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###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
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:
Penicillins
Attending: ___.
Chief Complaint:
Biliary pancreatitis
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
###RESPONSE: Penicillins {Allergy to penicillin}, Biliary pancreatitis {Gallstone pancreatitis}, Laparoscopic cholecystectomy {Laparoscopic cholecystectomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Mr. ___ is a ___ man who had severe biliary
pancreatitis resulting in pancreatic necrosis for which he was
treated with nasojejunal feedings and pancreatic rest. He had
initially had multisystem organ failure, which improved. Mr.
___ has a large postnecrotic pseudocyst, which has been
drained through a minimally invasive approach into his GI tract.
He has some debris, but this is not currently infected. The
patient was followed by Dr. ___ in his ___
clinic to discuss cholecystectomy. After discussion of all
risks, benefits and possible outcomes, patient was scheduled for
elective cholecystectomy on ___.
###RESPONSE: biliary
pancreatitis {Gallstone pancreatitis}, pancreatic necrosis {Necrosis of pancreas}, nasojejunal feedings {Nasojejunal feeding}, pancreatic rest {Ectopic pancreas}, multisystem organ failure {Multiple organ failure}, improved {Patient's condition improved}, pseudocyst {Pseudocyst}, drained {Incision AND drainage}, GI tract {Gastrointestinal tract structure}, clinic {Outpatient care management}, cholecystectomy {Cholecystectomy}, discussion {Discussion}, cholecystectomy {Cholecystectomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
Hiatal Hernia
___ esophagus
Esophageal ulcer
anxiety
Back pain
###RESPONSE: Hiatal Hernia {Hiatal hernia}, esophagus {Esophageal structure}, Esophageal ulcer {Ulcer of esophagus}, anxiety {Anxiety}, Back pain {Backache} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 passed of metastatic lung cancer. Father alive, had CVA
and MI. No history of pancreatic malignancy
###RESPONSE: metastatic lung cancer {Metastatic malignant neoplasm to lung}, alive {Alive}, CVA {Cerebrovascular accident}, pancreatic malignancy {Malignant tumor of pancreas} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Prior Discharge:
VS: 98.3, 83, 137/69, 16, 98% RA
GEN: NAD, AAO x 3
CV: RRR
PULM: CTAB
ABD: Laparoscopic incisions open to air with dermabond and c/d/i
EXTR: Warm, +pp, no c/c/e
###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, GEN {General examination of patient}, NAD {No abnormality detected}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, ABD {Examination of abdomen}, Laparoscopic {Laparoscopic procedure}, incisions {Surgical incision wound}, EXTR {Examination of limb}, Warm {Warm skin}, c {Cyanosis}, e {Edema of extremity} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Pathology: Pending
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
The patient with history of gallstone pancreatitis was admitted
to the HPB Surgical Service on ___ after he underwent
laparoscopic cholecystectomy. After a brief, uneventful stay in
the PACU, the patient arrived on the floor tolerating regular
diet , on IV fluids, and Dilaudid PCA for pain control. The
patient was hemodynamically stable.
Pain was well controlled. Diet was tolerated well. The patient
voided without problem. The patient received subcutaneous
heparin and venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
###RESPONSE: gallstone pancreatitis {Gallstone pancreatitis}, laparoscopic cholecystectomy {Laparoscopic cholecystectomy}, PACU {Postanesthesia care}, regular
diet {Normal diet}, IV fluids {Administration of intravenous fluids}, PCA {Patient controlled analgesia}, pain control {Pain control}, hemodynamically stable {Hemodynamically stable}, Pain was well controlled {Demonstrates adequate pain control}, Diet was tolerated well {Diet good}, voided without problem {Normal micturition}, heparin {Heparin therapy}, afebrile {Fever}, stable vital signs {Normal vital signs}, regular
diet {Normal diet}, ambulating {Fully mobile}, voiding without assistance {Continence independent}, pain was well
controlled {Demonstrates adequate pain control}, teaching {Patient education}, instructions {Recommendation to}, discharge plan {Discharge planning} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
alprazolam 1", oxycodone 7.5mg prn, protonix 40'
Discharge Medications:
1. ALPRAZolam 1 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q3H
Disp #*120 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H
###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:
Biliary pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Biliary pancreatitis {Gallstone pancreatitis}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were admitted to the surgery service at ___ for surgical
resection of your gallbladder. You have done well in the post
operative period and are now safe to return home to complete
your recovery with the following instructions:
.
Call Dr. ___ office at ___ if you have any
questions or concerns. During off hours: call Operator at
___ and ask to ___ team.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
###RESPONSE: surgical
resection of your gallbladder {Cholecystectomy}, post
operative {Postoperative state}, medications {Patient medication education}, medication {Medication education}, medications {Medication education}, ambulate {Ambulation training}, drink adequate amounts of fluids {Fluid intake education}, Avoid lifting
weights {Functional activity education}, follow-up {Follow-up arranged}, activity
restrictions {Functional activity education}, while taking pain
medications {Patient medication education}, Primary Care {Primary care management}, PCP {Primary care management}, increased pain {Increased pain}, swelling {Swelling}, redness {Redness of skin over lesion}, drainage {Discharge}, incision
site {Surgical incision wound}, shower {Functional activity education}, surgical incisions {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: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
CHIEF COMPLAINT: Chest pain, NSTEMI
Major Surgical or Invasive Procedure:
Cardiac Catheterization
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Chest pain {Chest pain}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, Cardiac Catheterization {Cardiac catheterization} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ year old man with a h/o COPD who p/w chest pain and elevated
troponin. Had CP on ___ after eating, resolved, did not
seek medical care. CP recurrent ___ and once again, resolved
with rest. Starting ___ at 2PM he developed left-sided and
substernal CP that radiated to the left arm. He described the
feeling as heavy pressure and stated that he felt lightheaded
and had a chill but no diaphoresis, nausea, or vomiting. Had
baseline SOB due to COPD which had been getting progressively
worse over the past few months but isn't acutely worse at this
time. Had never had CP before ___, no history of heart
disease.
Initially went to ___ where ekg showed mildly peaked T
waves laterally and poor R wave progression but no STE or STD.
Baseline BP was in the 120s, after NTG x 1 dropped to ___
systolic, was fluid responsive. CP 6 --> 3 after NTG, and then
resolved with 2.5mg IV morphine. Also given duonebs due to
wheezing on exam. Trop 0.157, MBI 10. Patient had taken ASA 81mg
earlier today so was given additional ASA for a total 325mg.
Guaic negative so heparin gtt was started and patient was
transferred to ___.
In the ___ ED initial VS were 98.1, 84, 136/83, 16, 98% on 2L.
No labs done. CXR showed flattened diaphragms but no acute
process. Patient was continued on heparin gtt. VS prior to
transfer were 97.6, 57, 132/80, 14, 98% on 2L.
On the floor patient was comfortable and denied any chest pain
or other complaints. He admitted that he had lost 10 lbs in the
past two weeks.
###RESPONSE: COPD {Chronic obstructive lung disease}, chest pain {Chest pain}, elevated
troponin {Troponin I above reference range}, CP {Chest pain}, resolved {Problem resolved}, medical care {Medical care}, CP {Chest pain}, recurrent {Recurrent disease}, resolved {Problem resolved}, left-sided and
substernal CP {Left sided chest pain}, radiated to the left arm {Pain radiating to left arm}, pressure {Tight chest}, lightheaded {Lightheadedness}, chill {Chill}, diaphoresis {Excessive sweating}, nausea {Nausea}, vomiting {Vomiting}, baseline {Baseline state}, SOB {Dyspnea}, COPD {Chronic obstructive lung disease}, worse {Patient's condition worsened}, worse {Patient's condition worsened}, heart
disease {Heart disease}, R wave progression {Electrocardiographic R wave abnormal}, STE {ST segment elevation}, STD {ST segment depression}, Baseline {Baseline state}, NTG {Administration of prophylactic glyceryl trinitrate}, NTG {Administration of prophylactic glyceryl trinitrate}, resolved {Problem resolved}, wheezing {Wheezing}, exam {Physical examination procedure}, Trop {Troponin measurement}, ASA {Administration of aspirin}, ASA {Administration of aspirin}, negative {No pathologic diagnosis}, heparin {Heparin therapy}, started {New medication added}, labs {Laboratory test}, CXR {Plain chest X-ray}, diaphragms {Diaphragmatic finding}, no acute {No abnormality detected}, heparin {Heparin therapy}, comfortable {Comfortable appearance}, chest pain {Chest pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY: None
3. OTHER PAST MEDICAL HISTORY: COPD
###RESPONSE: CARDIAC RISK FACTORS {Assessment for risk of cardiovascular disease}, Hypertension {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung 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:
Mother and father both died of stroke. Pt was worked up for
stroke w/negative results.
###RESPONSE: died {Dead}, stroke {Cerebrovascular accident}, worked up {Evaluation procedure}, stroke {Cerebrovascular accident}, negative {No pathologic diagnosis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Admission:
VS- T 98 BP 104-128/64-88 HR 58-62 RR ___ pO2 98(RA)
Wt: 64.5 kg
GENERAL- Patient appears comfortable in bed. Oriented x3. Mood,
affect appropriate.
HEENT- Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK- No JVD.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB; expiratory wheeze
audible from anterior and posterior.
ABDOMEN- Soft, NTND. No HSM or tenderness.
EXTREMITIES- No c/c/e.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES- Carotid 2+ DP 2+ ___ 2
Discharge:
VS- T 98.5 BP 96-117/60-74 HR ___ RR 18 pO2 95(RA)
I/O: ___
GENERAL- Patient appears comfortable in bed. Oriented x3. Mood,
affect appropriate.
NECK- No JVD.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB; expiratory wheeze
audible from anterior and posterior.
ABDOMEN- Soft, NTND. No HSM or tenderness.
EXTREMITIES- No c/c/e. R radial dressing clean, dry and intact.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES- Carotid 2+ DP 2+ ___ 2+
###RESPONSE: VS {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, GENERAL {General examination of patient}, comfortable {Comfortable appearance}, Oriented x3 {Oriented to person, time and place}, Mood {Level of mood - normal}, affect {Mood finding}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva were pink {Conjunctiva normal}, pallor {Pallor of skin of face}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, PMI {Finding of apex beat}, intercostal space {Structure of intercostal space}, midclavicular
line {Midclavicular line}, RR {Finding of rate of respiration}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, No m/r/g {Heart sounds normal}, thrills {Thrill}, lifts {Precordial heave}, No S3 {Third heart sound, S>3<, inaudible}, LUNGS {Examination of respiratory system}, chest wall deformities {Deformity of chest wall}, scoliosis {Scoliosis deformity of spine}, kyphosis {Kyphosis deformity of spine}, Resp {Examination of respiratory system}, accessory muscle {Accessory skeletal muscle}, CTAB {Normal breath sounds}, expiratory wheeze {Expiratory wheezing}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, EXTREMITIES {Examination of limb}, No c/c/e {No abnormality detected}, SKIN {Examination of skin}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, Carotid 2 {Normal carotid arterial pulse}, DP 2 {Dorsalis pulse present}, comfortable {Comfortable appearance}, Oriented x3 {Oriented to person, time and place}, Mood {Level of mood - normal}, affect appropriate {Appropriate affect}, JVD {Jugular venous engorgement}, PMI {Finding of apex beat}, intercostal space {Structure of intercostal space}, midclavicular
line {Midclavicular line}, normal S1, S2 {Heart sounds normal}, No m/r/g {Heart sounds normal}, thrills {Thrill}, lifts {Precordial heave}, No S3 {Third heart sound, S>3<, inaudible}, chest wall deformities {Deformity of chest wall}, scoliosis {Scoliosis deformity of spine}, kyphosis {Kyphosis deformity of spine}, Resp
were unlabored {Breathing easily}, accessory muscle use {Accessory respiratory muscles used}, CTAB {Normal breath sounds}, expiratory wheeze {Expiratory wheezing}, ABDOMEN- Soft {Abdomen soft}, NTND {Abdominal tenderness}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, No c/c/e {No abnormality detected}, radial {Radial pulse present}, clean, dry and intact {Wound healing well}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, Carotid 2 {Normal carotid arterial pulse}, DP 2 {Dorsalis pulse present} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
Admission:
___ 06:25AM BLOOD WBC-8.4 RBC-4.06* Hgb-12.8* Hct-39.7*
MCV-98 MCH-31.7 MCHC-32.4 RDW-12.4 Plt ___
___ 06:25AM BLOOD ___ PTT-108.5* ___
___ 06:25AM BLOOD CK(CPK)-640*
___ 06:25AM BLOOD CK-MB-81* MB Indx-12.7* cTropnT-0.67*
___ 06:25AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0
Discharge:
___ 06:25AM BLOOD WBC-8.4 RBC-4.06* Hgb-12.8* Hct-39.7*
MCV-98 MCH-31.7 MCHC-32.4 RDW-12.4 Plt ___
___ 06:42AM BLOOD Glucose-95 UreaN-8 Creat-0.9 Na-139 K-4.0
Cl-106 HCO3-27 AnGap-10
___ 06:42AM BLOOD CK(CPK)-438*
___ 06:42AM BLOOD CK-MB-35* MB Indx-8.0* cTropnT-1.45*
___ 06:42AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.0
###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}, PTT {Partial thromboplastin time, activated}, CK(CPK {Creatine kinase measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, 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}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, CK(CPK {Creatine kinase measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Studies:
CHEST (PORTABLE AP) ___ (final) "No acute cardiopulmonary
process"
Cardiac Cath ___ (prelim) "FINAL DIAGNOSIS: 1. One vessel
coronary artery disease with total occlusion of the mid-RCA.
The pLCx and mLAD were also noted to have ulcerated plaques of
~40%. 2. Borderline systemic systolic arterial hypotension. 3.
Successful angioplasty of the mid RCA total occlusion with a 3.0
mm balloon. 4. Successful angioplasty of the more proximal RCA
with a 3.0 mm balloon."
ECHO ___ (final) "The left atrium is normal in size. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with basal to mid inferior
akinesis/hypokinesis. Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion"
Pending Results:
None
###RESPONSE: CHEST (PORTABLE AP {Plain x-ray of chest anteroposterior view}, No acute {No abnormality detected}, Cardiac Cath {Cardiac catheterization}, One vessel
coronary artery disease {Single coronary vessel disease}, total occlusion {Complete obstruction}, mid-RCA {Structure of mid portion of right coronary artery}, mLAD {Structure of mid portion of anterior descending branch of left coronary artery}, plaques {Plaque}, systolic arterial hypotension {Abnormal systolic arterial pressure}, angioplasty {Angioplasty of blood vessel}, mid RCA {Structure of mid portion of right coronary artery}, total occlusion {Complete obstruction}, angioplasty {Angioplasty of blood vessel}, proximal {Structure of proximal portion of anterior descending branch of left coronary artery}, RCA {Right coronary artery structure}, ECHO {Echocardiography}, left atrium {Left atrial structure}, normal in size {Normal size}, mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, left
ventricular cavity {Structure of cavity of left cardiac ventricle}, size is normal {Normal size}, mild {Symptom mild}, left
ventricular systolic dysfunction {Left ventricular systolic dysfunction}, basal {Structure of base of heart}, akinesis {Akinesia}, hypokinesis {Hypokinesis of cardiac wall}, Tissue Doppler imaging {Doppler ultrasonography of heart tissue}, left ventricular {Left cardiac ventricular structure}, filling pressure {Normal cardiac flow}, Right
ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Normal ventricular wall motion}, aortic valve leaflets {Structure of cusp of aortic valve}, mildly thickened {Increased thickness}, aortic valve stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve leaflets are mildly thickened {Thickened mitral leaflet}, Trivial mitral
regurgitation {Mild mitral valve regurgitation}, pulmonary artery systolic
hypertension {Pulmonary hypertensive arterial disease}, pericardial
effusion {Pericardial 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:
___ year old man with a h/o COPD, HTN who p/w chest pain and
elevated troponin without ST elevation.
# NSTEMI: CK peaked at 640, troponin at 1.45. He remained chest
pain free following admission. Patient underwent cardiac cath
___, revealing total occlusion of mid-RCA, which was opened with
balloon angioplasty. Another more distal lesion in the RCA was
also opened with balloon angioplasty. Echo following
catheterization showed normal EF with with basal to mid inferior
akinesis/hypokinesis. He was discharged on high dose aspirin,
high dose atorvastatin, prasugrel and beta blocker.
# COPD: Was stable on home albuterol/advair
# HTN: Was stable in house; on admission, lowered lisinopril
dose to accomodate the addition of beta blocker.
Transitional Issues:
-Follow up with Dr. ___ in ___ weeks.
###RESPONSE: COPD {Chronic obstructive lung disease}, HTN {Hypertensive disorder, systemic arterial}, chest pain {Chest pain}, elevated troponin {Troponin I above reference range}, ST elevation {ST segment elevation}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, troponin {Troponin measurement}, chest
pain {Chest pain}, cardiac cath {Cardiac catheterization}, total occlusion {Complete obstruction}, mid-RCA {Structure of mid portion of right coronary artery}, balloon angioplasty {Angioplasty of artery}, distal {Structure of distal portion of right coronary artery}, lesion {Lesion}, RCA {Right coronary artery structure}, balloon angioplasty {Angioplasty of artery}, Echo {Echocardiography}, catheterization {Cardiac catheterization}, normal {Electrocardiogram normal}, basal {Structure of base of heart}, akinesis {Akinesia}, hypokinesis {Hypokinesis of cardiac wall}, aspirin {Administration of aspirin}, COPD {Chronic obstructive lung disease}, stable {Patient's condition stable}, HTN {Hypertensive disorder, systemic arterial}, stable {Patient's condition stable}, 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:
MEDICATIONS:
- Albuterol HFA 90mcg BID:prn
- Advair HFA BID
- Lisinopril 20mg daily
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH BID:PRN SOB
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 Tablet(s) by mouth once a day Disp #*30
Capsule Refills:*0
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Prasugrel 10 mg PO DAILY
RX *Effient 10 mg 1 Tablet(s) by mouth once a day Disp #*30
Capsule Refills:*0
5. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 Tablet(s) by mouth once a day Disp #*30
Capsule Refills:*0
6. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 Tablet(s) by mouth once a day Disp #*30
Capsule Refills:*0
7. Metoprolol Succinate XL 12.5 mg PO DAILY
hold for SBP <100, HR <60
RX *metoprolol succinate 25 mg 0.5 (One half) Tablet(s) by mouth
once a day Disp #*15 Capsule Refills:*0
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Primary: NSTEMI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: NSTEMI {Acute non-ST segment elevation myocardial infarction}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were admitted to the ___
with chest pain. While you were here, you had a cardiac
cathetization which showed blockage of one of the arteries that
feeds your heart ("Right Coronary Artery"). The blockage was
opened with a balloon angioplasty and you had increased blood
flow to the heart and your symptoms improved.
It was a pleasure taking care of you during your hospital stay.
###RESPONSE: chest pain {Chest pain}, cardiac
cathetization {Cardiac catheterization}, blockage {Coronary artery stenosis}, arteries {Coronary artery structure}, heart {Heart structure}, Right Coronary Artery {Right coronary artery structure}, blockage {Coronary artery stenosis}, balloon angioplasty {Angioplasty of artery}, increased blood
flow {Increased vascular flow}, heart {Heart structure}, improved {Patient's condition improved} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
Sanctura XR
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___ Left heart cardiac catheterization
###RESPONSE: chest pain {Chest pain}, Left heart cardiac catheterization {Catheterization of left heart} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Ms. ___ is an ___ year-old lady with a PMH of NSTEMI s/p
BMS to mid-LAD in ___, hypothyroidism and recurrent UTIs, now
presenting with chest pain, concerning for NSTEMI.
Patient reports having three nights of severe chest pain over
the past three nights at rest. Pain worsened last night. Notes
that pain is squeezing across the tops of her breasts,
associated with dyspnea and diaphoresis, consistent with pain
experienced at the time of prior MI. Each pain episode lasted
about ___ minutes, with about three episodes per night. Last
night, pain was worse than before. She did not take any meds
for her pain, just went back to sleep. At worst, it was about
an ___ in severity. With one episode, she had associated
palpitations.
Additionally, she reports "difficulty breathing" with walking,
at any distance. She also reports ongoing slight swelling in
her legs and pain with urination.
When she saw her PCP this morning, she was referred to the
emergency room for evaluation. On arrival to the ED, her
initial vital signs were: 97.9 62 125/63 18 96%. She reported
that her chest pain had been resolved since last night. EKG
showed NSR @ 64 bpm, LAD, IVCD, TWI in V2-V5. Labs were
consistent with troponin 0.08; chemistry panel with chloride
110, bicarb 21, Cr 1.2; H/H 10.6/32.7. UA with large ___, WBC
66, few bacteria. UCx was sent. Patient was given aspirin 81
mg, clopidogrel 75 mg and nitrofurantoin 100 mg. She was also
started on a heparin drip. Vital signs prior to transfer were:
98.0 64 134/64 18 98%.
On arrival to the floor, she reported no chest pain or
discomfort.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
###RESPONSE: NSTEMI {Acute non-ST segment elevation myocardial infarction}, BMS {Placement of stent in coronary artery}, mid-LAD {Structure of mid portion of anterior descending branch of left coronary artery}, hypothyroidism {Hypothyroidism}, recurrent UTIs {Recurrent urinary tract infection}, chest pain {Chest pain}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, severe {Symptom severe}, chest pain {Chest pain at rest}, at rest {Chest pain at rest}, Pain worsened {Increased pain}, pain is squeezing {Squeezing chest pain}, breasts {Breast structure}, dyspnea {Dyspnea}, diaphoresis {Excessive sweating}, pain {Chest pain}, MI {Myocardial infarction}, pain {Pain}, pain {Pain}, worse {Increased pain}, did not take any meds {Does not take medication}, pain {Pain}, palpitations {Palpitations}, difficulty breathing {Difficulty breathing}, walking {Does walk}, swelling in
her legs {Swelling of lower limb}, pain with urination {Dysuria}, emergency {Emergency treatment management}, evaluation {Evaluation procedure}, vital signs {Vital signs finding}, chest pain {Chest pain}, resolved {Problem resolved}, EKG {Electrocardiographic procedure}, NSR {Normal sinus rhythm}, LAD {Left axis deviation}, IVCD {Intraventricular conduction defect}, TWI {Inverted T wave}, V2 {Lead site V2}, V5 {Lead site V5}, Labs {Laboratory test}, troponin {Troponin measurement}, chloride {Chloride measurement, blood}, bicarb {Blood bicarbonate measurement}, Cr {Creatinine measurement}, H/H {Measurement of total hemoglobin concentration and hematocrit}, UA {Urinalysis}, WBC {White blood cell count}, bacteria {Bacteriuria}, UCx {Urine culture}, aspirin {Administration of aspirin}, started {New medication added}, heparin drip {Continuous infusion of heparin}, Vital signs {Vital signs finding}, chest pain {Chest pain}, discomfort {Discomfort}, review of systems {Review of systems}, stroke {Cerebrovascular accident}, TIA {Transient ischemic attack}, deep venous thrombosis {Deep venous thrombosis}, pulmonary embolism {Pulmonary embolism}, bleeding {Bleeding}, surgery {Surgical procedure}, myalgias {Muscle pain}, joint pains {Joint pain}, cough {Cough}, hemoptysis {Hemoptysis}, black
stools {Dark stools}, red stools {Red stools}, fevers {Fever}, chills {Chill}, rigors {Rigor}, exertional {Pain provoked by exertion}, buttock {Pain in buttock}, calf pain {Pain in calf}, review of systems {Review of systems}, negative {No abnormality detected}, Cardiac review of systems {Cardiovascular physical examination}, paroxysmal
nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, ankle edema {Ankle edema}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: NSTEMI s/p BMS to LAD
___
3. OTHER PAST MEDICAL HISTORY:
1. Recurrent urinary tract infection, followed by ___.
2. History of bronchitis.
3. Hypercholesterolemia.
4. Bilateral chronic venous insufficiency.
5. Hypothyroidism.
6. Depression.
7. Anemia.
8. Hearing loss.
9. Insomnia.
10. History of vaginal prolapse.
PAST SURGICAL HISTORY:
1. Cholecystectomy.
2. TAH/BSO.
###RESPONSE: CARDIAC RISK FACTORS {Assessment for risk of cardiovascular disease}, Diabetes {Diabetes mellitus}, Dyslipidemia {Dyslipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, PERCUTANEOUS CORONARY INTERVENTIONS {Percutaneous coronary intervention}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, BMS {Placement of stent in coronary artery}, LAD {Structure of anterior descending branch of left coronary artery}, Recurrent urinary tract infection {Recurrent urinary tract infection}, bronchitis {Bronchitis}, Hypercholesterolemia {Hypercholesterolemia}, chronic venous insufficiency {Peripheral venous insufficiency}, Hypothyroidism {Hypothyroidism}, Depression {Depressive disorder}, Anemia {Anemia}, Hearing loss {Hearing loss}, Insomnia {Insomnia}, vaginal {Vaginal structure}, prolapse {Prolapse}, Cholecystectomy {Cholecystectomy}, TAH/BSO {Total abdominal hysterectomy with bilateral salpingo-oophorectomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 age ___ "old age." Father died age ___ of colon
cancer. Both were in a nursing home and died within 12 days of
one another.
###RESPONSE: died {Dead}, old age {Old-age}, died {Dead}, colon
cancer {Malignant neoplasm of colon}, died {Dead} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0 117/70 62 18 95%RA
General: Comfortable, elderly, well-appearing, NAD.
HEENT: MMM, no scleral icterus, clear oropharynx.
Neck: 2+ carotid pulses, no JVD.
CV: I/VI systolic murmur at RUSB, nl S1/S2, RRR.
Lungs: CTAB, resp unlabored, no accessory muscle use
Abdomen: Soft, ND/NT, NABS
Back: No CVA tenderness
GU: No foley
Ext: 1+ non-pitting edema around ankles bilaterally
Neuro: Awake, alert and oriented x3, CNs II-XII intact and
symmetric. Moving all extremities.
Skin: No rashes.
PULSES: 2+ distal pulses.
DISCHARGE PHYSICAL EXAM:
VS: T 97.8 BP 153/77 HR 68 RR 20 SaO2 97% on RA
General: Comfortable, elderly, well-appearing, NAD.
HEENT: MMM, EOMI
Neck: JVP ~ 8cm H2O.
CV: RRR, ___ SEM, nl S1/S2.
Lungs: CTAB, resp unlabored, no accessory muscle use
Abdomen: Soft, ND/NT, NABS
Back: No CVA tenderness
GU: No foley
Ext: 1+ pitting edema around ankles bilaterally
Neuro: Awake, alert and oriented x3, CNs II-XII intact and
symmetric. Moving all extremities.
Skin: No rashes.
PULSES: 2+ distal pulses.
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, Comfortable {Comfortable appearance}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, scleral icterus {Scleral icterus}, oropharynx {Oropharyngeal structure}, Neck {Physical examination procedure}, 2+ carotid pulses {Carotid pulse present}, JVD {Jugular venous engorgement}, CV {Cardiovascular physical examination}, murmur {Murmur}, S2 {Normal second heart sound, S>2<}, RRR {Normal heart rate}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, resp unlabored {Breathing easily}, accessory muscle {Accessory skeletal muscle}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, NT {Abdominal tenderness}, NABS {Normal bowel sounds}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, GU {Examination of genitourinary system}, Ext {Examination of limb}, edema {Edema}, ankles {Ankle region structure}, Neuro {Neurological examination}, Awake {Awake}, alert {Mentally alert}, oriented {Orientated}, CNs II-XII {Cranial nerve structure}, intact {No abnormality detected}, all extremities {All extremities}, Skin {Examination of skin}, rashes {Eruption of skin}, PULSES {Pulse finding}, 2+ distal pulses {Peripheral pulses normal}, VS {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, SaO2 {Finding of oxygen saturation}, RA {Breathing room air}, General {General examination of patient}, Comfortable {Comfortable appearance}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, EOMI {Normal ocular motility}, Neck {Physical examination procedure}, JVP {Finding of jugular venous pressure}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, SEM {Ejection murmur}, nl S1/S2 {Heart sounds normal}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, resp unlabored {Breathing easily}, accessory muscle use {Accessory respiratory muscles used}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, NT {Abdominal tenderness}, NABS {Normal bowel sounds}, CVA tenderness {Renal angle tenderness}, Ext {Examination of limb}, edema {Edema}, ankles {Ankle region structure}, Neuro {Neurological examination}, Awake {Awake}, alert {Mentally alert}, oriented x3 {Oriented to person, time and place}, CNs II-XII {Cranial nerve structure}, intact {No abnormality detected}, Moving all extremities {Does move all four limbs}, Skin {Examination of skin}, rashes {Eruption of skin}, PULSES {Pulse finding}, 2+ distal pulses {Peripheral pulses normal} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 04:00PM BLOOD WBC-4.0 RBC-3.87* Hgb-10.6* Hct-32.7*
MCV-85 MCH-27.5 MCHC-32.5 RDW-15.3 Plt ___
___ 04:00PM BLOOD Neuts-50.0 ___ Monos-6.0 Eos-3.8
Baso-0.7
___ 04:16PM BLOOD ___ PTT-26.9 ___
___ 07:38AM BLOOD Glucose-99 UreaN-15 Creat-1.0 Na-143
K-3.9 Cl-108 HCO3-24 AnGap-15
___ 07:38AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.1
___ 04:00PM BLOOD CK(CPK)-144
___ 04:00PM BLOOD CK-MB-3
___ 04:00PM BLOOD cTropnT-0.08*
___ 04:40PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:40PM URINE RBC-0 WBC-66* Bacteri-FEW Yeast-NONE
Epi-1
PERTINENT LABS:
___ 08:41PM BLOOD CK(CPK)-161
___ 08:41PM BLOOD CK-MB-3 cTropnT-0.06*
___ 09:51PM BLOOD CK(CPK)-175
___ 09:51PM BLOOD CK-MB-4 cTropnT-0.10*
___ 07:38AM BLOOD cTropnT-0.11*
DISCHARGE LABS:
___ 07:38AM BLOOD WBC-5.1 RBC-4.13* Hgb-11.3* Hct-34.2*
MCV-83 MCH-27.3 MCHC-33.0 RDW-15.4 Plt ___
___ 07:38AM BLOOD ___ PTT-28.9 ___
___ 07:38AM BLOOD Glucose-99 UreaN-15 Creat-1.0 Na-143
K-3.9 Cl-108 HCO3-24 AnGap-15
___ 07:38AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.1
MICROBIOLOGY:
___ URINE CULTURE: Time Taken Not Noted Log-In
Date/Time: ___ 5:12 pm
URINE TAKEN FROM ___.
URINE CULTURE (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
AEROCOCCUS VIRIDANS. 10,000-100,000 ORGANISMS/ML..
IMAGING:
___ CXR PA/lat: 2 views were obtained of the chest. The
lungs are well expanded and clear. Retrocardiac density likely
corresponds to a small hiatal hernia. There is no pleural
effusion or pneumothorax. The heart is normal size with normal
cardiomediastinal contours.
IMPRESSION: No acute intrathoracic process. Small hiatal
hernia.
___ LEFT HEART CARDIAC CATHETERIZATION: Approach via
___ catheter in R radial artery.
Hemodynamic Measurements (mmHg):
Baseline
SiteSysDiasEndMeanA WaveV WaveHR
LV ___
Contrast Summary:
Contrast Total (ml)
Optiray (ioversol 320 mg/ml)80
Radiation Dosage:
Effective Equivalent Dose Index (mGy)___
Radiology Summary:
Total Runs
Total Fluoro Time (minutes) 9.0
Findings:
ESTIMATED blood loss: < 25 cc
Hemodynamics: (see above)
Coronary angiography: right dominant
LMCA: Normal
LAD: 99% restenosis in the mid LAD within the bare metal stent
with TIMI 1 flow into the distal LAD. The diagonal branch
remained patent and was a large vessel.
LCX: Large vessel vessel with a large OMB1 and birfurcating
OMB/PLB to the posterior wall. There were minor lumen
irregularities in the LCx.
RCA: The RCA had minor irregularities and gave rise to a small
PDA and RPLB.
Interventional details:
The patient presented with a NSTEMI following bare metal stent
placement in the mid LAD in ___. She re-developed
unstable symptoms and proceeded with cardiac catheterization.
Unfractionated heparin and eptifibatide were used for
anticoagulation.
Using a ___ Fr XB3.5 guiding catheter and a 0.014 BMW wire, the
LAD in-stent restenosis was dilated with a 2.5 mm Cutting
Balloon. A 2.5 mm x 26 mm Resolute drug eluting stent was
placed in the mid LAD and deployed at 14 atms. A 2.75 mm x 15
mm balloon was inflated to 24 atms throughout the stent. This
resulted in no residual stenosis within the stent and TIMI 3
flow into the distal vessel.
The procedure was performed from the right radial artery without
complications.
ASSESSMENT
1. Single vessel CAD with in-stent restenosis in the bare metal
stent in the mLAD
2. Successful drug-eluting stent of the mid LAD
PLAN
1. Aspirin indefinitely
2. Clopidogrel for up to one year
___ TTE: The left atrium and right atrium are normal in
cavity size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). The
right ventricular cavity is mildly dilated with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild aortic regurgitation. Mild mitral regurgitation.
Moderate tricuspid regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of ___, LV
systolic function has normalized.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Plt {Platelet count}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, CK(CPK {Creatine kinase measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, URINE {Evaluation of urine specimen}, Color {Color finding}, Appear-Clear {Urine looks clear}, URINE {Evaluation of urine specimen}, RBC {Red blood cell count}, WBC {White blood cell count}, Bacteri {Bacteriuria}, Yeast {Urine microscopy for yeasts}, CK(CPK {Creatine kinase measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK(CPK {Creatine kinase measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Plt {Platelet count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, URINE CULTURE {Urine culture}, URINE {Evaluation of urine specimen}, URINE CULTURE {Urine culture}, NEGATIVE {No pathologic diagnosis}, CXR PA/lat {Diagnostic radiography of chest, combined posteroanterior and lateral}, chest {Thoracic structure}, lungs {Lung structure}, clear {No abnormality detected}, density {Abnormally opaque structure}, hiatal hernia {Hiatal hernia}, pleural
effusion {Pleural effusion}, pneumothorax {Left pneumothorax}, heart {Heart structure}, normal size {Normal size}, normal {No abnormality detected}, cardiomediastinal {Mediastinal structure}, No acute intrathoracic process {No abnormality detected}, hiatal
hernia {Hiatal hernia}, LEFT HEART CARDIAC CATHETERIZATION {Catheterization of left heart}, catheter {Catheterization of left heart}, R radial artery {Structure of right radial artery}, Baseline {Baseline state}, blood loss {Hemorrhage}, Hemodynamics {Hemodynamic monitoring}, Coronary angiography {Angiography of coronary artery}, LMCA {Structure of left coronary artery main stem}, Normal {Normal appearance}, LAD {Structure of anterior descending branch of left coronary artery}, restenosis {Coronary stent stenosis}, mid LAD {Structure of mid portion of anterior descending branch of left coronary artery}, stent {Placement of stent in coronary artery}, TIMI 1 flow {Thrombolysis in Myocardial Infarction grade 1: penetration without perfusion}, distal LAD {Structure of distal portion of anterior descending branch of left coronary artery}, diagonal {Structure of diagonal branch of anterior descending branch of left coronary artery}, patent {Coronary artery patent}, large vessel {Large blood vessel structure}, LCX {Structure of circumflex branch of left coronary artery}, Large vessel {Large blood vessel structure}, vessel {Structure of circumflex branch of left coronary artery}, OMB1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, OMB {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, PLB {Structure of left posterior lateral branch of circumflex branch of left coronary artery}, posterior {Structure of diaphragmatic surface of heart}, wall {Cardiac wall structure}, lumen
irregularities {Luminal irregularities of coronary artery}, LCx {Structure of circumflex branch of left coronary artery}, RCA {Right coronary artery structure}, RCA {Right coronary artery structure}, irregularities {Luminal irregularities of coronary artery}, PDA {Structure of posterior descending coronary artery}, RPLB {Structure of posterior lateral branch of right coronary artery}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, stent
placement {Placement of stent in coronary artery}, mid LAD {Structure of mid portion of anterior descending branch of left coronary artery}, unstable {Patient's condition unstable}, cardiac catheterization {Catheterization of left heart}, heparin {Heparin therapy}, anticoagulation {Anticoagulant therapy}, catheter {Catheterization of left heart}, LAD {Structure of anterior descending branch of left coronary artery}, in-stent restenosis {Coronary stent stenosis}, dilated {Dilatation}, drug eluting stent {Endovascular insertion of drug eluting stent}, placed {Implantation procedure}, mid LAD {Structure of mid portion of anterior descending branch of left coronary artery}, stent {Placement of stent in coronary artery}, stenosis {Stenosis}, stent {Placement of stent in coronary artery}, TIMI 3 {Thrombolysis in Myocardial Infarction grade 3: complete perfusion}, distal vessel {Structure of distal portion of anterior descending branch of left coronary artery}, procedure {Procedure}, right radial artery {Structure of right radial artery}, Single vessel CAD {Single coronary vessel disease}, in-stent restenosis {Coronary stent stenosis}, stent {Placement of stent in coronary artery}, mLAD {Structure of mid portion of anterior descending branch of left coronary artery}, drug-eluting stent {Endovascular insertion of drug eluting stent}, mid LAD {Structure of mid portion of anterior descending branch of left coronary artery}, Aspirin {Administration of aspirin}, TTE {Transthoracic echocardiography}, left atrium {Left atrial structure}, right atrium {Right atrial structure}, normal in
cavity size {Normal size}, 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}, right ventricular cavity is mildly dilated {Dilatation of right cardiac ventricle}, normal {No abnormality detected}, wall
contractility {Finding of right ventricular wall motion}, aorta at the sinus {Structure of sinus of Valsalva}, ascending {Ascending aorta structure}, arch {Aortic arch structure}, normal {Normal appearance}, aortic valve leaflets {Structure of cusp of aortic valve}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, Mild (1+)
aortic regurgitation {Mild aortic valve regurgitation}, mitral valve leaflets are
mildly thickened {Thickened mitral leaflet}, mitral valve prolapse {Mitral valve prolapse}, Mild (1+)
mitral regurgitation {Mild mitral valve regurgitation}, Moderate [2+] tricuspid
regurgitation {Moderate tricuspid valve regurgitation}, pulmonary artery systolic
hypertension {Pulmonary hypertensive arterial disease}, pericardial effusion {Pericardial effusion}, Normal global and regional biventricular systolic
function {Normal left ventricular systolic function and wall motion}, Mild aortic regurgitation {Mild aortic valve regurgitation}, Mild mitral regurgitation {Mild mitral valve regurgitation}, Moderate tricuspid regurgitation {Moderate tricuspid valve regurgitation}, Mild pulmonary hypertension {Mild pulmonary hypertension}, study {Evaluation procedure}, LV
systolic function has normalized {Normal left ventricular systolic function and wall motion} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Ms. ___ is an ___ year-old lady with a PMH of NSTEMI s/p
BMS to mid-LAD in ___, hypothyroidism and recurrent UTIs,
admitted with chest pain, found to have unstable angina due to
in-stent restenosis. Admission was complicated by a urinary
tract infection.
ACTIVE ISSUES:
# Unstable angina: History of NSTEMI with BMS to LAD in ___,
and presented with chest pain that was c/w prior and concerning
for NSTEMI, as accompanied by elevated troponin (0.08). The
timing of her symptoms was quite concerning for in-stent
restenosis. She had no EKG changes. Her troponin initially
trended down to 0.06, and was accompanied by a low CK-MB at 3.
She received aspirin 325 mg PO, clopidogrel 300 mg PO, and was
started on a heparin drip on arrival. On ___, she was taken
to the cath lab for left heart cath. This revealed 99%
restenosis in the mid LAD within the bare metal stent with TIMI
1 flow into the distal LAD, with no other angiographically
significant disease. A single drug-eluting stent was placed in
the mid LAD. She was placed on an integrellin drip following the
catheterization, and this therapy was complicated by some oozing
from her peripheral IV site. She had no drop in her blood counts
with this bleeding. Aspirin should be continued indefinitely,
and clopidogrel should for continued for up to one year after
discharge.
# Urinary tract infection: Patient reproted dysuria, accompanied
by evidence of a UTI on UA (WBC 66 with few bacteria). Recurrent
UTIs due to anatomy. She had been on ciprofloxacin 250 mg PO BID
prior to admission. She was given one dose of nitrofurantoin in
ED, and then was transitioned back to ciprofloxacin 250 mg PO
BID. She will continue her previous course of ciprofloxacin
after discharge.
CHRONIC ISSUES:
# Systolic CHF: After her NSTEMI in ___, patient had an EF
that was decreased to 40%. On admission, she had mild edema at
the ankles, but no other overt signs of volume overload.
Following her cardiac cath on ___, a repeat TTE showed
improved EF to > 55%, along with normal global/regional
biventricular systolic function, mild aortic regurgitation, mild
mitral regurgitation, moderate tricuspid regurgitation, and mild
pulmonary hypertension (TR gradient 32 mmHg). She was continued
on her home aspirin, beta blocker, lisinopril and atorvastatin.
# GERD: Omeprazole was changed to pantoprazole, as omeprazole
interacts with clopidogrel.
# Hypothyroidism: Continued home levothyroxine.
# Hyperlipidemia: Continued home atorvastatin.
# Depression: Continued home mirtazipine.
TRANSITIONAL ISSUES:
# Continue aspirin indefinitely. Continue clopidogrel until
instructed by cardiologist to stop.
# CODE: full (confirmed with patient)
# CONTACT: Patient. HCP is daughter ___ (Phone number:
___, Cell phone: ___, ___ work
___ Alternate is son ___ ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin EC 81 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Mirtazapine 15 mg PO HS
4. Omeprazole 20 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Atorvastatin 80 mg PO DAILY
7. Ciprofloxacin HCl 250 mg PO Q12H
1st dose was ___ last day ___. Clopidogrel 75 mg PO DAILY
9. Lisinopril 2.5 mg PO DAILY
10. melatonin *NF* 3 mg Oral HS
11. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg Oral daily
12. Detrol LA *NF* (tolterodine) 4 mg Oral daily
13. magnesium *NF* 250 mg Oral HS
14. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Ciprofloxacin HCl 250 mg PO Q12H
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Mirtazapine 15 mg PO HS
7. Vitamin D 1000 UNIT PO DAILY
8. Nitroglycerin SL 0.3 mg SL PRN chest pain
RX *nitroglycerin 0.4 mg 1 tablet sublingually every 5 minutes
Disp #*30 Tablet Refills:*0
9. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth daily Disp #*30 Tablet Refills:*0
10. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg Oral daily
11. Detrol LA *NF* (tolterodine) 4 mg Oral daily
12. Lisinopril 2.5 mg PO DAILY
13. magnesium *NF* 250 mg Oral HS
14. melatonin *NF* 3 mg Oral HS
15. Aspirin EC 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
###RESPONSE: NSTEMI {Acute non-ST segment elevation myocardial infarction}, BMS {Placement of stent in coronary artery}, mid-LAD {Structure of mid portion of anterior descending branch of left coronary artery}, hypothyroidism {Hypothyroidism}, recurrent UTIs {Recurrent urinary tract infection}, chest pain {Chest pain}, unstable angina {Preinfarction syndrome}, in-stent restenosis {Coronary stent stenosis}, urinary
tract infection {Urinary tract infectious disease}, Unstable angina {Preinfarction syndrome}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, BMS {Placement of stent in coronary artery}, LAD {Structure of anterior descending branch of left coronary artery}, chest pain {Chest pain}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, in-stent
restenosis {Coronary stent stenosis}, no EKG changes {Electrocardiogram normal}, troponin {Troponin measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, aspirin {Administration of aspirin}, started {New medication added}, heparin drip {Continuous infusion of heparin}, left heart cath {Catheterization of left heart}, restenosis {Coronary stent stenosis}, mid LAD {Structure of mid portion of anterior descending branch of left coronary artery}, stent {Placement of stent in coronary artery}, TIMI
1 flow {Thrombolysis in Myocardial Infarction grade 1: penetration without perfusion}, distal LAD {Structure of distal portion of anterior descending branch of left coronary artery}, disease {Disease}, drug-eluting stent was placed {Endovascular insertion of drug eluting stent}, mid LAD {Structure of mid portion of anterior descending branch of left coronary artery}, catheterization {Catheterization of left heart}, therapy {Therapy}, oozing {Bleeding}, peripheral IV site {Assessment of peripheral intravenous catheter site}, no drop {No abnormality detected}, blood counts {Blood test}, bleeding {Bleeding}, Aspirin {Administration of aspirin}, Urinary tract infection {Urinary tract infectious disease}, dysuria {Dysuria}, UTI {Urinary tract infectious disease}, UA {Urinalysis}, WBC {White blood cell count}, bacteria {Bacteriuria}, Recurrent
UTIs {Recurrent urinary tract infection}, ciprofloxacin {Antibiotic therapy}, ciprofloxacin {Antibiotic therapy}, ciprofloxacin {Antibiotic therapy}, Systolic CHF {Chronic systolic heart failure}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, mild {Symptom mild}, edema at
the ankles {Ankle edema}, signs {Sign}, volume overload {Hypervolemia}, cardiac cath {Catheterization of left heart}, TTE {Transthoracic echocardiography}, improved {Patient's condition improved}, normal {Normal appearance}, biventricular {Cardiac ventricular structure}, systolic function {Normal cardiac output}, mild aortic regurgitation {Mild aortic valve regurgitation}, mild
mitral regurgitation {Mild mitral valve regurgitation}, moderate tricuspid regurgitation {Moderate tricuspid valve regurgitation}, mild
pulmonary hypertension {Mild pulmonary hypertension}, aspirin {Administration of aspirin}, GERD {Gastroesophageal reflux disease}, changed {Change of medication}, Hypothyroidism {Hypothyroidism}, Hyperlipidemia {Hyperlipidemia}, Depression {Depressive disorder}, aspirin {Administration of aspirin}, investigation {Evaluation procedure}, mg {Blood magnesium measurement}, mg {Blood magnesium measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: unstable angina
SECONDARY DIAGNOSES: CAD, hyperlipidemia, hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Disposition:
Home {Home health aide service management}, unstable angina {Preinfarction syndrome}, CAD {Coronary arteriosclerosis}, hyperlipidemia {Hyperlipidemia}, hypothyroidism {Hypothyroidism}, 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 {Assessment of mobility}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Ms. ___,
It was a pleasure to participate in your care here at ___
___! You were admitted with chest
pain that was similar to the pain that you had with your heart
attack in ___. You underwent a cardiac catheterization,
which showed a stenosis in your old stent, which was opened with
a new stent.
Please continue to take all of your medications as you were
prior to this admission. Your omeprazole was changed to
pantoprazole (a similar medication), as omeprazole had an
interaction with your other medications.
Please see below from your follow-up appointments.
Wishing you all the best!
###RESPONSE: chest
pain {Chest pain}, pain {Pain}, heart
attack {Myocardial infarction}, cardiac catheterization {Cardiac catheterization}, stenosis in your old stent {Coronary stent stenosis}, stent {Placement of stent in coronary artery}, continue {Recommendation to continue with drug treatment}, changed {Change of medication}, interaction with your other medications {Drug interactions identified - drug changed} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
###RESPONSE: Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, Sulfa {Allergy to sulfonamide antibiotic}, Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, dyspnea {Dyspnea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ with PMH significant for CAD s/p PCI who presents with
dyspnea associated with 4 pillow orthopnea and lower extremity
edema. The patient reports missing 2 doses of lasix this week.
The patient also complains of productive cough.
The patient reports he was treated for 'pneumonia' by his PCP in
late ___. Review of OMR shows no infiltrate on CXR and a
Z-pack was prescribed. He recovered from that illness, but has
developed worsening dyspnea and cough over the last two weeks.
Today, his daughter visited him and was worried about his
wheezing. She called PCP office and NP recommended going to
urgent care. At ___ urgent ___, reportedly chest
x-ray demonstrated bilateral pulmonary edema and patient was
sent to the ED.
In the ED initial vitals were: T99.0 HR133 BP137/74 RR18 96%RA.
Labs were significant for: troponin 0.01, BNP 1406 (no prior
levels), flu negative. CXR showed mild pulmonary vascular
congestion with small bilateral pleural effusions. EKG showed
Afib with RVR. The patient was given metoprolol 5mg IV x 2, 40
iv lasix, and duonebs. His heart rate remained labile in the ED.
Vitals prior to transfer were: T98.8 HR110-130 ___ RR20
97%RA.
On the floor, he continues to have cough. Denies sob, cp.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
###RESPONSE: CAD {Coronary arteriosclerosis}, PCI {Percutaneous coronary intervention}, dyspnea {Dyspnea}, orthopnea {Orthopnea}, lower extremity
edema {Edema of lower extremity}, lasix {Diuretic therapy}, productive cough {Productive cough}, pneumonia {Pneumonia}, PCP {Primary care management}, infiltrate {Infiltration}, CXR {Plain chest X-ray}, worsening {Patient's condition worsened}, dyspnea {Dyspnea}, cough {Cough}, worried {Worried}, wheezing {Wheezing}, called {Informing doctor}, PCP {Primary care management}, chest
x-ray {Plain chest X-ray}, bilateral pulmonary {Both lungs}, edema {Pulmonary edema}, vitals {Vital signs finding}, Labs {Laboratory test}, troponin {Troponin measurement}, BNP {Brain natriuretic peptide measurement}, CXR {Plain chest X-ray}, mild {Symptom mild}, pulmonary vascular
congestion {Pulmonary congestion}, bilateral pleural effusions {Bilateral pleural effusion}, EKG {Electrocardiographic procedure}, Afib with RVR {Atrial fibrillation with rapid ventricular response}, lasix {Diuretic therapy}, heart rate {Finding of heart rate}, Vitals {Vital signs finding}, cough {Cough}, Review of Systems {Review of systems}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, headache {Headache}, vision changes {Visual disturbance}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, sore throat {Sore throat}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, BRBPR {Hematochezia}, melena {Melena}, hematochezia {Hematochezia}, dysuria {Dysuria}, hematuria {Blood in urine} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
- CAD with MI at ___, s/p PCI with DES to pLAD in ___ (cardiac
cath showed collateralized total occlusion of the RCA and an 80%
proximal LAD lesion)
- DM2L HbA1c 6.8% in ___
- Afib on coumadin
- Hyperlipidemia
- Hypertension
- Bradycardia causing syncope s/p PPM ___ EnPulse)
- S/p Rt carotid endarterectomoy in ___
- Psoriasis
- Kidney stones
###RESPONSE: CAD {Coronary arteriosclerosis}, PCI {Percutaneous coronary intervention}, DES {Endovascular insertion of drug eluting stent}, cardiac
cath {Cardiac catheterization}, total occlusion {Complete obstruction}, RCA {Right coronary artery structure}, proximal LAD {Structure of proximal portion of anterior descending branch of left coronary artery}, lesion {Lesion}, HbA1c {Hemoglobin A1c measurement}, Afib {Atrial fibrillation}, coumadin {Warfarin therapy}, Hyperlipidemia {Hyperlipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, Bradycardia {Bradycardia}, syncope {Syncope}, PPM {Permanent cardiac pacemaker}, carotid endarterectomoy {Carotid endarterectomy}, Psoriasis {Psoriasis}, Kidney stones {Kidney stone} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
- Mother had diabetes. MI in her ___.
- Father had diabetes and emphysema. MI in his ___.
- Brother has CAD.
###RESPONSE: diabetes {Diabetes mellitus}, diabetes {Diabetes mellitus}, emphysema {Emphysema}, 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 PHYSICAL:
=====================
Vitals - T:98.0 BP:131/65 HR:120 RR:18 02 sat:95%RA wt 132.9kg
GENERAL: NAD, A&Ox3, pleasant
HEENT: MMM, good dentition
NECK: nontender supple neck, JVD to midneck at 45 degrees
CARDIAC: irregularly irregular, S1/S2, no murmurs, gallops, or
rubs
LUNG: Mild expiratory wheezes throughout, good air movement, no
crackles.
ABDOMEN: obese, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: 3+ edema to thighs bilaterally, moving all 4
extremities with purpose
SKIN: warm and well perfused, erythematous rash to bilateral
elbows with overlying silvery scale
DISCHARGE PHYSICAL:
======================
Vitals: 97.3, 100-136/52-78, 59-126, 18, 98 on RA
Weight on admission 132.9
DISCHARGE WEIGHT: 125.7
General: well appearing, obese male in NAD
Neck: unable to appreciate JVP
Lungs: CTA b/l, non-labored breathing
CV: ___, normal rate, normal S1/S2, no m/r/g
Abdomen: +BS, soft, obese, NT/ND
Ext: 1+ edema to ankles bilaterally
###RESPONSE: Vitals {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, 02 sat {Oxygen saturation measurement}, RA {Breathing room air}, GENERAL {General examination of patient}, NAD {No abnormality detected}, Ox3 {Oriented to person, time and place}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, good dentition {Normal dentition}, NECK {Physical examination procedure}, nontender {Abdominal tenderness}, supple {Normal movement of neck}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, irregularly irregular {Heart irregularly irregular}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, LUNG {Examination of respiratory system}, Mild {Symptom mild}, wheezes {Wheezing}, good air movement {Breath normal}, crackles {Respiratory crackles}, ABDOMEN {Examination of abdomen}, obese {Obese}, nontender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXTREMITIES {Examination of limb}, edema {Edema}, thighs {Thigh structure}, moving all 4
extremities {Does move all four limbs}, SKIN {Examination of skin}, warm {Warm skin}, well perfused {Normal tissue perfusion}, erythema {Erythema}, rash {Eruption of skin}, elbows {Skin structure of elbow}, Vitals {Vital signs finding}, Weight {Weight finding}, WEIGHT {Weight finding}, well appearing {Well cared for appearance}, obese {Obese}, NAD {Distress}, JVP {Finding of jugular venous pressure}, CTA b/l {Normal breath sounds}, labored breathing {Labored breathing}, normal rate {Normal heart rate}, normal S1/S2 {Heart sounds normal}, no m/r/g {Heart sounds normal}, soft {Abdomen soft}, obese {Obese}, edema to ankles {Ankle edema} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS:
====================
___ 09:15PM BLOOD WBC-10.0 RBC-3.99* Hgb-12.5* Hct-37.4*
MCV-94 MCH-31.4 MCHC-33.4 RDW-15.7* Plt ___
___ 09:15PM BLOOD Neuts-67.8 ___ Monos-9.3 Eos-3.5
Baso-0.3
___ 08:55AM BLOOD ___ PTT-37.1* ___
___ 09:15PM BLOOD Glucose-129* UreaN-19 Creat-1.2 Na-145
K-3.6 Cl-102 HCO3-29 AnGap-18
___ 09:15PM BLOOD proBNP-1406*
___ 09:15PM BLOOD cTropnT-0.01
___ 08:55AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.7
___ 08:55AM BLOOD TSH-2.6
___ 09:51PM BLOOD Lactate-2.0
DISCHARGE LABS:
===================
___ 05:28AM BLOOD WBC-9.0 RBC-4.24* Hgb-13.2* Hct-39.6*
MCV-93 MCH-31.1 MCHC-33.4 RDW-15.2 Plt ___
___ 05:28AM BLOOD ___
___ 05:28AM BLOOD Glucose-148* UreaN-35* Creat-1.5* Na-140
K-3.8 Cl-96 HCO3-31 AnGap-17
___ 05:28AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2
___ 06:35AM BLOOD proBNP-569
STUDIES:
===================
CXR (___):
FINDINGS:
Left-sided dual-chamber pacemaker device is noted with leads
terminating in the right atrium and right ventricle. Cardiac
silhouette size remains top normal. Mediastinal and hilar
contours are unchanged. The aorta is diffusely calcified. There
is mild upper zone vascular redistribution with pulmonary
vascular indistinctness suggestive of mild pulmonary vascular
congestion. Small bilateral pleural effusions are demonstrated.
Patchy opacities in the lung bases may reflect atelectasis
though infection is difficult to exclude. No pneumothorax is
present. No acute osseous abnormality is visualized.
IMPRESSION:
Patchy bibasilar airspace opacities, possibly atelectasis though
infection is not completely excluded. Mild pulmonary vascular
congestion with small bilateral pleural effusions
ECHOCARDIOGRAM (___):
The left atrium is moderately dilated. The right atrium is
dilated. The estimated right atrial pressure is ___ mmHg. There
is moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
a trivial/physiologic pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. Normal estimated intracardiac
filling pressures.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
###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}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, TSH {Thyroid stimulating hormone measurement}, Lactate {Lactic acid measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, Left-sided dual-chamber pacemaker {Cardiac pacemaker in situ}, right atrium {Right atrial structure}, right ventricle {Right cardiac ventricular structure}, Cardiac {Heart structure}, size {Normal size}, normal {No abnormality detected}, Mediastinal {Mediastinal structure}, hilar {Structure of hilum of lung}, unchanged {Patient condition unchanged}, aorta {Aortic structure}, calcified {Pathologic calcification, calcified structure}, mild {Symptom mild}, vascular {Blood vessel structure}, redistribution {Redistribution}, pulmonary
vascular {Structure of pulmonary blood vessel}, mild {Symptom mild}, pulmonary vascular
congestion {Pulmonary congestion}, bilateral pleural effusions {Bilateral pleural effusion}, opacities {Abnormally opaque structure}, lung bases {Structure of base of lung}, atelectasis {Atelectasis}, infection {Infectious disease}, pneumothorax {Pneumothorax}, No acute {No abnormality detected}, osseous {Bone structure}, abnormality {No abnormality detected}, bibasilar {Structure of base of lung}, opacities {Abnormally opaque structure}, atelectasis {Atelectasis}, infection {Infectious disease}, Mild {Symptom mild}, pulmonary vascular
congestion {Pulmonary congestion}, bilateral pleural effusions {Bilateral pleural effusion}, left atrium is moderately dilated {Left atrial dilatation}, right atrium is
dilated {Right atrial dilatation}, right atrial {Right atrial structure}, moderate symmetric left ventricular hypertrophy {Moderate left ventricular hypertrophy}, left
ventricular cavity {Structure of cavity of left cardiac ventricle}, size is normal {Normal size}, left ventricular
wall motion is normal {Finding of left ventricular wall motion}, left ventricular systolic
function is normal {Finding of left ventricular blood flow}, Right ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Normal ventricular wall motion}, aortic valve leaflets {Structure of cusp of aortic valve}, mildly thickened {Increased thickness}, aortic valve stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve leaflets are
mildly thickened {Thickened mitral leaflet}, Trivial mitral regurgitation {Mild mitral valve regurgitation}, pulmonary artery {Pulmonary artery structure}, systolic pressure is normal {Normal systolic arterial pressure}, pericardial effusion {Pericardial effusion}, LVH {Left ventricular hypertrophy}, normal global and regional
biventricular systolic function {Normal left ventricular systolic function and wall motion}, filling {Normal cardiac flow}, pressures {Pressure}, study {Evaluation procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ with PMH significant for HFpEF and CAD with 3-vessel
disease s/p DES to m-pLAD in ___ who presents with dyspnea and
worsening ___ edema. He was diuresed with a lasix gtt ___
mg/hr) and boluses PRN. He had an ECHO here which showed EF >
55%, similar to last ECHO in ___. Prior to discharge, he was
transitioned to torsemide 40 mg daily.
DRY WEIGHT: 125.7 kg
#Acute on chronic decompensated diastolic CHF: Admission weight
132.9 kg, dry weight 125.7 BNP 1400 on admission down to 569
prior to discharge. Missing 2 lasix doses prior to admission may
have been trigger.
- Discharge with: Torsemide 40 mg PO daily
- metoprolol succinate 300 mg daily
- TTE showed preserved EF (>55%)
#Afib w/ RVR: ___ be due to acute CHF exacerbation plus missing
___ home metoprolol dose. S/p 5 mg IV metop x 2 in the ED and
additional 25mg po metop once on the floor.
- Metoprolol succinate as above
- Continued warfarin (minor dose adjustment)
#CAD: MI at ___, s/p PCI with DES to pLAD in ___ (cardiac cath
showed collateralized total occlusion of the RCA and an 80%
proximal LAD lesion). Currently no CP. EKG unchanged from prior.
Trop neg x 1.
- Continue atorva 80, ASA 81, metop as above
#DM2: HbA1c 6.8% in ___.
- Held metformin, will restart on discharge
- SSI while in house
#HTN: Home lisin/HCTZ discontinued for ___ in ___. Given
preserved EF, it is not necessary that he be on an ACE for heart
failure.
- Continued metop as above
#Psoriasis:
- Continued betamethasone cream
TRANSITIONAL ISSUES:
[ ] Patient will need f/u labs within 1 week - Rx for ___ -
to monitor Cr (slightly elevated prior to d/c)
[ ] Patient needs close cardiology follow up for further
titrating of home diuretics
[ ] INR on ___, followed by ___ ACMS
###RESPONSE: HFpEF {Heart failure with normal ejection fraction}, CAD {Coronary arteriosclerosis}, 3-vessel
disease {Triple vessel disease of the heart}, DES {Endovascular insertion of drug eluting stent}, dyspnea {Dyspnea}, worsening {Patient's condition worsened}, edema {Edema}, diuresed {Diuretic therapy}, lasix {Diuretic therapy}, ECHO {Echocardiography}, ECHO {Echocardiography}, WEIGHT {Weight finding}, chronic decompensated diastolic CHF {Heart failure with normal ejection fraction}, weight {Weight finding}, weight {Weight finding}, BNP {Brain natriuretic peptide measurement}, lasix {Diuretic therapy}, TTE {Transthoracic echocardiography}, Afib w/ RVR {Atrial fibrillation with rapid ventricular response}, acute CHF exacerbation {Acute exacerbation of chronic congestive heart failure}, warfarin {Warfarin therapy}, CAD {Coronary arteriosclerosis}, PCI {Percutaneous coronary intervention}, DES {Endovascular insertion of drug eluting stent}, cardiac cath {Cardiac catheterization}, total occlusion {Complete obstruction}, RCA {Right coronary artery structure}, proximal LAD {Structure of proximal portion of anterior descending branch of left coronary artery}, lesion {Lesion}, EKG {Electrocardiographic procedure}, unchanged {Patient condition unchanged}, Trop {Troponin measurement}, ASA {Administration of aspirin}, DM2 {Diabetes mellitus type 2}, HbA1c {Hemoglobin A1c measurement}, Held {Recommendation to stop drug treatment}, restart {Restart of medication}, SSI {Sliding scale insulin regime}, HTN {Hypertensive disorder, systemic arterial}, discontinued {Recommendation to stop drug treatment}, heart
failure {Heart failure}, labs {Laboratory test}, monitor {Monitoring for signs and symptoms of infection}, elevated {Serum creatinine above reference range}, cardiology {Cardiology service}, follow up {Follow-up arranged}, diuretics {Diuretic therapy}, INR {Calculation of international normalized ratio} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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. Metoprolol Tartrate 50 mg PO BID
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Warfarin ___ mg PO DAILY16
4. Furosemide 40 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
Discharge Medications:
1. Outpatient Lab Work
Please check CHEM-7 (ICD-9 428.30)
and INR (ICD-9 427.31)
Fax to ___, MD at ___
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
6. Warfarin 10 mg PO 4X/WEEK (___)
RX *warfarin 5 mg 2 tablet(s) by mouth every ___,
___ Disp #*80 Tablet Refills:*0
7. Warfarin 7.5 mg PO 3X/WEEK (___)
RX *warfarin 2.5 mg 3 tablet(s) by mouth every ___,
___ Disp #*30 Tablet Refills:*0
8. Metoprolol Succinate XL 300 mg PO DAILY
RX *metoprolol succinate 100 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
9. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Multivitamins 1 TAB PO DAILY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
acute on chronic diastolic heart failure exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: acute on chronic diastolic heart failure {Acute on chronic diastolic heart failure}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for leg swelling and shortness
of breath. We found out that you had a heart failure
exacerbation. To treat this, we gave you a medicine (Lasix) to
make you pee and closely monitored your fluid status and your
labs. Your swelling and breathing improved and your labs showed
that your heart was recovering. We did an echocardiogram
(ultrasound of the heart) which showed that there had not been
any changes since your previous one.
We changed some of your heart failure medications. You should
review your medication list carefully. You should weigh yourself
every day and call your doctor if your weight goes up by more
than 3 lbs. You also need to have labs checked within 1 week
(ideally on ___. On ___, you should call your
primary care doctor or cardiologist to schedule an appointment
within a week. Their numbers are below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
###RESPONSE: leg swelling {Leg swelling symptom}, shortness
of breath {Dyspnea}, heart failure {Heart failure}, Lasix {Diuretic therapy}, monitored {Monitoring procedure}, labs {Laboratory test}, swelling {Swelling}, breathing {Difficulty breathing}, improved {Patient's condition improved}, labs {Laboratory test}, heart {Heart structure}, echocardiogram {Echocardiography}, ultrasound {Echocardiography}, heart {Heart structure}, changed {Change of medication}, heart failure {Heart failure}, medications {Administration of drug or medicament}, medication {Administration of drug or medicament}, weight goes up {Weight increased}, labs {Laboratory test}, checked {Monitoring procedure}, primary care {Primary care management} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
###RESPONSE: Penicillins {Allergy to penicillin}, Shortness of breath {Dyspnea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
This is a ___ year old male with history of HTN, HLD, CAD, CHF
(EF 55-60% in ___, Diabetes on insulin, hx of CVA, recently
diagnosed pericardial effusion, p/w acute-onset altered mental
status, unsteadiness, urinary incontinence today.
Patient's son is the one who provided the history. Patient's
son states that patient was sleeping in this morning, and much
less responsive. He reports that patient woke up with a blank
stare. Patient was also acutely noted to be incontinent of
urine once. His son reports that he was unable to walk around
steadily, and was having difficulty hold onto the walls/walker
to get around. Since then, he has been much less verbal with
difficulty with speech. At home, he was also endorsing some
L-sided abdominal and back pain. Son denies any falls or
headstrike. Son denies any fevers/chills; He does endorse some
wheezing but no chest pain, no
nausea/vomiting/diarrhea/constipation, no new swelling or focal
weakness anywhere aside from today's episode of generalized
weakness and unsteadiness on his feet. Of note, patient is on
Plavix.
In the ED, initial vitals: 99.4 102 186/90 15 98%
Labs were signficant for potassium of 5.3, but sample was
hemolyzed. Creatinine was 3.7 from baseline 1.8. pO2 from venous
O2 sats were 25. Patient triggered for shortness of breath. At
the time he was shaking, tachycardic to 100s; 94% on RA; placed
on NRB with improvement to 100%; rhonchi on L > R. Portable CXR
showing increased fluid overload. Patient was given Vancomycin
1g, Cefepime 1g, albuterol/ipratropium nebs, furosemide 40mg,
tylenol ___, 1L NS.
On transfer, vitals were: 101.8 105 161/87 33 100% bipap
On arrival to the MICU, patient was on BiPap. Patient's son
reports that his mental status is back to baseline. He also
reports that his grandson had a URI in the last week. Patient's
lasix dose was also decreased by half to 20mg last month.
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, CAD {Coronary arteriosclerosis}, CHF {Congestive heart failure}, Diabetes {Diabetes mellitus}, CVA {Cerebrovascular accident}, pericardial effusion {Pericardial effusion}, altered mental
status {Altered mental status}, unsteadiness {General unsteadiness}, urinary incontinence {Urinary incontinence}, sleeping {Asleep}, less responsive {Slowness and poor responsiveness}, incontinent of
urine {Urinary incontinence}, unable to walk {Unable to walk}, verbal {Vocal and verbal behavior finding}, difficulty with speech {Has difficulty with speech}, L-sided abdominal {Left sided abdominal pain}, back pain {Backache}, falls {Falls}, headstrike {Injury of head}, fevers {Fever}, chills {Chill}, wheezing {Wheezing}, chest pain {Chest pain}, nausea/vomiting/diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, swelling {Swelling}, weakness {Asthenia}, weakness {Asthenia}, unsteadiness {General unsteadiness}, feet {Foot structure}, vitals {Vital signs finding}, potassium {Potassium measurement}, Creatinine {Creatinine measurement}, baseline {Baseline state}, venous {Venous structure}, O2 sats {Finding of oxygen saturation}, shortness of breath {Dyspnea}, shaking {Tremor}, tachycardic {Tachycardia}, placed {Implantation procedure}, NRB {Oxygen administration by mask}, improvement {Patient's condition improved}, rhonchi {Wheeze - rhonchi}, L {Left thorax structure}, R {Right thorax structure}, CXR {Plain chest X-ray}, fluid overload {Hypervolemia}, vitals {Vital signs finding}, bipap {Bilevel positive airway pressure titration}, BiPap {Bilevel positive airway pressure titration}, mental status {Mental state finding}, baseline {Baseline state}, URI {Upper respiratory infection}, lasix {Diuretic therapy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
- Stroke in ___
- Hypertension, medication changes as above. His blood pressure
at home at been 150-180 systolic in ___, but not
recently measuring. Had been ~ 153/82 on ___ before
hydralazine increased.
- Hypercholesterolemia, on Statin
- Diabetes, on insulin (Lantus and Humalog SS)
- Orthostasis and possible convulsive syncope, as above
- Toes amputated on right owing to diabetes
- Cataracts - no surgery
- Diabetic neuropathy, on gabapentin 100/300
###RESPONSE: Stroke {Cerebrovascular accident}, Hypertension {Hypertensive disorder, systemic arterial}, medication changes {Change of medication}, blood pressure {On treatment for hypertension}, Hypercholesterolemia {Hypercholesterolemia}, Diabetes {Diabetes mellitus}, Orthostasis {Orthostatic hypotension}, convulsive syncope {Convulsive syncope}, Toes amputated {Amputation of toe}, right {Structure of right foot}, diabetes {Diabetes mellitus}, Cataracts {Cataract}, surgery {Surgical procedure}, Diabetic neuropathy {Neuropathy due to diabetes mellitus} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Possible stroke in parents, one definitely diabetic.
###RESPONSE: stroke {Cerebrovascular accident}, diabetic {Diabetes mellitus} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- T:100.8 BP:185/78 P:92 R: 18 O2: 100 on 2L NC
GENERAL: Alert, oriented to name and place. No acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Bilateral crackles
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, distended c/w obesity, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
EXT: Amputated toes
NEURO: Power ___ bilaterally in both lower and upper
extremities. Dyspraxic when trying to follow commands with left
upper extremity. Cn II-XII grossly intact.
DISCHARGE PHYSICAL EXAM:
VS - 98.0 157/70 70 18 100% on RA
GENERAL: Alert, oriented to name and place. No acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, swelling of the
eye noted
NECK: supple, JVP not elevated, no LAD
LUNGS: Crackles appreciated occasionally in bilateral lung
fields, good air movement, breathing comfortably without use of
accessory muscles
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, distended c/w obesity, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
EXT: Amputated toes, patient has an erythematous rash on the
back which is not pruritic, not spreading
NEURO: Power ___ bilaterally in both lower and upper
extremities. Dyspraxic when trying to follow commands with left
upper extremity. Cn II-XII grossly intact.
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, BP {Blood pressure finding}, NC {Normal head}, GENERAL {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, place {Oriented to place}, No acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, NECK {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, LUNGS {Examination of respiratory system}, crackles {Respiratory crackles}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, ABD {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, distended {Swollen abdomen}, obesity {Obesity}, bowel sounds
present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, EXT {Examination of limb}, Amputated toes {Amputation of toe}, NEURO {Neurological examination}, lower {Lower limb structure}, upper
extremities {Upper limb structure}, Dyspraxic {Dyspraxia}, follow commands {Normal motor response to command}, left
upper extremity {Structure of left upper limb}, grossly intact {Normal nervous system function}, VS {Vital signs finding}, RA {Breathing room air}, RA {Breathing room air}, Alert {Mentally alert}, oriented to name {Oriented to person}, place {Oriented to place}, No acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, swelling {Swelling}, eye {Structure of eye proper}, NECK {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, LUNGS {Examination of respiratory system}, Crackles {Respiratory crackles}, lung
fields {Structure of lung field}, good {No abnormality detected}, breathing comfortably {Breathing easily}, accessory muscles {Accessory skeletal muscle}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 S2 {Heart sounds normal}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, ABD {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, distended {Swollen abdomen}, obesity {Obesity}, bowel sounds
present {Normal bowel sounds}, rebound tenderness {Rebound tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, EXT {Examination of limb}, Amputated toes {Amputation of toe}, erythematous rash {Erythematous rash}, back {Structure of back of trunk}, pruritic {Pruritic disorder of skin}, NEURO {Neurological examination}, lower {Lower limb structure}, upper
extremities {Upper limb structure}, Dyspraxic {Dyspraxia}, follow commands {Normal motor response to command}, left
upper extremity {Structure of left upper limb}, Cn II-XII grossly intact {Normal central nervous system} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 03:25PM PLT COUNT-105*
___ 03:25PM NEUTS-81.3* LYMPHS-10.7* MONOS-7.3 EOS-0.5
BASOS-0.1
___ 03:25PM WBC-8.7 RBC-3.25* HGB-9.8* HCT-28.1* MCV-87
MCH-30.2 MCHC-34.9 RDW-15.2
___ 03:25PM ALBUMIN-3.5 CALCIUM-9.2 PHOSPHATE-3.0
MAGNESIUM-2.1
___ 03:25PM CK-MB-1 cTropnT-<0.01 ___
___ 03:25PM LIPASE-22
___ 03:25PM ALT(SGPT)-16 AST(SGOT)-34 ALK PHOS-52 TOT
BILI-0.5
___ 03:25PM estGFR-Using this
___ 03:25PM GLUCOSE-147* UREA N-47* CREAT-3.7*#
SODIUM-139 POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
___ 03:38PM ___ TO PTT-UNABLE TO ___
TO
___ 03:40PM LACTATE-1.2
___ 04:45PM ___ PTT-29.9 ___
___ 05:25PM URINE RBC-4* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 05:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:25PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:25PM URINE UHOLD-HOLD
___ 05:25PM URINE HOURS-RANDOM UREA N-692 CREAT-121
SODIUM-57 POTASSIUM-37 CHLORIDE-49
___ 07:35PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 08:04PM O2 SAT-31
___ 08:04PM ___ PO2-25* PCO2-51* PH-7.30* TOTAL
CO2-26 BASE XS--2
___ CXR:
Mild pulmonary edema, without pleural effusions
.
___ CXR:
Cardiomegaly with pulmonary edema, progressed since prior study
dated ___ CT head:
No acute intracranial abnormality
___ CT abdomen:
1. Small bilateral layering at nonhemorrhagic pleural effusions,
right greater than left.
2. Moderate diverticular disease of the sigmoid colon without
evidence of diverticulitis.
EKG: rate 97, sinus, 1st degree A-V block (PR 226ms) otherwise
normal intervals, normal axis; ___ ST-T wave changes,
non-specific; TWI in I and avL no longer noted (since comparison
___
___: Renal U/S:
IMPRESSION:
5 mm nonobstructing left lower pole renal stone and a sub cm
left lower pole simple renal cyst. Otherwise, normal renal
ultrasound.
###RESPONSE: NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium measurement}, cTropnT {Troponin T cardiac measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, PHOS {Phosphate, total measurement}, TOT
BILI {Bilirubin, total measurement}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, URINE {Urine culture}, RBC {Red blood cell count}, WBC {White blood cell count}, AST {Aspartate aminotransferase measurement}, PROTEIN {Measurement of protein in urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, URINE {Urine culture}, COLOR {Color finding}, URINE {Urine culture}, URINE {Urine culture}, CREAT {Creatinine measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, O2 SAT {Oxygen saturation measurement}, PH {pH measurement}, CXR {Plain chest X-ray}, Mild {Symptom mild}, edema {Edema}, pleural effusions {Pleural effusion}, CXR {Plain chest X-ray}, Cardiomegaly {Cardiomegaly}, edema {Edema}, No acute {No abnormality detected}, intracranial {Intracranial structure}, abnormality {No abnormality detected}, nonhemorrhagic {Hemorrhage}, pleural effusions {Pleural effusion}, right {Structure of right side of abdomen}, left {Structure of left side of abdomen}, Moderate {Symptom moderate}, disease {Disease}, sigmoid colon {Sigmoid colon structure}, diverticulitis {Diverticulitis}, EKG {Electrocardiographic procedure}, rate {Finding of heart rate}, sinus {Sinus rhythm}, 1st degree A-V block {First degree atrioventricular block}, normal {No abnormality detected}, intervals {Finding of electrocardiogram waveform}, normal {No abnormality detected}, axis {Electrocardiographic axis finding}, ST-T wave changes {Electrocardiographic ST segment changes}, TWI {Inverted T wave}, nonobstructing {Obstruction}, left lower pole renal {Structure of lower pole of left kidney}, stone {Kidney stone}, left lower pole {Structure of lower pole of left kidney}, simple renal cyst {Simple renal cyst}, normal {No abnormality detected}, renal
ultrasound {Echography of kidney} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
This is a ___ year old male with history of HTN, HLD, CAD, dCHF
(EF 55-60% in ___, Diabetes on insulin, hx of CVA, recently
diagnosed pericardial effusion, p/w acute-onset altered mental
status, unsteadiness, urinary incontinence found to also be in
respiratory distress.
#RESPIRATORY DISTRESS: Likely ___ flash pulmonary edema. Patient
being resuscitated with fluid and was also very hypertensive in
the ED to 180s systolic. From at___ notes, diuretics were also
decreased to 20mg which could have predisposed him to having an
episode of flash pulmonary edema. BNP on arrival was in the
11000s favoring acute diastolic CHF exacerbation. Patient was
placed on fluid restriction and diuresed with 40mg IV lasix.
However patient was also febrile to 101 in the ED and has had hx
of prior stroke, so there was some concern for aspiration. He
was therefore covered broadly with vanc/cefepime/flagyl (flagyl
added given concern for aspiration) but these antibiotics were
discontinued after a few days given lack of clinical evidence of
pneumonia. The patient's shortness of breath improved with
diuresis alone and he never complained of cough, had an elevated
WBC count, or was febrile after being admitted. An echo was
performed which compared favorably with his prior echo in ___
with no changes in ejection fraction.
#ALTERED MENTAL STATUS: Unclear etiology. Patient does have hx
of stroke but CT head was negative for acute intracranial
process. Given urinary incontinence, gait instability, normal
pressure hydrocephalus is also on differential but no prominence
of ventricles on CT head. Infectious etiology also on
differential given fevers in setting of AMS. Patient could have
also suffered a seizure given urinary incontinence although no
prior hx of seizures. Infectious work up sent off which came
back negative. Patient was back to baseline upon arrival to the
ICU and his mental status was stable and at his baseline
throughout admission. The most likely etiology of his acute
mental status decompensation is pulmonary edema and resulting
respiratory distress.
#Acute on chronic kidney disease: Patient had an increase from
his baseline creatinine of 3.3 to 4.1 which trended back down to
3.7. CKD thought to be due to worsening DM. Most likely etiology
is pre-renal due to to infection/dehydration. His creatinine was
trended daily and a renal ultrasound was negative for
obstruction or hydronephrosis.
#CHF: Patient has hx of dCHF. Echo on this admission reveals
preserved EF without new regional wall motion abnormalities when
compared with that from ___. Fluid restriction to 1.5L and
2g Na diet were employed with daily weights and strict ins and
outs recorded. His metoprolol 100 qdaily was increased to 150
qdaily for improved BP control.
#CAD: Patient's last cath was in ___ which was negative. ___
cath showed moderate single vessel disease and was advised to be
medically managed. His home aspirin, statin, and metprolol were
continued while he was hospitalized.
#HX OF STROKE: Patient has suffered stroke in the past and has
been on dual antiplatelet therapy since then. His home plavix
and aspirin were continued.
#HYPERTENSION: Hypertensive to 180s systolic on admission. Goal
BP for this elderly gentleman is 160s systolic, will attempt to
control BP in light of flash pulmonary edema on admission. His
home hydralazine and metoprolol were continued, and his
metporolol dose was increased to provide better control of his
blood pressures at home.
#DM - Stable, patient's home lantus regimen was continued with
additional insulin sliding scale while hospitalized.
TRANSITIONAL ISSUES:
-The patient had a mild erythematous rash on his back which he
did not find bothersome and is most likely due to a heat rash vs
mild allergic reaction. He was treated with ceterizine and was
asymptomatic. Please ensure this rash clears.
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, CAD {Coronary arteriosclerosis}, dCHF {Diastolic heart failure}, Diabetes {Diabetes mellitus}, CVA {Cerebrovascular accident}, pericardial effusion {Pericardial effusion}, altered mental
status {Altered mental status}, unsteadiness {General unsteadiness}, urinary incontinence {Urinary incontinence}, respiratory distress {Respiratory distress}, RESPIRATORY DISTRESS {Respiratory distress}, flash pulmonary edema {Acute pulmonary edema}, resuscitated {Resuscitation}, fluid {Administration of intravenous fluids}, hypertensive {Hypertensive disorder, systemic arterial}, diuretics {Diuretic therapy}, flash pulmonary edema {Acute pulmonary edema}, BNP {Brain natriuretic peptide measurement}, CHF exacerbation {Exacerbation of congestive heart failure}, fluid restriction {Fluid restriction}, diuresed {Diuretic therapy}, lasix {Diuretic therapy}, febrile {Fever}, stroke {Cerebrovascular accident}, aspiration {Aspiration pneumonia}, aspiration {Aspiration pneumonia}, antibiotics {Antibiotic therapy}, pneumonia {Pneumonia}, shortness of breath {Dyspnea}, improved {Patient's condition improved}, diuresis {Diuresis}, cough {Cough}, elevated
WBC count {Blood leukocyte number above reference range}, febrile {Fever}, echo {Echocardiography}, echo {Echocardiography}, ALTERED MENTAL STATUS {Altered mental status}, stroke {Cerebrovascular accident}, CT head {Computed tomography of head}, negative {No abnormality detected}, intracranial {Intracranial structure}, urinary incontinence {Urinary incontinence}, gait instability {Unsteady when walking}, normal
pressure hydrocephalus {Normal pressure hydrocephalus}, ventricles {Brain ventricle structure}, CT head {Computed tomography of head}, Infectious {Infectious disease}, fevers {Fever}, AMS {Altered mental status}, seizure {Seizure}, urinary incontinence {Urinary incontinence}, seizures {Seizure}, Infectious {Infectious disease}, negative {No abnormality detected}, baseline {Baseline state}, ICU {Admission to intensive care unit}, mental status {Altered mental status}, stable {Patient's condition stable}, baseline {Baseline state}, mental status {Altered mental status}, decompensation {Decompensation}, pulmonary edema {Pulmonary edema}, respiratory distress {Respiratory distress}, Acute on chronic kidney disease {Acute-on-chronic renal failure}, baseline {Baseline state}, creatinine {Creatinine measurement}, CKD {Chronic kidney disease}, DM {Diabetes mellitus}, pre-renal {Pre-renal acute kidney injury}, infection {Infectious disease}, dehydration {Dehydration}, creatinine {Creatinine measurement}, renal ultrasound {Echography of kidney}, negative {No abnormality detected}, obstruction {Obstruction}, hydronephrosis {Hydronephrosis}, CHF {Congestive heart failure}, dCHF {Diastolic heart failure}, Echo {Echocardiography}, without new regional wall motion abnormalities {Normal ventricular wall motion}, Fluid restriction {Fluid restriction}, diet {Dietary finding}, weights {Weight finding}, improved {Patient's condition improved}, BP {Blood pressure finding}, CAD {Coronary arteriosclerosis}, cath {Cardiac catheterization}, negative {No abnormality detected}, cath {Cardiac catheterization}, single vessel disease {Single coronary vessel disease}, aspirin {Administration of aspirin}, STROKE {Cerebrovascular accident}, stroke {Cerebrovascular accident}, antiplatelet therapy {Platelet aggregation inhibitor therapy}, aspirin {Administration of aspirin}, HYPERTENSION {Hypertensive disorder, systemic arterial}, Hypertensive {Hypertensive disorder, systemic arterial}, systolic {Blood pressure finding}, BP {Blood pressure finding}, systolic {Blood pressure finding}, BP {Blood pressure finding}, flash pulmonary edema {Acute pulmonary edema}, blood pressures {On treatment for hypertension}, DM {Diabetes mellitus}, Stable {Patient's condition stable}, regimen {Therapeutic regimen}, insulin sliding scale {Sliding scale insulin regime}, mild {Symptom mild}, erythematous rash {Erythematous rash}, back {Structure of back of trunk}, heat rash {Prickly heat}, mild {Symptom mild}, allergic reaction {Allergic reaction}, asymptomatic {Asymptomatic}, rash {Eruption of skin} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Gabapentin 100 mg PO DAILY
6. Gabapentin 300 mg PO HS
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Metoprolol Succinate XL 100 mg PO DAILY
9. HydrALAzine 25 mg PO TID
10. Glargine 20 Units Breakfast
11. Calcitriol 0.25 mcg PO EVERY OTHER DAY 3x/weekly
12. Furosemide 20 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
15. Acetaminophen 650 mg PO Q12H:PRN pain, fever
Discharge Medications:
1. Acetaminophen 650 mg PO Q12H:PRN pain, fever
2. Amlodipine 10 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Calcitriol 0.25 mcg PO EVERY OTHER DAY 3x/weekly
6. Clopidogrel 75 mg PO DAILY
7. Gabapentin 100 mg PO DAILY
8. Gabapentin 300 mg PO HS
9. HydrALAzine 25 mg PO TID
10. Glargine 20 Units Breakfast
11. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 50 mg 3 tablet(s) by mouth qdaily Disp
#*90 Tablet Refills:*0
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Vitamin D 1000 UNIT PO DAILY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Acute diastolic congestive heart failure
exacerbation
Secondary Diagnosis: Diabetes mellitus, coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: Home With Service {Home health aide service management}, diastolic congestive heart failure {Diastolic heart failure}, Diabetes mellitus {Diabetes mellitus}, coronary artery disease {Coronary arteriosclerosis}, Mental Status {Neurological mental status determination}, Clear {No abnormality detected}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___
___. You were admitted because you were having
shortness of breath and fevers. We determined that your
shortness of breath was likely due to an acute exacerbation of
your heart failure and haveing too much fluid in your lungs. We
gave you a medication to help you remove the fluid from your
lungs. Your kidney function was also slightly worse than usual
while you were admitted. We closely followed it while you were
hospitalized and it returned to what is normal for you. We also
noticed that your blood pressure was somewhat high while you
were here, so we increased one of your blood pressure
medications (metoprolol). This is noted on the medication list
you will be given at discharge.
Sincerely,
Your ___ Team
###RESPONSE: shortness of breath {Dyspnea}, fevers {Fever}, shortness of breath {Dyspnea}, acute exacerbation {Acute exacerbation of chronic obstructive airways disease}, heart failure {Heart failure}, fluid in your lungs {Pleural effusion}, medication {Patient medication education}, fluid {Administration of intravenous fluids}, lungs {Lung structure}, kidney {Kidney structure}, normal {No abnormality detected}, blood pressure {Blood pressure finding}, blood pressure
medications {Antihypertensive therapy}, medication {Patient medication education} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
presyncope (feeling faint, acute vision changes, palpitations,
tightness in his chest)
Major Surgical or Invasive Procedure:
none
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, presyncope {Near syncope}, feeling faint {Feeling faint}, palpitations {Palpitations}, chest {Thoracic 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: History of Present Illness:
___ F h/o presyncopal episodes the in the last 2 days,
associated with dyspnea as well as diaphoresis. Patient also
reports increased shortness of breath on exertion.
Two days prior to admission, the patient was standing in the
bathroom (no full bladder, not moving bowels) when she
experienced narrowing of her visual fields, disequilibium (not
vertiginous without nausea) sudden in onset. This was followed
by a tightening in the throat, diaphoresis, and heart
palpaitations. This resolved over the course of ___ minutes
after she sat down. There was no hearing involvement or loss of
consciousness. This was witness by her husband, who thought she
looked pale.
The day prior to admission, she had a second, similar episode
while standing in the kitchen. This resolved in approximately 15
minutes. Again, this did not occur after standing from sitting
nor was there any obvious vagal trigger. She was not exerting
herself at the time.
Notably, she is not light-headed when she stands. She has had no
chest pain whatsoever. She describes one episode of questionable
DOE recently but has not had more than very mild limitation of
activity or swelling of the ankles. She denies orthopnea. She
has no cardiac history. She has no history of anxiety and the
episodes have not involved any feeling of impending doom/near
death.
In the ED, initial vs were 97.6 60 192/88 16 98% RA. Received
ASA 325, 1L NS, and labs were all unremarkable (CBC, Chem 7,
troponin-t, CK). EKG as well as initial troponin were negative
for any acute ischemic disease. Remainder of laboratory work was
reassuring. Her chest x-ray was normal for any acute
cardiopulmonary disease. This imaging did reveal a left humeral
enchondroma.
The patient was high risk according to ___ Syncope Criteria,
she will be admitted to medicine for further evaluation of
possible arrhythmia, left ventricular outflow obstruction, ACS,
or other cardiac etiology. Patient denies any chest pain or
shortness of breath this time. Hemodynamically stable. Her VS
prior to admission were 58 156/64 13 98% RA Pain: 0.
On arrival to the floor, patient reports feeling at her
baseline. She reported the above history and was hemodynamically
stable.
###RESPONSE: dyspnea {Dyspnea}, diaphoresis {Excessive sweating}, shortness of breath on exertion {Dyspnea on exertion}, standing {Orthostatic body position}, bladder {Urinary bladder structure}, moving bowels {Finding of defecation}, narrowing of her visual fields {Generalized visual field constriction}, disequilibium {Unsteady when standing}, nausea {Nausea}, throat {Structure of anterior portion of neck}, diaphoresis {Excessive sweating}, heart {Heart structure}, palpaitations {Palpitations}, loss of
consciousness {Loss of consciousness}, standing {Orthostatic body position}, standing {Orthostatic body position}, sitting {Sitting position}, chest pain {Chest pain}, ankles {Ankle region structure}, orthopnea {Orthopnea}, anxiety {Anxiety}, feeling of impending doom/ {Sense of impending doom}, unremarkable {No abnormality detected}, acute ischemic disease {Acute ischemic heart disease}, chest x-ray {Plain chest X-ray}, cardiopulmonary disease {Cor pulmonale}, imaging {Imaging}, enchondroma {Enchondroma}, Syncope {Syncope}, arrhythmia {Cardiac arrhythmia}, ACS {Acute coronary syndrome}, chest pain {Chest pain}, shortness of breath {Dyspnea}, Hemodynamically stable {Hemodynamically stable}, Pain {Pain}, hemodynamically
stable {Hemodynamically 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: Past Medical History:
-Hypertension
-Hyperlipidemia
-Varicose veins
-Bilateral cataract removal
-Laparoscopic gastric bypass (___)
-Hiatal hernia s/p repair
-Broke left arm/hand with crush injury? Surgical intervention
with external fixation
-Varicose vein stripping (left leg)
###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, Varicose veins {Venous varices}, Bilateral cataract removal {Extraction of cataract of bilateral eyes}, Laparoscopic gastric bypass {Laparoscopic bypass of stomach}, Hiatal hernia {Hiatal hernia}, repair {Surgical repair}, left arm {Left upper arm structure}, hand {Hand structure}, crush injury {Crushing injury}, Surgical intervention {Surgical procedure}, external fixation {External fixation of bone}, Varicose vein stripping {Varicose vein stripping}, left leg {Structure of left lower limb} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
Brother has history of "heart rhythm irregularities" diagnosed
as a teenager because of an episode of syncope
Mother deceased at age ___ of uterian cancer
Father deceased at age ___ due to stroke
###RESPONSE: heart rhythm irregularities {Irregular heart beat}, syncope {Syncope}, uterian cancer {Malignant neoplasm of uterus}, stroke {Cerebrovascular accident} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.5 139/69 62 20 97% on RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft, obese abdomen with normoactive bowel sounds,
nondistended, nontender with no rubs or gallops, with no obvious
hernia
EXT WWP 2+ pulses palpable bilaterally, trace pretibial edema
bilaterally, with many varicose veins scattered across both legs
NEURO Alert, fluent, linear, prompt, CNs2-12 intact save an
exotropia with positive cover/uncover (no diplopia), motor
function grossly normal, sensory function intact, no cerebellar
abnormalities, reflexes 1+ globally, gait deferred.
SKIN no ulcers or lesions
DISCHARGE PHYSICAL EXAM:
afebrile, 100% RA
Laying flat: 160/64 58
Sitting: 160/70 57
Standing: 173/84 ___
GEN Pt is a very pleasant well nourished woman who is alert,
oriented, and in no acute distress. She is fully conversant,
speaking full sentences, without becoming short of breath. She
easily moves from the chair to the bed without assistence or
changes in breathing.
HEENT NCAT MMM EOMI sclera anicteric, OP clear, permanent
eyebrow and eyeliner tattoos
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB with scattered wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft, obese abdomen with normoactive bowel sounds,
nondistended, nontender with no rubs or gallops, with no obvious
hernia
EXT WWP 2+ pulses palpable bilaterally, trace pretibial edema
bilaterally, with many varicose veins scattered across both legs
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, GEN {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, NC {Normal head}, MMM {Moist oral mucosa}, EOMI {Normal ocular motility}, sclera anicteric {White sclera}, OP clear {Pharynx normal}, supple {Normal movement of neck}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, ronchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, ABD {Examination of abdomen}, soft {Abdomen soft}, obese abdomen {Obese abdomen}, normoactive bowel sounds {Normal bowel sounds}, nondistended {Normal abdominal contour}, nontender {Abdominal tenderness}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, hernia {Examination of limb}, WWP {Normal tissue perfusion}, edema {Edema}, varicose veins {Venous varices}, both legs {Both lower legs}, NEURO {Neurological examination}, Alert {Mentally alert}, exotropia {Exotropia}, diplopia {Diplopia}, motor
function grossly normal {Normal motor response to command}, reflexes {Normal reflex}, SKIN {Examination of skin}, ulcers {Ulcer}, lesions {Lesion}, RA {Breathing room air}, Sitting {Sitting position}, Standing {Orthostatic body position}, well nourished {Well nourished}, distress {Distress}, moves {Does move from lying to sitting}, sclera anicteric {White sclera}, eyebrow {Eyebrow structure}, tattoos {Tattoo of skin}, wheezes {Wheezing}, rales {Respiratory crackles}, ABD soft {Abdomen soft}, obese abdomen {Obese abdomen}, normoactive bowel sounds {Normal bowel sounds}, hernia {Herniated structure}, 2+ pulses palpable {Peripheral pulses normal}, edema {Edema}, varicose veins {Venous varices}, both legs {Both lower legs}, NEURO {Neurological examination}, motor function grossly normal {Normal motor response to command}, SKIN {Examination of skin}, ulcers {Ulcer}, lesions {Skin lesion} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
Admission labs:
___ 02:20PM GLUCOSE-92 UREA N-16 CREAT-0.7 SODIUM-141
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-30 ANION GAP-15
___ 02:20PM estGFR-Using this
___ 02:20PM NEUTS-49.8* ___ MONOS-4.5 EOS-4.0
BASOS-0.8
___ 02:20PM PLT COUNT-314
___ 07:25AM BLOOD WBC-4.1 RBC-4.82 Hgb-15.0 Hct-44.9 MCV-93
MCH-31.1 MCHC-33.5 RDW-13.5 Plt ___
___ 07:25AM BLOOD Glucose-95 UreaN-14 Creat-0.8 Na-144
K-4.1 Cl-101 HCO3-35* AnGap-12
___ 02:01AM BLOOD CK-MB-3 cTropnT-<0.01
___ 02:20PM BLOOD cTropnT-<0.01
___ 02:20PM BLOOD CK(CPK)-181
Imaging:
Chest PA and Lateral (___)
IMPRESSION:
1. No acute chest abnormality.
2. Chondroid matrix within the left humeral head likely
represents a benign entity such as enchondroma. If there is
pain referable to this region, this could be better evaluated
with MRI to exclude a more aggressive chondroid lesion.
Carotid doppler study:
Realtime evaluation of the carotid bifurcations shows no
significant plaque on
either side. Peak systolic and end diastolic velocities are
unremarkable.
The ICA/CCA ratio is 1.2 on both sides. The vertebral arteries
demonstrate
prograde flow.
IMPRESSION: Normal bilateral carotid Doppler. No evidence of
plaque or
hemodynamically significant stenosis.
Discharge labs:
___ 07:25AM BLOOD WBC-4.1 RBC-4.82 Hgb-15.0 Hct-44.9 MCV-93
MCH-31.1 MCHC-33.5 RDW-13.5 Plt ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-95 UreaN-14 Creat-0.8 Na-144
K-4.1 Cl-101 HCO3-35* AnGap-12
___ 02:01AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:25AM BLOOD Calcium-9.6 Phos-4.1 Mg-2.___ h/o HTN, HLD, and obesity s/p gastric bypass (___) who p/w
pre-syncope most consistent with vasovagal.
ACTIVE ISSUES:
# Presyncope: Her episodes have some characteristics of
vasovagal episodes. She describes prodromal symptoms consistent
with those preceeding a neurocardiogenic/vasovagal episode,
including diaphoresis, weakness, transient vision loss, and
increased heart rate. Episodes occurred while patient was
standing, not with exercise or time of situational or emotional
stress, again more consistent with a neurocardiogenic etiology.
They do not sound like orthostasis by history, nor is she
orthostatic on exam. Given the lack of symptoms during exertion,
arrhythmia is less likely although her brother does apparently
have some form of malignant arrhythmia. Seizure and stroke are
not on the differential. She has no reason to be hypoglycemic,
although her episodes do sound somewhat reminiscent of transient
hypoglycemia.
The patient was observed overnight during which she was
asymptomatic and no events recorded on telemetry. Her serial
troponins were negative with no abnormalities seen on EKG. She
was discharged with ___ of hearts and will follow up with
cardiology as an outpatient.
INACTIVE ISSUES:
# HTN: continue ASA, HCTZ
# HLD: continue pravastatin
# GERD: continue omeprazole
TRANSITIONAL ISSUES:
# SYNCOPE: Follow up with cardiology with ___ of Hearts monitor
# ENDOCHRONDROMA: Follow up with PCP given the incidental
finding of enchondroma on radiographic imaging. Consider
possible MRI as an outpatient
###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}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, Chest PA {Plain x-ray of chest posteroanterior view}, chest {Thoracic structure}, left humeral head {Bone structure of left humerus}, enchondroma {Enchondroma}, pain {Pain}, MRI {Magnetic resonance imaging}, lesion {Finding of lesion}, carotid bifurcations {Structure of carotid bifurcation}, plaque {Plaque}, unremarkable {No abnormality detected}, vertebral arteries {Structure of vertebral artery}, plaque {Plaque}, stenosis {Stenosis}, 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}, 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}, obesity {Obesity}, gastric bypass {Bypass of stomach}, pre-syncope {Near syncope}, Presyncope {Near syncope}, diaphoresis {Excessive sweating}, weakness {Asthenia}, increased heart rate {Tachycardia}, standing {Orthostatic body position}, emotional
stress {Emotional stress}, arrhythmia {Cardiac arrhythmia}, arrhythmia {Cardiac arrhythmia}, Seizure {Seizure}, stroke {Cerebrovascular accident}, hypoglycemia {Hypoglycemia}, asymptomatic {Asymptomatic}, no abnormalities seen {No pathologic diagnosis}, hearts {Cardiovascular physical examination}, follow up with
cardiology as an outpatient {Follow-up in outpatient clinic}, SYNCOPE {Syncope}, Follow up with cardiology {Follow-up cardiac assessment}, enchondroma {Enchondroma}, imaging {Imaging}, MRI {Magnetic resonance imaging} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Pravastatin 20 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
hold for sbp < 100
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
hold for sbp < 100
3. Omeprazole 20 mg PO DAILY
4. Pravastatin 20 mg PO DAILY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: pre-syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: pre-syncope {Near syncope}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness 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: Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you. You were admitted to the
___ for ___
(dizziness, feeling as if will pass out) symptoms prior to your
presentation.
Our diagnostic work-up did not reveal any abnormality. You
should follow-up with your primary care physician, and we have
also organized to have you follow-up with a cardiologist.
###RESPONSE: dizziness {Dizziness} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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: ORTHOPAEDICS
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Bactrim / Codeine
Attending: ___.
Chief Complaint:
R knee hematoma/pain/swelling
Major Surgical or Invasive Procedure:
R knee/thigh I&D/arthrotomy
###RESPONSE: Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, Codeine {Allergy to codeine}, R knee hematoma {Hematoma of right knee region}, pain {Pain of knee region}, swelling {Swollen knee}, R knee {Structure of right knee region}, thigh {Thigh structure}, arthrotomy {Arthrotomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
This is a ___ year old gentleman with HIV (last CD4 210, VL
150,000 per patient), followed at ___, restarted on HAART 3
weeks ago, who initially presented with right thigh and knee
pain
and swelling as well as fevers and is now found to have septic
arthritis of the right knee.
His current series of events began ___ weeks ago when he
was struck twice on the right thigh by a dishcart (he works in a
restaurant). He developed immediate pain afterwards which he
treated by icing it and with ibuprofen. He was seen in the ED
and
placed in an air cast which he wore for the next 3.5 weeks. The
injury did not break the skin as far as he is aware.
He subsequently developed a large bruise which became
increasingly swollen and painful. He was then seen about 10 days
ago by his PCP and told to stop wearing the air cast. By the
next
morning the leg had become significantly more swollen. He
developed fevers to 102.8 at home which he felt were likely due
to the pain and thus did not seek further evaluation at that
time. The fevers broke when he iced his knee. His pain continued
to get worse however and he continued to have fevers. He reports
not being able to bend his knee since the initial injury.
He finally presented to the ED on ___. Imaging in the ED was
suboptimal due to patient pain but showed a massive soft tissue
density in the anterior thigh with a broad differential
including
hematoma. His knee was aspirated and irrigated with fluid
showing
WBC of 192,500 with 92% PMNs and 111 RBCs. Labs showed WBC count
10.0, ESR 128, and CRP of 217.9.
###RESPONSE: HIV {Human immunodeficiency virus infection}, restarted {Restart of medication}, right thigh {Thigh pain}, knee
pain {Pain of knee region}, swelling {Swelling}, fevers {Fever}, septic
arthritis {Bacterial arthritis}, right knee {Structure of right knee region}, right thigh {Structure of right thigh}, pain {Pain}, placed in an air cast {Application of cast}, injury {Traumatic injury}, bruise {Contusion}, swollen {Swelling}, painful {Pain}, leg had become significantly more swollen {Swelling of lower limb}, fevers {Fever}, pain {Pain}, evaluation {Evaluation procedure}, fevers {Fever}, iced {Application of ice}, knee {Knee region structure}, pain {Pain}, fevers {Fever}, able to bend his knee {Normal active range of knee flexion}, injury {Traumatic injury}, Imaging {Imaging}, pain {Pain}, soft tissue {Structure of soft tissue}, density {Abnormally opaque structure}, anterior thigh {Femoral region structure}, hematoma {Hematoma}, knee {Knee region structure}, WBC {White blood cell count}, WBC count {White blood cell count}, ESR {Erythrocyte sedimentation rate measurement}, CRP {C-reactive protein 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: Past Medical History:
HIV, diagnosed ___, restarted on HAART ___
GERD
seizure
s/p ORIF L elbow
Transaminits with biopsy suggesting fatty liver
Shingle and chicken pox
PTSD
Anxiety
###RESPONSE: HIV {Human immunodeficiency virus infection}, restarted {Restart of medication}, GERD {Gastroesophageal reflux disease}, seizure {Seizure}, ORIF {Open reduction of fracture with internal fixation}, L elbow {Left elbow region structure}, Transaminits {Aspartate transaminase level above reference range}, biopsy {Biopsy}, fatty liver {Steatosis of liver}, Shingle {Herpes zoster}, chicken pox {Varicella}, PTSD {Posttraumatic stress disorder}, Anxiety {Anxiety} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
His mother is deceased at age ___ from lung cancer. She was also
a heavy drinker. His father is deceased at age ___ from suicide.
He has no brothers and no sisters.
###RESPONSE: deceased {Dead}, lung cancer {Malignant tumor of lung}, heavy drinker {Heavy drinker}, deceased {Dead} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS: Tm 101.0 Tc 98.1 128/72 64 20 100/3L\
General: NAD
EENT: EOM grossly intact, sclerae anicteric, moist mucous
membranes
CV: RRR, II/VI SEM (which he has previously been told he has),
no
rubs or gallops
Pulmonary: clear to auscultation bilaterally w/o wheezes /
rhonchi / rales
Extremities: right thigh and knee extensively wrapped with drain
collecting serosanguinous fluid, appear warm and well perfused,
SKIN: no rashes, no jaundice
NEURO: awake, alert and oriented x3, CN grossly intact,
sensation
intact in lower extremities bilaterally
PSYCH: irritable, non-anxious, oherwise normal affect
###RESPONSE: VS {Vital signs finding}, General {General examination of patient}, NAD {No abnormality detected}, NT {Abdominal tenderness}, grossly intact {Normal nervous system function}, sclerae anicteric {White sclera}, moist mucous
membranes {Moist oral mucosa}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, SEM {Ejection murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Pulm {Examination of respiratory system}, clear to auscultation bilaterally {Normal breath sounds}, rhonchi {Wheeze - rhonchi}, rales {Respiratory crackles}, Extremities {Examination of limb}, right thigh {Structure of right thigh}, knee {Knee region structure}, collecting serosanguinous fluid {Serosanguineous discharge from wound}, warm {Warm skin}, well perfused {Normal tissue perfusion}, SKIN {Examination of skin}, rashes {Eruption of skin}, jaundice {Jaundice}, NEURO {Neurological examination}, awake {Awake}, alert {Mentally alert}, oriented {Orientated}, grossly intact {Normal nervous system function}, sensation
intact {Normal sensation}, lower extremities {Lower limb structure}, irritable {Feeling irritable}, anxious {Anxiety}, affect {Mood finding} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 04:20PM BLOOD WBC-10.0# RBC-3.44*# Hgb-10.4*#
Hct-28.7*# MCV-84 MCH-30.2 MCHC-36.2* RDW-13.9 Plt ___
___ 05:15AM BLOOD WBC-6.9 RBC-3.32* Hgb-9.9* Hct-28.3*
MCV-85 MCH-29.9 MCHC-35.1* RDW-14.7 Plt ___
___ 04:20PM BLOOD Neuts-87.5* Bands-0 Lymphs-6.4* Monos-3.4
Eos-2.3 Baso-0.4
___ 04:20PM BLOOD ESR-128*
___ 06:35AM BLOOD Glucose-98 UreaN-10 Creat-0.7 Na-134
K-3.9 Cl-101 HCO3-24 AnGap-13
___ 06:20AM BLOOD ALT-61* AST-71* LD(LDH)-156 AlkPhos-72
TotBili-1.6*
___ 04:20PM BLOOD CRP-217.9*
###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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the 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 to the orthopaedics service from the
ED on ___. On ___ he went to the OR for the above
listed procedure. Please read the operative note for more
detail. After being extubated, he was taken to the PACU where
he did well and was then taken to the floor. His pain was well
controlled while on the floor and the tolerated a regular diet.
After verifying a set of blood cultures negative for at least 48
hours, he had a PICC line placed for home IV antibiotics. After
receiving teaching on how to care for the picc he was discharged
to home with ___ and home ___.
###RESPONSE: procedure {Procedure}, extubated {Removal of endotracheal tube}, pain was well
controlled {Demonstrates adequate pain control}, regular diet {Normal diet}, blood cultures {Blood culture}, negative {No abnormality detected}, PICC line placed {Insertion of peripherally inserted central catheter}, IV antibiotics {Intravenous antibiotic therapy}, teaching {Patient education} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Truvada (tenofovir and emtricitabine)
Norvir (Ritonavir) 100mg daily
Atazanavir 300 mg daily
Sertraline 50mg daily
Buproprion 200mg SR daily
Alprazolam 1mg PRN insomnia
Discharge Medications:
1. Wheelchair
with elevating leg rests.
Disp # 1
Diagnosis: Right Knee infection
2. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams
Intravenous Q4H (every 4 hours) for 4 weeks: ID to manage total
length of treatment.
Disp:*qs * Refills:*0*
3. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous Q8PM () for 3 weeks.
Disp:*21 syringe* Refills:*0*
4. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO QAM (once a day (in the morning)).
5. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as
needed) as needed for irritation.
6. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
9. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
10. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
11. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for Pain.
Disp:*40 Tablet(s)* Refills:*0*
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
16. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*40 Tablet, Rapid Dissolve(s)* Refills:*0*
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R knee septic arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Home With Service {Home health aide service management}, R knee septic arthritis {Infective arthritis of right knee}, Mental Status {Neurological mental status determination}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Wound Care:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
-Keep pin sites clean and dry.
-Sutures/staples will be removed at your first post-operative
visit.
Activity:
-Continue to be weight bearing on your right leg.
-You should not lift anything greater than 5 pounds.
-Elevate Right leg to reduce swelling and pain.
-Do not remove splint/brace. Keep splint/brace dry.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Full weight bearing, CPM
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Site: Right knee
Description: surgical site with staples intact, minimal serosang
drainage. Dsd/kerlix c/d/i
Care: dsg changes gauze to dry daily
###RESPONSE: Sutures {Removal of suture}, staples will be removed {Removal of staples}, weight bearing {Weight-bearing}, right leg {Structure of right lower limb}, should not lift {Recommendation to avoid activity}, Right leg {Structure of right lower limb}, swelling {Swelling}, pain {Pain}, splint {Application of splint}, splint {Application of splint}, regular diet {Normal diet}, control your
pain {Pain control}, narcotic {Narcotherapy}, prescriptions {Prescription}, narcotic {Narcotherapy}, pain medications {Administration of analgesic}, Narcotic {Narcotherapy}, pain medication {Administration of analgesic}, drowsiness {Drowsy}, Do not drink
alcohol {Education about alcohol consumption}, narcotic medications {Narcotherapy}, while taking narcotic pain
medications {Narcotics education}, Full weight bearing {Full weight-bearing gait training}, cough and deep breathe {Deep breathing and coughing exercises}, Right knee {Structure of right knee region}, surgical site {Operative site}, serosang
drainage {Serosanguineous discharge from wound} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: 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:
pcn
Attending: ___.
Chief Complaint:
Diarrhea, nausea, chest discomfort
Major Surgical or Invasive Procedure:
___ Placement
###RESPONSE: pcn {Allergy to penicillin}, Diarrhea {Diarrhea}, nausea {Nausea}, chest discomfort {Chest discomfort}, Placement {Implantation 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: History of Present Illness:
___ female with stage IV endometrial cancer on
anastrazole, DM2, CAD, CKD, chronic respiratory failure with
hypoxemia on home oxygen, and morbid obesity presents from her
PCP's office with gastrointestinal illness and chest discomfort.
She was in her usual state of health until ___, when she
experienced the onset of fever, headache, diarrhea, heaving
(mostly dry), and malaise. She noted some chest discomfort
accompanying the dry heaves that felt "like someone punching
her" in the chest (not like the pressure she felt with her prior
MI). Her PCP was concerned about EKG changes, and sent her to
the hospital.
She has a history of cardiac disease, including an MI in ___.
At that time, she was cathed and found to have significant
disease but due to intolerance of the procedure no intervention
was carried out. She has been medically managed in the interim.
In the ED, initial vitals were T 99.4 HR 72 BP 102/45 RR 18 SpO2
98%2L. CT head w/o contrast was unremarkable. CXR showed mild
cardiomegaly with central vascular congestion. Labs were
remarkable for K of 3.0 for which she was given 40meq potassium.
Vitals prior to transfer were T 100.4 HR 66 BP 129/69 RR 18
SpO296%2L.
On the floor, vitals are stable and she feels better. She denies
heaves, chest pain, difficulty breathing, nausea, or abdominal
pain. She does endorse ongoing diarrhea.
###RESPONSE: stage IV {Clinical stage IV}, endometrial cancer {Endometrial carcinoma}, DM2 {Diabetes mellitus type 2}, CAD {Coronary arteriosclerosis}, CKD {Chronic kidney disease}, chronic respiratory failure {Chronic respiratory failure}, hypoxemia {Hypoxemia}, morbid obesity {Morbid obesity}, gastrointestinal illness {Disorder of gastrointestinal tract}, chest discomfort {Chest discomfort}, fever {Fever}, headache {Headache}, diarrhea {Diarrhea}, heaving {Retching}, malaise {Malaise}, chest discomfort {Chest discomfort}, dry heaves {Retching}, chest {Thoracic structure}, pressure {Tight chest}, MI {Myocardial infarction}, EKG changes {Electrocardiogram abnormal}, cardiac disease {Heart disease}, MI {Myocardial infarction}, cathed {Cardiac catheterization}, disease {Disease}, procedure {Procedure}, vitals {Vital signs finding}, SpO2 {Finding of oxygen saturation}, CT head w/o contrast {Computed tomography of head without contrast}, unremarkable {No abnormality detected}, CXR {Plain chest X-ray}, cardiomegaly {Cardiomegaly}, vascular {Blood vessel structure}, congestion {Congestion}, Labs {Laboratory test}, potassium {Potassium measurement}, Vitals {Vital signs finding}, vitals are stable {Normal vital signs}, feels better {Patient's condition improved}, heaves {Retching}, chest pain {Chest pain}, difficulty breathing {Difficulty breathing}, nausea {Nausea}, abdominal
pain {Abdominal pain}, diarrhea {Diarrhea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
Endometrial cancer: Diagnosed ___, Stage IV, s/p hysterectomy
and radiation, on anastrazole
DM2: Latest HbA1C 4.5 (___)
CAD: ___ ___, underwent cardiac catheterization
without intervention
Chronic respiratory failure: 2L home oxygen
CKD stage 3
HTN
hypothyroidism
thrombocytopenia
anemia
depression
###RESPONSE: Endometrial cancer {Endometrial carcinoma}, Stage IV {Clinical stage IV}, hysterectomy {Hysterectomy}, radiation {Radiation oncology AND/OR radiotherapy}, DM2 {Diabetes mellitus type 2}, HbA1C {Hemoglobin A1c measurement}, CAD {Coronary arteriosclerosis}, cardiac catheterization {Cardiac catheterization}, Chronic respiratory failure {Chronic respiratory failure}, CKD stage 3 {Chronic kidney disease stage 3}, HTN {Hypertensive disorder, systemic arterial}, hypothyroidism {Hypothyroidism}, thrombocytopenia {Thrombocytopenic disorder}, anemia {Anemia}, depression {Depressive disorder} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
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