and place}, NAD {No abnormality detected}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, RRR {Normal heart rate}, CTAB {Normal breath sounds}, soft {Abdomen soft}, nondistended {Normal abdominal contour}, mild {Symptom mild}, tenderness {Tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, warm {Warm skin}, Pulses {Pulse finding}, fem 2+ {Normal femoral pulse} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 07:10AM BLOOD WBC-10.0# RBC-3.39* Hgb-9.8* Hct-29.8*
MCV-88 MCH-28.8 MCHC-32.8 RDW-18.2* Plt ___
___ 06:50AM BLOOD Hct-32.6*
___ 06:50AM BLOOD UreaN-27* Creat-2.2* K-3.4
___ 07:10AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.8
###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}, Hct {Hematocrit determination}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, K {Blood potassium 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:
Mr. ___ was admitted on ___ under the care of Dr.
___. He underwent ___ angiogram on ___ that showed occlusion
of the superficial femoral artery with
reconstitution in the above-knee popliteal artery and 2-vessel
runoff to the foot. Given these findings, the operation was
terminated at that point with a plan for surgical bypass at a
later point. The following day he underwent a mesenteric
angiogram via brachial approcah. He underwent balloon
angioplasty of iliac artery stenosis and balloon angioplasty of
SMA stenosis. Post-operatively he recovered well. He continued
to have generalized abdominal pain and a GI consult was
obtained. Since he had evidence of gastritis and duodenal ulcers
in ___ on EGD, and since he
is unsure if he took PPI since then, the gastroenterologists
felt that remaining ulcers may also be contributing to the
abdominal pain. They recommended increasing PPI to 40 mg PO BID
for 2 weeks, avoiding NSAIDs and will consider repeat EGD as
outpatient if no improvement. He was discharged home on ___
tolerating a regular diet but with similar abdominal complaints
as prior.
###RESPONSE: angiogram {Angiography}, occlusion {Complete obstruction}, superficial femoral artery {Structure of superficial femoral artery}, above-knee popliteal artery {Structure of supragenicular popliteal artery}, vessel {Blood vessel structure}, foot {Foot structure}, operation {Surgical procedure}, surgical bypass {Construction of shunt}, mesenteric
angiogram {Angiography of mesenteric artery}, balloon
angioplasty {Angioplasty of artery}, iliac artery stenosis {Iliac artery stenosis}, balloon angioplasty of
SMA {Percutaneous balloon angioplasty of superior mesenteric artery}, stenosis {Stenosis}, Post-operatively {Postoperative state}, generalized abdominal pain {Generalized abdominal pain}, gastritis {Gastritis}, duodenal ulcers {Ulcer of duodenum}, EGD {Esophagogastroduodenoscopy}, ulcers {Ulcer}, abdominal pain {Abdominal pain}, EGD {Esophagogastroduodenoscopy}, tolerating {Tolerating diet}, regular diet {Normal diet}, abdominal {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: Medications on Admission:
amlodipine 10mg daily, clonidine 0.1mg bid, isosorbide
mononitrate 180mg daily, metoprolol XL 50mg daily, omeprazole
40mg daily, papaverine 150mg bid, simvastatin 40mg daily,
aspirin 325mg daily, plavix 75mg daily, niacin 1000mg daily,
benicar 40mg daily, clonazepam 0.5mg tid, zolpidem 5mg daily,
MVI
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Papaverine 150 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO Q12H (every 12 hours).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Niacin 500 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
14. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
RLE ischemia
Abdominal pain
Discharge Condition:
Good
###RESPONSE: RLE {Structure of right lower limb}, Abdominal pain {Abdominal pain}, Good {Patient's condition satisfactory} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Call your doctor or go to the ER if you experience any of the
following: fever > 101.5, severe pain, bleeding from groin, or
any other concerning symptoms
###RESPONSE: Call your doctor {Informing doctor}, fever {Fever}, severe pain {Severe pain}, bleeding {Bleeding}, groin {Inguinal region structure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Penicillins / Prednisone
Attending: ___.
Chief Complaint:
Palpitations, diaphoresis
Major Surgical or Invasive Procedure:
___: Biopsy of retroperitoneal mass by ___ under
fluoroscopic guidance
###RESPONSE: Penicillins {Allergy to penicillin}, Prednisone {Allergy to prednisone}, Palpitations {Palpitations}, diaphoresis {Excessive sweating}, Biopsy of retroperitoneal mass by ___ under
fluoroscopic guidance {Biopsy of retroperitoneum using fluoroscopic guidance} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness: This is a ___ YO M CAD, chronic,
likely diastolic CHF who is representing to the ED after
presenting with diaphoresis, nausea, presyncope at rehab. After
being recently discharged from ___, while at rehab, he was
sitting in his wheelchair when he developed diaphoresis at rest.
He did have a bowel movement about half hour prior to event.
Diaphoresis was associated with nausea and feeling of confusion.
Experienced chest palpitations. Unclear if Mr ___ lost
consciousness; denies any loss of stool or urine. Discomfort
lasted about 10 minutes and then resolved; has not recurred.
Most recently he was admitted to the hospital on ___
after being pushed down the stairs; he also had fevers and
chills at that point and was found to be hypotensive and in
renal failure. He was transferred to the MICU briefly for
management; his hypotension was fluid responsive, his renal
failure responded to fluids. He was started on vancomycin and
levoquin for pneumonia and was ruled out for influenza.
.
In the ED one set of cardiac enzymes were obtained. UA was done
which was positive and urine cultures were sent. Aspirin was
given. Chest X-ray was obtained which showed improving
bibasilar infiltrate compared to prior images. EKG showed new
afib, rate controlled, with old T wave inversions (I, aVL, V5,
V6). Lower extremity dopplers obtained which were negative.
His vitals in the ED were 84 112/75, 16, 96% RA.
###RESPONSE: CAD {Coronary arteriosclerosis}, chronic {Chronic disease}, diastolic CHF {Heart failure with normal ejection fraction}, diaphoresis {Excessive sweating}, nausea {Nausea}, presyncope {Near syncope}, sitting {Sitting position}, diaphoresis {Excessive sweating}, bowel movement {Does defecate}, Diaphoresis {Excessive sweating}, nausea {Nausea}, confusion {Clouded consciousness}, chest {Thoracic structure}, palpitations {Palpitations}, lost
consciousness {Loss of consciousness}, loss of stool {Incontinence of feces}, urine {Urinary incontinence}, Discomfort {Discomfort}, resolved {Problem resolved}, fevers {Fever}, chills {Chill}, hypotensive {Low blood pressure}, renal failure {Renal failure syndrome}, transferred to the MICU {Patient transfer to intensive care unit}, hypotension {Low blood pressure}, fluid {Administration of fluid therapy}, renal
failure {Renal failure syndrome}, fluids {Administration of fluid therapy}, vancomycin {Antibiotic therapy}, pneumonia {Pneumonia}, influenza {Influenza}, cardiac enzymes {Cardiac enzymes/isoenzymes measurement}, UA {Urinalysis}, urine cultures {Urine culture}, Aspirin {Administration of aspirin}, Chest X-ray {Plain chest X-ray}, bibasilar {Structure of base of lung}, infiltrate {Infiltration}, EKG {Electrocardiographic procedure}, afib {Atrial fibrillation}, rate {Finding of heart rate}, T wave inversions {Inverted T wave}, I {Lead site V1}, aVL {aVL}, V5 {Lead site V5}, V6 {Lead site V6}, Lower extremity dopplers {Doppler ultrasonography of vascular structure of lower limb}, negative {No abnormality detected}, vitals {Vital signs finding} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
1) HTN
2) DM - diet controlled, with neuropathy
3) CAD s/p MI ___ s/p CABG in ___ with multiple CHF
hospitalizations since then.
4) CHF
5) etoh abuse
6) Gout
7) CRI, baseline Cr 1.2; per patient ___ longterm NSAID use
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, DM - diet controlled {Type 2 diabetes mellitus controlled by diet}, neuropathy {Neuropathy}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, CABG {Coronary artery bypass grafting}, CHF {Congestive heart failure}, CHF {Congestive heart failure}, etoh abuse {Alcohol abuse}, Gout {Inflammatory disorder due to increased blood urate level}, CRI {Chronic renal insufficiency}, 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: 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 grandmother with CHF.
###RESPONSE: CHF {Congestive 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: Physical Exam:
###RESPONSE: Physical Exam {Physical examination procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam: 98.9, 121/77, 74, 29, 96% RA
Gen: Sitting up in bed in NAD
Card: Irregular rhythm, no extrasystolic HS
Resp: lungs CTAB
Abd: soft NT ND
Ext: no ___ edema
Neuro: no focal deficits
###RESPONSE: Physical Exam {Physical examination procedure}, RA {Breathing room air}, Gen {General examination of patient}, Sitting up in bed {Fowler's position}, NAD {No abnormality detected}, Card {Cardiovascular physical examination}, Irregular rhythm {Irregular heart beat}, Resp {Examination of respiratory system}, CTAB {Normal breath sounds}, Abd {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, edema {Edema}, Neuro {Neurological examination}, no focal deficits {Normal nervous system function} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
Electrolytes:
GLUCOSE-117* UREA N-18 CREAT-1.4* SODIUM-141 POTASSIUM-3.8
CHLORIDE-103 TOTAL CO2-25 ANION GAP-17
.
Urine analysis:
URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR
BILIRUBIN-SM UROBILNGN-8* PH-7.0 LEUK-TR
___ BACTERIA-RARE YEAST-NONE EPI-0
.
CARDIAC ENZYMES:
CK-MB-2 cTropnT-<0.01
cTropnT-<0.01
cTropnT < 0.01
.
CEA: < 1
PSA 0.9
___: pending
.
EKG: Atrial fibrillation. Left axis deviation may be due to left
anterior
fascicular block, although it is non-diagnostic. Anterior
myocardial
infarction of indeterminate age but it may be old. Anterolateral
lead
ST-T wave abnormalities are non-specific but cannot exclude
ischemia.
Clinical correlation is suggested. Since the previous tracing of
___
right precordial lead T wave changes appear less prominent but
there may be no significant change.
.
Abd/pelvis CT:
IMPRESSION:
1. Large conglomerate retroperitoneal lymphadenopathy along with
bilateral
common and external iliac lymphadenopathy with mediastinal
lymphadenopathy and right hilar lymphadenopathy raise concern
for the lymphoma.
2. Bilateral ground-glass opacity, increased interstitial
markings in the
right lung and micronodular lesions bilaterally, also concerning
for
lymphangitic spread.
3. 4.7 cm lesion in the interpolar region of the right kidney
likely also
represents lymphoma. (please note that the pattern of lymph
adenopathy is
unusual for metastases from renal cell carcinoma)
4. Spleen is elongated, measuring 16.9 cm.
.
ECHO: The left atrium is dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. No pathologic valvular abnormality seen.
.
###RESPONSE: Electrolytes {Electrolytes measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, Urine analysis {Urinalysis}, URINE BLOOD {Urine blood test}, PROTEIN {Measurement of protein in urine}, GLUCOSE {Glucose measurement, blood}, KETONE {Urinalysis, acetone or ketone bodies measurement}, PH {pH measurement}, cTropnT {Troponin T cardiac measurement}, EKG {Electrocardiographic procedure}, Atrial fibrillation {Atrial fibrillation}, Left axis deviation {Left axis deviation}, left
anterior
fascicular block {Left anterior fascicular block}, myocardial
infarction {Myocardial infarction}, T wave abnormalities {Electrocardiographic T wave abnormal}, ischemia {Ischemia}, right {Structure of right side of heart}, T wave changes {Electrocardiographic T wave abnormal}, retroperitoneal lymphadenopathy {Retroperitoneal lymphadenopathy}, common {Iliac lymphadenopathy}, external iliac lymphadenopathy {External iliac lymphadenopathy}, mediastinal
lymphadenopathy {Mediastinal lymphadenopathy}, hilar lymphadenopathy {Hilar lymphadenopathy}, lymphoma {Malignant lymphoma}, ground-glass opacity {Ground glass lung opacity}, increased {Increased size}, right lung {Right lung structure}, lesions {Lesion}, lymphangitic spread {Lymphangitis carcinomatosa}, lesion {Lesion}, right kidney {Right kidney structure}, lymphoma {Malignant lymphoma}, lymph
adenopathy {Lymphadenopathy}, metastases {Metastatic malignant neoplasm to lung}, renal cell carcinoma {Renal cell carcinoma}, Spleen {Splenic structure}, ECHO {Echocardiography}, left atrium {Left atrial structure}, dilated {Dilatation}, Left ventricular wall {Left cardiac ventricular structure}, thickness {Normal thickness}, cavity {Structure of cavity of left cardiac ventricle}, size {Normal size}, regional/global systolic function are
normal {Normal left ventricular systolic function and wall motion}, ventricular septal defect {Ventricular septal defect}, Right
ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Normal ventricular wall motion}, ascending aorta {Ascending aorta structure}, dilated {Dilatation}, aortic valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve appears
structurally normal {Mitral valve normal}, trivial mitral regurgitation {Mild mitral valve regurgitation}, mitral valve prolapse {Mitral valve prolapse}, pulmonary artery {Pulmonary artery structure}, systolic pressure is normal {Normal systolic arterial pressure}, pericardial effusion {Pericardial effusion}, biventricular {Cardiac ventricular structure}, systolic
function {Normal left ventricular systolic function and wall motion}, No pathologic {No pathologic diagnosis}, valvular {Cardiac valve structure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
1. Fevers/Neoplastic Process: Differential initially broad
encompassing hospital acquired pneumonia versus neoplastic
process. A subacute neoplastic process is more likely given
several weeks-months of night sweats, malaise, and fevers with
finding of extensive retroperitoneal and mediastinal adenopathy
on CT. Other possibly pertinent symptoms include note of
intermittent hematuria, intermittent abdominal discomfort.
Other laboratory findings of note: anemia, microscopic
hematuria, ESR > 100, CRP > upper limit of assay. Preliminary
staining is suggestive of a carcinoma given findings of
organizing tubular structures seen on microscopy. The type of
carcinoma is still under review but some stains are suggestive
of renal cell carcinoma. CT suggests there is a renal nodule
that is less likely to be renal cell. At this point, we have
told Mr ___ that the culmination of our studies so far suggest
that he likely has an underlying carcinoma leading to his
constellation of symptoms, however this is not definitive, and
if it is a carcinoma, we don't yet have a finalized primary
source. According to pathology, it should take an additional
week or so before the pathology report is finalized. He was set
up for a primary care appointment with me on ___, and I emphasized the importance of follow-up.
.
While he was in the hospital, we also evaluated other sources of
fever. A chest x-ray revealed a multifocal pneumonia. Given
his recent hospitalization, we treated this as a hospital
acquired pneumonia with an 8 day course of vancomycin and
cefepime and covered him with azithromycin for a 7 day course
for the possibility of atypicals. His cough slowly improved
over the course of his hospitalization and his fevers trended
down. He did not have any leukocytosis during the course of his
hospitalization. At time of discharge, he was afebrile for > 48
hours and his antibiotics course was complete.
.
2) Atrial fibrillation: Was found to be in new onset atrial
fibrillation in ED. Unclear what precipitant of afib could be;
could be secondary to recent pneumonia/infection. Also has
significant mediastinal adenopathy; could represent infiltrative
or compressive process creating an irritant focus. Had no RVR;
rates were 70 - 80. CHADS score was +3. Coumadin was started
with goal INR near 2. Carvedilol was continued at dose of 12.5
mg BID. He was discharged and set up with ___
clinic. He was discharged with a ___ mg alternating dose
coumadin regimen.
.
3) Acute on Chronic renal failure: Creatinine was initially
elevated on presentation, however her electrolytes were
consistent with prerenal disease. Following administration of
fluids, his creatinine resolved to below her baseline.
.
4) Coronary artery disease: Troponin levels were checked on
admission and were negative. He was continued on his statin,
aspirin, beta blocker and Ace inhibitor. His lisinopril was
held as this tended to precipitously decrease his blood pressure
< 80 systolic. At time of discharge, his lisinopril continued
to be held.
.
5) Congestive heart failure: There was no evidence for fluid
overload; there were no rales on lung exam. His JVP was not
elevated. He has unilateral 1+ left lower extremity edema; he
was continued on lasix 80 mg daily.
.
6) Left ankle pain: Differential is gout vs trauma from recent
fall. Mild inflammatory changes seen along left foot (erythema,
decreased range of motion, mildly warm). Started on colchicine
with improvement in symptoms. Has crystal proven gout last year
after left ankle joint was tapped. Was discharged with a 3 day
continued supply of colchicine.
.
7) Dispo: Was discharged to assisted living facility after
cleared by physical therapy. Appointments were set up with
primary care and is being followed by ___ clinic.
###RESPONSE: Fevers {Fever}, hospital acquired pneumonia {Nosocomial pneumonia}, night sweats {Night sweats}, malaise {Malaise}, fevers {Fever}, retroperitoneal {Retroperitoneal lymphadenopathy}, mediastinal adenopathy {Mediastinal lymphadenopathy}, CT {Computed tomography}, hematuria {Blood in urine}, abdominal discomfort {Abdominal discomfort}, laboratory {Laboratory test}, anemia {Anemia}, microscopic
hematuria {Microscopic hematuria}, ESR {Erythrocyte sedimentation rate above reference range}, CRP {C-reactive protein measurement}, carcinoma {Carcinoma}, microscopy {Microscopy}, carcinoma {Carcinoma}, renal cell carcinoma {Renal cell carcinoma}, CT {Computed tomography}, renal {Kidney structure}, renal {Kidney structure}, cell {Cell structure}, carcinoma {Carcinoma}, carcinoma {Carcinoma}, fever {Fever}, chest x-ray {Plain chest X-ray}, pneumonia {Pneumonia}, hospital
acquired pneumonia {Nosocomial pneumonia}, vancomycin {Antibiotic therapy}, atypicals {Atypical pneumonia}, cough {Cough}, improved {Patient's condition improved}, fevers {Fever}, leukocytosis {Leukocytosis}, afebrile {Fever}, antibiotics {Antibiotic therapy}, Atrial fibrillation {Atrial fibrillation}, atrial
fibrillation {Atrial fibrillation}, afib {Atrial fibrillation}, pneumonia {Pneumonia}, infection {Infectious disease}, mediastinal adenopathy {Mediastinal lymphadenopathy}, infiltrative {Infiltration}, compressive {Compression}, RVR {Atrial fibrillation with rapid ventricular response}, rates {Finding of heart rate}, regimen {Therapeutic regimen}, Acute on Chronic renal failure {Acute-on-chronic renal failure}, Creatinine was initially
elevated {Serum creatinine above reference range}, electrolytes {Finding of electrolyte levels}, disease {Disease}, administration of
fluids {Administration of fluid therapy}, creatinine {Creatinine measurement}, resolved {Problem resolved}, baseline {Baseline state}, Coronary artery disease {Coronary arteriosclerosis}, Troponin {Troponin measurement}, checked {Monitoring procedure}, negative {No abnormality detected}, aspirin {Administration of aspirin}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, decrease his blood pressure
< 80 systolic {Decreased systolic arterial pressure}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, Congestive heart failure {Congestive heart failure}, no evidence {No abnormality detected}, fluid
overload {Hypervolemia}, rales {Respiratory crackles}, lung exam {Examination of respiratory system}, JVP was not
elevated {Normal jugular venous pressure}, left lower extremity edema {Edema of left lower limb}, lasix {Diuretic therapy}, Left ankle {Structure of left ankle}, pain {Pain}, gout {Inflammatory disorder due to increased blood urate level}, trauma {Traumatic injury}, fall {Falls}, Mild inflammatory {Mild inflammation}, left foot {Structure of left foot}, erythema {Erythema}, warm {Warm skin}, improvement {Patient's condition improved}, gout {Inflammatory disorder due to increased blood urate level}, left {Left hip region structure}, ankle joint {Ankle joint structure}, tapped {Arthrocentesis}, Dispo {Patient disposition}, physical therapy {Physical therapy assessment} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Aspirin 325 mg PO Daily
Citalopram 20mg PO daily
Carvedilol 12.5 mg PO BID
Omperazole 40mg PO daily
Simvastatin 80mg PO Daily
Clonzaepam 1mg PO TID
Trazodone 100mg PO QHS PRN
Colchicine 0.6mg PO Daily PRN Gout
Lisinopril 40mg PO Daily
Lasix 80mg PO daily
Ferrous Sulfate 325mg PO daily
NTG 0.3mg SL PRN .
MVI 1 Tab PO Daily .
Thiamine 100mg PO Daily .
Folate 1mg PO Daily
Acet 325mg PO Q6 PRN Pain .
Oxycodone 10 mg q6-8 hrs PRN .
Lidoderm 5% adhesive patch topical 12 hrs on 12 hrs off
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
13. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
two tablets daily at 4PM or as directed by your physician or
clinic.
Disp:*60 Tablet(s)* Refills:*2*
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN as needed for chest pain.
15. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*3 Tablet(s)* Refills:*0*
16. Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO every ___ hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
17. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath.
Disp:*1 1* Refills:*0*
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
20. Maalox 200-200-20 mg/5 mL Suspension Sig: ___ PO PRN as
needed for pain.
Disp:*1 1* 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:
1. New onset atrial fibrillation
2. Urinary tract infection
3. Coronary disease
4. Congestive heart failure
Discharge Condition:
Stable for rehab facility. Saturating well on room air.
###RESPONSE: atrial fibrillation {Atrial fibrillation}, Urinary tract infection {Urinary tract infectious disease}, Coronary disease {Coronary arteriosclerosis}, Congestive heart failure {Congestive heart failure}, Stable {Patient's condition stable}, on room air {Breathing room air} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr ___,
It was a pleasure caring for you while you were at ___
___. As you know, the result of some of our studies are
concerning for a cancer diagnosis, however we do not yet have
enough information to suggest what kind of cancer you may have.
In the coming weeks, these results should become clearer, and
this will help us to develop a plan. You are not alone in this
challenge; there will be several doctors who ___ be
participating in your care. The most important things for you
will be to keep your mind and body as healthy as you can so that
you can put your best foot forward. You will be followed by me
in primary care so that I can coordinate all of your care in the
coming months. Following up with all of your appointments is
one of your most important priorities.
.
I've explained some of the important points of your
hospitalization at ___ below:
(1) When you came into the hospital, you had symptoms of fevers,
cough, and night sweats. A lot of these symptoms could be
because of the possibility of cancer. However, when we did a
chest x-ray, we found that you also had a pneumonia in your
lungs. This could explain some of your symptoms. We started
you on antibiotics for 8 days which led to improvement in your
cough and fevers.
(2) While you were hospitalized we found that your heart was
beating irregularly in a rhythm that we call atrial
fibrillation. This can happen when you have an underlying
infection like pneumonia. Sometimes this heart rhythm can lead
to formations of a clot in your heart which can increase your
risk of stroke. To help treat this, we started you on a
medicine called coumadin, which helps to thin the blood. This
medicine will require frequent monitoring of your labs and your
assisted living facility will help draw these. It is important
that you take this medicine daily as directed to ensure that you
do not develop a clot.
(3) While you were here you also developed pain in your left
foot that we felt was consistent with gout. We started you on
colchicine which helped your pain and also increased your pain
medicine. You will have enough colchicine for another three
days to continue to treat your gout.
.
We made the following medication changes to your usual meds that
are summarized below:
(1) You should take coumadin (the blood thinner) 5 mg every
___ and ___, and 2.5mg on ___,
___ and ___. This dose may be adjusted after we check
your blood. The ___ lab will be checking your
blood at your assisted living facility on ___.
From then on you will get labs checked every week so that your
dose can be adjusted appropriately.
(2) You should stop taking lisinopril, a blood pressure medicine
that was decreasing your blood pressure too much. You can
restart this as an outpatient as directed by your outpatient
team.
(3) You should take colchicine 0.6 mg daily for another 3 days
after you leave the hospital.
(4) You should take oxycodone 10 mg as needed every six hours
for pain.
(5) You can use your albuterol inhaler ___ puffs as needed for
wheezing and shortness of breath.
(6) You can take maalox as needed for your stomach pain.
.
If you experience worsening fevers, diaphoresis, vomiting,
worsening cough, worsening blood in your urine, or any other
concerning symptoms, please let your primary care doctor know or
return to the emergency department.
###RESPONSE: cancer {Malignant neoplasm}, cancer {Malignant neoplasm}, fevers {Fever}, cough {Cough}, night sweats {Night sweats}, cancer {Malignant neoplasm}, chest x-ray {Plain chest X-ray}, pneumonia {Pneumonia}, lungs {Lung structure}, antibiotics {Antibiotic therapy}, improvement {Patient's condition improved}, cough {Cough}, fevers {Fever}, heart was
beating irregularly {Irregular heart beat}, rhythm {Irregular heart beat}, atrial
fibrillation {Atrial fibrillation}, infection {Infectious disease}, pneumonia {Pneumonia}, this heart rhythm {Irregular heart beat}, clot {Blood clot}, heart {Heart structure}, increase your
risk of stroke {At increased risk of cerebrovascular accident}, coumadin {Administration of prophylactic anticoagulant}, thin the blood {Anticoagulant therapy}, monitoring {Monitoring response to treatment}, clot {Blood clot}, pain {Pain}, left
foot {Structure of left foot}, gout {Inflammatory disorder due to increased blood urate level}, pain {Pain}, pain
medicine {Administration of analgesic}, gout {Inflammatory disorder due to increased blood urate level}, medication changes {Change of medication}, blood thinner {Anticoagulant therapy}, check
your blood {Blood test}, checking your
blood {Blood test}, stop taking {Recommendation to stop treatment}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, blood pressure medicine {On treatment for hypertension}, decreasing your blood pressure {Finding of decreased blood pressure}, restart {Restart of medication}, pain {Pain}, wheezing {Wheezing}, shortness of breath {Dyspnea}, stomach pain {Stomach ache}, fevers {Fever}, diaphoresis {Excessive sweating}, vomiting {Vomiting}, cough {Cough}, blood in your urine {Blood in urine} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending: ___
Chief Complaint:
BRBPR, LLQ pain
Major Surgical or Invasive Procedure:
.
###RESPONSE: BRBPR {Hematochezia}, LLQ {Structure of left lower quadrant of abdomen} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
This is a ___ yo F with h/o PAF on coumadin who presents with
BRBPR and LLQ pain X 3 days. Her symptoms began ___ night
when she began to experience BRBPR with minimal amounts of loose
stools. This was associated with crampy LLQ > RLQ pain. Denies
n/v, melena, fevers. + chills. These symptoms continued until
___ when the blood became less brisk with an increase in the
amount of loose stools. She attempted to keep well hydrated over
the weekend but began to feel increasingly lightheaded to the
point that she felt she may pass out if she stood up too
quickly. The pt has had BRBPR in the past ___ hemorrhoids but
reports those past episodes were not nearly as significant and
not accompanied by abdominal pain. She was recently started on a
baby ASA 1 week ago and also reports that her lasix dose was
increased 2 weeks ago. No recent antibiotics. Denies recent
change in diet, including increased ingestion of leafy, green
vegetables. She went to see her PCP today who noted her SBP to
be in the ___ (usual baseline 140s) and referred her to the ED
for further evaluation.
.
In the ED, pt AF, BP 97/49, HR 61. Rectal exam significant only
for small amounts of dried blood in the vault, NGL was negative.
Labs were significant for WBC 15.2, Hct 43.5, BUN 31, Cr 2.0,
lactate 1.4, and INR 17.1. A CT abd/pelvis was significant for
pancolitis. She was given 2 units FFP, 10 mg IV vitamin K,
protonix 40 IV X 1, levaquin 750 mg IV X 1, flagyl 500 mg IV X
1, and a total of 3 L IVFs. Repeat INR 2.6. She remained
hemodynamically stable and did not have any episodes of BRBPR in
the ED in spite of having several BMs. She was then admitted to
the ___ for further management.
.
ROS otherwise only positive for stable DOE. She is unable to
walk up a flight of stairs without becoming signicantly winded.
ROS otherwise negative.
.
###RESPONSE: PAF {Paroxysmal atrial fibrillation}, BRBPR {Hematochezia}, LLQ {Structure of left lower quadrant of abdomen}, BRBPR {Hematochezia}, minimal {Symptom mild}, loose
stools {Loose stool}, crampy {Stomach cramps}, LLQ {Structure of left lower quadrant of abdomen}, RLQ {Structure of right lower quadrant of abdomen}, n/v {Nausea and vomiting}, melena {Melena}, fevers {Fever}, chills {Chill}, loose stools {Loose stool}, lightheaded {Lightheadedness}, BRBPR {Hematochezia}, hemorrhoids {Hemorrhoids}, abdominal pain {Abdominal pain}, ASA {Administration of aspirin}, lasix {Diuretic therapy}, increased {Increasing dosage of medication}, antibiotics {Antibiotic therapy}, baseline {Baseline state}, evaluation {Evaluation procedure}, AF {Atrial fibrillation}, Rectal exam {Rectal examination}, WBC {White blood cell count}, BUN {Blood urea nitrogen measurement}, lactate {Lactic acid measurement}, INR {Calculation of international normalized ratio}, CT abd/pelvis {Computed tomography of abdomen and pelvis}, IVFs {Administration of intravenous fluids}, INR {Calculation of international normalized ratio}, hemodynamically stable {Hemodynamically stable}, BRBPR {Hematochezia}, ROS {Review of systems}, DOE {Dyspnea on exertion}, unable to
walk up a flight of stairs without becoming signicantly {Deterioration in ability to walk up stairs}, winded {Winded}, ROS {Review of systems} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PAF on coumadin
HTN (baseline BP 140/70s)
h/o CHF (EF 20% in ___, TTE in ___ with nl EF)
mod MR and TR
s/p PPM ___ syncope in ___, s/p dual chamber PPM replacement in
___
Melanoma s/p resection
Asthma
Depression
Breast cancer ___ years ago, s/p R lumpectomy and XRT, s/p L
lumpectomy in early ___ ___ yrs ago that was negative
Pancreatic lesion, reportedly extensively worked up ___ yrs ago
that was negative, stable lesion on serial CTs
Post granulomatous infection of liver and spleen
Seasonal allergies
Gout
###RESPONSE: PAF {Paroxysmal atrial fibrillation}, HTN {Hypertensive disorder, systemic arterial}, baseline {Baseline state}, BP {Blood pressure finding}, CHF {Congestive heart failure}, TTE {Transthoracic echocardiography}, MR {Mitral valve regurgitation}, PPM {Permanent cardiac pacemaker}, syncope {Syncope}, chamber {Cardiac chamber structure}, PPM replacement {Replacement of permanent transvenous electrodes}, Melanoma {Malignant melanoma of skin}, resection {Excision}, Asthma {Asthma}, Depression {Depressive disorder}, Breast cancer {Malignant neoplasm of breast}, R lumpectomy {Lumpectomy of right breast}, XRT {X-ray beam therapy}, L
lumpectomy {Lumpectomy of left breast}, negative {No pathologic diagnosis}, Pancreatic {Pancreatic structure}, lesion {Lesion}, negative {No pathologic diagnosis}, stable {Patient's condition stable}, lesion {Lesion}, CTs {Computed tomography}, granulomatous infection {Infective granuloma}, liver {Liver structure}, spleen {Splenic structure}, Seasonal allergies {Seasonal allergy}, Gout {Inflammatory disorder due to increased blood urate level} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
father with colon CA
###RESPONSE: colon CA {Neoplasm of colon} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS: Temp: 98.9 BP: 145/45 HR: 64 RR: 22 O2sat 100% on 2L NC
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions
NECK: supple, no LAD, jvd flat
RESP: + bibasilar rales that clear with deeper breaths
CV: RR, II/VI holosystolic murmur radiating to apex
ABD: Soft, diffusely TTP especially over LLQ, + guarding, +
rebound, normoactive BS, no HSM
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3
RECTAL: guaiac positive, dried blood in vault
###RESPONSE: VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2sat {Oxygen saturation measurement}, NC {Normal head}, GEN {General examination of patient}, comfortable {Comfortable appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, anicteric {White sclera}, dry MM {Mucous membrane dryness}, op {Oropharyngeal structure}, lesions {Lesion}, NECK {Physical examination procedure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, jvd flat {Normal jugular venous pressure}, RESP {Examination of respiratory system}, bibasilar {Structure of base of lung}, rales {Respiratory crackles}, clear {Normal breath sounds}, CV {Cardiovascular physical examination}, RR {Finding of rate of respiration}, murmur {Murmur}, apex {Structure of apex of heart}, ABD {Examination of abdomen}, Soft {Abdomen soft}, TTP {Tenderness}, LLQ {Structure of left lower quadrant of abdomen}, guarding {Abdominal guarding}, rebound {Rebound tenderness}, normoactive BS {Normal bowel sounds}, HSM {Hepatosplenomegaly}, EXT {Examination of limb}, no c/c/e {No abnormality detected}, warm {Warm skin}, good pulses {Normal pulse}, SKIN {Examination of skin}, rashes {Eruption of skin}, jaundice {Jaundice}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, CTA {Normal breath sounds}, guaiac {Guaiac test for occult blood in feces specimen} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ 04:35PM GLUCOSE-95 UREA N-31* CREAT-2.0* SODIUM-136
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14
___ 04:35PM CALCIUM-8.4 PHOSPHATE-3.8 MAGNESIUM-2.4
___ 04:35PM ALT(SGPT)-21 AST(SGOT)-35 LD(LDH)-370*
AMYLASE-71 TOT BILI-0.4 LIPASE-88*
.
___ 11:57PM LACTATE-1.0
___ 07:00PM LACTATE-1.4
.
###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}, CALCIUM {Blood calcium measurement}, PHOSPHATE {Phosphate, total measurement}, MAGNESIUM {Blood magnesium measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Serum total lactate dehydrogenase measurement}, AMYLASE {Amylase measurement}, TOT BILI {Bilirubin, total measurement}, LIPASE {Triacylglycerol lipase 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:
# Bright red blood per rectum- Evidence of pancolitis on initial
CT, stool studies significant for c diff colitis. Bleeding
stopped once INR was corrected. GI was consulted and suggest a
colonoscopy in about 4 weeks, after colitis has had time to
improve. Follow up scheduled with GI, ___ to check INR and hct
3 times per week.
.
# C Difficile colitis: Diarrhea improved on Flagyl, planned 14
day course.
.
# Supratherapeutic INR: Coumadin restarted prior to discharge
without GI bleed. She was discharged on approx ___ the dose of
coumadin she was on prior to admission. ___ to check INR 3
times per week. Nutritionist saw pt to eduated re: food
restrictions while on coumadin.
.
# Falls/imbalance- Patient had a fall while in the ___ ICU
overnight, and hit her head (likely on an open cabinet door
adjacent to the toilet), requiring 3 stitches for a laceration.
A CT head was obtained immediately after and showed no acute
hemorrhage. There had been no significant events on telemetry
and no indication of pacemaker malfunction. A CT spine was
obtained and the read showed no fracture, and her C-spine was
cleared. Approximately 12 hours later, a nurse observed the
patient to be extremely unsteady on her feet, somewhat
tremulous, and not as easily conversant as prior. A second CT
head was obtained and was negative for edema or new subdural.
The patient was observed overnight on fall precautions and there
were no further events, and her mental status was at baseline.
The attending radiologist later re-read the C-spine study and
notified the team that there was possible cervical cord
compression.
.
# Cervical Cord compression w/o radiculopathy: Possible C6-C7
cord compression based on CT cervical spine. No associated
neurologic deficits. Neurosurgery was consulted and recommended
myelogram for further assessment. The family and patient chose
not to have the CT myelogram done. They stated that they would
never opt for surgery, and if that was the only recommendation
to come out of CT myelogram, they felt there was no use for the
study. Neurosurgery team confirmed this was in fact the case.
Family is aware that if symptoms develop, falls increase from
weakness, or any other concerns for symptomatic cord
compression, and they should see PCP immediately to discuss CT
myelogram and possible decompressive surgery.
.
#CKD, stage III: Pt in ARF at admission, resolved to baseline
creatinine of 1.3
.
#Chronic systolic heart failure: Past EF 20% per family, however
recent echo in ___ with EF > 60%. Pt was continued on
isosorbide, metoprolol, lasix. Lisinopril was held as pt
noticed that she had a chronic cough that had resolved during
the hospitalization while off of Lisinopril. Plan is to hold
off on restarting, note any cough symptoms at home, and follow
up with PCP ___ 2 weeks to discuss whether Lisinopril could in
fact be cause of cough. Also will need to discuss whether
alternative ___ needed. Digoxin was held at request of family.
No recent CHF exacerbations, most recent EF >60%, and pacer
interrogations show atrial fibrillation despite therapuetic
digoxin levels. They asked to stop this because they were
concerned that it may be the cause of the patients chronic
diarrhea. They are aware that they will need to follow up with
cardiologist Dr. ___ need to restart digoxin.
###RESPONSE: Bright red blood per rectum {Hematochezia}, CT {Computed tomography}, stool studies {Stool microscopy}, c diff colitis {Clostridium difficile colitis}, Bleeding {Bleeding}, INR {Calculation of international normalized ratio}, colonoscopy {Colonoscopy}, colitis {Colitis}, INR {Calculation of international normalized ratio}, C Difficile colitis {Clostridium difficile colitis}, Diarrhea {Diarrhea}, improved {Patient's condition improved}, INR {Calculation of international normalized ratio}, restarted {Restart of medication}, GI bleed {Gastrointestinal hemorrhage}, INR {Calculation of international normalized ratio}, food
restrictions {Restricting food intake}, Falls {Falls}, fall {Falls}, head {Head structure}, laceration {Laceration}, CT head {Computed tomography of head}, acute
hemorrhage {Acute hemorrhage}, telemetry {Electroencephalogram telemetry}, CT spine {Computed tomography of spine}, fracture {Fracture}, C-spine {Structure of cervical vertebral column}, unsteady on her feet {Unsteady when standing}, tremulous {Tremor}, CT
head {Computed tomography of head}, negative {No pathologic diagnosis}, edema {Edema}, fall {Falls}, precautions {Safety precautions}, baseline {Baseline state}, C-spine {Structure of cervical vertebral column}, cervical cord
compression {Compression of cervical spinal cord}, Cervical Cord compression {Compression of cervical spinal cord}, radiculopathy {Nerve root disorder}, C6-C7 {Structure of intervertebral foramen of sixth cervical vertebra}, cord compression {Compression of cervical spinal cord}, CT cervical spine {Computed tomography of cervical spine}, neurologic deficits {Neurological deficit}, myelogram {Myelogram}, CT myelogram {Computed tomography myelogram}, surgery {Surgical procedure}, CT myelogram {Computed tomography myelogram}, falls {Falls}, weakness {Asthenia}, cord
compression {Compression of cervical spinal cord}, CT
myelogram {Computed tomography myelogram}, surgery {Surgical procedure}, CKD, stage III {Chronic kidney disease stage 3}, ARF {Acute kidney injury}, baseline {Baseline state}, creatinine {Serum creatinine within reference range}, Chronic systolic heart failure {Chronic systolic heart failure}, echo {Echocardiography}, lasix {Diuretic therapy}, chronic cough {Chronic cough}, resolved {Problem resolved}, hold {Recommendation to stop drug treatment}, restarting {Restart of medication}, cough {Cough}, cough {Cough}, held {Recommendation to stop drug treatment}, CHF exacerbations {Exacerbation of congestive heart failure}, atrial fibrillation {Atrial fibrillation}, chronic
diarrhea {Chronic diarrhea}, restart {Restart 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:
ASA 81 mg daily
Coumadin 4 mg daily
Zestril 10 mg daily
Lopressor 25 mg bid
Digoxin 125 mcg daily
Isosorbide dinitrate 20 mg bid
Lasix 40 mg qod, 20 mg qod
Singulair 10 mg daily
Prednisone 10 mg prn (for gout flares)
Allegra 60 mg bid
Advair 250/50 1 puff bid
Allopurinol ___ mg daily
Celexa 20 mg daily
Omeprazole 20 mg daily
Caltrate daily
.
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
2. Allopurinol ___ mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO
twice a day.
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO every other day.
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day.
9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
12. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. DISCONTINUED MEDICATIONS
STOP TAKING DIGOXIN AND LISINOPRIL UNTIL YOU SEE ___. ___.
15. INR checks
Please check INR and Hct 3 times per week for the next 2 weeks.
###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:
c difficile colitis
acute renal failure (now resolved)
Discharge Condition:
stable
###RESPONSE: Home With Service {Home health aide service management}, c difficile colitis {Clostridium difficile colitis}, acute renal failure {Acute kidney injury}, resolved {Problem resolved}, 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:
Please call your PCP with shortness of breath, weight gain of
more than 2 pounds in one day, dizziness, blood in stool, or
other concerning symptoms.
###RESPONSE: shortness of breath {Dyspnea}, weight gain {Weight gain}, dizziness {Dizziness}, blood in stool {Hematochezia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 / Erythromycin Base / Codeine / Ultram / Oxycodone /
Lipitor / Vicodin / Combivent / Latex / simvastatin
Attending: ___.
Chief Complaint:
SOB, cough
Major Surgical or Invasive Procedure:
none
###RESPONSE: Penicillins {Allergy to penicillin}, Erythromycin {Allergy to erythromycin}, Codeine {Allergy to codeine}, Ultram {Allergy to tramadol}, Lipitor {Allergy to atorvastatin}, Latex {Allergy to Hevea brasiliensis latex protein}, simvastatin {Allergy to simvastatin}, 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:
___ with history of COPD on home O2 at night, Pulmicort,
albuterol, history of fibromyalgia, hypertension, presenting
with two-day history of worsening shortness of breath and
wheezing. Symptoms started on ___ evening. Slight cough. No
fevers or chills. Does describe some body aches. No nausea or
vomiting or diarrhea. Went to ___'s office today where an x-ray
of the chest performed and showed no evidence of pneumonia.
Given her wheezing, just into the emergency department for
nebulizer treatments and steroid initiation.
In the ED, initial vital signs were 96.3 66 151/77 100% 2L NC.
Labs were notable for K of 3.1. Otherwise, no leukocytosis. CXR
was negative for pneumonia. Patient was given 60mg prednisone
and 750mg levofloxacin in addition to albuterol nebs. She was
also given 60 meq of potassium chloride. After several neb
treatments she was still notably tachypneic and wheezing. She
was admitted to the medicine service for management of COPD
exacerbation.
On the floor, pt complains of 3 days of increased SOB and
wheezing with feeling of body aches and sore throat. She has a
___ year old grandson who she takes care of and thinks she may
have caught a cold from him. Denies increased sputum production.
Cough is increased but nonproductive. No fevers or chills.
###RESPONSE: COPD {Chronic obstructive lung disease}, home O2 {Home oxygen therapy}, fibromyalgia {Fibromyalgia}, hypertension {Hypertensive disorder, systemic arterial}, worsening {Patient's condition worsened}, shortness of breath {Dyspnea}, wheezing {Wheezing}, cough {Cough}, No
fevers {Temperature normal}, chills {Chill}, body aches {Generalized aches and pains}, nausea {Nausea}, vomiting {Vomiting}, diarrhea {Diarrhea}, x-ray {Radiographic imaging procedure}, chest {Plain chest X-ray}, no evidence {No abnormality detected}, pneumonia {Pneumonia}, wheezing {Wheezing}, emergency {Emergency treatment management}, nebulizer treatments {Nebulizer therapy}, steroid {Steroid therapy}, vital signs {Vital signs finding}, 2L NC {Oxygen administration by nasal cannula}, Labs {Laboratory test}, K {Blood potassium measurement}, leukocytosis {Leukocytosis}, CXR {Plain chest X-ray}, negative {Standard chest X-ray normal}, pneumonia {Pneumonia}, prednisone {Steroid therapy}, levofloxacin {Antibiotic therapy}, nebs {Nebulizer therapy}, neb {Nebulizer therapy}, tachypneic {Tachypnea}, wheezing {Wheezing}, COPD
exacerbation {Acute exacerbation of chronic obstructive airways disease}, increased {Patient's condition worsened}, SOB {Dyspnea}, wheezing {Wheezing}, body aches {Generalized aches and pains}, sore throat {Sore throat}, cold {Common cold}, increased {Patient's condition worsened}, sputum production {Sputum finding}, Cough {Cough}, increased {Patient's condition worsened}, nonproductive {Dry cough}, No fevers {Temperature normal}, chills {Chill} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
-COPD
- Depression
- Chronic pain syndrome/fibromyalgia
- Low back pain
- s/p tibial plateau fracture
- Hypertension
- Hypokalemia
- GERD
- Tobacco abuse
- Hyperlipidemia
###RESPONSE: COPD {Chronic obstructive lung disease}, Depression {Depressive disorder}, Chronic pain syndrome {Chronic pain syndrome}, fibromyalgia {Fibromyalgia}, Low back pain {Low back pain}, tibial plateau fracture {Fracture of tibial plateau}, Hypertension {Hypertensive disorder, systemic arterial}, Hypokalemia {Hypokalemia}, GERD {Gastroesophageal reflux disease}, Tobacco abuse {Tobacco dependence syndrome}, Hyperlipidemia {Hyperlipidemia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Mother died of emphysema, colon cancer. Father died in his ___
of heart problems (bypass, valve). Sister with pancreatitic
cancer, sister with HIV and breast cancer, brother died at ___ of
tuberculosis, brother with drug abuse and bad kidneys.
-sister: breast cancer
-sister: pancreatic cancer
-mother: gastric cancer
-grand father: gastric cancer
-Father: lung cancer, CAD
###RESPONSE: died {Dead}, emphysema {Emphysema}, colon cancer {Malignant neoplasm of colon}, died {Dead}, heart problems {Heart disease}, bypass {Cardiac revascularization with bypass anastomosis}, valve {Cardiac valve structure}, pancreatitic
cancer {Malignant tumor of pancreas}, HIV {Human immunodeficiency virus infection}, breast cancer {Malignant neoplasm of breast}, died {Dead}, tuberculosis {Tuberculosis}, drug abuse {Drug abuse}, kidneys {Kidney disease}, breast cancer {Malignant neoplasm of breast}, pancreatic cancer {Malignant tumor of pancreas}, gastric cancer {Malignant tumor of stomach}, gastric cancer {Malignant tumor of stomach}, lung cancer {Malignant tumor of lung}, CAD {Coronary arteriosclerosis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Admission exam:
Vitals- 97.9, 147/74, 81, 18, 96% on 2L
General- Pleasant middle aged ___ woman breathing
comfortably in full sentences. Alert, oriented, no acute
distress.
HEENT- Sclera anicteric, MMM, PERRL, EOMI, oropharynx clear
Neck- supple, JVP not elevated
Lungs- diffuse posterior wheezing with poor air movement at the
apices but good air movement at the bases. No crackles or
rhonchi.
CV- Regular rate and rhythm, 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
Neuro- CNs2-12 intact, motor function grossly normal
Discharge exam:
VS: 98.8, 120/77, 72, 18, 100% on 2L
General- Pleasant middle aged ___ woman breathing
comfortably in full sentences. Alert, oriented, no acute
distress.
HEENT- Sclera anicteric, MMM, PERRL, EOMI, oropharynx clear
Neck- supple, JVP not elevated
Lungs- CTAB. No wheezes, crackles, or rhonchi.
CV- Regular rate and rhythm, 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
Neuro- CNs2-12 intact, motor function grossly normal
###RESPONSE: Vitals {Vital signs finding}, 2L {Oxygen therapy}, General {General examination of patient}, middle aged {Middle-age}, breathing
comfortably {Breathing easily}, full sentences {Able to complete sentence in one breath}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, Lungs {Examination of respiratory system}, wheezing {Wheezing}, apices {Structure of apex of lung}, good air movement {Breath normal}, bases {Structure of base of lung}, crackles {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, 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}, Neuro {Neurological examination}, CNs2-12 {Cranial nerve structure}, intact {No abnormality detected}, motor function grossly normal {Normal motor response to command}, VS {Vital signs finding}, 2L {Oxygen therapy}, General {General examination of patient}, middle aged {Middle-age}, breathing
comfortably {Breathing easily}, full sentences {Able to complete sentence in one breath}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, oropharynx clear {Pharynx normal}, Neck- supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, crackles {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 + S2 {Heart sounds normal}, murmurs {Heart murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, 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 {Physical examination procedure}, foley {Urinary catheter in situ}, Ext {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, CNs2-12 {Cranial nerve structure}, intact {No abnormality detected}, motor function grossly normal {Normal motor response to command} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
Admission labs:
___ 02:00PM BLOOD WBC-6.0 RBC-3.76* Hgb-11.7* Hct-35.5*
MCV-94 MCH-31.1 MCHC-33.0 RDW-14.7 Plt ___
___ 02:00PM BLOOD Neuts-76.4* Lymphs-17.0* Monos-2.9
Eos-3.3 Baso-0.3
___ 02:00PM BLOOD Glucose-147* UreaN-15 Creat-0.7 Na-141
K-3.1* Cl-102 HCO3-30 AnGap-12
___ 07:00AM BLOOD Calcium-10.2 Phos-3.4 Mg-2.0
Discharge labs:
___ 07:10AM BLOOD WBC-8.9 RBC-3.94* Hgb-11.9* Hct-36.7
MCV-93 MCH-30.2 MCHC-32.4 RDW-14.4 Plt ___
___ 07:10AM BLOOD Glucose-89 UreaN-18 Creat-0.8 Na-144
K-3.8 Cl-104 HCO3-28 AnGap-16
___ 07:10AM BLOOD Calcium-9.9 Phos-3.1 Mg-2.2
Pertinent micro:
Blood cultures pending x2
Pertinent imaging:
CXR: In comparison with study of ___, there is little change and
no
evidence of acute cardiopulmonary disease. There is a streak of
fibrosis or
atelectasis again in the left mid zone. Otherwise, no
pneumonia, vascular
congestion, or pleural effusion.
###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}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, 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}, 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}, BLOOD 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}, Blood cultures {Blood culture}, CXR {Plain chest X-ray}, study {Evaluation procedure}, no
evidence {No abnormality detected}, disease {Disease}, fibrosis {Fibrosis}, atelectasis {Atelectasis}, left {Left lung structure}, mid zone {Structure of middle zone of lung}, pneumonia {Pneumonia}, vascular {Blood vessel structure}, congestion {Congestion}, pleural effusion {Pleural effusion} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
___ with history of COPD, HTN, depression, fibromyalgia with
recent hospitalization for COPD flare who presents with acute
SOB and wheezing on exam consistent with recurrent COPD flare.
# COPD with acute exacerbation: She appeared euvolemic with no
suspected CHF, normal TTE in ___. Positive URI symptoms
likely triggered flare. Of note, pt was supposed to follow up
with pulmonology for PFTs but had to reschedule. She was started
on a prednisone taper and a 3 day course of levaquin. Her
symptoms improved dramatically. She was discharged on flovent
instead of budesonide. Her home COPD medications were otherwise
unchanged.
# Hypokalemia: Etiology likely secondary to diuretic and/or
frequent administration of albuterol. She normally takes 20meq
KCl daily at home. HCTZ was held, and K improved. Blood
pressures remained well controlled. Recommend uptitrating
lisinopril as needed.
Chronic issues:
# Anemia: Hct at baseline. History of normal iron studies.
# HTN: held HCTZ and continued lisinopril as above.
# Fibromyalgia: continued home gabapentin and ibuprofen
# Depression: continued home zoloft. SW consult.
# PACT patient: PACT aware of admission, following.
Transitional issues:
# HCTZ discontinued; can uptitrate lisinopril as needed.
# Budesonide d/c'd and flovent started
###RESPONSE: COPD {Chronic obstructive lung disease}, HTN {Hypertensive disorder, systemic arterial}, depression {Depressive disorder}, fibromyalgia {Fibromyalgia}, COPD flare {Acute exacerbation of chronic obstructive airways disease}, SOB {Dyspnea}, wheezing {Wheezing}, exam {Physical examination procedure}, recurrent {Recurrent disease}, COPD flare {Acute exacerbation of chronic obstructive airways disease}, COPD {Chronic obstructive lung disease}, acute exacerbation {Acute exacerbation of chronic obstructive airways disease}, euvolemic {Normal blood volume}, CHF {Congestive heart failure}, normal {No abnormality detected}, TTE {Transthoracic echocardiography}, URI {Upper respiratory infection}, flare {Acute infective exacerbation of chronic obstructive airways disease}, PFTs {Measurement of respiratory function}, prednisone {Steroid therapy}, taper {Medication decreased}, improved {Patient's condition improved}, COPD {Chronic obstructive lung disease}, medications {Administration of drug or medicament}, Hypokalemia {Hypokalemia}, secondary {Medication side effects present}, diuretic {Diuretic therapy}, held {Recommendation to stop drug treatment}, K {Blood potassium measurement}, improved {Patient's condition improved}, Blood
pressures {Blood pressure monitoring}, well controlled {Disease condition determination, well controlled}, Anemia {Anemia}, Hct {Hematocrit determination}, baseline {Baseline state}, normal iron studies {Serum iron within reference range}, HTN {Hypertensive disorder, systemic arterial}, held {Recommendation to stop drug treatment}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, Fibromyalgia {Fibromyalgia}, Depression {Depressive disorder}, discontinued {Recommendation to stop drug treatment}, 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: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Gabapentin 800 mg PO TID
3. Gabapentin 400 mg PO HS
4. Hydrochlorothiazide 25 mg PO DAILY
hold for sbp <100
5. Ibuprofen 800 mg PO Q8H:PRN pain
6. Lisinopril 5 mg PO DAILY
7. Pravastatin 80 mg PO DAILY
8. Sertraline 200 mg PO DAILY
9. Montelukast Sodium 10 mg PO DAILY
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
11. Budesonide Nasal Inhaler *NF* 90 mcg Other BID
12. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Gabapentin 800 mg PO TID
3. Gabapentin 400 mg PO HS
4. Ibuprofen 800 mg PO Q8H:PRN pain
5. Lisinopril 5 mg PO DAILY
6. Montelukast Sodium 10 mg PO DAILY
7. Pravastatin 80 mg PO DAILY
8. Sertraline 200 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
12. PredniSONE 60 mg PO once a day Duration: 1 Days
13. PredniSONE 40 mg PO once a day Duration: 3 Days Start:
After 60 mg tapered dose.
14. PredniSONE 30 mg PO once a day Duration: 3 Days Start:
After 40 mg tapered dose.
15. PredniSONE 20 mg PO once a day Duration: 3 Days Start:
After 30 mg tapered dose.
16. PredniSONE 10 mg PO once a day Duration: 3 Days Start:
After 20 mg tapered dose.
17. Fluconazole 150 mg PO ONCE Duration: 1 Doses
RX *fluconazole 150 mg 1 tablet(s) by mouth once Disp #*2 Tablet
Refills:*0
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Chronic obstructive pulmonary disease
Upper respiratory tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Chronic obstructive pulmonary disease {Chronic obstructive lung disease}, Upper respiratory tract infection {Upper respiratory infection}, 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 ___,
___ were admitted to ___ for shortness of breath likely
related to an exacerbation of your COPD. ___ were started on
antibiotics and a prednisone taper with nebulizers to help ___
breathe. Your symptoms improved notably, and we now feel ___ are
safe to leave the hospital.
We made the following changes to your medications:
START prednisone 10mg 3 tabs x3 days, 3x 3 days, 2 x 3 days , 1
x 3 days (this is waiting at your pharmacy)
START fluconazole 125mg once if ___ begin having symptoms of
yeast infection
START flovent (this is waiting at your pharmacy)
STOP HCTZ
STOP budesonide
###RESPONSE: shortness of breath {Dyspnea}, exacerbation of your COPD {Acute exacerbation of chronic obstructive airways disease}, started {New medication added}, antibiotics {Antibiotic therapy}, prednisone {Steroid therapy}, nebulizers {Nebulizer therapy}, improved {Patient's condition improved}, prednisone {Steroid therapy}, yeast {Yeast detected}, infection {Infectious disease} |