text
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father died at ___ after ___ MIs
Mother died at ___, had CHF
Sister died of breast cancer
 

###RESPONSE: died {Dead}, MIs {Myocardial infarction}, died {Dead}, CHF {Congestive heart failure}, died {Dead}, breast cancer {Malignant neoplasm of breast}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Admission:
VS: T 98.4 BP 105/52 HR 64 RR 20 SpO2 98%2L
General: Obese woman sleeping in hospital bed, easily arousable. 

HEENT: NCAT, MMM, no teeth
Neck: Supple, no LAD, no JVD
CV: Distant heart sounds. Regular rate and rhythm, no M/R/G 
appreciated.
Lungs: Clear to auscultation bilaterally.
Abdomen: Obese, soft, non-distended, non-tender. Bowel sounds 
present.
GU: Deferred
Ext: Warm, 2+ distal pulses bilaterally, darkened skin around 
ankles (?stasis dermatitis), no edema 
Neuro: Alert, oriented, moving all extremities

Discharge:
VS: T 97.8 BP 104/52 HR (not recorded) RR 18 SpO2 94%RA
General: Obese woman in hospital bed, no distress.  
HEENT: NCAT, mucous membranes moist  
Neck: Supple, no LAD  
CV: Regular rate and rhythm, distant heart sounds, no 
appreciable murmurs/rubs/gallops  
Lungs: Poor aeration throughout, otherwise clear to auscultation
Abdomen: Obese, soft, non-distended. Bowel sounds present.  
Ext: Warm, 2+ distal pulses bilaterally, darkened skin around 
ankles (?stasis dermatitis), 2+ pitting edema
Neuro: Alert, oriented, moving all extremities  

 

###RESPONSE: VS {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, SpO2 {Finding of oxygen saturation}, General {General examination of patient}, Obese {Obese}, sleeping in hospital bed {Inpatient stay}, HEENT {Physical examination procedure}, NC {Normal head}, MMM {Moist oral mucosa}, no teeth {Edentulous}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, CV {Cardiovascular physical examination}, Distant heart sounds {Heart sounds diminished}, Regular rate and rhythm {Normal heart rate}, no M/R/G {Heart sounds normal}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, Abdomen {Examination of abdomen}, Obese {Obese abdomen}, soft {Abdomen soft}, non-distended {Normal abdominal contour}, non-tender {Abdominal tenderness}, Bowel sounds 
present {Normal bowel sounds}, GU {Examination of genitourinary system}, Ext {Examination of limb}, Warm {Warm skin}, 2+ distal pulses {Peripheral pulses normal}, darkened {Dark color}, skin around 
ankles {Skin structure of ankle}, stasis dermatitis {Stasis dermatitis}, edema {Edema}, Neuro {Neurological examination}, Alert {Mentally alert}, oriented {Orientated}, all extremities {All extremities}, VS {Vital signs finding}, SpO2 {Finding of oxygen saturation}, RA {Breathing room air}, General {General examination of patient}, Obese {Obese}, distress {Distress}, HEENT {Physical examination procedure}, NCAT {Normal head}, mucous membranes moist {Moist oral mucosa}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, distant heart sounds {Heart sounds diminished}, murmurs {Heart murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Lungs {Examination of respiratory system}, clear to auscultation {Normal breath sounds}, Abdomen {Examination of abdomen}, Obese {Obese abdomen}, soft {Abdomen soft}, non-distended {Normal abdominal contour}, Bowel sounds present {Normal bowel sounds}, Ext {Examination of limb}, Warm {Warm skin}, 2+ distal pulses {Peripheral pulses normal}, darkened {Dark color}, skin around 
ankles {Skin structure of ankle}, stasis dermatitis {Stasis dermatitis}, 2+ pitting edema {2+ pitting edema}, Neuro {Neurological examination}, Alert {Mentally alert}, oriented {Oriented to person}, moving all extremities {Does move all four limbs}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 01:50PM BLOOD WBC-6.8 RBC-3.51* Hgb-9.5* Hct-29.2* 
MCV-83 MCH-27.1 MCHC-32.5 RDW-15.7* Plt Ct-62*
___ 08:25AM BLOOD WBC-5.2 RBC-3.67* Hgb-10.0* Hct-30.8* 
MCV-84 MCH-27.2 MCHC-32.5 RDW-15.8* Plt Ct-59*
___ 07:15AM BLOOD WBC-3.7* RBC-3.13* Hgb-8.4* Hct-26.3* 
MCV-84 MCH-26.9* MCHC-32.1 RDW-15.2 Plt Ct-46*
___ 01:30PM BLOOD WBC-3.4* RBC-3.12* Hgb-8.4* Hct-26.4* 
MCV-85 MCH-27.0 MCHC-31.9 RDW-15.3 Plt Ct-51*
___ 05:40AM BLOOD WBC-3.0* RBC-3.23* Hgb-8.9* Hct-27.3* 
MCV-84 MCH-27.6 MCHC-32.7 RDW-15.4 Plt Ct-53*
___ 05:36AM BLOOD WBC-1.9* RBC-3.08* Hgb-8.2* Hct-25.6* 
MCV-83 MCH-26.6* MCHC-31.9 RDW-15.2 Plt Ct-54*
___ 07:15AM BLOOD WBC-1.5* RBC-2.89* Hgb-7.7* Hct-24.0* 
MCV-83 MCH-26.6* MCHC-32.0 RDW-15.2 Plt Ct-71*
___ 03:40PM BLOOD WBC-2.2* RBC-3.07* Hgb-8.2* Hct-26.0* 
MCV-85 MCH-26.8* MCHC-31.6 RDW-15.3 Plt Ct-88*
___ 07:00AM BLOOD WBC-1.5* RBC-2.79* Hgb-7.6* Hct-23.6* 
MCV-85 MCH-27.4 MCHC-32.4 RDW-15.2 Plt Ct-81*
___ 01:20PM BLOOD WBC-1.9* RBC-3.24* Hgb-8.6* Hct-27.4* 
MCV-85 MCH-26.6* MCHC-31.5 RDW-15.1 Plt Ct-93*
___ 06:35AM BLOOD WBC-1.9* RBC-2.88* Hgb-7.9* Hct-24.2* 
MCV-84 MCH-27.5 MCHC-32.6 RDW-15.2 Plt Ct-90*

___ 01:50PM BLOOD Neuts-87.6* Lymphs-6.4* Monos-5.7 Eos-0.1 
Baso-0.1
___ 05:36AM BLOOD Neuts-73.4* Lymphs-17.0* Monos-7.0 
Eos-2.3 Baso-0.3
___ 07:15AM BLOOD Neuts-65 Bands-0 ___ Monos-5 Eos-5* 
Baso-0 ___ Myelos-0
___ 06:35AM BLOOD Neuts-61.4 ___ Monos-12.3* 
Eos-1.5 Baso-0.9

___ 01:50PM BLOOD Glucose-165* UreaN-19 Creat-1.0 Na-140 
K-3.0* Cl-98 HCO3-33* AnGap-12
___ 05:40AM BLOOD Glucose-103* UreaN-23* Creat-1.1 Na-135 
K-3.8 Cl-101 HCO3-30 AnGap-8
___ 06:35AM BLOOD Glucose-101* UreaN-16 Creat-0.7 Na-139 
K-4.1 Cl-103 HCO3-31 AnGap-9

___ 01:50PM BLOOD CK(CPK)-26*
___ 08:35PM BLOOD ALT-23 AST-28 CK(CPK)-20* AlkPhos-158* 
TotBili-1.8*
___ 05:36AM BLOOD CK(CPK)-11*
___ 07:00AM BLOOD ALT-24 AST-35 LD(LDH)-165 AlkPhos-288* 
TotBili-0.3
___ 06:35AM BLOOD ALT-31 AST-48* AlkPhos-297* TotBili-0.3

___ 01:50PM BLOOD CK-MB-1 cTropnT-0.21*
___ 08:35PM BLOOD CK-MB-1 cTropnT-0.17*
___ 03:15AM BLOOD CK-MB-1 cTropnT-0.16*
___ 08:25AM BLOOD CK-MB-1 cTropnT-0.19*
___ 07:15AM BLOOD CK-MB-1 cTropnT-0.14*

___ 01:50PM BLOOD Calcium-8.0* Phos-1.2* Mg-1.3*
___ 05:40AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.0
___ 06:35AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.6

Imaging
___ CHEST (PA & LAT): IMPRESSION:  Mild cardiomegaly with 
central vascular congestion, but without frank edema.

___ CT HEAD W/O CONTRAST: IMPRESSION:  No acute 
intracranial process.  Small hypodensity in the left centrum 
semiovale may relate to small vessel ischemic change, however, 
given assymetric with the right side, nonurgent brain MRI would 
further evaluate.

___  Cardiovascular ECHO: Poor echo windows. The left 
atrium is mildly dilated. There is mild symmetric left 
ventricular hypertrophy with normal cavity size and global 
systolic function (LVEF>55%). Due to suboptimal technical 
quality, a focal wall motion abnormality cannot be fully 
excluded. There is no ventricular septal defect. Right 
ventricular chamber size and free wall motion are normal. The 
aortic root is mildly dilated at the sinus level. The aortic 
valve leaflets (3) are mildly thickened but aortic stenosis is 
not present. Mild (1+) aortic regurgitation is seen. The mitral 
valve appears structurally normal with trivial mitral 
regurgitation. The pulmonary artery systolic pressure could not 
be determined. There is no pericardial effusion. 

___ RENAL U.S.: IMPRESSION: 1.  No definite ultrasound 
findings to suggest pyelonephritis, although this diagnosis 
cannot be excluded sonographically.  2.1 cm hypoechoic lesion in 
the
right upper renal pole, poorly visualized and indeterminate; 
this could represent a cyst but in the current clinical setting, 
focal infection or abscess cannot be excluded.  Per the 
patient's report, there has been a recent abdominal CT performed 
at ___ comparison to this study is recommended.  Of 
note, if this study is uploaded into PACS, an addendum could be 
issued at that time.  If this study cannot be obtained, further 
evaluation could be performed with CT. 3.  Right lower pole 15 
mm cyst or calyceal diverticulum.  4.  Possible duplex right 
kidney.  

___ CT ABD & PELVIS WITH CO: IMPRESSION: 1.  Large 
rim-enhancing fluid collection along the lower abdominal 
incision site, likely a seroma, is stable to slightly smaller 
since ___. 
Recommended clinical correlation to assess for possible 
superinfection. 2.  No intra-abdominal pathology identified to 
explain the patient's symptoms. 3.  Unexplained massive 
splenomegaly.
4.  Cholelithiasis.

___ CHEST PORT. LINE PLACEM: IMPRESSION: 1.  Right PICC at 
the cavoatrial junction. 2.  Stable cardiomegaly.

MICROBIOLOGY
___ 3:15 am BLOOD CULTURE      RIGHT ARM. 

                            **FINAL REPORT ___

   Blood Culture, Routine (Final ___: 
      ESCHERICHIA COLI.    FINAL SENSITIVITIES. 
         Cefazolin interpretative criteria are based on a dosage 
regimen of
         2g every 8h. 

                              SENSITIVITIES: MIC expressed in 
MCG/ML
                      
_________________________________________________________
                             ESCHERICHIA COLI
                             |   
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--    16 I
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

 

###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}, 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}, 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}, 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}, 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}, 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}, 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}, 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}, 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}, 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}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, Neuts {Neutrophil count}, Monos {Monocyte count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, CK(CPK {Creatine kinase measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, CK(CPK {Creatine kinase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, CK(CPK {Creatine kinase measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Serum total lactate dehydrogenase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Imaging {Imaging}, CHEST (PA {Plain x-ray of chest posteroanterior view}, cardiomegaly {Cardiomegaly}, vascular {Blood vessel structure}, congestion {Congestion}, edema {Edema}, AST {Aspartate aminotransferase measurement}, No acute {No abnormality detected}, intracranial {Intracranial structure}, centrum 
semiovale {Structure of centrum semiovale}, small vessel {Structure of small blood vessel (organ)}, ischemic change {Ischemia}, right side {Structure of right half of head}, brain MRI {Magnetic resonance imaging of brain}, evaluate {Evaluation procedure}, Cardiovascular ECHO {Echocardiography}, echo {Echocardiography}, left 
atrium {Left atrial structure}, dilated {Dilatation}, mild symmetric left 
ventricular hypertrophy {Mild left ventricular hypertrophy}, normal cavity {Normal size cardiac chamber}, systolic function {Normal left ventricular systolic function and wall motion}, focal wall motion abnormality {Left ventricular wall motion abnormality}, ventricular septal defect {Ventricular septal defect}, Right 
ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Normal ventricular wall motion}, aortic root is mildly dilated {Aortic root dilatation}, sinus {Structure of sinus of Valsalva}, aortic 
valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, Mild (1+) aortic regurgitation {Mild mitral valve regurgitation}, mitral 
valve {Mitral valve structure}, trivial mitral 
regurgitation {Mild mitral valve regurgitation}, pulmonary artery {Pulmonary artery structure}, systolic pressure {Normal systolic arterial pressure}, pericardial effusion {Pericardial effusion}, RENAL U.S {Echography of kidney}, ultrasound 
findings {Ultrasound scan finding}, pyelonephritis {Pyelonephritis}, lesion {Lesion}, right upper renal pole {Structure of upper pole of right kidney}, cyst {Cyst of kidney}, infection {Infectious disease}, abscess {Abscess}, evaluation {Evaluation procedure}, Right lower pole {Structure of lower pole of right kidney}, cyst {Cyst}, calyceal diverticulum {Diverticulum of renal calyx}, duplex {Double kidney}, right 
kidney {Right kidney structure}, fluid collection {Accumulation of fluid}, lower abdominal {Lower abdomen structure}, seroma {Seroma}, stable {Patient's condition stable}, infection {Infectious disease}, intra-abdominal {Structure of intraabdominal region}, pathology {Abnormal histology findings}, mass {Mass}, splenomegaly {Splenomegaly}, Cholelithiasis {Calculus in biliary tract}, CHEST {Thoracic structure}, Right {Structure of right half of chest wall}, PICC {Peripherally inserted central venous catheter in situ}, Stable {Symptom not changed}, cardiomegaly {Cardiomegaly}, MICROBIOLOGY {Microbiology}, CULTURE {Blood culture}, RIGHT ARM {Right upper arm structure}, Blood Culture {Blood culture}, regimen {Therapeutic regimen}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 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 chest discomfort and possible EKG changes in 
the context of a gastrointestinal illness.
.
# Nausea/vomiting/diarrhea  
Patient presented following three days of diarrhea, nausea, and 
dry heaving. This was more severe than her chronic diarrhea from 
radiation, and was likely the result of a viral or bacterial 
gastroenteritis. Stool studies and C. diff testing were 
negative, and according to the patient's oncologist, Arimidex 
was not likely causative. Ondansetron was originally given for 
nausea but this was changed to compazine given concern about QTc 
prolongation. The nausea and vomiting resolved over the course 
of the hospital stay, and the diarrhea improved significantly.
. 
# Chest pain  
Patient presented with chest discomfort that occurred in the 
context of dry heaving. Her PCP was concerned about EKG changes 
(septal Q waves and T wave inversions), especially concerning 
given the patient's significant history of CAD, including an MI 
that led to a cardiac catheterization in ___ (occlusion of the 
cardiac vessels was found at that time but patient did not 
tolerate the procedure and no intervention was done). However, 
following admission the patient noted that the discomfort was 
different from the pressure she had felt during her prior MI, 
and repeat EKG was similar to prior baseline (___). Troponins 
were elevated to 0.21 but downtrended. The overall presentation 
was not considered highly concerning for acute coronary 
syndrome, so anticoagulation was avoided given baseline 
thrombocytopenia. Cardiology (Atrius) was consulted and agreed 
that this was likely demand ischemia in the context of 
hypovolemia rather than ACS.
.  
# Fever/GNR bacteremia (E.Coli)
Febrile to 100.4 at ED, and had several further low-grade fevers 
on the floor. UA was positive for nitrites, and given diarrhea, 
GI was considered another possible source of infection. She was 
started on Bactrim on ___, but this was changed to meropenem on 
___ when blood cultures grew gram negative rods. This was 
continued despite final culture results showing pan-sensitive E. 
coli due to concern about cross-reactivity of cephalosporins 
with a penicillin allergy and fluoroquinolones in the context of 
prolonged QTc. ID consulted and determined that it was likely 
safe for her to try ceftriaxone, which she did on ___, and she 
was discharged on this after PICC placement.  Surveillance blood 
cultures were negative.  Renal U/S and CT scan of abd/pelvis 
were obtained, which did not show evidence of abscess.  She did 
have a fluid collection in the abdomen, but this is known from 
prior imaging approximately 1 month ago, and has improved in 
size.  The collection is most likely a seroma.  
.
#Pancytopenia  
Downtrending WBCs (to 1.5), hematocrit, and platelets; she was 
placed on neutropenic precautions. Possibly secondary to 
infection, antibiotics (Bactrim or meropenem), or other 
medication effect. OSH records showed baseline WBCs over past 
few months in 3s following radiation treatment. Although the 
levels did not return to baseline, they stabilized prior to 
discharge, and she will follow up with her outpatient providers.
 .
# Elevated bicarb  
Bicarb elevated to 33 on admission, likely representing a 
metabolic alkalosis due to GI losses from diarrhea. Metabolic 
compensation for a chronic respiratory acidosis may also have 
contributed.  Trended down shortly after admission.
.
# Diabetes  
Patient's home NPH was continued, and she was placed on an 
insulin sliding scale.
.
# Endometrial cancer  
Completed radiation therapy; not a candidate for chemo. Arimidex 
was continued.
.
TRANSITIONAL ISSUES
1.  complete course of IV antibiotics for E. coli bacteremia
2.  repeat CBC in 2 days to monitor leukopenia, anemia, 
thrombocytopenia
3.  repeat LFT's at PCP ___
4.  non-emergent MRI head to evaluate small hypodensity seen on 
CT head from ___ (see below for report)
5.  consider serial imaging of abdomen to monitor lesions in 
right kidney and fluid collection in abdomen. 
.
 

###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}, chest discomfort {Chest discomfort}, EKG changes {Electrocardiogram abnormal}, gastrointestinal illness {Disorder of gastrointestinal tract}, Nausea/vomiting/diarrhea {Nausea, vomiting and diarrhea}, diarrhea {Diarrhea}, nausea {Nausea}, dry heaving {Retching}, severe {Symptom severe}, chronic diarrhea {Chronic diarrhea}, radiation {Radiation oncology AND/OR radiotherapy}, viral {Viral gastroenteritis}, bacterial 
gastroenteritis {Bacterial gastroenteritis}, Stool studies {Stool microscopy}, nausea {Nausea}, changed {Change of medication}, QTc 
prolongation {Prolonged QT interval}, nausea and vomiting {Nausea and vomiting}, resolved {Problem resolved}, diarrhea {Diarrhea}, improved {Patient's condition improved}, Chest pain {Chest pain}, chest discomfort {Chest discomfort}, dry heaving {Retching}, EKG changes {Electrocardiogram abnormal}, Q waves {Finding of electrocardiogram Q wave}, T wave inversions {Inverted T wave}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, cardiac catheterization {Cardiac catheterization}, occlusion {Complete obstruction}, cardiac {Heart structure}, vessels {Blood vessel structure}, procedure {Procedure}, discomfort {Discomfort}, pressure {Tight chest}, MI {Myocardial infarction}, EKG {Electrocardiographic procedure}, baseline {Baseline state}, Troponins {Troponin measurement}, elevated {Elevation}, acute coronary 
syndrome {Acute coronary syndrome}, anticoagulation {Anticoagulant therapy}, baseline {Baseline state}, thrombocytopenia {Thrombocytopenic disorder}, Cardiology {Cardiology service}, demand ischemia {Ischemia co-occurrent and due to increased oxygen demand}, hypovolemia {Hypovolemia}, ACS {Acute coronary syndrome}, Fever {Fever}, GNR bacteremia {Bacteremia caused by Gram-negative bacteria}, E.Coli {Infection caused by Escherichia coli}, Febrile {Fever}, low-grade fevers {Low grade pyrexia}, UA {Urinalysis}, positive for nitrites {Nitrite detected in urine}, diarrhea {Diarrhea}, GI {Infection of gastrointestinal tract}, infection {Local infection of wound}, changed {Change of medication}, blood cultures {Blood culture}, culture {Microbial culture}, E. 
coli {Infection caused by Escherichia coli}, penicillin allergy {Allergy to penicillin}, prolonged QTc {Prolonged QT interval}, PICC placement {Insertion of peripherally inserted central catheter}, Surveillance blood 
cultures {Infection surveillance}, negative {No pathologic diagnosis}, Renal U/S {Echography of kidney}, CT scan of abd/pelvis {Computed tomography of abdomen and pelvis}, abscess {Abscess}, fluid collection {Accumulation of fluid}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, imaging {Imaging}, improved {Patient's condition improved}, seroma {Seroma}, Pancytopenia {Pancytopenia}, Downtrending {Serial hematocrit determinations}, WBCs {White blood cell count}, hematocrit {Hematocrit determination}, platelets {Platelet}, neutropenic {Neutropenia}, precautions {Safety precautions}, infection {Infectious disease}, antibiotics {Antibiotic therapy}, medication {Antibiotic therapy}, e WBCs {White blood cell count}, radiation {Radiation oncology AND/OR radiotherapy}, baseline {Baseline state}, stabilized {Stable hematocrit}, Elevated bicarb  {Serum bicarbonate above reference range}, Bicarb elevated {Serum bicarbonate above reference range}, metabolic alkalosis {Metabolic alkalosis}, GI losses {Volume depletion, gastrointestinal loss}, diarrhea {Diarrhea}, chronic respiratory acidosis {Chronic respiratory acidosis}, Diabetes {Diabetes mellitus}, insulin sliding scale {Sliding scale insulin regime}, Endometrial cancer {Endometrial carcinoma}, radiation therapy {Radiation oncology AND/OR radiotherapy}, chemo {Chemotherapy}, IV antibiotics {Intravenous antibiotic therapy}, E. coli bacteremia {Bacteremia caused by Coliform}, CBC {Complete blood count}, monitor {Monitoring for signs and symptoms of infection}, leukopenia {Leukopenia}, anemia {Anemia}, thrombocytopenia {Thrombocytopenic disorder}, LFT's {Hepatic function panel}, MRI head {Magnetic resonance imaging of head}, CT head {Computed tomography of head}, imaging of abdomen {Imaging of abdomen}, lesions {Lesion}, right kidney {Right kidney structure}, fluid collection {Accumulation of fluid}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Levothyroxine Sodium 100 mcg PO DAILY 
2. anastrozole *NF* 1 mg Oral daily 
3. Omeprazole 40 mg PO DAILY 
4. Fluoxetine 40 mg PO DAILY 
5. Simvastatin 20 mg PO DAILY 
6. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 
7. Lisinopril 5 mg PO DAILY 
8. Metoprolol Succinate XL 100 mg PO BID 
9. Aspirin 81 mg PO DAILY 
10. TraZODone 25 mg PO HS 
11. Nitroglycerin SL 0.4 mg SL PRN chest pain 
12. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain 
13. Naproxen 220 mg PO Q8H:PRN pain 
14. Humulin N 15 Units Breakfast
Humulin N 15 Units Bedtime

 
Discharge Medications:
1. anastrozole *NF* 1 mg Oral daily 
2. Aspirin 81 mg PO DAILY 
3. Fluoxetine 40 mg PO DAILY 
4. Humulin N 15 Units Breakfast
Humulin N 15 Units Bedtime
5. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 
6. Levothyroxine Sodium 100 mcg PO DAILY 
7. Lisinopril 5 mg PO DAILY 
8. Metoprolol Succinate XL 100 mg PO BID 
9. Nitroglycerin SL 0.4 mg SL PRN chest pain 
10. Omeprazole 40 mg PO DAILY 
11. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain 
12. Simvastatin 20 mg PO DAILY 
13. TraZODone 25 mg PO HS 
14. Naproxen 220 mg PO Q8H:PRN pain 
15. CeftriaXONE 2 gm IV Q24H 
RX *ceftriaxone 2 gram 2 g IV once daily Disp #*7 Syringe 
Refills:*0
16. Outpatient Lab Work
Please check CBC with differential on ___ and fax results to 
PCP ___ MD Phone: ___ 
Fax: ___ 
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
1. Diarrhea
2. Urinary tract infection
3. GNR bacteremia
4. Pancytopenia
5. Demand ischemia

 
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}, Diarrhea {Diarrhea}, Urinary tract infection {Urinary tract infectious disease}, GNR bacteremia {Bacteremia caused by Gram-negative bacteria}, Pancytopenia {Pancytopenia}, Demand ischemia {Ischemia co-occurrent and due to increased oxygen demand}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, assistance or aid (walker 
or cane) {Assistance with walking using device}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital at ___ 
___ from ___ to ___ for assessment of your 
chest pain and nausea/vomiting.  Your symptoms resolved on their 
own but you were found to have a bacterial infection in your 
blood.  You were started on antibiotics and will continue these 
at home until ___.  Your blood counts were found to be low 
but stable; you will need repeat blood work drawn by the 
visiting nurse on ___.  Please continue to speak with your 
primary care doctor and oncologist regarding these findings. 

While you were here, a CAT scan of the head was performed 
showing a small area of asymmetry; please speak with your 
primary care doctor regarding ___ nonurgent MRI for further 
evaluation. 

It was a pleasure caring for you during your admission at ___.
 

###RESPONSE: assessment {Evaluation procedure}, chest pain {Chest pain}, nausea/vomiting {Nausea and vomiting}, resolved {Problem resolved}, bacterial infection {Bacterial infectious disease}, blood {Blood culture}, antibiotics {Antibiotic therapy}, blood counts {Blood test}, stable {Patient's condition stable}, blood {Blood test}, CAT scan of the head {Computed tomography of head}, MRI {Magnetic resonance imaging}, evaluation {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: 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: OBSTETRICS/GYNECOLOGY
 

###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: 
Shellfish Derived
 
Attending: ___.
 
Chief Complaint:
Incisional pain
 
Major Surgical or Invasive Procedure:
Scar injection

 

###RESPONSE: Shellfish {Allergy to shellfish}, Incisional {Surgical incision wound}, pain {Pain}, Scar {Scar}, injection {Injection}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ s/p TAH/BSO on ___ who presented to ED with 
abdominal pain x 10d.  Pain started after having large BM 10d 
ago - she stood up from the toilet and was instantly doubled 
over in pain.  It was the first BM since before her surgery.  
The pain at that time was deep abdominal in location and has 
overall improved since that time, turning into the what she 
describes as ""gas pain"". She has had 2 BM since that time, ___ 
ago and again 2 days ago.  She has been taking colace BID.

She started having burning pain on her ___ skin and 
""about 4 layers deep to the skin"" in the same area roughly 8 
days ago.  ""It feels like my skin is on fire.""  Touching her 
skin exacerbates the pain.  She reports that even when sleeping, 
when her sheets touch the ___ skin, it wakes her 
from
sleep.  She is unable to wear underpants or pants ___ to pain. 
She has never experienced this before; she recovered well after 
her liposuction procedure.

+ nausea when pain is worst, denies emesis.  Tolerating liquids, 
pudding, and yogurt.  Passing flatus.  Denies fevers, chills, 
abnormal vaginal discharge or bleeding.  Has had occasional hot 
flashes and vaginal dryness.  Not sexually active.

In the ED, she received morphine 8mg IV, zofran 4mg IV, and 
dilaudid 0.5 IV.  The dilaudid has had the best effect.  She had 
2L of NS.
 

###RESPONSE: TAH/BSO {Total abdominal hysterectomy with bilateral salpingo-oophorectomy}, abdominal pain {Abdominal pain}, Pain {Abdominal pain}, BM {Passes stool completely}, pain {Abdominal pain}, BM {Passes stool completely}, surgery {Surgical procedure}, pain {Abdominal pain}, abdominal {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, improved {Patient's condition improved}, pain {Pain}, BM {Passes stool completely}, burning pain {Burning pain}, skin {Skin structure}, skin {Skin structure}, skin {Skin structure}, skin {Skin structure}, pain {Abdominal pain}, sleeping {Asleep}, skin {Skin structure}, pain {Pain}, liposuction procedure {Liposuction of subcutaneous tissue}, nausea {Nausea}, pain {Pain}, emesis {Vomiting}, Tolerating liquids {Tolerating oral fluid}, Passing flatus {Passing flatus}, fevers {Fever}, chills {Chill}, abnormal vaginal discharge {Vaginal discharge problem}, bleeding {Bleeding from vagina}, hot 
flashes {Menopausal flushing}, vaginal dryness {Vaginal dryness}, Not sexually active {Currently not sexually active}, IV {Intravenous therapy}, IV {Intravenous therapy}, IV {Intravenous 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:
GYNHx:
- denies h/o abnl pap, last pap ___ neg
- Denies h/o STI
- female partners

___: GO

PMH: Mild asthma, chronic back pain - disc degeneration, GERD,
Depression, Insomnia

PSH: 
- TAH BSO as above
- Liposuction x 2, ___ - stomach and thighs
 

###RESPONSE: abnl pap {Abnormal cervical smear}, STI {Sexually transmitted infectious disease}, Mild asthma {Mild asthma}, chronic back pain {Chronic back pain}, disc degeneration {Degeneration of intervertebral disc}, GERD {Gastroesophageal reflux disease}, Depression {Depressive disorder}, Insomnia {Insomnia}, TAH BSO {Total abdominal hysterectomy with bilateral salpingo-oophorectomy}, Liposuction {Liposuction of subcutaneous tissue}, stomach {Stomach structure}, thighs {Structure of left thigh}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
NC
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
On admission: 
VS:  98.9    67   112/70   16   98RA
uncomfortable appearing
RRR
CTAB
abd - soft, mildly distended +tympany, esp in upper quadrants; 
mostly TTP in 5cm circumferential area around incision, from 
below umbilicus to the mons.  no crepitus.  no cutaneous 
numbness.

inc: Pfannensteil, well healed, partially epithelialized, no 
erythema, exudates, or induration

ext NT b/l
pelvic: deferred

 

###RESPONSE: Physical Exam {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, RRR {Normal heart rate}, CTAB {Normal breath sounds}, soft {Abdomen soft}, distended {Swollen abdomen}, tympany {Abdomen tympanitic}, upper quadrants {Structure of upper abdominal quadrant}, TTP {Tenderness}, incision {Abdomen incision}, umbilicus {Umbilical structure}, mons {Mons pubis structure}, crepitus {Subcutaneous crepitus}, cutaneous 
numbness {Numbness of skin}, well healed {Surgical wound, healed}, epithelialized {Epithelialization}, erythema {Erythema}, exudates {Exudate}, induration {Induration}, ext {Examination of limb}, NT {Abdominal tenderness}, pelvic {Manual pelvic examination}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 07:15PM BLOOD WBC-6.3 RBC-4.60 Hgb-10.3* Hct-33.8* 
MCV-74* MCH-22.5* MCHC-30.6* RDW-14.1 Plt ___
___ 06:20AM BLOOD WBC-5.4 RBC-4.25 Hgb-9.8* Hct-32.3* 
MCV-76* MCH-23.0* MCHC-30.2* RDW-13.9 Plt ___
___ 07:15PM BLOOD Neuts-61.0 ___ Monos-3.5 Eos-3.5 
Baso-0.5
___ 07:15PM BLOOD Glucose-101* UreaN-9 Creat-0.9 Na-137 
K-4.3 Cl-102 HCO3-27 AnGap-12
___ 06:20AM BLOOD Glucose-90 UreaN-13 Creat-1.0 Na-137 
K-4.4 Cl-100 HCO3-28 AnGap-13
___ 06:20AM BLOOD Calcium-9.8 Phos-4.0 Mg-2.2

___ 02:58AM URINE Blood-TR Nitrite-NEG Protein-30 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
___ 02:58AM URINE RBC-2 WBC-0 Bacteri-NONE Yeast-NONE 
Epi-22
URINE CULTURE (Final ___: 
      MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT 
WITH SKIN
      AND/OR GENITAL CONTAMINATION. 

CT ___: IMPRESSION: No definite intra-abdominal abscess. There 
is a small amount of fluid at the operative site, not 
unanticipated. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, URINE Blood {Blood in urine}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, URINE {Evaluation of urine specimen}, RBC {Red blood cell count}, WBC {White blood cell count}, URINE CULTURE {Urine culture}, SKIN {Skin structure}, intra-abdominal abscess {Abdominal abscess}, fluid {Effusion}, operative site {Operative site}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. ___ was admitted from the ED early on ___ with abdominal 
pain and incisional pain. CT had demonstrated no acute 
intraabdominal process. Her pain was felt to be consistent with 
post-operative neuropathy. She was started on tylenol, motrin, 
and dilaudid prn for pain. She was started on a bowel regimen. 
The chronic pain service saw her later that morning and 
performed an incisional injection with steroids and bupivicaine. 
She was also started on gabapentin. She had some immediate 
relief of her pain, however the majority of the benefit wore off 
after several hours. Lidocaine patches were applied with 
excellent relief. She reported a good decrease in her pain where 
she was able to tolerate some touch and the feel of 
clothing/blankets on her skin. She did remain constipated, but 
felt ready for discharge home on ___. Follow-up with the 
chronic pain clinic was arranged.
 

###RESPONSE: abdominal 
pain {Abdominal pain}, incisional {Surgical incision wound}, pain {Pain}, CT {Computed tomography}, intraabdominal {Structure of intraabdominal region}, pain {Abdominal pain}, post-operative {Postoperative state}, neuropathy {Neuropathy}, pain {Abdominal pain}, bowel {Intestinal structure}, regimen {Therapeutic regimen}, pain service saw {Seen by pain management service}, incisional {Surgical incision wound}, injection {Injection}, steroids {Steroid therapy}, pain {Abdominal pain}, pain {Abdominal pain}, skin {Skin structure}, constipated {Constipation}, ready for discharge {Ready for discharge}, chronic pain {Chronic pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
percocet prn, colace, prilosec  
 
Discharge Medications:
1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed for pain.  
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 
times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) 
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO BID (2 times a day).  
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 
times a day).
Disp:*90 Capsule(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO every four (4) 
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: 
Two (2) patch Topical DAILY (Daily): Keep on for 12 hours, off 
for 12 hours .
Disp:*20 patch* Refills:*2*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Cutaneous neuropathy

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Cutaneous {Skin structure}, neuropathy {Neuropathy}, 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 for nerve pain around your incision. You 
received an injection of an anesthetic and steroid which helped 
lessen the pain. We started you on a medication called 
gabapentin which should start to work in a few days. You also 
were given lidocaine patches to put on your skin and a narcotic 
called dilaudid to help lessen the pain until the steroid 
medication starts to work. You should also continue to take 
Ibuprofen and colace. It is important to drink lots of fluid to 
help keep your stools soft.
 

###RESPONSE: nerve {Nerve structure}, pain {Pain}, incision {Surgical incision wound}, injection {Injection}, steroid {Steroid therapy}, pain {Pain}, medication {Prescription of drug}, skin {Skin structure}, pain {Pain}, steroid 
medication {Steroid therapy}, drink lots of fluid {Fluid intake encouragement}, stools soft {Soft stool}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: OBSTETRICS/GYNECOLOGY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
nausea/vomiting
 
Major Surgical or Invasive Procedure:
none
 

###RESPONSE: nausea/vomiting {Nausea and vomiting}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Patient is a ___ year old G1P0 at approximately 15+2 weeks by 
unsure LMP of ___ presenting to the ED with nausea and 
vomiting unable to tolerate PO intake for 3 days. Patient 
reports a history of hyperemesis gravidarum since about 8 weeks 
gestation. She was seen for an initial prenatal visit by 
RN-Midwife at ___. She denies having had 
any ultrasounds yet. She has had her initial prenatal labs. She 
had a prescription for PO Zofran which she said was not helping. 
She was seen twice at the ___ urgent care unit for IVF and IV 
antiemetics. Symptoms persisted for 1 month before spontaneous 
resolving. Her symptoms recurred on ___ with severe nausea and 
vomiting. Last meal was chicken soup on that date which she 
could not keep down. She has tried water and ginger ale which 
also makes her nauseated. She is not currently taking any 
antiemetics.

ROS: (+) Back/shoulder pain with emesis, (+) epigastric pain 
with emesis, (+) chills, (+) 8 lb weight loss. Denies fever, 
myalgias, diarrhea, SOB, dizziness, rhinorrhea, cough. No sick 
contacts. Seasonal flu shot 1 month ago. No H1N1.
 

###RESPONSE: nausea and 
vomiting {Nausea and vomiting}, hyperemesis gravidarum {Excessive vomiting in pregnancy}, gestation {Pregnancy}, initial prenatal visit {Prenatal initial visit}, ultrasounds {Ultrasonography}, prescription {Prescription}, IVF {Administration of intravenous fluids}, IV {Administration of drug or medicament via intravenous route}, resolving {Patient's condition improved}, nausea and 
vomiting {Nausea and vomiting}, nauseated {Nausea}, shoulder pain {Shoulder pain}, emesis {Vomiting}, epigastric pain {Epigastric pain}, emesis {Vomiting}, chills {Chill}, weight loss {Weight loss}, fever {Fever}, myalgias {Muscle pain}, diarrhea {Diarrhea}, SOB {Dyspnea}, dizziness {Dizziness}, rhinorrhea {Nasal discharge}, cough {Cough}, Seasonal flu shot {Administration of vaccine product containing only Influenza virus antigen}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
PRENATAL COURSE
___ ___ by 17wk U/S (changed from initial ___ ___
*)Labs: A+/Ab-,RI,HbsAg-,RPRnr,HIV-,GC/CT-
*)CF negative, nl hgb electrophoresis
*)No screening/ultrasound prior to this admission

PAST OBSTETRIC HISTORY
G1

PAST GYNECOLOGIC HISTORY
- no paps yet
- denies STDs
- normal menses

PAST MEDICAL HISTORY
denies

PAST SURGICAL HISTORY
denies
 

###RESPONSE: U/S {Ultrasonography}, HIV {Human immunodeficiency virus infection}, GC {Gonorrhea}, CT {Chlamydia culture}, hgb {Measurement of total hemoglobin concentration}, electrophoresis {Electrophoresis measurement}, ultrasound {Ultrasonography}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
noncontributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
(on admission)
PE: T 97.8->98.4, BP 129/62->103/56, P ___, RR 20, O2 100%
FHR: 156 bpm
GENERAL: appears tired and weak, lying in stretcher.
CV: RRR
ABDOMEN: soft, gravid, tender to palpation in epigastrium, 
mildly
tender RLQ
EXTREMITIES: no edema

(___) RUQ ULTRASOUND
IMPRESSION: 
Normal-appearing gallbladder. No findings to suggest acute 
cholecystitis. 
  
___ FETAL SURVEY
There is a single live intrauterine pregnancy with fetus in 
cephalic position.  The placenta is fundal. There is no evidence 
of previa. There is a normal amount of amniotic fluid. Views of 
the head, face, stomach, cord insertion site, bladder were 
normal. There is an echogenic focus in the left cardiac 
ventricle. There is polydactyly in the left hand and probably 
polydactyly in the left foot. Both kidneys show caliectasis 
measuring 3 mm.
  
The following biometric data were obtained:
BPD: 17 weeks 2 days  
HC: 16 weeks 6 days 
AC: 17 weeks 4 days 
FL: 17 weeks 5 days 
  
AGE BY ULTRASOUND: 17 weeks 2 days
AGE BY LMP: 15 weeks 3 days
EFW: 199g

IMPRESSION: Single live intrauterine pregnancy at 17 weeks 2 
days. There is an echogenic focus in the left ventricle. 
Bilateral caliectasis without hydronephrosis. Left hand 
polydactyly.
 

###RESPONSE: BP {Blood pressure finding}, RR {Finding of rate of respiration}, FHR {Finding of heart rate}, GENERAL {General examination of patient}, tired {Tired}, weak {Asthenia}, lying {Lying in bed}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, ABDOMEN {Examination of abdomen}, soft {Abdomen soft}, gravid {Finding of gravida}, tender {Abdominal tenderness}, palpation {Palpation}, epigastrium {Epigastric region structure}, tender {Abdominal tenderness}, RLQ {Right lower quadrant pain}, EXTREMITIES {Examination of limb}, edema {Edema}, RA {Breathing room air}, ND {Swollen abdomen}, gallbladder {Gallbladder structure}, acute 
cholecystitis {Acute cholecystitis}, single live intrauterine pregnancy {Fetus present}, fetus {Entire fetus}, cephalic position {Cephalic fetal presentation}, placenta {Placental structure}, fundal {Structure of fundus uteri}, no evidence {No abnormality detected}, previa {Placenta previa}, normal amount of amniotic fluid {Amniotic fluid volume within reference range}, head {Fetal head structure}, face {Face structure}, stomach {Stomach structure}, cord insertion site {Umbilical cord structure}, bladder {Urinary bladder structure}, left cardiac 
ventricle {Left cardiac ventricular structure}, polydactyly {Polydactyly}, left hand {Structure of left hand}, polydactyly {Polydactyly}, left foot {Structure of left foot}, Both kidneys {Both kidneys}, caliectasis {Dilatation of calyx}, BPD {Bronchopulmonary dysplasia of newborn}, ULTRASOUND {Ultrasonography}, Single live intrauterine pregnancy {Fetus present}, left ventricle {Left cardiac ventricular structure}, caliectasis {Dilatation of calyx}, hydronephrosis {Hydronephrosis}, Left hand {Structure of left hand}, polydactyly {Polydactyly}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ WBC-12.7 RBC-3.63 Hgb-10.7 Hct-32.5 MCV-89 Plt-460
___ Neuts-90.2 ___ Monos-2.1 Eos-0.2 Baso-0.1
___ ___ PTT-30.7 ___

___ Glu-97 BUN-4 Cre-0.5 Na-138 K-3.4 Cl-107 HCO3-14
___ Glu-89 BUN-3 Creat-0.4 Na-139 K-3.1 Cl-111 HCO3-16
___ Glu-86 BUN-2 Creat-0.3 Na-138 K-3.2 Cl-109 HCO3-18
___ ALT-9 AST-13 AlkPhos-48 TotBili-0.5 Lipase-17
___ Calcium-8.7 Phos-2.1 Mg-1.5 TSH-0.062
___ Calcium-8.4 Phos-3.8 Mg-2.0
___ Calcium-7.7 Phos-2.6 Mg-1.5
___ BLOOD T4-11.0 T3-149 Lactate-0.9

___ BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG 
Barbitr-NEG Tricycl-NEG

HELICOBACTER PYLORI ANTIBODY TEST (Final ___: 
  NEGATIVE BY EIA

URINE CULTURE (Final ___: 
  MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
  WITH SKIN AND/OR GENITAL CONTAMINATION
 

###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}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, TSH {Thyroid stimulating hormone measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, URINE CULTURE {Urine culture}, GENITAL {Genital structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ G1 admitted at 17+1 weeks gestation with hyperemesis.
.
Ms ___ was admitted for IV hydration, antiemetics, and 
electrolyte repletion. She complained of epigastric pain and she 
underwent a right upper quandrant ultrasound which was normal. 
Her ___ was recalculated based on her full fetal survey. An 
additional finding on her fetal survey included an echogenic 
focus in the left ventricle and bilateral caliectasis without 
hydronephrosis, and left hand polydactyly. Ms ___ was 
counseled regarding these findings and opted to have a Quad 
Screen and declined an amniocentesis. The Quad screen was sent 
during this admission. By hospital day #3, she was tolerating 
po's and was discharged home. She will have close outpatient 
followup.
 

###RESPONSE: gestation {Pregnancy}, hyperemesis {Hyperemesis}, IV hydration {Administration of intravenous fluids}, electrolyte repletion {Administration of electrolytes}, epigastric pain {Epigastric pain}, right upper quandrant ultrasound {Ultrasonography of abdomen, right upper quadrant and epigastrium}, left ventricle {Left cardiac ventricular structure}, caliectasis {Dilatation of calyx}, hydronephrosis {Hydronephrosis}, left hand {Structure of left hand}, polydactyly {Polydactyly}, Quad {Measurement of alpha fetoprotein and human chorionic gonadotropin and unconjugated estriol in serum or plasma specimen}, amniocentesis {Amniocentesis}, Quad {Measurement of alpha fetoprotein and human chorionic gonadotropin and unconjugated estriol in serum or plasma specimen}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Flintstones vitamins
 

###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:
pregnancy at 17 weeks gestation
hyperemesis
 
Discharge Condition:
stable
 

###RESPONSE: pregnancy {Pregnancy}, 17 weeks gestation {Gestation period, 17 weeks}, hyperemesis {Hyperemesis}, stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
try to stay hydrated. Use medication as needed for your nausea. 
call your doctor with any abdominal pain/cramping, leaking of 
fluid, vaginal bleeding, fevers > 100.4, persistent 
nausea/vomiting, unable to tolerate fluids, or with any 
questions or concerns you may have
 

###RESPONSE: nausea {Nausea}, abdominal pain {Abdominal pain}, cramping {Cramping pain}, leaking {Discharge}, fluid {Effusion}, vaginal bleeding {Bleeding from vagina}, fevers {Fever}, nausea/vomiting {Nausea and vomiting}, fluids {Tolerating oral fluid}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                      Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___
 
Chief Complaint:
Shortness of Breath
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: 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:
Ms. ___ is a ___ yo F w/hx of afib on coumadin, COPD, MR, TR 
who presented on ___ from her nursing home with falls and 
questionable left facial droop.  She was initially a code stroke 
in the ED.  She was evaluated by neurology who determined that 
she did not have a stroke and she did not require further 
neurologic evaluation.  She had CT head noncon and CTA 
head/neck, both were negative. She also had a negative urine and 
CXR except cardiomegaly.  On admission she required 3L NC.  Over 
the course of her hospitalization she has developed worsening 
hypoxia so that in the evening of ___ she required 100% 
facemask.  She was given 40mg IV Lasix and urinated 1700ml and 
improved to 2L NC.  CTA done overnight showed no PE but did show 
bileratal pleural effusions L>R with LLL collapse and 
mediastinal lymphadenopathy.  Over the course of the day on 
___ she again had worsening oxygen requirement and developed 
worsening tachycardia with afib and RVR.  Blood pressure was 
stable in the 130s-140s/80s-90s.
.
On arrival to the ICU, she is breathing comfortably. She denies 
shortness of breath, chest pain, palpitations.  She has not had 
fevers, chills or night sweats.  She has no cough.
.
Review of systems: 
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or 
gain. Denies headache, sinus tenderness, rhinorrhea or 
congestion. Denies cough, shortness of breath, or wheezing. 
Denies chest pain, chest pressure, palpitations, or weakness. 
Denies nausea, vomiting, diarrhea, constipation, abdominal pain, 
or changes in bowel habits. Denies dysuria, frequency, or 
urgency. Denies arthralgias or myalgias. Denies rashes or skin 
changes. 

 

###RESPONSE: afib {Atrial fibrillation}, COPD {Chronic obstructive lung disease}, MR {Mitral valve regurgitation}, falls {Falls}, left {Structure of left half of face}, facial droop {Weakness of face muscles}, stroke {Cerebrovascular accident}, evaluated by neurology {Seen by neurologist}, stroke {Cerebrovascular accident}, neurologic evaluation {Neurological examination}, CT head {Computed tomography of head}, CTA 
head/neck {Computed tomography angiography of head and neck with contrast}, negative {No abnormality detected}, negative {No abnormality detected}, CXR {Plain chest X-ray}, cardiomegaly {Cardiomegaly}, NC {Oxygen administration by nasal cannula}, worsening {Patient's condition worsened}, hypoxia {Hypoxia}, 100% 
facemask {Oxygen administration by mask}, IV {Intravenous therapy}, improved {Patient's condition improved}, NC {Oxygen administration by nasal cannula}, CTA {Computed tomography angiography with contrast}, PE {Pulmonary embolism}, bileratal pleural effusions {Bilateral pleural effusion}, LLL {Structure of lower lobe of left lung}, collapse {Atelectasis}, mediastinal lymphadenopathy {Mediastinal lymphadenopathy}, worsening {Patient's condition worsened}, worsening {Patient's condition worsened}, tachycardia {Tachycardia}, afib and RVR {Atrial fibrillation with rapid ventricular response}, Blood pressure was 
stable {Stable blood pressure}, ICU {Patient transfer to intensive care unit}, breathing comfortably {Breathing easily}, shortness of breath {Dyspnea}, chest pain {Chest pain}, palpitations {Palpitations}, fevers {Fever}, chills {Chill}, night sweats {Night sweats}, cough {Cough}, Review of systems {Review of systems}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, headache {Headache}, sinus tenderness {Tenderness over frontal sinus}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, Denies cough {Does not cough}, shortness of breath {Dyspnea}, wheezing {Wheezing}, chest pain {Chest pain}, chest pressure {Tight chest}, palpitations {Palpitations}, weakness {Asthenia}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, changes in bowel habits {Altered bowel function}, dysuria {Dysuria}, frequency {Increased frequency of urination}, urgency {Urgent desire to urinate}, arthralgias {Joint pain}, myalgias {Muscle pain}, rashes {Eruption of skin}, skin 
changes {Skin appearance abnormal}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
-Afib on warfarin  
-Chronic leukocytosis and thrombocytosis  
-COPD  
-Mitral and tricuspid regurgitation  
-Chronic gait instability  
-HTN  
-Depression  
-s/p back surgery for tumor resection on spinal cord. Did not 
received chemo or radiation per son.  
-Spinal stenosis  
-Hysterectomy  
-Osteoporosis  
-GERD  
 

###RESPONSE: Afib {Atrial fibrillation}, on warfarin {Warfarin therapy}, leukocytosis {Leukocytosis}, thrombocytosis {Thrombocytosis}, COPD {Chronic obstructive lung disease}, Mitral {Mitral valve regurgitation}, tricuspid regurgitation {Tricuspid valve regurgitation}, gait instability  {Unsteady when walking}, HTN {Hypertensive disorder, systemic arterial}, Depression {Depressive disorder}, back {Structure of back of trunk}, surgery {Surgical procedure}, tumor resection {Excision of neoplasm}, spinal cord {Spinal cord structure}, chemo {Chemotherapy}, radiation {Radiation oncology AND/OR radiotherapy}, Spinal stenosis {Spinal stenosis}, Hysterectomy {Hysterectomy}, Osteoporosis {Osteoporosis}, GERD  {Gastroesophageal reflux 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:
Family Hx: son with CAD s/p MI  
 

###RESPONSE: CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Vitals: T: BP: P: R: 18 O2:  
General: Alert, oriented, breathing in the ___ without clear 
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds at the bases bilaterally, L 
moreso than R side. No crackles or wheezes.
CV: Tachycardic, irregular, no mumurs appreciated.
Abdomen:  soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: warm, well perfused, 2+ pulses, R leg wrapped in bandages.

 

###RESPONSE: Physical Exam {Physical examination procedure}, Vitals {Vital signs finding}, BP {Blood pressure finding}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, Decreased breath sounds {Decreased breath sounds}, bases {Structure of base of lung}, L {Structure of base of left lung}, R side {Structure of base of right lung}, crackles {Respiratory crackles}, wheezes {Wheezing}, CV {Cardiovascular physical examination}, Tachycardic {Tachycardia}, irregular {Irregular heart beat}, mumurs {Heart murmur}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, Ext {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, R leg {Structure of right lower leg}, wrapped in bandages {Application of bandage}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:24PM URINE  HOURS-RANDOM
___ 06:24PM URINE  UHOLD-HOLD
___ 06:24PM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 06:24PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 
LEUK-NEG
___ 05:38PM   GLUCOSE-112* UREA N-23* CREAT-1.0 SODIUM-144 
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-24 ANION GAP-16
___ 05:38PM   estGFR-Using this
___ 05:38PM   WBC-20.3* RBC-6.11* HGB-10.7* HCT-38.6 
MCV-63* MCH-17.6* MCHC-27.8* RDW-19.3*
___ 05:38PM   PLT COUNT-657*
___ 05:38PM   ___ PTT-31.7 ___
 

###RESPONSE: COLOR {Color finding}, PROTEIN {Measurement of protein in urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Patient transferred to ICU with worsening hypoxia and afib with 
RVR.

1. Hypoxia:  On admission patient had a new oxygen requirement, 
3L nasal cannula, while at baseline she was on room air.  
Throughout her admission, patient denied shortness of breath but 
did complain of fatigue.  Given her rapid heart rate, the 
patient underwent a CTA to rule out PE.  CTA showed bilateral 
pleural effusions with LLL collapse, but no PE.  Given CTA 
findings her initial presentation was thought to be secondary to 
heart failure, possibly exacerbated by a fib w/ RVR and she was 
diuresed with po lasix.  CTA did show extensive mediastinal 
lymphadenopathy and so infectious vs. malignant etiologies were 
considered.  
.
Over the course of her hospitalization, she required two 
admissions to the MICU.  On ___ she decompensated with 
hypoxia and A-fib with RVR with a question of aspiration event. 
Her a-fib was managed by increasing metoprolol dose and digoxin 
loading/maintenance with good HR (70s-80s) and BP control 
(110-120s).  Given the rise in WBC, she was started and 
completed an 8 day course for HCAP with vanc and zosyn.  She was 
diuresed in the with iv lasix.  A TEE was done that showed 
diastolic dysfunction and BNP was elevated to 10K.  CE were 
trended but were flat.  She was transferred to the floor for 
further management. 
.
On the floor patient improved with diuresis and antibiotic 
course.  Her leukocytosis also downtrended.  Speech and swallow 
consulted who did not see si/sx of aspiration.  However, there 
remained concern that patient was aspirating and she was placed 
on aspiration precautions.  She had another episode of hypoxia 
with afib and RVR requiring NRB; ABG on NRB showed 7.52/36/65/30 
with lactate 4.8.  She was transferred to the MICU a second 
time.  A repeat Chest CT was concerning for right middle lobe 
pneumonia, patient weaned off to nasal cannula and lactate 
trended down.  Patient was diuresed and transferred back to the 
floor.  On ___, patient spiked a fever, and was started on iv 
meropenem and vanc for an 8 day course of aspiration pneumonia, 
and pan-cultured.  She improved with antibiotics and 
defervesced.  Urine and blood culture showed no growth on 
discharge.
.
Patient was managed with chest ___ and aggressive pulmonary 
toilet.  Pulmonology was consulted, who agreed with management 
of antibiotics, diuresis, and BP/rate control.  Given her 
anatomy thoracentesis thought to be unlikely to result in 
re-expansion of her left lung.  Goals of care were discussed 
further with patient.  Patient decided that further MICU 
transfers were not align with her goals of care and decided to 
be DNI.  Patient was discharged to nursing facility with plans 
to transition to hospice care.  Ultimately decision was made 
with family and patient for do not hospitalize as this would not 
be consistent with patient's goals of care.
- Continue iv vanc and meropenem until ___ to complete 8 
day course
- Continue nasal cannula, wean as tolerated
- Patient has decided to be: DNR/DNI/DNH
.
2. Afib with RVR: This may have been precipitated by lung 
etiology given hypoxia.  Blood pressure was initially stable 
though dipped into the low 100s systolic.  She was on Metoprolol 
on admission which was increased to 75mg PO TID.  Patient had 
several episodes of RVR to 160s which were managed with gentle 
bolus, with minimal response, then IV metoprolol and IV dilt.  
She was ruled out for an MI, and infectious work up was 
revealing for pneumonia.  Her coumadin was initially held given 
her history of falls.  This was restarted during her 
hospitalization.  However, as patient remained hypoxic and weak, 
further discussions regarding risk/benefit of coumadin were had 
with patient and son. Ultimately, the immediate risks of bleed 
were thought to outweigh the long-run benefits. Coumadin was 
stopped on discharge.
- Hold metoprolol or diltiazam if SBP<100, HR<60
.
3. Acute Heart Failure: CT scans notable for bilateral pleural 
effusions. A TTE was done that showed EF 55%, RV moderately 
dilated with mild global free wall hypokinesis. CE were 
negative.  She was maintained with lasix, bb, ccb, and digoxin.  
She was transitioned from iv lasix to 40mg PO lasix, to keep net 
even to 500cc net negative.
- Suspect that lasix dose will need to be reduced.  When patient 
stops iv antibiotics please determine new lasix dose by PO 
intake and fluid status.  Consider reducing dose back to home 
dose of 10mg daily.
.
4. Extensive Mediastinal Lymphadenopathy: This was seen on CTA 
and the differential thought to include infection vs. 
malignancy.  On repeat imaging, there was small improvement in 
lymphadenopathy after diuresis and antibiotic treatment.  
Pulmonology consulted and given goals of care (as stated above), 
further invasive work up was not in line with patient's wishes.  
As stated above she spiked a temp ___ and was pan-cultured and 
started on ___ x8days for aspiration pna.
.
5. Leukocytosis: Seen by hematologist Dr. ___ at ___, 
with leukocytosis in the past in ___.  Throughout her 
admission, WBC ranged from 9 to 30 w/ primarily PMN diff (90s).  
She was treated for pneumonia infection with two course of 
antibiotics which improved her leukocytosis.
.
6. Thrombocytosis: It was confirmed w/ her outpatient 
hematologist that patient has a known JACK2 mutation by PCR.  
She was continued on Hydroxyurea 3 days per week.
 

###RESPONSE: transferred to ICU {Patient transfer to intensive care unit}, worsening {Patient's condition worsened}, hypoxia {Hypoxia}, afib with 
RVR {Atrial fibrillation with rapid ventricular response}, Hypoxia {Hypoxia}, nasal cannula {Oxygen administration by nasal cannula}, baseline {Baseline state}, on room air {Breathing room air}, shortness of breath {Dyspnea}, fatigue {Fatigue}, rapid heart rate {Tachycardia}, CTA {Computed tomography angiography with contrast}, PE {Pulmonary embolism}, CTA {Computed tomography angiography with contrast}, bilateral 
pleural effusions {Bilateral pleural effusion}, LLL {Structure of lower lobe of left lung}, collapse {Atelectasis}, PE {Pulmonary embolism}, CTA {Computed tomography angiography with contrast}, heart failure {Heart failure}, a fib w/ RVR {Atrial fibrillation with rapid ventricular response}, diuresed {Diuretic therapy}, lasix {Diuretic therapy}, CTA {Computed tomography angiography with contrast}, mediastinal 
lymphadenopathy {Mediastinal lymphadenopathy}, infectious {Infectious disease}, malignant {Malignant neoplasm}, admissions to the MICU {Admission to intensive care unit}, hypoxia {Hypoxia}, A-fib with RVR {Atrial fibrillation with rapid ventricular response}, aspiration {Aspiration}, a-fib {Atrial fibrillation}, good HR (70s-80s) {Normal heart rate}, BP control 
(110-120s) {Normal blood pressure}, WBC {White blood cell count}, HCAP {Nosocomial pneumonia}, diuresed {Diuretic therapy}, lasix {Diuretic therapy}, TEE {Transesophageal echocardiography}, diastolic dysfunction {Diastolic dysfunction}, BNP {Brain natriuretic peptide measurement}, improved {Patient's condition improved}, diuresis {Diuretic therapy}, antibiotic {Antibiotic therapy}, leukocytosis {Leukocytosis}, Speech and swallow 
consulted {Speech therapy assessment}, aspiration {Aspiration}, aspiration precautions {Aspiration precautions}, hypoxia {Hypoxia}, afib and RVR {Atrial fibrillation with rapid ventricular response}, NRB {Oxygen administration by mask}, ABG {Analysis of arterial blood gases and pH}, NRB {Oxygen administration by mask}, lactate {Lactic acid measurement}, transferred to the MICU {Patient transfer to intensive care unit}, Chest CT {Computed tomography of chest}, right middle lobe 
pneumonia {Right middle zone pneumonia}, nasal cannula {Oxygen administration by nasal cannula}, lactate {Lactic acid measurement}, diuresed {Diuretic therapy}, fever {Fever}, aspiration pneumonia {Aspiration pneumonia}, pan-cultured {Microbial culture}, improved {Patient's condition improved}, antibiotics {Antibiotic therapy}, Urine {Urine culture}, blood culture {Blood culture}, chest {Thoracic structure}, pulmonary 
toilet {Airway toilet}, antibiotics {Antibiotic therapy}, diuresis {Diuretic therapy}, rate {Rate measurement}, thoracentesis {Thoracentesis}, left lung {Left lung structure}, hospice care {Hospice care}, nasal cannula {Oxygen administration by nasal cannula}, DNR {Not for resuscitation}, Afib with RVR {Atrial fibrillation with rapid ventricular response}, lung {Lung structure}, hypoxia {Hypoxia}, Blood pressure {Blood pressure finding}, stable {Patient's condition stable}, low 100s systolic {Decreased systolic arterial pressure}, RVR {Atrial fibrillation with rapid ventricular response}, IV {Intravenous therapy}, IV {Intravenous therapy}, MI {Myocardial infarction}, infectious {Infectious disease}, pneumonia {Pneumonia}, falls {Falls}, hypoxic {Hypoxia}, weak {Asthenia}, discussions {Discussion}, bleed {Bleeding}, SBP {Decreased systolic arterial pressure}, HR {Bradycardia}, Acute Heart Failure {Acute heart failure}, CT scans {Computed tomography}, bilateral pleural 
effusions {Bilateral pleural effusion}, TTE {Transthoracic echocardiography}, RV moderately 
dilated {Dilatation of right cardiac ventricle}, wall hypokinesis {Hypokinesis of cardiac wall}, CE {Contrast echocardiography}, negative {No abnormality detected}, lasix {Diuretic therapy}, iv {Intravenous therapy}, lasix {Diuretic therapy}, lasix {Diuretic therapy}, lasix {Diuretic therapy}, iv antibiotics {Intravenous antibiotic therapy}, lasix {Diuretic therapy}, Mediastinal Lymphadenopathy {Mediastinal lymphadenopathy}, CTA {Computed tomography angiography with contrast}, infection {Infectious disease}, malignancy {Malignant neoplasm}, imaging {Imaging}, lymphadenopathy {Lymphadenopathy}, diuresis {Diuretic therapy}, antibiotic {Antibiotic therapy}, spiked a temp {Fever}, pan-cultured {Microbial culture}, aspiration pna {Aspiration pneumonia}, Leukocytosis {Leukocytosis}, Seen by hematologist {Seen by hematologist}, leukocytosis {Leukocytosis}, WBC {White blood cell count}, pneumonia {Pneumonia}, infection {Infectious disease}, antibiotics {Antibiotic therapy}, improved {Patient's condition improved}, leukocytosis {Leukocytosis}, Thrombocytosis {Thrombocytosis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
1. Omeprazole 40 mg daily  
2. Aspirin 81 mg daily  
3. Mirtazapine 45 mg QHS  
4. Escitalopram 20 mg daily  
5. Tiotropium Bromide 18 mcg inh daily  
6. Fluticasone-Salmeterol 250-50 mcg/Dose inh BID  
7. Metoprolol 50 mg BID  
8. Diltiazem 120 mg daily  
9. Coumadin 4 mg daily  
10. Cephalexin 500mg TID (started pm of ___  
11. APAP 650mg q4h prn  
12. Colace 100mg BID  
13. Hydroxyurea 500mg ___  
14. MVI daily  
15. Senna 2 tabs QHS  
16. Milk of Mg 30ml QID prn  
17. Furosemide 10mg daily  
.

 
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
2. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at 
bedtime).  
3. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID 
(3 times a day).  
6. Diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One 
(1) Capsule, Sust. Release 24 hr PO once a day.  
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.  
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 
times a day) as needed for pain.  
9. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 3X/WEEK 
(___).  
10. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) 
as needed for constipation.  
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 
(2 times a day).  
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)  
Injection TID (3 times a day).  
14. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000) 
mg Intravenous Q48H (every 48 hours) for 8 days: To be completed 
___.  
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) 
ML PO Q6H (every 6 hours) as needed for constipation.  
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: 
One (1)  Inhalation twice a day.  
17. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: 
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).  
19. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation 
every six (6) hours.  
20. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr 
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).  
21. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr 
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.  
22. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln 
Intravenous Q8H (every 8 hours) for 8 days: To be completed 
___.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
___ Diagnosis:
Primary:
Acute CHF exacerbation
Pneumonia
Lung collapse
Atrial fibrillation with rapid ventricular rate

 
Discharge Condition:
A&Ox3

 

###RESPONSE: Acute CHF exacerbation {Acute exacerbation of chronic congestive heart failure}, Pneumonia {Pneumonia}, Lung collapse {Atelectasis}, Atrial fibrillation with rapid ventricular rate {Atrial fibrillation with rapid ventricular response}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
We had the pleasure of taking care of you while you were at the 
___.  You were admitted because you fell and because of 
shortness of breath.  Your shortness of breath was from volume 
overload from your heart failure, lung collapse, and infection.  
We treated you with lasix, antibiotics, and inhalers.  You also 
had a very fast heart rate due to your atrial fibrillation.  We 
increased your metoprolol and started you on a new medication 
called digoxin.  While you were here we did a chest CT that 
showed opacities and enlarged lymph nodes in the lung.  A 
pulmonologist saw you and you agreed that you did not want 
further invasive testing.  You also decided that you did not 
want any ICU tranfers and to change your code status from do not 
resuscitate (DNR) and okay to intubate, to DNR/DNI (do not 
resuscitate and do not intubate). 

We have made the following changes to your medications:
1. We have changed your metoprolol to metoprolol succinate daily 
for your atrial fibrillation
2. We have started you on digoxin for atrial fibrillation
3. We have stopped your cephalexin
4. We have started you on lidocaine patch for pain
5. We have started you on vancomycin and meropenem for 
aspiration pneumonia
6. We have increased your lasix dose to 40mg daily
7. We have stopped your coumadin

If you feel lightheaded or your blood pressure drops, you should 
not take your lasix.
 

###RESPONSE: fell {Elderly fall}, shortness of breath {Dyspnea}, shortness of breath {Dyspnea}, volume 
overload {Hypervolemia}, heart failure {Heart failure}, lung collapse {Atelectasis}, infection {Infectious disease}, lasix {Diuretic therapy}, antibiotics {Antibiotic therapy}, inhalers {Oxygen therapy}, fast heart rate {Tachycardia}, atrial fibrillation {Atrial fibrillation}, increased {Increasing dosage of medication}, medication {Patient medication education}, chest CT {Computed tomography of chest}, opacities {Abnormally opaque structure}, enlarged lymph nodes {Lymphadenopathy}, lung {Lung structure}, ICU tranfers {Patient transfer to intensive care unit}, do not 
resuscitate {Not for resuscitation}, DNR {Not for resuscitation}, DNR {Not for resuscitation}, do not 
resuscitate {Not for resuscitation}, atrial fibrillation {Atrial fibrillation}, atrial fibrillation {Atrial fibrillation}, pain {Pain}, aspiration pneumonia {Aspiration pneumonia}, lasix {Diuretic therapy}, lightheaded {Lightheadedness}, blood pressure drops {Decreased blood oxygen pressure}, 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: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
achalasia
 
Major Surgical or Invasive Procedure:
___: ___ myotomy and partial fundoplication

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, achalasia {Achalasia}, myotomy {Division of muscle}, partial fundoplication {Partial fundoplication}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mr. ___ is a ___ with h/o Marfan Syndrome c/b aortic
aneurysm, ASD and mitral valve regurgitation s/p aortic root
replacement, MVR and ASD repair who p/w worsening dysphagia c/f
achalasia. Briefly, patient reports onset of difficulty fully
swallowing food beginning ___ years ago. Since then, his symptoms
have progressed to significant chest pain with PO intake. He
reports the sensation of food becoming stuck in his chest that 
is
only able to be swallowed after he drinks large volumes of 
water.
This in turn causes significant nausea, some emesis, and
regurgitation of undigested foods. He reports an 11 lb weight
loss in recent months, but has been able to gain this back with
conscious efforts to eat full meals despite symptoms. He has 
been
evaluated via esophageal manometry and was found to have 100%
failure of esophageal contractions with all swallows and lack of
obvious ___. He underwent confirmatory barium swallow
that also demonstrated dilation of esophagus proximal to ___ 
with
significant delay in passage of a barium tablet without numerous
sips of water. After thorough GI evaluation, he was diagnosed
with presumed Type 2 achalasia and is now referred to surgical
clinic for operative evaluation.

On further review, the patient reports intermittent chest pain
for which he sometimes presents to the ED for evaluation. He 
most
recently underwent exercise stress test on ___ that was
negative for any signs of myocardial ischemia. He also
intermittently develops profuse epistaxis (not on
anticoagulation), for which he has seen his PCP and was
reportedly prescribed nasal sprays and reassured by his PCP. He
otherwise denies fevers/chills, severe abdominal pain, SOB,
dysuria.

 

###RESPONSE: Marfan Syndrome {Marfan's syndrome}, aortic
aneurysm {Aortic aneurysm}, ASD {Atrial septal defect}, mitral valve regurgitation {Mitral valve regurgitation}, aortic root
replacement {Replacement of aortic root}, ASD repair {Closure of atrial septal defect}, dysphagia {Dysphagia}, achalasia {Achalasia}, chest pain {Chest pain}, nausea {Nausea}, emesis {Vomiting}, regurgitation of undigested foods {Regurgitation of food}, weight
loss {Weight loss}, esophageal manometry {Esophageal manometry}, esophageal contractions {Nutcracker esophagus}, swallows {Does swallow}, barium swallow {Barium swallow}, dilation of esophagus {Dilation of esophagus}, GI evaluation {Evaluation of gastrointestinal tract}, achalasia {Achalasia}, surgical {Surgical procedure}, evaluation {Evaluation procedure}, chest pain {Chest pain}, evaluation {Evaluation procedure}, exercise stress test {Exercise tolerance test}, signs {Sign}, myocardial ischemia {Myocardial ischemia}, epistaxis {Bleeding from nose}, fevers {Fever}, chills {Chill}, abdominal pain {Abdominal pain}, dysuria {Dysuria}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Ascending aortic aneurysm
Gastroesophageal Reflux Disease
Lactose intolerance
Marfan's syndrome

Past Surgical History
-MV repair and ASD closure (___) by Dr. ___ aortic root replacement
with a 32 mm Valsalva Dacron graft and ascending aortic
replacement with a 24 mm Gelweave tube graft.

 

###RESPONSE: Ascending aortic aneurysm {Aneurysm of ascending aorta}, Gastroesophageal Reflux Disease {Gastroesophageal reflux disease}, Lactose intolerance {Intolerance to lactose}, Marfan's syndrome {Marfan's syndrome}, -MV repair {Repair of mitral valve}, ASD closure {Closure of atrial septal defect}, aortic root replacement {Replacement of aortic root}, Dacron graft {Polyethylene terephthalate graft operations on aorta}, ascending aortic
replacement {Replacement of ascending aorta}, graft {Structure of transplant}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father, brother and sister with ___. Father died at 
age ___, brother died at age ___, and sister died at age ___.

 

###RESPONSE: died {Dead}, died {Dead}, 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:
Vitals _______
GEN: A&Ox3, NAD, resting comfortably 
HEENT: NCAT, EOMI, sclera anicteric. 
CV: Regular
PULM: no respiratory distress, CTAB. 
ABD: soft, mild tenderness, ND, no rebound or guarding, lap 
sites
c/d/i with one mildly saturated 
EXT: warm, well-perfused, no edema 
 

###RESPONSE: Vitals {Vital signs finding}, GEN {General examination of patient}, Ox3 {Oriented to person, time and place}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, EOMI {Normal ocular motility}, sclera anicteric {White sclera}, CV {Cardiovascular physical examination}, PULM {Examination of respiratory system}, distress {Distress}, CTAB {Normal breath sounds}, ABD {Examination of abdomen}, soft {Abdomen soft}, tenderness {Tenderness}, ND {Swollen abdomen}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXT {Examination of limb}, warm {Warm skin}, well-perfused {Normal tissue perfusion}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:15AM BLOOD WBC-8.8 RBC-4.53* Hgb-13.5* Hct-39.4* 
MCV-87 MCH-29.8 MCHC-34.3 RDW-13.8 RDWSD-43.4 Plt ___
___ 06:15AM BLOOD Glucose-119* UreaN-11 Creat-0.8 Na-137 
K-4.4 Cl-100 HCO3-24 AnGap-13
___ 06:15AM BLOOD Calcium-9.1 Phos-4.9* Mg-1.8
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
 The patient presented to pre-op on ___. Patient was 
evaluated by anaesthesia.  
 The patient was taken to the operating room for ___ 
myotomy and partial fundoplication. There were no adverse events 
in the operating room; please see the operative note for 
details. Pt was taken to the PACU until stable, then transferred 
to the ward for observation.  
 Neuro: The patient was alert and oriented throughout 
hospitalization; pain was initially managed with a PCA. Pain was 
very well controlled. The patient was then transitioned to 
liquid oral pain medication.
 CV: The patient remained stable from a cardiovascular 
standpoint; vital signs were routinely monitored.  
 Pulmonary: The patient remained stable from a pulmonary 
standpoint; vital signs were routinely monitored. Good pulmonary 
toilet, early ambulation and incentive spirometry were 
encouraged throughout hospitalization.  
 GI/GU/FEN: The patient was initially kept NPO. Afterwards, the 
patient was started on a clears diet, which he tolerated well. 
Subsequently he was advanced to a mechanical soft diet which he 
tolerated well without nausea or vomiting. 
 ID: The patient's fever curves were closely watched for signs 
of infection, of which there were none.  
 HEME: The patient's blood counts were closely watched for signs 
of bleeding, of which there were none.  
 Prophylaxis: The patient received subcutaneous heparin and ___ 
dyne boots were used during this stay and was encouraged to get 
up and ambulate as early as possible.  
 At the time of discharge, the patient was doing well, afebrile 
and hemodynamically stable. The patient was tolerating a 
mechanical soft diet, ambulating, voiding without assistance, 
and pain was well controlled. The patient received discharge 
teaching and follow-up instructions with understanding 
verbalized and agreement with the discharge plan.  

 

###RESPONSE: myotomy {Division of muscle}, partial fundoplication {Partial fundoplication}, stable {Patient's condition stable}, Neuro {Neurological examination}, alert {Mentally alert}, pain {Pain}, Pain was 
very well controlled {Demonstrates adequate pain control}, stable {Patient's condition stable}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, stable {Patient's condition stable}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, incentive spirometry {Incentive spirometry}, diet {Dietary finding}, mechanical soft diet {Soft diet}, nausea {Nausea}, vomiting {Vomiting}, fever {Fever}, watched for signs 
of infection {Monitoring for signs and symptoms of infection}, signs {Sign}, bleeding {Bleeding}, Prophylaxis {Preventive procedure}, hemodynamically stable {Hemodynamically stable}, mechanical soft diet {Soft diet}, voiding without assistance {Continence independent}, pain was well controlled {Demonstrates adequate pain control}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
AMOXICILLIN - amoxicillin 500 mg capsule. 4 capsule(s) by mouth 
Once as needed for ___ minutes prior to dental procedure
ATENOLOL - atenolol 25 mg tablet. 1 tablet(s) by mouth once a 
day
GABAPENTIN - gabapentin 300 mg capsule. 1 capsule(s) by mouth 
three times daily
OMEPRAZOLE - omeprazole 40 mg capsule,delayed release. 1 
capsule(s) by mouth in am

 
Discharge Medications:
1.  Acetaminophen (Liquid) 650 mg PO Q4H:PRN Pain - Mild 
RX *acetaminophen 500 mg/15 mL 30 mL by mouth every eight (8) 
hours Disp #*450 Milliliter Refills:*0 
2.  Omeprazole 40 mg PO DAILY 
RX *omeprazole 40 mg 1 capsule(s) by mouth Daily Disp #*30 
Capsule Refills:*0 
3.  OxycoDONE Liquid 5 mg PO Q4H:PRN Pain - Moderate 
RX *oxycodone 5 mg/5 mL ___ mL by mouth every four (4) hours 
Disp ___ Milliliter Milliliter Refills:*0 
4.  Atenolol 25 mg PO DAILY  
5.  Gabapentin 300 mg PO BID  

 

###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:
achalasia

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: achalasia {Achalasia}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr ___,

It was a pleasure taking care of you here at ___ 
___. You were admitted to our hospital for 
___ myotomy and partial fundoplication on ___. You 
tolerated the procedure well and are ambulating, tolerating a 
regular diet, and your pain is controlled by pain medications by 
mouth. You are now ready to be discharged to home. Please follow 
the recommendations below to ensure a speedy and uneventful 
recovery. 

ACTIVITY:
- Do not drive until you have stopped taking pain medicine and 
feel you could respond in an emergency.
- You may climb stairs. You should continue to walk several 
times a day. 
- You may go outside, but avoid traveling long distances until 
you see your surgeon at your next visit. 
- You may start some light exercise when you feel comfortable. 
Slowly increase your activity back to your baseline as 
tolerated.
- Heavy exercise may be started after 6 weeks, but use common 
sense and go slowly at first. 
- No heavy lifting (10 pounds or more) until cleared by your 
surgeon, usually about 6 weeks. 
- You may resume sexual activity unless your doctor has told you 
otherwise.

HOW YOU MAY FEEL: 
- You may feel weak or ""washed out"" for 6 weeks. You might want 
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your 
throat during the surgery.

YOUR BOWELS:
- Constipation is a common side effect of narcotic pain medicine 
such as oxycodone. If needed, you may take a stool softener 
(such as Colace, one capsule) or gentle laxative (such as milk 
of magnesia, 1 tbs) twice a day. You can get both of these 
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain 
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get 
diarrhea, don't take anti-diarrhea medicines. Drink plenty of 
fluids and see if it goes away. If it does not go away, or is 
severe and you feel ill, please call your surgeon.

PAIN MANAGEMENT:
- You are being discharged with a prescription for oxycodone for 
pain control. You may take liquid Tylenol as directed, not to 
exceed 3500mg in 24 hours. Take regularly for a few days after 
surgery but you may skip a dose or increase time between doses 
if you are not having pain until you no longer need it. You may 
take the oxycodone for moderate and severe pain not controlled 
by the Tylenol. You may take a stool softener while on narcotics 
to help prevent the constipation that they may cause. Slowly 
wean off these medications as tolerated. 
- Your pain should get better day by day. If you find the pain 
is getting worse instead of better, please contact your surgeon.

If you experience any of the following, please contact your 
surgeon: 
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- pain that is getting worse over time or pain with fever
- shaking chills, fever of more than 101
- a drastic change in nature or quality of your pain
- nausea and vomiting, inability to tolerate fluids, food, or 
your medications
- if you are getting dehydrated (dry mouth, rapid heart beat, 
feeling dizzy or faint especially while standing)
-any change in your symptoms or any symptoms that concern you

Additional: 
*- pain that is getting worse over time, or going to your chest 
or back
*- urinary:  burning or blood in your urine or the inability to 
urinate

MEDICATIONS:
- Take all the medicines you were on before the operation just 
as you did before, unless you have been told differently.
- If you have any questions about what medicine to take or not 
to take, please call your surgeon. 

WOUND CARE: 
-Dressing Removal:***
-You may shower with any bandage strips that may be covering 
your wound. Do not scrub and do not soak or swim, and pat the 
incision dry. If you have steri strips, they will fall off by 
themselves in ___ weeks. If any are still on in two weeks and 
the edges are curling up, you may carefully peel them off.  

-Do not take baths, soak, or swim for 6 weeks after surgery 
unless told otherwise by your surgical team. 
-Notify your surgeon if you notice abnormal (foul smelling, 
bloody, pus, etc) or increased drainage from your incision site, 
opening of your incision, or increased pain or bruising. Watch 
for signs of infection such as redness, streaking of your skin, 
swelling, increased pain, or increased drainage. 

Please call with any questions or concerns. Thank you for 
allowing us to participate in your care. We hope you have a 
quick return to your usual life and activities. 

-- Your ___ Care Team

 

###RESPONSE: myotomy {Division of muscle}, partial fundoplication {Partial fundoplication}, procedure {Procedure}, tolerating a 
regular diet {Tolerating normal diet}, pain {Pain}, climb stairs {Does walk up stairs}, walk {Walking practice}, exercise {Exercises}, exercise {Exercises}, washed out {Exhaustion}, sore throat {Sore throat}, throat {Structure of anterior portion of neck}, surgery {Surgical procedure}, Constipation {Constipation}, prescription {Prescription}, pain {Pain}, bowels {Intestinal structure}, diarrhea {Diarrhea}, diarrhea {Diarrhea}, diarrhea {Diarrhea}, prescription {Prescription}, pain control {Pain control}, after 
surgery {Postoperative state}, pain {Pain}, severe pain {Severe pain}, constipation {Constipation}, pain {Pain}, pain {Pain}, sharp pain {Sharp pain}, severe pain {Severe pain}, chest pain {Chest pain}, pressure {Tight chest}, squeezing {Squeezing chest pain}, tightness {Tight chest}, cough {Cough}, shortness of breath {Dyspnea}, wheezing {Wheezing}, pain {Pain}, pain {Pain}, fever {Fever}, shaking {Tremor}, chills {Chill}, fever {Fever}, pain {Pain}, nausea and vomiting {Nausea and vomiting}, dehydrated {Dehydration}, dry mouth {Xerostomia}, rapid heart beat {Tachycardia}, dizzy {Dizziness}, faint {Feeling faint}, standing {Orthostatic body position}, pain {Pain}, chest {Radiating chest pain}, blood in your urine {Blood in urine}, operation {Surgical procedure}, WOUND CARE {Wound care}, -Dressing Removal {Removal of dressing}, wound {Wound}, incision {Surgical incision wound}, soak {Soak}, after surgery {Postoperative state}, drainage {Wound discharge}, incision site {Surgical incision wound}, incision {Surgical incision wound}, increased pain {Increased pain}, bruising {Contusion}, signs of infection {Monitoring for signs and symptoms of infection}, redness {Redness of skin over lesion}, skin {Skin structure}, swelling {Swelling}, increased pain {Increased pain}, drainage {Wound discharge}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
Hydrochlorothiazide / Lipitor / Ultram
 
Attending: ___.
 
Chief Complaint:
___, poor PO intake
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Hydrochlorothiazide {Allergy to hydrochlorothiazide}, Lipitor {Allergy to atorvastatin}, poor PO intake {Decrease in appetite}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ y/o F referred in by her PCP. Patient has history of severe 
AS (peak gradient of 58, mean of 35, EF55% in ___, dCHF, HTN. 
She went in to her PCP with dyspnea on exertion, and routine 
labs showed a BUN/Cr of 50/2.4 so patient referred into ___ 
ED. She has had increased Lasix dosing, and decreased PO intake 
(has had increased GERD recently and thus not tolerating 
excellent PO, has plans for GI f/u in coming weeks). In this 
context, patient has had dyspnea while ambulating. On ROS she 
denies fever/chills/chest pain, shortness of breath at rest. 
Denies any urinary/stool changes, does have +left knee pain and 
is s/p left TKR. Left knee pain radiates up to left groin, is 
chronic and patient did not take her Tylenol today for it.
In the ED, initial vitals were: 97.6 84 145/89 16 100% RA
- Exam significant for LLL mild crackles and occ. wheeze
___ RUSB SEM
- Labs were significant for unremarkable CBC, BUN/Creat 50/2.4
- Imaging revealed: (own read) no acute intrathoracic process
- The patient was given tyelnol x1
Admitted for work-up ___ and possible TTE.
Vitals prior to transfer were: 97.7 77 143/64 24 97% RA
Upon arrival to the floor, pt appears well.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or 
gain. Denies headache, sinus tenderness, rhinorrhea or 
congestion. Denies chest pain or tightness, palpitations. Denies 
nausea, vomiting, diarrhea, constipation or abdominal pain. No 
recent change in bowel or bladder habits. No dysuria. Denies 
arthralgias or myalgias.
 

###RESPONSE: dCHF {Decompensated chronic heart failure}, HTN {Hypertensive disorder, systemic arterial}, dyspnea on exertion {Dyspnea on exertion}, decreased PO intake {Inadequate oral intake}, GERD {Gastroesophageal reflux disease}, dyspnea while ambulating {Dyspnea on exertion}, fever {Fever}, chills {Chill}, chest pain {Chest pain}, shortness of breath {Dyspnea}, urinary {Urinary incontinence}, stool {Hematochezia}, left knee {Structure of left knee region}, pain {Pain of knee region}, left TKR {Total replacement of left knee joint}, Left knee {Structure of left knee region}, pain {Pain of knee region}, radiates {Radiating pain}, left groin {Left inguinal region structure}, chronic {Chronic pain}, vitals {Vital signs finding}, RA {Breathing room air}, Exam {Physical examination procedure}, LLL {Structure of lower lobe of left lung}, crackles {Respiratory crackles}, wheeze {Wheezing}, SEM {Ejection murmur}, unremarkable {No abnormality detected}, CBC {Complete blood count}, work-up {Evaluation procedure}, TTE {Transthoracic echocardiography}, Vitals {Vital signs finding}, RA {Breathing room air}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, headache {Headache}, sinus {Nasal sinus structure}, tenderness {Tenderness}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, change in bowel {Altered bowel function}, bladder habits {Alteration in patterns of urinary elimination}, dysuria {Dysuria}, arthralgias {Joint pain}, myalgias {Muscle pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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  
- Hyperchloseterolemia  
- AAA - infra-renal 
- GERD  
- Left Renal Mass  
-> nodular enhancing solid/cystic left renal mass 16x13mm  
- Spinal stenosis  
-> with symptoms and signs of radicular compression with an MRI  

from ___ disclosing severe spinal stenosis at the L4-L5 level,  

grade 1 spondylolisthesis of L4 over L5, severe foraminal 
stenosis  
at L4-L5 and mild-to-moderate stenosis at L3-L4  
- degenerative joint disease of ankles and knees secondary to 
severe  
mechanical alterations w/ Tricompartmental OA of left knee 
thyroid nodules 
.  
Cardiac Risk Factors: (-)Diabetes, (+) Dyslipidemia and 
Hypertension  

 

###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, Hyperchloseterolemia {Hypercholesterolemia}, AAA - infra-renal {Aneurysm of infrarenal abdominal aorta}, GERD {Gastroesophageal reflux disease}, Left Renal {Left kidney structure}, Mass {Nodule of lung}, left renal {Left kidney structure}, mass {Nodule of lung}, Spinal stenosis {Spinal stenosis}, signs {Sign}, compression {Compression}, MRI {Magnetic resonance imaging}, spinal stenosis {Spinal stenosis}, L4 {Entire body of fourth lumbar vertebra}, L5 {Entire body of fifth lumbar vertebra}, grade 1 spondylolisthesis {Spondylolisthesis, grade 1}, L4 {Entire body of fourth lumbar vertebra}, L5 {Entire body of fifth lumbar vertebra}, foraminal 
stenosis {Stenosis of lumbar vertebral foramen}, L4 {Entire body of fourth lumbar vertebra}, L5 {Entire body of fifth lumbar vertebra}, stenosis {Stenosis}, L3 {Entire body of third lumbar vertebra}, L4 {Entire body of fourth lumbar vertebra}, degenerative joint disease of ankles {Osteoarthritis of ankle}, knees {Osteoarthritis of knee}, OA {Osteoarthritis of knee}, left knee {Structure of left knee region}, thyroid nodules {Thyroid nodule}, Cardiac Risk Factors {Assessment for risk of cardiovascular disease}, Diabetes {Diabetes mellitus}, Dyslipidemia {Dyslipidemia}, Hypertension {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Non contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:
===================
Vitals: 96.9 156/76 69 16 100%RA
wt 67.25
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP mildly elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, SEM ___ at LUSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales, 
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present, 
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema
Neuro: AAOx3

DISCHARGE PHYSICAL EXAM:
====================
Vitals:  Tc 98.0 HR 64 BP 120-160/50-70 RR 16 SpO2 100%RA Wt 
67.6kg
General: Alert, oriented, no acute distress  
 HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL  
 Neck: Supple, JVP mildly elevated, no LAD  
 CV: Regular rate and rhythm, normal S1 + S2, SEM ___ at LUSB  
 Lungs: Mild bibasilar crackles, no wheezes
 Abdomen: Soft, non-tender, non-distended, bowel sounds present, 
no organomegaly, no rebound or guarding  
 GU: No foley  
 Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
 Neuro: AAOx2 (said year was ___
 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, elevated {Raised jugular venous pressure}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, SEM {Ejection murmur}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, GU {Examination of genitourinary system}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, Ox3 {Oriented to person, time and place}, Vitals {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, JVP {Finding of jugular venous pressure}, elevated {Raised jugular venous pressure}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 + S2 {Heart sounds normal}, SEM {Ejection murmur}, Lungs {Examination of respiratory system}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, wheezes {Wheezing}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, tender {Abdominal tenderness}, distended {Swollen abdomen}, bowel sounds present {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, GU {Examination of genitourinary system}, foley {Urinary catheter in situ}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:

___ 10:36AM BLOOD WBC-9.3 RBC-4.32 Hgb-12.0 Hct-38.0 MCV-88 
MCH-27.8 MCHC-31.6* RDW-14.3 RDWSD-45.7 Plt ___
___ 10:36AM BLOOD Neuts-72.5* ___ Monos-5.2 
Eos-0.7* Baso-0.2 Im ___ AbsNeut-6.76* AbsLymp-1.97 
AbsMono-0.49 AbsEos-0.07 AbsBaso-0.02
___ 10:36AM BLOOD UreaN-50* Creat-2.4*# Na-139 K-4.0 Cl-99
___ 10:36AM BLOOD proBNP-199
___ 10:36AM BLOOD 25VitD-29*
___ 06:04PM URINE Hours-RANDOM UreaN-625 Creat-79 Na-66 
K-30 Cl-51
___ 06:04PM URINE Osmolal-453

OTHER PERTINENT LABS:

___ 10:36AM BLOOD UreaN-50* Creat-2.4*# Na-139 K-4.0 Cl-99
___ 06:57AM BLOOD Glucose-86 UreaN-51* Creat-2.2* Na-139 
K-4.3 Cl-105 HCO3-23 AnGap-15
___ 03:05PM BLOOD Glucose-94 UreaN-47* Creat-2.0* Na-139 
K-4.3 Cl-104 HCO3-23 AnGap-16
___ 07:17AM BLOOD Glucose-82 UreaN-34* Creat-1.5* Na-141 
K-4.1 Cl-108 HCO3-22 AnGap-15
___ 10:36AM BLOOD 25VitD-29*

IMAGING:
CXR ___ - No acute intrathoracic process.

MICRO: none

DISCHARGE LABS:
___ 07:55AM BLOOD WBC-5.2 RBC-3.95 Hgb-10.7* Hct-34.5 
MCV-87 MCH-27.1 MCHC-31.0* RDW-14.0 RDWSD-45.1 Plt ___
___ 07:55AM BLOOD Glucose-81 UreaN-29* Creat-1.4* Na-143 
K-4.4 Cl-107 HCO3-26 AnGap-14
___ 07:55AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.8
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Baso {Basophil count}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, CXR {Plain chest X-ray}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
SUMMARY:
___ y/o F referred in by her PCP. Patient has history of severe 
AS (peak gradient of 58, mean of 35, EF55% in ___, dCHF, HTN. 
She went in to her PCP with dyspnea on exertion, and routine 
labs showed a BUN/Cr of 50/2.4 in setting of increased lasix 
dosing x3 days and decreased PO intake.  

___ on CKD:  
 Baseline Creat 1.3. Admitted with Cr 2.4 in setting of 
increased lasix dosing last week, decreased PO intake over past 
week due to worsening reflux after eating spicy food. SCr 
improved with IV fluids. Creatinine was 1.4 after PO intake only 
for 1 day prior to discharge

#chronic compensated diastolic heart failure:  
No e/o acute fluid overload. Above ___ likely in setting of 
overdiuresis and poor PO intake. Held home lasix upon discharge.

#HTN: Continued home amplodipine 
 
#GERD: Continued omeprazole, ranitidine. Patient states her 
reflux was much improved while inpatient, although she reports 
taking her outpatient medications as prescribed. She lives with 
her son and daughter-in-law. Patient is well versed in her 
medications, though she takes them herself out of the bottles 
each day.
 
#Vitamin D deficiency: Continued home vitamin D  

TRANSITIONAL ISSUES:
- Discharge weight: 67.6 kg
- ___: Please check CMP to monitor Creatinine/electrolytes on 
___ or ___ and fax results to patient's PCP ___ 
___ at ___.
- Patient states poor PO intake due to reflux/GERD exacerbation. 
Improved on home regimen while inpatient. Defer additional 
management of outpatient GERD medications to PCP.
- Furosemide was held during hospitalization given ___ and fluid 
resuscitation. Defer restarting this medication to 
PCP/Cardiologist.
- Recommend continued goals of care discussion with PCP. Patient 
may benefit from palliative care/hospice referral.
- DNR/DNI 
- contact: ___ (son/HCP) ___ 
 
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY 
2. Aspirin 81 mg PO DAILY 
3. Omeprazole 20 mg PO BID 
4. Pravastatin 20 mg PO DAILY 
5. Furosemide 20 mg PO DAILY 
6. Ranitidine 150 mg PO QHS 
7. Vitamin D ___ UNIT PO DAILY 
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 
9. Acetaminophen 650 mg PO QHS 

 
Discharge Medications:
1. Amlodipine 10 mg PO DAILY 
2. Aspirin 81 mg PO DAILY 
3. Omeprazole 20 mg PO BID 
4. Pravastatin 20 mg PO DAILY 
5. Ranitidine 150 mg PO QHS 
6. Vitamin D ___ UNIT PO DAILY 
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 
8. Acetaminophen 650 mg PO QHS 

 

###RESPONSE: dCHF {Decompensated chronic heart failure}, HTN {Hypertensive disorder, systemic arterial}, dyspnea on exertion {Dyspnea on exertion}, lasix {Diuretic therapy}, decreased PO intake {Inadequate oral intake}, CKD {Chronic kidney disease}, Baseline {Baseline state}, lasix {Diuretic therapy}, decreased PO intake {Inadequate oral intake}, reflux {Gastric reflux}, improved {Patient's condition improved}, IV fluids {Administration of intravenous fluids}, compensated {Compensated cardiac failure}, diastolic heart failure {Diastolic heart failure}, fluid overload {Hypervolemia}, poor PO intake {Decrease in appetite}, lasix {Diuretic therapy}, HTN {Hypertensive disorder, systemic arterial}, GERD {Gastroesophageal reflux disease}, reflux {Gastric reflux}, improved {Patient's condition improved}, Vitamin D deficiency {Vitamin D deficiency}, weight {Weight finding}, Creatinine {Creatinine measurement}, poor PO intake {Decrease in appetite}, reflux {Gastric reflux}, GERD {Gastroesophageal reflux disease}, GERD {Gastroesophageal reflux disease}, palliative care {Palliative care}, hospice {Hospice care}, referral {Patient referral}, DNR {Not for resuscitation}, constipation {Constipation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
PRIMARY: 
-acute kidney injury 

SECONDARY: 
-hypertension
-gastroenterologist 
-severe aortic stenosis
-chronic compensated diastolic congestive heart failure 

 
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}, acute kidney injury {Acute kidney injury}, hypertension {Hypertensive disorder, systemic arterial}, aortic stenosis {Aortic valve stenosis}, compensated {Compensated cardiac failure}, diastolic congestive heart failure {Diastolic heart failure}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}, cane {Uses single walking stick}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,

It was a pleasure caring for you at the ___ 
___. You were recently admitted for elevated 
creatinine, a measure of your kidney function. You were treated 
with IV fluids and improved. Please ensure that you are eating 
and drinking well at home, as dehydration is likely the cause. 
Please discuss optimizing your reflux medication regimen with 
your primary care doctor.

Please continue taking all of your medications as prescribed and 
keep all of your follow-up appointments.

It was a pleasure caring for you.

Sincerely,
Your ___ care team
 

###RESPONSE: elevated 
creatinine {Serum creatinine above reference range}, IV fluids {Administration of intravenous fluids}, improved {Patient's condition improved}, dehydration {Dehydration}, reflux {Gastric reflux}, regimen {Therapeutic regimen}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
Codeine / Peanut
 
Attending: ___
 
Chief Complaint:
Cough
 
Major Surgical or Invasive Procedure:
Right thoracentesis with drainage of 5 cc purulent fluid 
___

 

###RESPONSE: Codeine {Allergy to codeine}, Peanut {Allergy to peanut}, Cough {Cough}, thoracentesis {Thoracentesis}, drainage {Drainage procedure}, purulent fluid {Purulent discharge}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mr. ___ is an ___ year old male with history of atrial 
fibrillation on warfarin, esophageal diverticulum/dysphagia, and 
blindness here with chronic non-productive cough and new 
right-sided pleuritic chest pain developing ___ the last 48 
hours. His pain is characterized by a ___ stabbing sensation at 
worst (now ___ relived with analgesic medications but worsened 
with inspiration or movement. His pain radiates to his 
back/shouders. He has had similar pain ___ the past, most 
recently ___ ___, and has received diagnoses of pneumonia. He 
denies subjective fevers at home, fatigue, hoarseness, malaise, 
lymphadenopathy, diaphoresis, left-sided chest pain, 
lightheadedness, nausea, vomiting, or other somatic complaints.

Per OMR, he was admitted on ___ (and discharged same day) 
with a diagnosis of mutifocal pneumonia after presenting with 
left-sided pleuritic chest pain; discharged with prescription 
for 5 days of levofloxacin and recommendations to have repeat 
CXR to evaluate for resolution of pneumonia. Presented later to 
PCP ___ ___ with non-productive cough but without other 
symptoms/signs of pneumonia - diagnosed with latent pleural 
irritation secondary to bronchitis. He has not had imaging ___ 
the interval from ___ until now.

___ the ED, initial VS were 99.0, 83, 156/81, 16, 100%. Initial 
labs demonstrated leukocytosis with 14,600 WBCs, of which 88% 
were PMNs. A CXR revealed bibasilar airspace opacities and 
possible left pleural effusion. His d-dimer was 882. A 
subsequent CTA chest demonstrated possible right-sided empyema 
and LLL, RML multifocal pneumonia. He received 1g ceftriaxone 
and 500mg azithromycin initially at 2330 on ___. He required 
an extended stay ___ the ED due to bed availability and was then 
managed by ___, who added 150mg clindamcyin at 0140 on ___ 
due to empyema presence. He was started on some of his home 
medications, including warfarin 5mg daily, atenolol, and 
mirtazapine. He required acetaminophen, tramadol, and oxycodone 
for control of pleuritic pain. IP was consulted, who recommended 
discontinuing warfarin (INR was 2.0) and considering FFP for 
reversal of anticoagulation pending possible thoracentesis 
and/or chest tube placement. He remained afebrile during his 
time ___ the ED.

ROS:
(+) Per HPI
(-) Denies fatigue, subjective fever, fatigue, weight change, 
headache, tinnitus, dysphagia, odynophagia, hoarseness, 
palpitations, dyspnea, paroxysmal nocturnal dyspnea, orthopnea, 
abdominal pain, nausea, vomiting, diarrhea, melena, 
hematochezia, lymphadenopathy, dysuria, new bruising, new 
bleeding, rash, or other somatic complaints.
 

###RESPONSE: atrial 
fibrillation {Atrial fibrillation}, on warfarin {Warfarin therapy}, esophageal diverticulum {Diverticulum of esophagus}, dysphagia {Dysphagia}, chronic {Chronic disease}, non-productive cough {Dry cough}, right-sided pleuritic chest pain {Right sided chest pain}, pain {Pain}, stabbing {Stabbing pain}, worsened {Increased pain}, pain {Pain}, shouders {Shoulder region structure}, pain {Pain}, pneumonia {Pneumonia}, fevers {Fever}, fatigue {Fatigue}, hoarseness {Hoarse}, malaise {Malaise}, lymphadenopathy {Lymphadenopathy}, diaphoresis {Excessive sweating}, left-sided chest pain {Left sided chest pain}, lightheadedness {Lightheadedness}, nausea, vomiting {Nausea and vomiting}, pneumonia {Pneumonia}, left-sided {Left sided chest pain}, pleuritic chest pain {Pleuritic pain}, prescription {Prescription}, recommendations to {Recommendation to}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, PCP {Primary care management}, non-productive cough {Dry cough}, signs {Sign}, pneumonia {Pneumonia}, bronchitis {Bronchitis}, imaging {Imaging}, leukocytosis {Leukocytosis}, CXR {Plain chest X-ray}, bibasilar {Structure of base of lung}, opacities {Abnormally opaque structure}, left {Structure of left pleural cavity}, pleural effusion {Pleural effusion}, CTA chest {Computed tomography angiography of chest with contrast}, right-sided {Right lung structure}, empyema {Empyema}, LLL {Structure of lower lobe of left lung}, RML {Right middle zone pneumonia}, pneumonia {Pneumonia}, empyema {Empyema}, pleuritic pain {Pleuritic pain}, anticoagulation {Anticoagulant therapy}, thoracentesis {Thoracentesis}, chest tube placement {Insertion of pleural tube drain}, fatigue {Fatigue}, fever {Fever}, fatigue {Fatigue}, headache {Headache}, tinnitus {Tinnitus}, dysphagia {Dysphagia}, odynophagia {Swallowing painful}, hoarseness {Hoarse}, palpitations {Palpitations}, dyspnea {Dyspnea}, paroxysmal nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, abdominal pain {Abdominal pain}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, melena {Melena}, hematochezia {Hematochezia}, lymphadenopathy {Lymphadenopathy}, dysuria {Dysuria}, bruising {Contusion}, bleeding {Bleeding}, rash {Eruption of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- atrial fibrillation on warfarin
- benign prostatic hypertrophy previously with chronic 
indwelling Foley now s/p TURP
- esophageal diverticulum leading to dysphagia
- HTN
- blindness secondary to macular degeneration on left, retinal 
detachment on right
- gait disorder
- kyphoscoliosis
- left inguinal herniorrhaphy ___
- neuropathy
 

###RESPONSE: atrial fibrillation {Atrial fibrillation}, on warfarin {Warfarin therapy}, benign prostatic hypertrophy {Benign prostatic hyperplasia}, Foley {Catheterization of urinary bladder}, TURP {Transurethral prostatectomy}, esophageal diverticulum {Diverticulum of esophagus}, dysphagia {Dysphagia}, HTN {Hypertensive disorder, systemic arterial}, blindness {Blindness AND/OR vision impairment level}, macular degeneration {Degenerative disorder of macula}, left {Structure of macula lutea of left eye}, retinal 
detachment {Retinal detachment}, right {Structure of retina of right eye}, gait disorder {Abnormal gait}, kyphoscoliosis {Kyphosis deformity of spine}, left {Structure of left inguinal canal}, inguinal herniorrhaphy {Repair of inguinal hernia using surgical sutures}, neuropathy {Neuropathy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father with history of MI

 

###RESPONSE: MI {Myocardial infarction}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:
VS on arrival to floor: 97.8, 146/62, 89, 18, 0.99 on 3L NC
 Gen: NAD, AAOx3, comfortably lying ___ bed and conversant
 HEENT: NC/AT, right pupil clouded, yellowed and orbit sunken ___ 
socket, left pupil cloudy; sclera anicteric; oropharynx clear 
without exudate or erythema, mucosa moist but slightly dry; no 
LAD
 CV: irregularly irregular, no m/r/g
 Pulm: difficult to assess as patient moving small volumes of 
air, but lung sounds decreased at left posterior bases 
associated with left-sided dullness to percussion and egophany
 Abd: BS+, soft, NT, ND, no HSM, no palpable masses, ___ 
negative
 MSK: dorsalis pedis and radial pulses 2+ bilaterally, no c/c/e
 Neuro: oriented x3, CNII-XII intact, moving all extremities, 
sensation grossly intact

DISCHARGE PHYSICAL EXAM:
Unchanged.
 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, NC {Normal head}, Gen {General examination of patient}, NAD {No abnormality detected}, Ox3 {Oriented to person, time and place}, lying {Lying in bed}, HEENT {Physical examination procedure}, NC {Normal head}, right pupil {Structure of pupil of right eye}, yellowed {Scleral icterus}, orbit sunken {Sunken eyes}, left pupil {Structure of pupil of left eye}, sclera anicteric {White sclera}, oropharynx clear {Pharynx normal}, exudate {Exudate}, erythema {Erythema}, mucosa moist {Moist oral mucosa}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, irregularly irregular {Heart irregularly irregular}, no m/r/g {Heart sounds normal}, Pulm {Examination of respiratory system}, lung sounds decreased {Decreased breath sounds}, bases {Structure of base of lung}, left-sided {Structure of left half of chest wall}, dullness to percussion {Dullness to percussion over Traube's space}, egophany {Egophony}, Abd {Examination of abdomen}, BS+ {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, palpable masses {Palpable mass}, MSK {Musculoskeletal system physical examination}, dorsalis pedis {Dorsalis pulse present}, radial pulses 2+ bilaterally {Normal radial pulse}, Neuro {Neurological examination}, oriented {Orientated}, CNII {Optic nerve structure}, XII intact {Intact hypoglossal nerve}, all extremities {All extremities}, sensation grossly intact {Normal sensation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 04:45PM BLOOD WBC-14.6* RBC-4.38* Hgb-13.7* Hct-41.7 
MCV-95 MCH-31.2 MCHC-32.7 RDW-13.7 Plt ___
___ 04:45PM BLOOD Neuts-88.0* Lymphs-5.5* Monos-5.4 Eos-0.9 
Baso-0.2
___ 03:09AM BLOOD ___
___ 04:45PM BLOOD Glucose-122* UreaN-15 Creat-0.8 Na-141 
K-5.0 Cl-103 HCO3-29 AnGap-14
___ 04:45PM BLOOD ALT-11 AST-16 AlkPhos-120 TotBili-0.7
___ 04:45PM BLOOD Lipase-17
___ 04:45PM BLOOD Albumin-3.3*
___ 08:55AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.1
___ 04:58PM BLOOD Lactate-1.7

DISCHARGE LABS:
___ 05:22AM BLOOD WBC-14.3* RBC-4.17* Hgb-12.7* Hct-40.1 
MCV-96 MCH-30.5 MCHC-31.7 RDW-13.6 Plt ___
___ 05:22AM BLOOD Neuts-87.7* Lymphs-5.5* Monos-6.1 Eos-0.7 
Baso-0.1
___ 05:22AM BLOOD ___

MICROBIOLOGY:
___ 10:15 am FLUID,OTHER      RT LUNG EMPYEMA. 

   GRAM STAIN (Final ___: 
      3+  ___ per 1000X FIELD):   POLYMORPHONUCLEAR 
LEUKOCYTES. 
      3+  ___ per 1000X FIELD):   GRAM POSITIVE COCCI. 
                                    ___ PAIRS, CHAINS, AND 
CLUSTERS. 
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE ROD(S). 
      SMEAR REVIEWED; RESULTS CONFIRMED. 
      Reported to and read back by ___ ___ ___ 240PM. 

   FLUID CULTURE (Preliminary): 
      STREPTOCOCCUS ANGINOSUS (___) GROUP.    MODERATE 
GROWTH. 

   ANAEROBIC CULTURE (Preliminary):    NO ANAEROBES ISOLATED. 

Blood culture ___ x 2: no growth

STUDIES:
- Video swallow study ___: IMPRESSION: Penetration with 
nectar thick liquid and aspiration with thin consistency barium.

- CT guided thoracentesis ___: IMPRESSION: CT-guided 
empyema aspiration yielding 6 cc of purulent tan pus. 
Microbiology and cytology are pending.

- CTA CHEST W AND W/O CONTRAST ___:
IMPRESSION:
1.  No evidence of pulmonary embolism or acute aortic pathology. 

2.  Multifocal pulmonary opacities, most confluent ___ the left 
lower lobe and ___ the right middle lobe, compatible with 
multifocal pneumonia.  Enhancing small fluid collection ___ the 
right mid lung pleural space concerning for empyema. 
3.  Moderate sized right pleural effusion. 

- CTA CHEST W AND W/O CONTRAST ___:
IMPRESSION: 
1.  Multiple bilateral nodular opacities, with the most 
confluence at the left base, consistent with multifocal 
pneumonia.  A dedicated chest CT after resolution of symptoms 
can be considered to evaluate for nodules. 
2.  Stable left adrenal nodule, likely an adenoma.  
3.  No evidence of a pulmonary embolism or acute aortic injury. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, LUNG {Lung structure}, EMPYEMA {Empyema}, GRAM STAIN {Gram stain method}, CULTURE {Microbial culture}, ANAEROBIC CULTURE {Anaerobic microbial culture}, Blood culture {Blood culture}, Video swallow study {Videofluoroscopy swallow}, nectar thick liquid {Dietary liquid consistency - nectar thick liquid}, aspiration {Pulmonary aspiration}, consistency {Consistency finding}, CT guided thoracentesis {Thoracentesis using computed tomography guidance}, empyema aspiration {Drainage of empyema}, purulent {Purulent}, pus {Pus}, Microbiology {Microbiology}, cytology {Cytology examination - general}, pulmonary embolism {Pulmonary embolism}, aortic {Aortic structure}, pulmonary {Lung structure}, opacities {Abnormally opaque structure}, left 
lower lobe {Structure of lower lobe of left lung}, right middle lobe {Structure of middle lobe of right lung}, pneumonia {Pneumonia}, fluid collection {Accumulation of fluid}, right mid lung pleural space {Structure of right pleural cavity}, empyema {Empyema}, right {Structure of right pleural cavity}, pleural effusion {Pleural effusion}, CTA CHEST W {Computed tomography angiography of chest with contrast}, W/O CONTRAST {Computed tomography of chest without contrast}, opacities {Abnormally opaque structure}, left base {Structure of base of left lung}, pneumonia {Pneumonia}, chest CT {Computed tomography of chest}, nodules {Nodule}, left adrenal {Structure of left adrenal gland}, nodule {Nodule}, adenoma {Adenoma}, pulmonary embolism {Pulmonary embolism}, aortic injury {Injury of aorta}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 ___ on ___ for workup and 
treatment of multifocal pneumonia. His hospital course is as 
follows:

1) Multifocal right middle lobe and left lower lobe pneumonia 
with right parapneumonic effusion: suspicion of empyema ___ 
setting of esophageal diverticulum and dysphagia. History of 
multifocal pneumonia ___ ___, similar clinically. Patient 
remained afebrile, with stable vital signs throughout admission. 
Initially the patient was started on ceftriaxone, azithromycin, 
and clindamycin. Given likely aspiration pneumonia, he underwent 
video swallow study as above. Per speech pathology 
recommendations, diet should be nectar thickened liquids, soft 
solids; POs while upright w/ oral care before meals.  He 
underwent CT-guided thoracentesis and drainage of 5 cc purulent 
fluid at ___ location on ___. Initial gram stain of pleural 
fluid growing 3+ GPCs and 1+ GPRs.  Patient treated with 
clindamycin and levofloxacin per ID recs, which will continue 
for four weeks.  He will require follow-up ___ ___ clinic to 
determine resolution of pneumonia and determination of 
antibiotic duration.  Patient's white blood cell count was 
rising on day of discharge, but with no change ___ clinical 
status.  Patient should have a CBC checked on ___ to follow up 
this finding.

2) Atrial fibrillation/anticoagulation - CHADS2 score equal to 
2. Taking 4 mg daily of warfarin at home. Rate controlled with 
atenolol. INR was mildly prolonged on arrival, suggestive of 
inhibition of metabolism by antibiotics. Temporarily 
discontinued warfarin ___, then restarted 4mg 
daily on ___ after thoracentesis completed. Continued atenolol 
daily. INR on discharge equal to 1.7.

3) Hypertension - Well-controlled. Continued home atenolol.

4) Benign prostatic hypertrophy previously with chronic 
indwelling Foley now s/p TURP - No issues throughout admission. 
Voiding regularly.

5) Blindness secondary to macular degeneration on left, retinal 
detachment on right - Chronic, stable. Redirected as necessary. 
Continued home levobunolol.

TRANSITIONAL ISSUES:
- Please check kidney function and CBC on ___
- Small 5-mm nodule ___ the right lobe of the thyroid may need 
dedicated imaging, such as ultrasound.
- ___ recs: okay for rehab or home w 24hr assistance and home ___
- Will require follow-up with PCP ___ ___
- Will require follow-up ___ ___ clinic to determine resolution of 
pneumonia and determination of antibiotic duration.
- Will need CT scan ___ weeks after discharge to follow-up 
resolution of pneumonia.
 

###RESPONSE: pneumonia {Pneumonia}, right middle lobe {Structure of middle lobe of right lung}, left lower lobe pneumonia {Structure of lower lobe of left lung}, right {Right lung structure}, parapneumonic effusion {Pleural effusion associated with pulmonary infection}, empyema {Empyema}, esophageal diverticulum {Diverticulum of esophagus}, dysphagia {Dysphagia}, pneumonia {Pneumonia}, stable vital signs {Normal vital signs}, aspiration pneumonia {Aspiration pneumonia}, video swallow study {Videofluoroscopy swallow}, diet should be nectar thickened liquids {Dietary liquid consistency - nectar thick liquid}, soft 
solids {Soft diet}, CT-guided thoracentesis {Thoracentesis using computed tomography guidance}, drainage {Drainage procedure}, purulent 
fluid {Purulent discharge}, gram stain {Gram stain method}, pleural 
fluid {Pleural fluid examination abnormal}, require follow-up {Requires follow-up}, pneumonia {Pneumonia}, antibiotic {Antibiotic therapy}, white blood cell count {White blood cell count}, CBC {Complete blood count}, follow up {Follow-up status}, Atrial fibrillation {Atrial fibrillation}, anticoagulation {Anticoagulant therapy}, antibiotics {Antibiotic therapy}, thoracentesis {Thoracentesis}, Hypertension {Hypertensive disorder, systemic arterial}, Benign prostatic hypertrophy {Benign prostatic hyperplasia}, Foley {Catheterization of urinary bladder}, TURP {Transurethral prostatectomy}, Voiding {Micturition finding}, Blindness {Blindness AND/OR vision impairment level}, macular degeneration {Degenerative disorder of macula}, left {Structure of macula lutea of left eye}, retinal 
detachment {Retinal detachment}, right {Structure of retina of right eye}, Chronic {Chronic disease}, stable {Patient's condition stable}, check kidney function {Renal function monitoring}, CBC {Complete blood count}, nodule {Nodule}, right lobe of the thyroid {Structure of right lobe of thyroid gland}, imaging {Imaging}, ultrasound {Ultrasonography}, require follow-up {Requires follow-up}, PCP {Primary care management}, require follow-up {Requires follow-up}, pneumonia {Pneumonia}, antibiotic {Antibiotic therapy}, CT scan {Computed tomography}, follow-up {Follow-up status}, pneumonia {Pneumonia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY 
Hold for HR<60 or sBP<100. 
2. Levobunolol 0.25% 1 DROP LEFT EYE DAILY 
3. Mirtazapine 30 mg PO HS 
4. Warfarin 4 mg PO DAILY16 
5. Docusate Sodium 100 mg PO BID 
6. DiphenhydrAMINE 25 mg PO HS:PRN insomnia 
7. Acetaminophen 500 mg PO Q6H:PRN pain 

 
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain 
2. Atenolol 25 mg PO DAILY 
Hold for HR<60 or sBP<100. 
3. Docusate Sodium 100 mg PO BID 
4. Levobunolol 0.25% 1 DROP LEFT EYE DAILY 
5. Mirtazapine 30 mg PO HS 
6. DiphenhydrAMINE 25 mg PO HS:PRN insomnia 
7. Warfarin 4 mg PO DAILY16 
8. Clindamycin 300 mg PO Q6H 
RX *clindamycin HCl [Cleocin] 300 mg 1 capsule(s) by mouth every 
six (6) hours Disp #*120 Capsule Refills:*0
9. Levofloxacin 500 mg PO DAILY 
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth daily 
Disp #*30 Tablet Refills:*0

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
PRIMARY:
- multifocal pneumonia with complicated parapneumonic effusion, 
empyema
SECONDARY:
- dysphagia secondary to esophageal diverticulum

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: pneumonia {Pneumonia}, parapneumonic effusion {Pleural effusion associated with pulmonary infection}, empyema {Empyema}, dysphagia {Dysphagia}, esophageal diverticulum {Diverticulum of esophagus}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___,

Thank you for choosing ___ for your medical care. You were 
admitted with pain ___ your chest caused by a pneumonia. Your 
pneumonia is probably caused by swallowing dysfunction.

You are now ready for discharge. Please take all your 
medications as instructed by your doctors. Please keep all of 
your appointments with your doctors, and bring a copy of your 
medications to these visits. Upon discharge, please call your 
PCP, ___, at ___ or return to the ED if you 
experience any of the following: loss of conciousness, fever, 
chest pain, trouble breathing, coughing up blood or pus, 
palpitations, lightheadedness, or any other symptoms that 
concern you.

It is important that you take precautions while eating to 
minimize the risk of choking or inhaling small bits of food. You 
must sit fully upright while eating and take only small sips of 
liquids. Swallow twice for each bite and sip and clear your 
throat after each swallow. Clean and rinse your mouth before 
each meal to decrease the amount of bacteria ___ your throat. You 
should remain seated upright for one hour after meals.
 

###RESPONSE: medical care {Medical care}, pain {Pain}, chest {Thoracic structure}, pneumonia {Pneumonia}, pneumonia {Pneumonia}, ready for discharge {Ready for discharge}, PCP {Primary care management}, loss of conciousness {Loss of consciousness}, fever {Fever}, chest pain {Chest pain}, trouble breathing {Difficulty breathing}, coughing up blood {Hemoptysis}, pus {Pus}, palpitations {Palpitations}, lightheadedness {Lightheadedness}, choking {Choking}, mouth {Mouth region structure}, throat {Structure of anterior portion of neck}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: OBSTETRICS/GYNECOLOGY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Compazine / Percocet
 
Attending: ___
 
Chief Complaint:
Post dates pregnancy
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: Post dates pregnancy {Prolonged pregnancy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ G7P2 at 41___ presents to L&D for cytotec induction of
labor. She has not had her cervix checked in Dr ___.
She does not have a ride home. She was seen earlier today in the
ED with a URI and was prescribed azithromycin and prednisone but
has not filled those prescriptions. 

Denies VB, LOF, ctx. Reports AFM. No CP/SOB/wheeze. No HA/visual
changes/RUQ pain.

 

###RESPONSE: induction of
labor {Induction of labor}, cervix {Cervix uteri structure}, URI {Upper respiratory infection}, VB {Bleeding from vagina}, LOF {Amniotic fluid leaking}, ctx {Contraction of uterus during labor}, AFM {Fetal movement finding}, CP {Chest pain}, SOB {Dyspnea}, wheeze {Wheezing}, HA {Headache}, visual
changes {Sight deteriorating}, RUQ pain {Right upper quadrant 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:
PNC:
- ___: ___ by 6week u/s not c/w LMP 
- Labs: A+/Ab-/RI/RPR NR/HBsAg-/GBS unk
- FFS, GLT, GBS results not available but normal per pt
Issues:
- current pregnancy dated by 6 wk ultrasound- reportedly had IUD
in place; ultrasound failed to demonstrate IUD within or outside
of uterus.  
- Per Dr ___, uncomplicated antenatal course, other 
than
episode of trauma at 28 wks.
- ultrasound at 40.1 wks noted an EFW of 3341g ___ 
percentile).
- h/o crack cocaine use w/ prior pregnancy, now clean
- h/o domestic violence
- h/o pre-eclampsia w/previous pregnancy

PAST OBSTETRIC HISTORY: records inconsistent.
G7P2
___ SVD, c/b pre-E, 7#7 
___ SVD, 6#6
SAB x 3
TAB x 1

PAST GYNECOLOGICAL HISTORY
- h/o Chlamydia, TOC neg
- h/o abnl pap, LSIL at initial OB visit

PAST MEDICAL HISTORY
- Asthma, no steriods, no intubation, last hospitalized ___ ago,
uses daughter's inhaler
- h/o ADD/ADHD, depression, anxiety, PTSD, ?bipolar d/o, 
multiple
suicide attempts
- Pulmonary nodule, PPD negative ___

PAST SURGICAL HISTORY
- tonsillectomy
- drainage abscess R elbow
- D&C x2

 

###RESPONSE: Labs {Laboratory test}, FFS {Fetal fibronectin measurement}, GLT {Glucose load test}, pregnancy {Pregnancy}, ultrasound {Ultrasonography}, IUD
in place {Intrauterine contraceptive device in situ}, ultrasound {Ultrasonography}, uterus {Uterine structure}, uncomplicated antenatal course {Normal pregnancy}, trauma {Traumatic injury}, ultrasound {Ultrasonography}, cocaine {Cocaine abuse}, pregnancy {Pregnancy}, pre-eclampsia {Pre-eclampsia}, previous pregnancy {Previous pregnancies}, SAB {Miscarriage}, TAB {Therapeutic abortion procedure}, Chlamydia {Chlamydial infection}, abnl pap {Abnormal cervical smear}, LSIL {Low-grade squamous intraepithelial lesion}, Asthma {Asthma}, steriods {Steroid therapy}, intubation {Intubation}, ADD/ADHD {Attention deficit hyperactivity disorder}, depression {Depressive disorder}, anxiety {Anxiety}, PTSD {Posttraumatic stress disorder}, bipolar d/o {Bipolar disorder}, suicide attempts {Suicidal intent}, Pulmonary nodule {Nodule of lung}, PPD {Mantoux: positive}, tonsillectomy {Tonsillectomy}, drainage {Drainage procedure}, abscess {Abscess}, R elbow {Right elbow region structure}, D&C {Dilation and curettage of uterus}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
non-contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Exam on admission: 
VS 98.0 75 129/75 18 98-99%RA, ___ 145
A&O NARD
RRR
CTAB no wheezes, rare bronchial breath sounds
Abd soft, gravid nontender
EFW 8# by ___
Ext NT no edema

SVE ___
Toco ___
FHT 140/mod/+accels/-decels

 

###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, A {Mentally alert}, O {Orientated}, RRR {Normal heart rate}, CTAB {Normal breath sounds}, wheezes {Wheezing}, bronchi {Wheeze - rhonchi}, Abd {Examination of abdomen}, soft {Abdomen soft}, gravid {Abdominal pregnancy}, nontender {Abdominal tenderness}, Ext {Examination of limb}, NT {Abdominal tenderness}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 08:56AM BLOOD WBC-13.0* RBC-3.47* Hgb-9.9* Hct-29.5* 
MCV-85 MCH-28.5 MCHC-33.5 RDW-14.1 Plt ___
___ 12:19PM BLOOD WBC-14.4* RBC-3.87* Hgb-11.1* Hct-32.8* 
MCV-85 MCH-28.8 MCHC-33.9 RDW-14.0 Plt ___
___ 12:19PM BLOOD Neuts-71.3* ___ Monos-5.0 Eos-0.6 
Baso-0.2
___ 12:19PM BLOOD Glucose-92 UreaN-5* Creat-0.5 Na-138 
K-3.9 Cl-106 HCO3-20* AnGap-16
___ 10:26PM URINE Blood-NEG Nitrite-NEG Protein-30 
Glucose-300 Ketone-80 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 12:19PM URINE Blood-NEG Nitrite-NEG Protein-NEG 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, 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}, URINE Blood {Blood in urine}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, URINE Blood {Blood in urine}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Ms. ___ was admitted to the L+D for post dates induction of 
labor. She had a succesful induction with cytotec and pitocin 
and delivered a liveborn infant without complications. 

Her post-partum course was uncomplicated.  Social work saw her 
due to her complex history.  Her pani was well controlled, she 
was ambulatory and eating a regular diet. She was discharged on 
post-partum day 2 with follow-up. 
 

###RESPONSE: post dates {Prolonged pregnancy}, induction of 
labor {Induction of labor}, post-partum {Postpartum state}, regular diet {Normal diet}, post-partum {Postpartum state}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
- PNV
- albuterol (___)
- prescribed azithromycin (Zpack) and prednisone in ED, rx not
yet filled

 
Discharge Medications:
1. Motrin 800 mg Tablet Sig: One (1) Tablet PO every six (6) 
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
s/p vaginal delivery

 
Discharge Condition:
stable

 

###RESPONSE: vaginal delivery {Vaginal delivery}, stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
No heavy lifting or intercourse
 

###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: 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: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
R ankle fracture dislocation, open
 
Major Surgical or Invasive Procedure:
ORIF R ankle and I&D ___

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, R ankle {Structure of right ankle}, fracture {Open fracture}, dislocation {Dislocation}, ORIF {Open reduction of fracture with internal fixation}, R ankle {Structure of right ankle}, I&D {Incision AND drainage}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Chief Complaint:  ankle pain
Reason for Orthopedics Consult: management of open fracture
 
HISTORY OF PRESENT ILLNESS: 
Patient is a ___ yo male previously healhty presenting w/ fall 
from 6 feet, from ladder. Patient landed on LLE w/ forced 
eversion and subsequent open fracture/dislocation. Denies head 
strike or LOC. Denies neck pain, back pain, chest pain, abd 
pain. Denies pelvic or thigh pain. 

Was emergently reduced in ED under conscious sedation. 

In the ED, initial vitals were 77 160/60 16 100%.  Per the ED, 
the patient's exam did not show evidence of neurovascular 
symptoms.

Review of systems:  
(+) Per HPI  
(-) Denies fever, chills, night sweats, recent weight loss or 
gain. Denies headache, neck or back pain. Denies cough, 
shortness of breath, chest pain. Denies nausea, vomiting, 
diarrhea, abdominal pain, or changes in bowel habits. Denies 
dysuria, frequency, or urgency. 
 
PAST MEDICAL HISTORY:  
none
 
MEDICATIONS:  
none
 
ALLERGIES:  
NKDA
 
SOCIAL HISTORY:  
Denies alcohol, drugs, smoking
 
PHYSICAL EXAM:  
GENERAL: Alert, oriented, no acute distress  
HEENT: Sclera anicteric, MMM, oropharynx clear  
NECK: C-spine is non-tender to palpation
LUNGS: Clear to auscultation bilaterally
CV: Regular rate and rhythm, 
ABD: soft, non-tender, non-distended, 
PELVIS: stable
EXT: open fracture/likely dislocation of LLE at level of distal 
tibia. +DP. Unable to assess.  Warm, well perfused, 2+ pulses, 
no clubbing, cyanosis or edema. ___

 
Labs: pending
 
Images:  
  

ASSESSMENT & PLAN:  
___ yo male w/ type II open fracture/dislocation of distal 
tib/fib.  

1. Ancef 2g, tetanus
2. Imaging
3. Admit to ___ for surgical repair
4. Preop labs

 

###RESPONSE: ankle pain {Ankle pain}, open fracture {Open fracture}, fall {Falls}, LLE {Structure of left lower limb}, eversion {Eversion}, open fracture {Open fracture}, dislocation {Dislocation}, head 
strike {Injury of head}, LOC {Loss of consciousness}, neck pain {Neck pain}, back pain {Backache}, chest pain {Chest pain}, abd 
pain {Abdominal pain}, pelvic {Pain in pelvis}, thigh pain {Thigh pain}, conscious sedation {Induction of conscious sedation}, vitals {Vital signs finding}, neurovascular 
symptoms {Neurological symptom}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Weight gain}, headache {Headache}, neck {Neck pain}, back pain {Backache}, Denies cough {Does not cough}, shortness of breath {Dyspnea}, chest pain {Chest pain}, nausea {Nausea}, vomiting {Vomiting}, diarrhea {Diarrhea}, abdominal pain {Abdominal pain}, changes in bowel habits {Altered bowel function}, dysuria {Dysuria}, frequency {Finding of frequency of urination}, urgency {Urgent desire to urinate}, smoking {Smoker}, GENERAL {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx {Oropharyngeal structure}, NECK {Physical examination procedure}, C-spine {Structure of cervical vertebral column}, non-tender {Cervical spine normal}, palpation {Palpation}, LUNGS {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, ABD {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, PELVIS {Structure of pelvis}, EXT {Examination of limb}, open fracture {Open fracture}, dislocation {Dislocation}, LLE {Structure of left lower limb}, distal 
tibia {Bone structure of distal tibia}, DP {Structure of dorsalis pedis artery}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, open fracture {Open fracture}, dislocation {Dislocation}, distal 
tib {Bone structure of distal tibia}, fib {Bone structure of distal fibula}, tetanus {Tetanus}, Imaging {Imaging}, surgical repair {Surgical repair}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
none
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
not contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
AFVSS
NAD
RLE: 
dressing c/d/i
___ intact dp/t
___
 

###RESPONSE: VS {Vital signs finding}, NAD {No abnormality detected}, RLE {Structure of right lower limb}, dressing {Application of dressing}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 presented to the emergency department and was 
evaluated by the orthopedic surgery team. The patient was found 
to have right ankle open fracture dislocation and was admitted 
to the orthopedic surgery service.  The patient was taken to the 
operating room on ___ for R ankle I&D and ORIF, which the 
patient tolerated well (for full details please see the 
separately dictated operative report). The patient was taken 
from the OR to the PACU in stable condition and after recovery 
from anesthesia was transferred to the floor.  The patient was 
initially given IV fluids and IV pain medications, and 
progressed to a regular diet and oral medications by POD#1. The 
patient was given perioperative antibiotics and anticoagulation 
per routine.  The patients home medications were continued 
throughout this hospitalization.  The patient worked with ___ who 
determined that discharge to home was appropriate. The ___ 
hospital course was otherwise unremarkable.

At the time of discharge the patient was afebrile with stable 
vital signs that were within normal limits, pain was well 
controlled with oral medications, incisions were 
clean/dry/intact, and the patient was voiding/moving bowels 
spontaneously. The patient is NWB in the right lower extremity, 
and will be discharged on lovenox for DVT prophylaxis.  The 
patient will follow up in two weeks per routine. A thorough 
discussion was had with the patient regarding the diagnosis and 
expected post-discharge course, and all questions were answered 
prior to discharge.

 

###RESPONSE: evaluated by the orthopedic surgery team {Orthopedic assessment}, right ankle {Structure of right ankle}, open fracture {Open fracture}, dislocation {Dislocation}, admitted 
to the orthopedic surgery service {Admission by orthopedic surgeon}, R ankle {Structure of right ankle}, I&D {Incision AND drainage}, ORIF {Open reduction of fracture with internal fixation}, operative {Surgical procedure}, PACU {Postanesthesia care}, stable condition {Patient's condition stable}, anesthesia {Absence of sensation}, given IV fluids {Administration of intravenous fluids}, IV {Intravenous therapy}, pain medications {Administration of analgesic}, regular diet {Normal diet}, oral medications {Administration of drug or medicament via oral route}, antibiotics {Antibiotic therapy}, anticoagulation {Anticoagulant therapy}, unremarkable {No abnormality detected}, stable 
vital signs {Normal vital signs}, pain {Pain}, oral medications {Administration of drug or medicament via oral route}, incisions {Incision}, voiding {Normal micturition}, moving bowels {Finding of defecation}, right lower extremity {Structure of right lower limb}, DVT {Deep venous thrombosis}, prophylaxis {Preventive procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
none
 
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H 
2. Docusate Sodium 100 mg PO BID 
3. Enoxaparin Sodium 40 mg SC QHS 
Start: Today - ___, First Dose: Next Routine Administration 
Time 
RX *enoxaparin 40 mg/0.4 mL 1 syringe at bedtime Disp #*14 
Syringe Refills:*0
4. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN pain 
RX *oxycodone 5 mg ___ tablet(s) by mouth q3hrs Disp #*80 Tablet 
Refills:*0

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
R ankle fracture dislocation

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: R ankle {Structure of right ankle}, fracture {Open fracture}, dislocation {Dislocation}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - requires assistance or aid {Finding of walking aid use}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians 
at discharge.
- Continue all home medications unless specifically instructed 
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate 
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should 
drink eight 8oz glasses of water daily and take a stool softener 
(colace) to prevent this side effect.

ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks

WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken 
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless 
otherwise instructed
- Do NOT get splint wet

ACTIVITY AND WEIGHT BEARING:
NWB R ankle 

Danger Signs:

Please call your PCP or surgeon's office and/or return to the 
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning 
changes in your incision
- Persistent or increasing numbness, tingling, or loss of 
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid, 
medications down
- Any other medical concerns

 

###RESPONSE: Do not drink alcohol {Education about alcohol consumption}, pain relievers {Administration of analgesic}, pain relievers {Administration of analgesic}, constipation {Constipation}, take a stool softener {Administration of laxative}, dressing {Application of dressing}, wound {Wound}, draining {Wound discharge}, Splint {Application of splint}, R ankle {Structure of right ankle}, PCP {Primary care management}, pain {Pain}, pain medications {Administration of analgesic}, redness {Redness of skin over lesion}, swelling {Swelling}, drainage {Discharge}, incision {Incision}, numbness, tingling {Numbness and tingling sensation of skin}, loss of 
sensation {Numbness}, Fever {Fever}, chills {Chill}, Chest pain {Chest pain}, Shortness of breath {Dyspnea}, Nausea {Nausea}, vomiting {Vomiting}, liquid {Liquid}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Dyspnea and hemoptysis
 
Major Surgical or Invasive Procedure:
intubation - ___
arterial line placement - ___
cardiac catheterization - ___
 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, Dyspnea {Dyspnea}, hemoptysis {Hemoptysis}, intubation {Intubation}, arterial line placement {Insertion of catheter into artery}, cardiac catheterization {Cardiac catheterization}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mr. ___ is an ___ year old man with COPD, CAD, CHF and Afib who 
presented to ___ complaining of dyspnea and hemoptysis. Patient 
reports productive cough with yellow sputum for the past 3 weeks 
that was treated with azithromycin by his primary care doctor 
one week ago. Patient also c/o hemoptysis for the past ___ days, 
which he described as ""big globs"" of blood. Patient also 
endorses fever and chills at home. 

  At ___, initial VS were 98.1 140 132/67 24 76% RA that 
improved to 95% on NRB. Labs revelaed WBC 13.1 91.6%N and INR 
8.0. CXR revealed RUL consolidation c/f PNA, and he received CTX 
1g IV, Vitamin K and was transfered to ___ for further care. 

  At ___ initail VS were 99.0 120 111/70 24 94% 15L NRB. Labs 
revealed lactate 2.9, WBC 13 92.5%N, HCT 40.7, Cr 2.2, proBNP 
4254, TropT 0.28. ABG 7.43, 28, 81. Patient received 2 units 
FFP, 40mg IV lasix, 10mg IV diltiazem, 30mg PO diltiazem, 500mg 
IV azithromycin and 1g IV vancomycin. The patient was then 
admitted to the MICU.

  On arrival to the MICU, the patient happeard was dyspnic with 
oxygen saturation of 90% on NRB and was placed on non-invasive 
ventillation with improvement to 100% oxygen saturation. 
  
Review of systems:  
(+) Per HPI  
(-) Denies fever, chills, night sweats, recent weight loss or 
gain. Denies headache, sinus tenderness, rhinorrhea or 
congestion. Denies  shortness of breath, cough, dyspnea or 
wheezing. Denies chest pain, chest pressure, palpitations. 
Denies  constipation, abdominal pain, diarrhea, dark or bloody 
stools. Denies dysuria, frequency, or urgency. Denies 
arthralgias or myalgias. Denies rashes or skin changes.  

 

###RESPONSE: COPD {Chronic obstructive lung disease}, CAD {Coronary arteriosclerosis}, CHF {Congestive heart failure}, Afib {Atrial fibrillation}, dyspnea {Dyspnea}, hemoptysis {Hemoptysis}, productive cough {Productive cough}, yellow sputum {Yellow sputum}, hemoptysis {Hemoptysis}, fever {Fever}, chills {Chill}, RA {Breathing room air}, improved {Patient's condition improved}, NRB {Oxygen administration by mask}, CXR {Plain chest X-ray}, RUL {Structure of upper lobe of right lung}, consolidation {Consolidation}, PNA {Pneumonia}, NRB {Oxygen administration by mask}, lasix {Diuretic therapy}, dyspnic {Dyspnea}, NRB {Oxygen administration by mask}, non-invasive 
ventillation {Non-invasive ventilation}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, headache {Headache}, sinus {Nasal sinus structure}, tenderness {Tenderness}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, shortness of breath {Dyspnea}, cough {Cough}, dyspnea {Dyspnea}, wheezing {Wheezing}, chest pain {Chest pain}, chest pressure {Tight chest}, palpitations {Palpitations}, constipation {Constipation}, abdominal pain {Abdominal pain}, diarrhea {Diarrhea}, dark {Dark stools}, bloody 
stools {Hematochezia}, dysuria {Dysuria}, frequency {Increased frequency of urination}, urgency {Urgent desire to urinate}, arthralgias {Joint pain}, myalgias {Muscle pain}, rashes {Eruption of skin}, skin changes {Skin appearance abnormal}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- Atrial fibrillation and systolic CHF. EF of 35% to 40%
- CAD s/p CABG (2 vessel, LIMA to LAD, rSVG to OM) in ___
- Rheumatic heart disease s/p bioprosthetic AVR in ___
- Mitral valve prolapse
- Bioprosthetic AVR ___ (bovine)
- AAA 3.9 cm in ___ follow at ___
- Hypertension
- High cholesterol
- Restrictive lung disease
- Asthma
- Polymyalgia rheumatica, on 10mg prednisone daily
- History of cholecystectomy
- Hemorrhoids
- Chronic renal insufficiency, baseline creatinine 1.6 to 1.9
- Cataract surgery, left
- Anemia
- Seasonal allergy
- Chronic anal fissure

 

###RESPONSE: Atrial fibrillation {Atrial fibrillation}, systolic CHF {Chronic systolic heart failure}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, LIMA {Structure of left internal thoracic artery}, LAD {Structure of anterior descending branch of left coronary artery}, OM {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, Rheumatic heart disease {Rheumatic heart disease}, bioprosthetic AVR {Repair of aortic valve with tissue graft}, Mitral valve prolapse {Mitral valve prolapse}, Bioprosthetic AVR {Repair of aortic valve with tissue graft}, AAA {Abdominal aortic aneurysm}, Hypertension {Hypertensive disorder, systemic arterial}, High cholesterol {Hypercholesterolemia}, Restrictive lung disease {Restrictive lung disease}, Asthma {Asthma}, Polymyalgia rheumatica {Polymyalgia rheumatica}, cholecystectomy {Cholecystectomy}, Hemorrhoids {Hemorrhoids}, Chronic renal insufficiency {Chronic renal insufficiency}, Cataract surgery, left {Surgery of cataract of left eye}, Anemia {Anemia}, Seasonal allergy {Seasonal allergy}, Chronic anal fissure {Chronic anal fissure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Pt is adopted, so unknown.
 

###RESPONSE: adopted {Adopted}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Admission 
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
General: Tachypnic, oriented, mild respiratory distress  
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL  
Neck: supple, JVP elevated to 16cm H2O, no LAD  
CV: tachycardic irrgeular rhythm, no rubs, gallops  
Lungs: Rales in RUL and ___ bases, no wheezes,  
Abdomen: soft, non-distended, bowel sounds present, no 
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place  
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema 
Neuro: CNII-XII intact, MAEW

 

###RESPONSE: Physical Exam {Physical examination procedure}, General {General examination of patient}, Tachypnic {Tachypnea}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, tachycardic {Tachycardia}, irrgeular rhythm {Irregular heart beat}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Lungs {Examination of respiratory system}, Rales {Respiratory crackles}, RUL {Structure of upper lobe of right lung}, bases {Structure of base of lung}, wheezes {Wheezing}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, tenderness {Tenderness}, palpation {Palpation}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, GU {Examination of genitourinary system}, foley in place {Urinary catheter in situ}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, CNII {Optic nerve structure}, XII intact {Intact hypoglossal nerve}, MAEW {Does move all four limbs}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 10:50AM BLOOD WBC-13.0*# RBC-4.32* Hgb-12.6* Hct-40.7 
MCV-94 MCH-29.2 MCHC-31.0 RDW-14.0 Plt ___
___ 10:50AM BLOOD Neuts-92.5* Lymphs-4.0* Monos-3.0 Eos-0.4 
Baso-0.2
___ 10:50AM BLOOD ___ PTT-33.8 ___
___ 10:50AM BLOOD Glucose-157* UreaN-69* Creat-2.2* Na-135 
K-4.9 Cl-99 HCO3-21* AnGap-20
___ 10:50AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.6
___ 11:05AM BLOOD Lactate-2.9*

Cardiac Labs:
___ 10:50AM BLOOD CK-MB-8 cTropnT-0.29* proBNP-4254*
___ 10:50AM BLOOD cTropnT-0.28*
___ 10:50AM BLOOD CK(CPK)-283
___ 10:13PM BLOOD CK-MB-4 cTropnT-0.37*
___ 10:13PM BLOOD CK(CPK)-215
___ 05:35AM BLOOD CK-MB-4 cTropnT-0.24*
___ 05:35AM BLOOD CK(CPK)-169
___ 01:24PM BLOOD CK-MB-5 cTropnT-0.18*
___ 01:24PM BLOOD CK(CPK)-138

Interim Labs:
___ 05:35AM BLOOD Cortsol-30.1*

Microbiology:
___ BLOOD CULTURE Blood Culture, Routine-PENDING 
___ BLOOD CULTURE Blood Culture, Routine-PENDING 
___ URINE URINE CULTURE-FINAL 
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL 
{YEAST} 
___ MRSA SCREEN MRSA SCREEN-FINAL 
___ URINE Legionella Urinary Antigen -FINAL 
___ URINE URINE CULTURE-FINAL 
___ BLOOD CULTURE Blood Culture, Routine-FINAL 
___ BLOOD CULTURE Blood Culture, Routine-FINAL 
.
Imaging:
CXR ___
Possible asymmetric right greater than left, pulmonary edema; 
superimposed 
infectious process not excluded. Given history of hemoptysis, 
underlying 
pulmonary hemorrhage is not excluded. Small right pleural 
effusion. 

CXR ___
Status post median sternotomy for CABG with overall stable 
cardiac and 
mediastinal contours. Prosthetic aortic valve. There is interval 
worsening 
of bilateral airspace and interstitial process which may reflect 
pulmonary 
edema, worsening pneumonia, or a progressing hypersensitivity 
reaction.  
Pulmonary hemorrhage could also have this appearance. Clinical 
correlation is advised. No pneumothorax. No acute pulmonary 
abnormality appreciated. 

TTE ___
The left atrium is mildly dilated. There is mild symmetric left 
ventricular hypertrophy with normal cavity size. Due to 
suboptimal technical quality, a focal wall motion abnormality 
cannot be fully excluded. Overall left ventricular systolic 
function is borderline low (LVEF 50%). A bioprosthetic aortic 
valve prosthesis is well seated, with normal leaflet/disc motion 
and transvalvular gradients. No aortic regurgitation is seen. 
The mitral valve leaflets are mildly thickened. Mild to moderate 
(___) mitral regurgitation is seen. The estimated pulmonary 
artery systolic pressure is normal. There is no pericardial 
effusion. 
IMPRESSION: Mild symmetric left ventricular hypertrophy with 
borderline low left ventricular systolic function. Well-seated 
bioprosthetic aortic valve with normal transvalvular gradients. 
Mild to moderate mitral regurgitation.
Compared with the prior study (images reviewed) of ___, the 
left ventricular function appears less vigorous. The gradients 
across the bioprosthetic aortic valve are normal.  

CXR ___
FINDINGS: As compared to the previous radiograph, there are 
unchanged 
bilateral airspace opacities and a small right pleural effusion. 
The 
opacities and the effusion have not changed in the interval. 
Moderate 
cardiomegaly, status post CABG with subsequent position of the 
surgical 
material. No other relevant findings. 

CXR ___
IMPRESSION: Slight improvement in diffuse pulmonary opacities, 
suggesting 
decrease in edema, with probable superimposed pneumonia. 

CT Chest ___
FINDINGS: There is mild, apical-predominant centrilobular and 
paraseptal 
emphysema. Diffuse ground-glass opacities are present throughout 
both lungs, involving all lobes and extending to the pleural 
surfaces. Early fibrosis with mild honeycombing at the lung 
bases. Mild diffuse peribronchial wall thickening, but no 
interstitial thickening. No pleural effusions.  Heart is normal 
in size, without pericardial effusion. Changes of coronary 
artery bypass grafting, with mediastinal clips. Note is made of 
a prosthetic aortic valve and discarded right atrial/ventricular 
pacemaker leads. Diffuse calcific atherosclerosis is present in 
the thoracic aorta.  Prominent mediastinal nodes measure up to 
12 mm in short axis in the superior right paratracheal region, 
10 mm in the inferior right paratracheal region, and 13 mm in 
the subcarinal region. Changes of median sternotomy, with 
multiple chronically fractured and malpositioned sternal wires. 
No sternal fluid collections or osseous abnormalities. 
Examination is not tailored for subdiaphragmatic evaluation, but 
reveals a 
nasogastric tube in appropriate position. Gastric diverticulum 
arises from 
the greater curvature. Cholecystectomy changes. Accesorry 
splenule is 
present. Multiple colonic diverticula, without acute 
inflammation.  
IMPRESSION: Diffuse ground-glass pulmonary opacities and early 
fibrosis.  
Given patient history, this may represent acute-on-chronic 
organizing 
pneumonia, acute interstitial pneumonitis, less likely fibrosis 
with 
superimposed infection.  
.
Right Heart Cardiac Catheterization ___
Cardiac Output Results
PhaseFick C.O. (l/min)Fick C.I.(l/min/m2)
     4.39               2.25
Hemodynamic Measurements (mmHg)
Baseline
SiteSysDiasEndMeanA WaveV WaveHR
RA      ___
RV      ___
___    ___
___      ___
Radiology Summary
Total Cine Runs
Fluoro Time (minutes)0.90
Effective Equivalent Dose Index (mGy) 12.43
Findings
ESTIMATED blood loss: <10 cc
Hemodynamics (see above): 
Assessment & Recommendations
1.Mild pulmonary hypertension
2.Mildly elevated filling pressures.
3.Preserved Cardiac Output.
4.No indication for selective pulmonary vasodilators.
.
___ CXR
REPORT: Status post sternotomy. NG tube courses throughout the 
mediastinum to its expected location in the stomach. The ET tube 
is in good position, lying about 4 cm above the carina. 
There is a right-sided internal jugular line in unchanged 
position. There is symmetrical blunting of both costophrenic 
sulci. Generalized increased lung markings consistent most with 
fluid overload are grossly unchanged. 
More confluent abnormalities in the left lung base in particular 
are also 
unchanged. I note also CT from ___ suggesting this and 
in fact very little fluid overload, so presumptively the changes 
represent the ongoing alveolitis-type changes identified on that 
radiograph. 
.
___ CXR
FINDINGS: Bilateral diffuse lung opacities are presisting. On 
concurrent 
review with prior chest CT dated ___, these opacities 
represent a 
combination of ground-glass opacities and consolidation and 
bibasilar 
fibrosis, unchanged since ___, but improved since ___. All these changes are more on the right side and may 
represent continuing 
alveolitis. As appreciated on recent chest CT, there was no 
component of 
pulmonary edema then nor in today's radiograph. Mild widening of 
the 
mediastinum is from increased mediastinal fat in conjunction 
with multiple 
lymph nodes as appreciated on the chest CT. There is evidence of 
prior median sternotomy and sternal sutures are intact. 
Effusions, if any, are small bilaterally and unchanged. There is 
no pneumothorax. Heart size is normal.  
Hilar contours are unremarkable. Aorta has a mild tortuous 
course and 
demonstrates mild-to-moderate and severe atherosclerotic 
calcification. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, cTropnT {Troponin T cardiac measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, CXR {Plain chest X-ray}, pulmonary edema {Pulmonary edema}, infectious process {Infectious disease}, hemoptysis {Hemoptysis}, pulmonary hemorrhage {Pulmonary hemorrhage}, pleural 
effusion {Pleural effusion}, CXR {Plain chest X-ray}, Status post {Postoperative state}, median sternotomy {Median sternotomy}, CABG {Coronary artery bypass grafting}, cardiac {Heart structure}, mediastinal {Mediastinal structure}, aortic valve {Aortic valve structure}, pulmonary 
edema {Pulmonary edema}, pneumonia {Pneumonia}, hypersensitivity 
reaction {Hypersensitivity reaction}, Pulmonary hemorrhage {Pulmonary hemorrhage}, pneumothorax {Pneumothorax}, TTE {Transthoracic echocardiography}, left atrium {Left atrial structure}, dilated {Dilatation}, mild symmetric left 
ventricular hypertrophy {Mild left ventricular hypertrophy}, aortic 
valve {Aortic valve structure}, aortic regurgitation {Aortic valve regurgitation}, mitral valve leaflets are mildly thickened {Thickened mitral leaflet}, Mild {Mild mitral valve regurgitation}, moderate 
(___) mitral regurgitation {Moderate mitral valve regurgitation}, pulmonary 
artery {Pulmonary artery structure}, pericardial 
effusion {Pericardial effusion}, Mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, aortic valve {Aortic valve structure}, Mild {Mild mitral valve regurgitation}, moderate mitral regurgitation {Moderate mitral valve regurgitation}, left ventricular {Left cardiac ventricular structure}, aortic valve {Aortic valve structure}, CXR {Plain chest X-ray}, opacities {Abnormally opaque structure}, pleural effusion {Pleural effusion}, opacities {Abnormally opaque structure}, effusion {Effusion}, cardiomegaly {Cardiomegaly}, status post {Postoperative state}, CABG {Coronary artery bypass grafting}, CXR {Plain chest X-ray}, opacities {Abnormally opaque structure}, edema {Edema}, pneumonia {Pneumonia}, CT Chest {Computed tomography of chest}, centrilobular {Centriacinar emphysema}, paraseptal 
emphysema {Paraseptal emphysema}, ground-glass opacities {Ground glass lung opacity}, both lungs {Both lungs}, pleural 
surfaces {Pleural membrane structure}, fibrosis {Fibrosis}, honeycombing {Honeycomb appearance}, lung 
bases {Structure of base of lung}, thickening {Increased thickness}, thickening {Increased thickness}, pleural effusions {Pleural effusion}, Heart {Heart structure}, normal 
in size {Normal size}, pericardial effusion {Pericardial effusion}, coronary 
artery bypass grafting {Coronary artery bypass grafting}, aortic valve {Aortic valve structure}, right atrial {Right atrial structure}, ventricular {Cardiac ventricular structure}, atherosclerosis {Atherosclerosis}, thoracic aorta {Thoracic aorta structure}, mediastinal nodes {Mediastinal lymph node structure}, median sternotomy {Median sternotomy}, fractured {Fracture of bone}, sternal {Structure of sternal region}, osseous {Bone structure}, nasogastric tube in appropriate position {Nasogastric tube in situ}, Gastric diverticulum {Gastric diverticulum}, greater curvature {Structure of greater curvature of stomach}, Cholecystectomy {Cholecystectomy}, Accesorry 
splenule {Accessory spleen}, colonic diverticula {Diverticulosis of colon}, acute 
inflammation {Acute inflammation}, Diffuse {Diffuse pain}, ground-glass pulmonary opacities {Ground glass lung opacity}, fibrosis {Fibrosis}, chronic 
organizing 
pneumonia {Chronic pneumonia}, acute interstitial pneumonitis {Primary atypical interstitial pneumonia}, fibrosis {Fibrosis}, superimposed infection {Superimposed infection}, Right Heart Cardiac Catheterization {Catheterization of right heart}, Hemodynamic Measurements {Hemodynamic measurements}, blood loss {Hemorrhage}, Mild pulmonary hypertension {Mild pulmonary hypertension}, Preserved Cardiac Output {Normal cardiac output}, CXR {Plain chest X-ray}, Status post {Postoperative state}, sternotomy {Sternotomy}, mediastinum {Mediastinal structure}, stomach {Stomach structure}, carina {Structure of carina of trachea}, costophrenic 
sulci {Structure of costophrenic angle}, lung {Lung structure}, fluid overload {Hypervolemia}, left lung base {Structure of base of left lung}, fluid overload {Hypervolemia}, radiograph {Plain radiography}, CXR {Plain chest X-ray}, lung {Lung structure}, opacities {Abnormally opaque structure}, chest CT {Computed tomography of chest}, opacities {Abnormally opaque structure}, ground-glass opacities {Ground glass lung opacity}, consolidation {Consolidation}, bibasilar {Structure of base of lung}, fibrosis {Fibrosis}, improved {Patient's condition improved}, right side {Right lung structure}, chest CT {Computed tomography of chest}, pulmonary edema {Pulmonary edema}, radiograph {Plain radiography}, mediastinum {Mediastinal structure}, mediastinal {Mediastinal structure}, fat {Structure of adipose tissue}, lymph nodes {Structure of lymph node}, chest CT {Computed tomography of chest}, median sternotomy {Median sternotomy}, sternal {Structure of sternal region}, pneumothorax {Pneumothorax}, Heart {Heart structure}, size is normal {Normal size}, unremarkable {No abnormality detected}, Aorta {Aortic structure}, atherosclerotic {Atherosclerosis}, calcification {Pathologic calcification, calcified structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ with COPD, CAD, CHF and Afib presenting with cough, dyspnea 
and hemoptysis admitted with PNA and pulmonary edema.

# Dyspnea and Sepsis: Patient likely had bacterial pneumonia 
that followed a viral URI several weeks ago. On admission, felt 
to have pulmonary edema and pneumonia, treated for both with 
ceftriaxone/azithromycin and diuresis.  After 7L diuresis, 
patient had no improvement.  On ___ he was noted to have 
increasing respiratory distress and was electively intubated.  
Following intubation he became hypotensive and required pressor 
support during ___ and ___.  Cardiac Catheterization showed 
wedge of 14 with V wave of 80. CT Chest revealed ground-glass 
opacities consistent with acute-on-chronic organizing pneumonia 
or acute interstitial pneumonitis.  Was treated with high dose 
steroids with apparent initial improvement and was extubated.  
His mental status was very altered after extubation requiring 
olanazpine with mild effect.  He had a respiratory 
decompensation after several days of extubation requiring 
reintubation.  Abx were broadened to vanco/zosyn and he was 
started on solumedrol 1gm IV for 3 days for concern for 
undertreated COP, as his infectious work-up to date had not been 
revealing and his extensive work-up for cardiac causes of his 
dyspnea and respiratory failure was negative. As such, given the 
lack of an alternative diagnosis and the suspicion that COP may 
be the cause of his respiratory failure, aggressive 
glucocorticoid treatment was pursued in an effort to give him 
every chance to survive his acute illness. After three days of 
treatment with pulse-dose Solumedrol, however, there was no 
meaningful improvement in his respiratory status and his overall 
clinical status was progressively worsening with progressive 
acute renal failure, falling platelets, and worsening mental 
status (decreasing responsiveness despite holding sedative.) To 
objectively assess his pulmonary response to steroids, we 
obtained a repeat CT scan after completing three days of pulse 
dose steroids which did not show improvement. Given this, and 
given overall status of resp failure, renal failure, altered 
mental status - several meetings were held with the patient's 
son ___ (the patient's HCP) and decision was made to move to 
___.  Terminally extubated and passed away on ___ with son at 
bedside.
.
# AMS - ICU delirium compounded by high steroid dose.  Managed 
with olanzapine with mild effect. His mental status deteriorated 
to the point that he was essentially non-responsive, including 
several absent brinstem reflexed (no corneal reflex, no cough, 
no gag, minimal pupillary response) prior to his being 
transitioned to ___ care. 
.
# Anuric renal failure - Patient was noted to have increasing 
Creatinine after reintubation that was concerning for ATN due to 
an episode of hypotension and hypoperfusion.  His creatinine 
continued to rise and he developed anuric renal failure over the 
last day of his ICU stay. 
.
# Afib w/ RVR: Patient had a HR in the 140s at ___ and received 
10mg IV and 30mg PO diltiazem at ___ ED. His HR was controlled 
to 100-120 by arrival to the ICU.  His home metoprolol was 
initially resumed, stopped ___ given hypotension.  Digoxin was 
started ___ for rhythm control.
 

###RESPONSE: COPD {Chronic obstructive lung disease}, CAD {Coronary arteriosclerosis}, CHF {Congestive heart failure}, Afib {Atrial fibrillation}, cough {Cough}, dyspnea {Dyspnea}, hemoptysis {Hemoptysis}, PNA {Pneumonia}, pulmonary edema {Pulmonary edema}, Dyspnea {Dyspnea}, Sepsis {Sepsis}, bacterial pneumonia {Bacterial pneumonia}, viral URI {Viral upper respiratory tract infection}, pulmonary edema {Pulmonary edema}, pneumonia {Pneumonia}, diuresis {Diuresis}, diuresis {Diuresis}, respiratory distress {Respiratory distress}, intubated {Intubation}, intubation {Intubation}, hypotensive {Low blood pressure}, pressor 
support {Vasopressor therapy}, Cardiac Catheterization {Cardiac catheterization}, CT Chest {Computed tomography of chest}, ground-glass 
opacities {Ground glass lung opacity}, pneumonia {Pneumonia}, acute interstitial pneumonitis {Primary atypical interstitial pneumonia}, extubated {Removal of endotracheal tube}, mental status was very altered {Altered mental status}, extubation {Removal of endotracheal tube}, extubation {Removal of endotracheal tube}, cardiac {Heart disease}, dyspnea {Dyspnea}, respiratory failure {Respiratory failure}, respiratory failure {Respiratory failure}, acute renal failure {Acute kidney injury}, falling platelets {Platelet count below reference range}, worsening mental 
status {Altered mental status}, steroids {Steroid therapy}, CT scan {Computed tomography}, resp failure {Respiratory failure}, renal failure {Renal failure syndrome}, altered 
mental status {Altered mental status}, extubated {Removal of endotracheal tube}, AMS {Altered mental status}, delirium {Delirium}, mental status deteriorated {Altered mental status}, no corneal reflex {Corneal reflex absent}, cough {Cough}, gag {Gagging}, Anuric {Anuria}, renal failure {Renal failure syndrome}, ATN {Acute tubular necrosis}, hypotension {Low blood pressure}, anuric {Anuria}, renal failure {Renal failure syndrome}, Afib w/ RVR {Atrial fibrillation with rapid ventricular response}, hypotension {Low blood pressure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Aspirin 81 mg daily
Omeprazole 20 mg daily
Saline Nasal spray daily
Warfarin 2.5 mg daily
Lasix 20 mg daily
Metoprolol Succinate 50 mg daily
Pravastatin 80 mg daily
Ropinirole 0.5 mg BID
Fluticasone 110 mcg/Actuation 2 Puff BID
Fluticsone 50 mcg nasal spray
Prednisone 10 mg daily

 
Discharge Medications:
Patient expired
 

###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:
Expired
 
Discharge Diagnosis:
Hypoxic respiratory failure
Anuric renal failure
Atrial fibrillation with RVR
Delirium
 
Discharge Condition:
Patient expired after having been transitioned to CMO after 
progressive multiorgan system failure prompted discussion with 
his family and HCP. 
 

###RESPONSE: Hypoxic {Hypoxia}, respiratory failure {Respiratory failure}, Anuric {Anuria}, renal failure {Renal failure syndrome}, Atrial fibrillation with RVR {Atrial fibrillation with rapid ventricular response}, Delirium {Delirium}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Patient expired.
 

###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: 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:
Hyperglycemia/altered mental status/cough
 
Major Surgical or Invasive Procedure:
There were no major surgical or invasive procedures during 
hospitalization. 

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Hyperglycemia {Hyperglycemia}, altered mental status {Altered mental status}, cough {Cough}, surgical {Surgical 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:
___ with history of dementia, hypertention, diabetes presenting 
with lethargy, cough for one week, noted to have a pneumonia on 
a chest x-ray at ___ yesterday. Patient was started on 
azithromycin for this by basilar pneumonia. Patient is in a 
memory unit. At this unit, they do have access to 
rehabilitation. Patient normally uses a walker. Because of the 
weakness for the past one week, the patient has been using a 
wheelchair. Patient's thought his medical care in ___, 
and never establish primary care in ___, the doctor at 
his facility has been continuing medications from his doctor in 
___. Daughter concerned that the patient is not 
receiving adequate attention at facility. Doctor at facility 
concerned that glucose 367 today. Low 200s here. Patient denies 
complete ROS. A&Ox1. Patient sent to ___ for further 
evaluation.  
 
 -In the ED, initial vitals were: T 98.7 HR 80 BP 136/91 RR 18 
SpO2 97% RA  
 -Exam notable for: bibasilar crackles, otherwise normal exam  
 -Labs notable for WBC 9.0, Cr 0.8, lactate 2.7  
 -CXR was notable LLL opacity concerning for PNA  
 -Received: 1 L IV NS, Levofloxacin 750 mg IV, Olanzapine 10 mg 
PO total, and his home medications (Metformin, Memantine, 
Aspirin, Glipizide, Lisinopril  
 -Transfer VS were: T 102.4 HR 102 BP 128/75 RR 23 SpO2 95% RA  
 -On arrival to the floor, the patient unable to engage in ROS 
evaluation. Patient appeared to be sleeping comfortably. He was 
continued on IV abx, his home medications, and started on 
insulin sliding scale.  
 On arrival to the floor, patient was sleeping comfortably, not 
responsive to voice and unable to participate in ROS. Family 
members were in the room who reports the patient has been 
complaining of cough and more lethargic compared to baseline 
mental status. The patient was given 1 L IV fluids, continued on 
IV abx, started on insulin sliding scale, but otherwise 
continued on his home medications.  
 

###RESPONSE: dementia {Dementia}, hypertention {Hypertensive disorder, systemic arterial}, diabetes {Diabetes mellitus}, lethargy {Lethargy}, cough {Cough}, pneumonia {Pneumonia}, chest x-ray {Plain chest X-ray}, basilar pneumonia {Basal pneumonia}, rehabilitation {Rehabilitation therapy}, weakness {Asthenia}, evaluation {Evaluation procedure}, RA {Breathing room air}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, CXR {Plain chest X-ray}, LLL {Structure of lower lobe of left lung}, opacity {Abnormally opaque structure}, PNA {Pneumonia}, IV {Intravenous therapy}, IV {Intravenous therapy}, RA {Breathing room air}, evaluation {Evaluation procedure}, sleeping {Asleep}, IV abx {Intravenous antibiotic therapy}, sleeping {Asleep}, cough {Cough}, lethargic {Lethargy}, baseline {Baseline state}, mental status {Mental state finding}, IV {Intravenous therapy}, IV abx {Intravenous antibiotic therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
-Hypertension
-Hyperlipidemia
-Dementia
-Type II Diabetes Mellitus
-___: hospitalized at ___ due to hyperglycemia secondary to 
underlying pneumonia. 
 

###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, Dementia {Dementia}, Type II Diabetes Mellitus {Diabetes mellitus type 2}, hyperglycemia {Hyperglycemia}, pneumonia {Pneumonia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father had CAD and died of MI. Mother had stomach cancer  
 

###RESPONSE: CAD {Coronary arteriosclerosis}, died {Dead}, MI {Myocardial infarction}, stomach cancer {Malignant tumor of stomach}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 T 98.3 BP 153/84 HR 95 RR 20 SpO2 98 RA  
General: Sleeping comfortably, snoring, does not respond to 
voice  
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, 
neck supple, JVP not elevated, no LAD  
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops  
Lungs: L basilar inspiratory crackles, no wheezing or rhonci  
Abdomen: Soft, non-tender, non-distended, bowel sounds present, 
no organomegaly, no rebound or guarding  
GU: Foley in place  
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
Neuro: CNII-XII intact, ___ strength upper/lower extremities, 
grossly normal sensation, 2+ reflexes bilaterally, gait 
deferred.  

DISCHARGE PHYSICAL EXAM
======================
Vitals:     98.4   122/75  82  18  94RA 
General: Awake, alert and oriented x 1 (to person)
HEENT: Sclerae anicteric, MMM, neck supple, JVP not elevated. 
CV: RRR, normal S1 + S2, no murmurs. 
Lungs: Clear to auscultation  
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding. 
Ext: Warm, well perfused, no lower extremity edema.  
 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, 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}, Sleeping {Asleep}, snoring {Snoring}, respond to 
voice {Responds to voice}, HEENT {Physical examination procedure}, Sclerae anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Lungs {Examination of respiratory system}, L basilar {Structure of base of left lung}, crackles {Respiratory crackles}, wheezing {Wheezing}, rhonci {Wheeze - rhonchi}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, tender {Abdominal tenderness}, distended {Swollen abdomen}, bowel sounds present {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, GU {Examination of genitourinary system}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, CNII {Optic nerve structure}, XII intact {Intact hypoglossal nerve}, upper {Upper limb structure}, lower extremities {Lower limb structure}, normal sensation {Normal sensation}, 2+ reflexes {Normal reflex}, gait {Finding of gait}, PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, Awake {Awake}, alert {Mentally alert}, oriented {Orientated}, HEENT {Physical examination procedure}, Sclerae anicteric {White sclera}, MMM {Moist oral mucosa}, neck {Neck structure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, Lungs {Examination of respiratory system}, Clear to auscultation {Normal breath sounds}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, tender {Abdominal tenderness}, distended {Swollen abdomen}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS
=============
___ 08:02PM BLOOD WBC-7.3 RBC-3.87* Hgb-12.8* Hct-37.4* 
MCV-97 MCH-33.1* MCHC-34.2 RDW-13.2 RDWSD-46.6* Plt ___
___ 08:02PM BLOOD Neuts-63.4 Lymphs-16.3* Monos-15.0* 
Eos-4.1 Baso-0.7 Im ___ AbsNeut-4.64 AbsLymp-1.19* 
AbsMono-1.10* AbsEos-0.30 AbsBaso-0.05
___ 08:02PM BLOOD Glucose-203* UreaN-17 Creat-0.8 Na-134 
K-4.2 Cl-94* HCO3-28 AnGap-16
___ 09:00PM BLOOD Calcium-9.3 Phos-3.7 Mg-1.6

DISCHARGE LABS
=============
___ 06:45AM BLOOD WBC-5.6 RBC-3.99* Hgb-12.7* Hct-38.5* 
MCV-97 MCH-31.8 MCHC-33.0 RDW-13.1 RDWSD-46.5* Plt ___
___ 06:45AM BLOOD Glucose-288* UreaN-15 Creat-0.8 Na-142 
K-4.5 Cl-101 HCO3-22 AnGap-24*
___ 06:45AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.8

HEMOGLOBIN A1C
==============
___ 09:15AM BLOOD %HbA1c-8.0* eAG-183*

URINE STUDIES
============
___ 11:03PM URINE Color-Straw Appear-Clear Sp ___
___ 11:03PM URINE Blood-NEG Nitrite-NEG Protein-TR 
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 11:03PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0

MICROBIOLOGY
============
___: BLOOD CULTURE X 2: PENDING.
___: BLOOD CULTURE X 1: PENDING.

___ 4:40 am URINE      Source: Catheter. 
                            **FINAL REPORT ___
   URINE CULTURE (Final ___:    NO GROWTH. 

IMAGING
=======
IMPRESSION: 
Left lower lobe opacity may reflect pneumonia.  Comparing with 
prior
radiograph would be helpful to determine progression or 
improvement.

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, eAG {Glucose measurement estimated from glycated hemoglobin}, URINE Color-Straw {Normal urine color}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, RBC {Red blood cell count}, WBC {White blood cell count}, MICROBIOLOGY {Microbiology}, CULTURE {Blood culture}, CULTURE {Blood culture}, URINE CULTURE {Urine culture}, IMAGING {Imaging}, Left lower lobe {Structure of lower lobe of left lung}, opacity {Abnormally opaque structure}, pneumonia {Pneumonia}, radiograph {Plain radiography}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 gentleman with history of dementia, hypertension, 
and diabetes presenting with lethargy found to have LLL PNA 
complicated by hyperglycemia.

# Community Acquired Left Lower Lobe Pneumonia: Patient was 
initially treated as an outpatient with azithromycin for 
suspected pneumonia, however, hyperglycemia ensued in the 
setting of pneumonia leading to admission to ___ (patient 
lives in a memory unit at ___ on ___ and they were 
concerned regarding his hyperglycemia). CXR at ___ confirmed 
left lower lobe pneumonia. He initially was started on 
levofloxacin and was subsequently transitioned to ceftriaxone 
and azithromycin. On admission, required supplemental O2 (up to 
3L) but was quickly weaned back to room air. He was asymptomatic 
with normal saturation on room air for 3 days at the time of 
discharge, at which point he had taken 6 days of antibiotics and 
the decision was made to end his course.

# Type II Diabetes Mellitus Complicated by Hyperglycemia: At 
Memory unit at ___ on the ___ patient had blood sugars 
in the high 300s. Given concern for the hyperglycemia, was 
transferred to ___ for evaluation. As noted above, etiology of 
the hyperglycemia was in the setting of pneumonia. At his 
facility he is on metformin 1000 mg PO BID and glipizide 2.5 mg 
PO daily. Initially, these were held and he was continued 
insulin sliding scale. He resumed his home glipizide and 
metformin. He remained hyperglycemia, so sitagliptin was added 
and metformin and glipizide were increased. He continued to 
require sliding scale insulin at discharge.

During hospitalization, his hemoglobin A1C was noted to be 8.0%. 


As insulin administration in the Memory Unit at his facility is 
somewhat complicated, an attempt was made to develop an oral 
diabetes regimen. ___ Diabetes was consulted for further 
recommendations. They recommended the above regimen with a plan 
to increase his oral agents and try to wean off the sliding 
scale. If he is unable, the ___ clinic can change him to a 
basal bolus insulin regimen and rehab providers and family can 
determine how this will impact his living situation.

# Hypertension: Continued lisinopril 30 mg PO daily.

# Dementia: Alert and oriented x 1 at baseline. Continued 
meantime 5 mg PO BID. His home ___ was not on formulary at 
the hospital. He was discharged on memantine 5 mg PO BID and 
galantine 16 mg PO daily. 

TRANSITIOANL ISSUES
=================
Transitional Issues:
- needs vitamin D checked as an outpatient
- ___ follow up
- Patient was persistently hyperglycemic on metformin, 
glipizide, Januvia. Insulin sliding scale was added to the 
regimen. We recommend gradually increasing his glipizide and 
tapering down his sliding scale to get him off insulin and 
hopefully transition back to the memory unit. If he is unable to 
come off the insulin, the ___ clinic can transition him to a 
basal/bolus insulin regimen at his follow up appointment and if 
this is a barrier to returning to the memory unit, his long term 
residential situation will need to be re-addressed with family. 
- Code Status: DNR/DNI (confirmed, has MOLST)  
- Contact Information: ___ (___ ___  
 

###RESPONSE: dementia {Dementia}, hypertension {Hypertensive disorder, systemic arterial}, lethargy {Lethargy}, LLL {Structure of lower lobe of left lung}, PNA {Pneumonia}, hyperglycemia {Hyperglycemia}, Left Lower Lobe Pneumonia {Left lower zone pneumonia}, pneumonia {Pneumonia}, hyperglycemia {Hyperglycemia}, pneumonia {Pneumonia}, hyperglycemia {Hyperglycemia}, CXR {Plain chest X-ray}, left lower lobe pneumonia {Left lower zone pneumonia}, asymptomatic {Asymptomatic}, on room air {Breathing room air}, antibiotics {Antibiotic therapy}, Type II Diabetes Mellitus {Diabetes mellitus type 2}, Hyperglycemia {Hyperglycemia}, hyperglycemia {Hyperglycemia}, evaluation {Evaluation procedure}, hyperglycemia {Hyperglycemia}, pneumonia {Pneumonia}, hyperglycemia {Hyperglycemia}, oral {Administration of drug or medicament via oral route}, diabetes regimen {Diabetic care}, Diabetes {Diabetes mellitus}, regimen {Therapeutic regimen}, clinic {Outpatient care management}, insulin regimen {Insulin regime}, Hypertension {Hypertensive disorder, systemic arterial}, Dementia {Dementia}, Alert {Mentally alert}, oriented {Orientated}, baseline {Baseline state}, regimen {Therapeutic regimen}, clinic {Outpatient care management}, insulin regimen {Insulin regime}, DNR {Not for resuscitation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY 
2. Atorvastatin 10 mg PO QPM 
3. galantamine 16 mg oral QDaily 
4. GlipiZIDE 2.5 mg PO DAILY 
5. Lisinopril 30 mg PO DAILY 
6. Memantine 5 mg PO BID 
7. MetFORMIN (Glucophage) 1000 mg PO BID 
8. Vitamin D ___ UNIT PO Q21DAYS 

 
Discharge Medications:
1.  Insulin SC 
      Sliding Scale

Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin 
2.  Januvia (SITagliptin) 100 mg oral DAILY  
3.  GlipiZIDE 5 mg PO BID  
4.  Aspirin 81 mg PO DAILY  
5.  Atorvastatin 10 mg PO QPM  
6.  galantamine 16 mg oral QDaily  
7.  Lisinopril 30 mg PO DAILY  
8.  Memantine 5 mg PO BID  
9.  MetFORMIN (Glucophage) 1000 mg PO BID  
10.  Vitamin D ___ UNIT PO Q21DAYS  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
-Community Acquired Pneumonia
-Type II Diabetes Mellitus
-Dementia 
-Hypertension

 
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: Community Acquired Pneumonia {Community acquired pneumonia}, Type II Diabetes Mellitus {Diabetes mellitus type 2}, Dementia {Dementia}, Hypertension {Hypertensive disorder, systemic arterial}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, 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. ___,

You were admitted to ___ after 
you were noted to have elevated blood sugars. You were also 
noted to have a pneumonia. The reason for the elevated blood 
sugars was likely secondary to the underlying pneumonia. 

You initially required oxygen but after receiving intravenous 
antibiotics, you were able to breath comfortably on room air. 

in order to better control your blood sugars and optimize you on 
an oral medication regimen to control your blood sugars, you 
were seen by the Diabetes specialists at ___. They 
recommended continuing with metformin, glipizide and 
sitagliptin. You will remain on sliding scale insulin for now. 
This will be stopped if recovery from your illness or increased 
doses of your oral medications will allow. 

Best Wishes,
Your ___ Care Team 
 

###RESPONSE: pneumonia {Pneumonia}, pneumonia {Pneumonia}, intravenous 
antibiotics {Intravenous antibiotic therapy}, on room air {Breathing room air}, oral medication {Administration of drug or medicament via oral route}, regimen {Therapeutic regimen}, oral medications {Administration of drug or medicament via oral route}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
lisinopril / lorazepam
 
Attending: ___.
 
Chief Complaint:
Left foot pain 
 
Major Surgical or Invasive Procedure:
none
 

###RESPONSE: Left foot {Structure of left foot}, pain {Pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ y/o M transfered from ___ today for
angiogram/plasty with Dr. ___. He was originally admitted 
to
___ due to confusion and fatigue as well as
dehydration. He was being treated for a pneumonia upon transfer.
Pt. presents today to ___ with a year long history of left 
foot
discomfort, specifically his left hallux, which ___ has been
feeling worse over the past week.  Pt. also states he has gout 
in
his left foot. 

Medicine HPI:
___ yo M w/ PMH of COPD, CKD (unknown baseline cr), CVA with 
residual left arm paresis, and peripheral vascular disease who 
was transferred here for vascular surgery evaluation given 
problems with his toes. While on the floor he PEA arrested and 
was coded x 3 min, then while enroute to the ICU he PEA arrested 
again. Per mention, there was felt to be RV strain on a bedside 
informal TTE and therefore it was felt to likely be due to a 
pulmonary embolism so he was started on a heparin drip. He was 
tranisently on pressors and monitored with an A line. He was 
extubated on ___ without difficulty and was off pressors since 
then as well. He continues to be monitored on telemetry without 
any additional ectopy.
Of note, prior to transfer, the patient was being examined and 
noted to have active hemorrhage from his prior Left AC IV site. 
He was laying in a large pool of blood. Stat Hct was stable and 
VS were wnl. The pressure was applied to stop the bleeding and 
the patient was cleaned up for transfer.
 

###RESPONSE: angiogram {Angiography}, confusion {Clouded consciousness}, fatigue {Fatigue}, dehydration {Dehydration}, pneumonia {Pneumonia}, left 
foot {Structure of left foot}, discomfort {Discomfort}, left {Structure of left hand}, hallux {Great toe structure}, gout {Inflammatory disorder due to increased blood urate level}, left foot {Structure of left foot}, COPD {Chronic obstructive lung disease}, CKD {Chronic kidney disease}, CVA {Cerebrovascular accident}, left arm {Left upper arm structure}, paresis {Muscle weakness}, peripheral vascular disease {Peripheral vascular disease}, evaluation {Evaluation procedure}, toes {Structure of all toes}, RV {Right cardiac ventricular structure}, strain {Muscle strain}, TTE {Transthoracic echocardiography}, pulmonary embolism {Pulmonary embolism}, heparin {Heparin therapy}, extubated {Removal of endotracheal tube}, telemetry {Cardiac telemetry}, hemorrhage {Hemorrhage}, Left {Left cerebral hemisphere structure}, Hct was stable {Stable hematocrit}, VS {Vital signs finding}, bleeding {Bleeding}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Vascualr complications, chronic kidney disease, anemia,
COPD, hisotry of pneumonia, failure to thrive, polyneuropathy
with diabetes, hypertension, vascular dementia, idiopathic
pulmonary fibrosis. Pt. is a poor historian but states he had a 
kidney removed.

 

###RESPONSE: Vascualr complications {Peripheral vascular complication}, chronic kidney disease {Chronic kidney disease}, anemia {Anemia}, COPD {Chronic obstructive lung disease}, pneumonia {Pneumonia}, failure to thrive {Failure to thrive}, polyneuropathy {Polyneuropathy}, diabetes {Diabetes mellitus}, hypertension {Hypertensive disorder, systemic arterial}, vascular dementia {Vascular dementia}, idiopathic
pulmonary fibrosis {Idiopathic pulmonary fibrosis}, poor historian {Poor historian}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
n/c
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VASCULAR SURGERY ADMISSION EXAM:
not recorded

MEDICINE ADMISSION EXAM:
VS 98.0, 103/42, 82, 18, 98% 2L
GEN: A+Ox2 (person and date, not to place but knows its a 
hospital), mildy hard of hearing.
HEENT PEERLA, MMM, no elevated JVP.
PULM moving good air bilaterally, no audible wheezes or crackles 
anteriorly
CV RRR no mrg appreciated, no echymotic areas on his chest, no 
crepitus to palpation. mild tenderness on palpation there.
ABD soft NT ND increased bowel sounds
EXT WWP 2+ pulses palpable bilaterally, no c/c/e. LEft arm with 
dressing saturated in blood in a pool of blood
NEURO CNs2-12 intact, left arm hemiparetic, moving lwoer 
extremities
SKIN no ulcers or lesions
Labs: Reviewed, please see below.

DEATH EXAM: see death note under 
###RESPONSE: VS {Vital signs finding}, GEN {General examination of patient}, Ox2 {Orientated}, person {Oriented to person}, place {Oriented to place}, hard of hearing {Hearing difficulty}, PEERLA {Pupils equal and reacting to light}, MMM {Moist oral mucosa}, elevated JVP {Raised jugular venous pressure}, PULM {Examination of respiratory system}, wheezes {Wheezing}, crackles {Respiratory crackles}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, no mrg {Heart sounds normal}, echymotic {Ecchymosis}, chest {Thoracic structure}, crepitus {Bone crepitus}, palpation {Palpation}, tenderness {Tenderness}, palpation {Palpation}, ABD soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, increased bowel sounds {Bowel sounds hyperactive}, EXT {Examination of limb}, WWP {Normal tissue perfusion}, 2+ pulses palpable {Peripheral pulses normal}, LEft arm {Left upper arm structure}, dressing {Application of dressing}, NEURO {Neurological examination}, CNs2-12 intact {Normal nervous system function}, left arm {Left upper arm structure}, hemiparetic {Muscle weakness}, lwoer 
extremities {Lower limb structure}, 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: Brief Hospital Course
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:

___ 05:50PM BLOOD WBC-9.2 RBC-3.72* Hgb-12.1* Hct-37.5* 
MCV-101* MCH-32.5* MCHC-32.2 RDW-15.4 Plt ___
___ 05:50PM BLOOD ___ PTT-34.5 ___
___ 05:50PM BLOOD Glucose-142* UreaN-27* Creat-1.7* Na-140 
K-4.2 Cl-104 HCO3-24 AnGap-16
___ 10:31PM BLOOD ALT-121* CK(CPK)-89 AlkPhos-100 
Amylase-70 TotBili-0.6
___ 05:50PM BLOOD Calcium-9.1 Phos-3.1 Mg-2.0
___ 10:30PM BLOOD Type-ART pO2-82* pCO2-37 pH-7.09* 
calTCO2-12* Base XS--18
___ 10:30PM BLOOD Glucose-202* Lactate-12.5* Na-140 K-5.2* 
Cl-113*
___ 10:30PM BLOOD freeCa-1.25

LABS ON DAY OF DEATH:

___ 01:36AM BLOOD WBC-12.0* RBC-3.23* Hgb-10.6* Hct-32.0* 
MCV-99* MCH-32.6* MCHC-33.0 RDW-15.3 Plt ___
___ 08:00PM BLOOD Hct-33.4*
___ 01:36AM BLOOD Glucose-98 UreaN-39* Creat-2.3* Na-146* 
K-4.1 Cl-111* HCO3-21* AnGap-18
___ 01:36AM BLOOD ALT-123* AST-136* AlkPhos-110 
Amylase-162* TotBili-0.9
___ 01:36AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1
___ 09:07AM BLOOD Type-ART pO2-113* pCO2-31* pH-7.46* 
calTCO2-23 Base XS-0
___ 09:07AM BLOOD O2 Sat-98
___ 01:43AM BLOOD freeCa-1.14

PERTINENT MICRO: NONE

PERTINENT IMAGING:
EKG: Sinus rhythm. Generalized low voltage. Q-T interval 
prolongation. T wave
abnormalities. No previous tracing available for comparison. 
Clinical
correlation is suggested.
 
Read ___.
 IntervalsAxes
___
___

ADMISSION CXR:
___ male patient with left lower extremity ischemia,
scheduled for angio but presenting with pneumonia.  Evaluate for 
interval
change. 
Patient's condition required examination in sitting position 
using AP frontal
and left lateral views.  There is moderate cardiac enlargement, 
predominantly
involving the left heart.  The thoracic aorta is of ordinary 
dimension but
demonstrates advanced walled calcifications both in the aortic 
arch as well as
in the entire ascending aorta.  Aortic valve calcifications are 
suspected on
the lateral view.  There exists a diffuse haze over the entire 
left-sided
hemithorax and thickening of the left-sided pleural space is 
noted along the
left lateral chest wall.  There exists some crowded vasculature 
in the left
lower lobe area in retrocardiac position possibly suggesting 
some atelectasis
but acute discrete parenchymal infiltrates identifying a 
pneumonia cannot be
seen.  The right hemithorax is better penetrated and there is no 
evidence of
pleural thickenings on that side.  Also, the lateral pleural 
sinuses are free,
thus no evidence of acute pleural effusion is present.  
Accessible areas of
the pulmonary vasculature do not demonstrate any advanced CHF or 
pulmonary
edema.  Our records do not include a previous chest examination, 
thus there is
no possibility to comment on interval changes

FOLLOW UP CXR:
As compared to the previous radiograph, the patient has been
extubated.  The signs previously indicative of pulmonary edema 
have
substantially decreased.  However, there still is a 
mild-to-moderate left
pleural effusion with subsequent retrocardiac atelectasis.  
Moderate
cardiomegaly.  No evidence of pneumonia.
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, pH {pH measurement}, Glucose {Glucose measurement, blood}, Na {Blood sodium measurement}, K {Blood potassium measurement}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Hct {Hematocrit determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, pH {pH measurement}, EKG {Electrocardiographic procedure}, Sinus rhythm {Sinus rhythm}, Q-T interval 
prolongation {Prolonged QT interval}, T wave
abnormalities {Electrocardiographic T wave abnormal}, left lower extremity {Structure of left lower limb}, ischemia {Ischemia}, angio {Angiography}, pneumonia {Pneumonia}, sitting position {Sitting position}, AP {Diagnostic radiography, anteroposterior}, lateral {Diagnostic radiography of chest, lateral}, cardiac enlargement {Hypertrophic cardiomegaly}, left heart {Structure of left side of heart}, thoracic aorta {Thoracic aorta structure}, calcifications {Pathologic calcification, calcified structure}, aortic 
arch {Aortic arch structure}, entire ascending aorta {Entire ascending aorta}, Aortic valve calcifications {Aortic valve calcification}, lateral {Diagnostic radiography of chest, lateral}, left-sided
hemithorax {Entire left thorax}, thickening {Increased thickness}, left-sided pleural {Left pleura structure}, chest wall {Chest wall structure}, left
lower lobe {Structure of lower lobe of left lung}, atelectasis {Atelectasis}, infiltrates {Infiltration}, pneumonia {Pneumonia}, right hemithorax {Right thorax structure}, pleural thickenings {Thickening of pleura}, pleural effusion {Pleural effusion}, pulmonary vasculature {Structure of pulmonary blood vessel}, CHF {Congestive heart failure}, pulmonary
edema {Pulmonary edema}, radiograph {Plain radiography}, signs {Sign}, pulmonary edema {Pulmonary edema}, pleural effusion {Pleural effusion}, atelectasis {Atelectasis}, cardiomegaly {Cardiomegaly}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 ___ y/o M was transferred from ___ with a 
chief complaint of L foot pain which he has had for about ___ 
year. He was brought to ___ to have an angiogram/plasty with 
Dr. ___. Upon presentation to us patient was currently on 
antibiotics for treatment of pneumonia. He stated his foot was 
painful, specifically his left hallux. It was decided to change 
his oral antibiotics (Levaquin) to IV antibiotics and wait for 
his pneumonia to resolve before taking the patient for Angio. 

On hospital night 1 patient arrested presumably due to a 
pulmonary embolism. He was successfully resuscitated and 
transferred to the CVICU intubated on vasopressors and NO. A 
heparin gtt was empirically started given dilated RV as seen on 
bedside
echo. it was also noted that he was no longer producing any 
urine.

On hospital day 2 the patient was extubated and had oxygen sats 
of 94% with 50% mask. All pressors were stopped and his kidney 
function began to return (UO was between ___ cc/hr). A renal 
consult was called. 

Patient was transferred from the Vascular Surgery service to the 
medical service, given his complicated course, and the decision 
that he would hold off on any vascular decision.  

Prior to admission to the internal medicine service late on the 
evening of ___, pt was noted to be bleeding from a pulled 
IV site with substantial amount of blood pooled beneath is arm. 
A stat hematocrit was performed prior to transfer which was 
stable. His VS were stable. Once patient arrived to the medicine 
floor, he was monitored on telemetry given his recent PEA 
arrest. He was continued on IV antibiotics for his previously 
diagnosed pneumonia, although it was noted he had no pneumonia 
on his current CXR. He was continued on IV heparin gtt for 
presumed PE on a tighter therapeutic range given his recent 
bleeding, with plans to repeat a formal TTE in the morning and 
pursue further workup of his PEA arrest. Of note, the patient's 
spouse had a lengthy discussion with the on call ___ 
resident and it was determined that the patient would continue 
to have a DNR code status (intubation acceptable). 

Once on the floor, a repeat hematocrit was to be drawn given his 
recent bleeding. However, this could not be drawn given 
patient's confusion and agitation which was acute in nature. He 
was given a dose of zyprexa for agitation and shortly thereafter 
was noted to convert to asystole on the tele monitor. The 
nightfloat intern was called to pronounce the patient. The death 
note is copied below:

Death Note
___

Called to patient's bedside because of asystole on telemetry.  
He
was not responsive to voice or pain. Pulses absent. No heart
sounds or breath sounds present.  Pupils not reactive to light.
His most recent code status is DNR.  No resuscitative attempts
made. Patient pronounced dead at 3:42 am on ___.  Wife 
___
notified, she declined autopsy. Attending of record, ___, notified.

 

###RESPONSE: foot pain {Foot pain}, angiogram {Angiography}, plasty {Angioplasty of blood vessel}, antibiotics {Antibiotic therapy}, pneumonia {Pneumonia}, foot was 
painful {Foot pain}, hallux {Great toe structure}, oral antibiotics {Oral antibiotic therapy}, IV antibiotics {Intravenous antibiotic therapy}, pneumonia {Pneumonia}, pulmonary embolism {Pulmonary embolism}, resuscitated {Resuscitation}, intubated {Intubation}, heparin {Heparin therapy}, dilated RV {Dilatation of right cardiac ventricle}, echo {Echocardiography}, extubated {Removal of endotracheal tube}, kidney 
function {Renal function monitoring}, bleeding {Bleeding}, arm {Upper limb structure}, VS {Vital signs finding}, stable {Patient's condition stable}, telemetry {Cardiac telemetry}, IV antibiotics {Intravenous antibiotic therapy}, pneumonia {Pneumonia}, pneumonia {Pneumonia}, CXR {Plain chest X-ray}, IV {Administration of drug or medicament via intravenous route}, heparin {Heparin therapy}, PE {Pulmonary embolism}, bleeding {Bleeding}, TTE {Transthoracic echocardiography}, workup {Evaluation procedure}, DNR {Not for resuscitation}, bleeding {Bleeding}, confusion {Clouded consciousness}, agitation {Feeling agitated}, agitation {Feeling agitated}, asystole {Asystole}, tele {Cardiac telemetry}, asystole {Asystole}, telemetry {Cardiac telemetry}, responsive to voice {Responds to voice}, pain {Finding of response to pain}, Pulses absent {Absent pulse}, No heart
sounds {Heart sound inaudible}, breath sounds {Absent breath sounds}, Pupils not reactive to light {No pupillary reaction to light}, DNR {Not for resuscitation}, Patient pronounced dead {Patient status determination, deceased}, autopsy {Consent for postmortem declined}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Levofloxacin 500mg qd x3days
albuterol nebulizer 4x daily
ranitidine HCL 150mg qd
multivitamin qd PO
Lidocaine HCL 1 patch
Glipizide 5mg qd po
gabapentin 300mg poqd
colace 100mg po qd
clopidogrel 75mg
Vit D 1000 units qd PO
aspirin 81mg qd
allopurinol ___ qd
acetaminophen 325mg qd
Venlafaxine HCL 37.5 mg hs 
Mirtazapine 7.5 mg hs
Pravastatin 40mg qd
Insuline Sliding scale
Insuline Glargine 18 U
Ferrous Sulfate 325mg bid po
Carvedilol 12.5 bid 
tramadol 50mg q6h prn pain
milk of mag 10 ml po prn constipation

 
Discharge Medications:
EXPIRED
 

###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:
Expired
 
Discharge Diagnosis:
EXPIRED
 
Discharge Condition:
EXPIRED
 

###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 Instructions:
EXPIRED
 

###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: 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: 
Abacavir Sulfate / Aspirin / fluconazole / levetiracetam / 
morphine
 
Attending: ___.
 
Chief Complaint:
fevers and diarrhea
 
Major Surgical or Invasive Procedure:
Endoscopy and Colonoscopy ___

 

###RESPONSE: Abacavir Sulfate {Allergy to abacavir}, Aspirin {Allergy to aspirin}, fluconazole {Allergy to fluconazole}, levetiracetam {Allergy to lofepramine}, morphine {Allergy to morphine}, fevers {Fever}, diarrhea {Diarrhea}, Endoscopy {Endoscopy}, Colonoscopy {Colonoscopy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms ___ is a ___ with HIV/AIDS with poor medication 
compliance(CD4 24(3%), HIV VL 70K ___, depression, and hx of 
seizures, who was recently admitted with fever, non-bloody 
diarrhea, and ___ (___), who now re-presets with 
similar symptoms.  
She notes that she was in her usual state of health until 
approximately ___ when she noticed a fever to 103. She denied 
any other symptoms at that time; no sinus congestion, headache, 
body ache, sore throat, cough, shortness of breath, abdominal 
pain, nausea, vomiting, or diarrhea. She took some Tylenol and 
fever resolved. She felt very constipated so took some castor 
oil on ___. This resulted in copious non-bloody diarrhea. She 
intermittently had fever up to 102 so decided to present to the 
ED on ___, and she was admitted from ___. Her labs were 
notable for Cr of 1.8 from baseline of 0.8 just 6 days prior. 
LFTs were slightly elevated at AST/ALT of 139/42, AP 128, Tbili 
0.2. UA and CXR were negative. Extensive stools studies were 
negative. She was started empirically on ciprofloxacin and 
metronidazole which were stopped by ID recs.  
She now represents with fevers, diarrhea, nausea and mylagias. 
She reports 4 loose bowel movements in the past few days. Today 
she checked her fever which was 102 which promted the ED visit. 
She denies any sick contact or travel history. No raw food.  
 
In the ED, initial VS were 102.2 123 115/98 20 93% .  
Exam notable for: TTP in LLQ, no rebound or gaurding.  
Labs showed WBC of 7.0, H/H at baseline (11.8/34.8), plt 175. 
BMP notable for elevated Cr of 1.5 (basline 0.7-0.8), Na 137, Cl 
94. ALT: 39 AST: 111 AP: 155 Tbili: 0.3 Alb: 3.2  
Imaging showed no acute cardiopulmonary process.  
Received ceftriaxone, flagyl per ID recs, 2L NS, and tylenol 1g. 
 

 

###RESPONSE: HIV {Human immunodeficiency virus infection}, AIDS {Acquired immune deficiency syndrome}, HIV {Human immunodeficiency virus infection}, depression {Depressive disorder}, seizures {Seizure}, fever {Fever}, bloody 
diarrhea {Hemorrhagic diarrhea}, fever {Fever}, sinus congestion {Congestion of nasal sinus}, headache {Headache}, body ache {Generalized aches and pains}, sore throat {Sore throat}, cough {Cough}, shortness of breath {Dyspnea}, abdominal 
pain {Abdominal pain}, nausea, vomiting {Nausea and vomiting}, diarrhea {Diarrhea}, fever {Fever}, resolved {Problem resolved}, constipated {Constipation}, bloody diarrhea {Hemorrhagic diarrhea}, fever {Fever}, Cr {Finding of creatinine level}, baseline {Baseline state}, LFTs {Hepatic function panel}, elevated {Finding of increased blood pressure}, AST {Aspartate aminotransferase measurement}, ALT {Alanine aminotransferase measurement}, AP {Alkaline phosphatase measurement}, UA {Urinalysis}, CXR {Plain chest X-ray}, stools studies {Stool microscopy}, ID {Infectious disease}, fevers {Fever}, diarrhea {Diarrhea}, nausea {Nausea}, mylagias {Muscle pain}, loose bowel movements {Loose stool}, fever {Fever}, VS {Vital signs finding}, Exam {Examination of abdomen}, TTP in LLQ {Tenderness of left lower quadrant of abdomen}, rebound {Rebound tenderness}, gaurding {Abdominal guarding}, WBC {White blood cell count}, H/H {Measurement of total hemoglobin concentration and hematocrit}, baseline {Baseline state}, BMP {Serum metabolic panel}, elevated Cr {Serum creatinine above reference range}, basline {Baseline state}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AP {Alkaline phosphatase measurement}, Imaging {Imaging}, ID {Infectious disease}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- AIDS (resistant disease - followed by ID, Dr. ___
-- CD4 nadir 8 in ___, improved to 77 in ___
-- CD4 20 ___
-- HIV Viral Load in ___ - 159,154 copies/ml
-- Opportunistic infections: esophageal candidiasis
-- CIN II-III s/p LEEP procedure
-- several mutations listed in OMR problem list
- Depression
- Gastritis secondary to H. Pylori
- Nephrolithiasis
- Cervical spondylosis
- Migraines
- Excision of left wrist ganglion cyst ___
- Genital and vaginal condyloma
- Left carpal tunnel syndrome
- S/p open cholecystectomy
- H/o right sided Bell's palsy
- H/o diverticulitis with microperforation (patient is not clear 
of this history)
- H/o CMV esophagitis and ?colitis
 

###RESPONSE: AIDS {Acquired immune deficiency syndrome}, disease {Disease}, ID {Infectious disease}, improved {Patient's condition improved}, HIV Viral Load {Human immunodeficiency virus viral load}, infections {Infectious disease}, esophageal candidiasis {Candidiasis of the esophagus}, CIN {Cervical intraepithelial neoplasia}, LEEP {Loop electrosurgical excision procedure}, procedure {Procedure}, mutations {Genetic mutation}, problem {Problem}, Depression {Depressive disorder}, Gastritis secondary to H. Pylori {Gastritis caused by Helicobacter pylori}, Nephrolithiasis {Kidney stone}, Cervical spondylosis {Cervical spondylosis}, Migraines {Migraine}, Excision {Excision}, left wrist {Structure of left wrist region}, ganglion cyst {Ganglion cyst}, Genital {Genital structure}, vaginal condyloma {Condyloma acuminata of vagina}, Left {Left upper arm structure}, carpal tunnel syndrome {Carpal tunnel syndrome}, cholecystectomy {Cholecystectomy}, right sided {Structure of right facial muscle}, Bell's palsy {Bell's palsy}, diverticulitis {Diverticulitis}, CMV esophagitis {Esophagitis caused by Cytomegalovirus}, colitis {Cytomegaloviral colitis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 alive with a history of hypertension. Father deceased 
from stroke. Three sisters and six brothers alive. No children.

 

###RESPONSE: alive {Alive}, hypertension {Hypertensive disorder, systemic arterial}, deceased {Dead}, stroke {Cerebrovascular accident}, alive {Alive}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
On Admission:
-------------
Vitals: 98.2 117/56 97 100%RA  
General: Alert, oriented, ill appearing, fatigued  
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear 
without exudates  
Neck: Supple, no cervical or supraclavicular LAD  
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur 
in the apex  
Lungs: Clear to auscultation bilaterally, no wheezes, rales, 
rhonchi  
Abdomen: Soft, non-distended, very mild tenderness in the lower 
abdomen, bowel sounds present, no rebound or guarding  
Ext: Warm, well perfused, no edema  
Neuro: Alert and oriented x 3, CNII-XII intact  
Skin: no rashes  

At Discharge:
-------------
VS - 98 128-150/70-101 52-104 17 99% RA  
General: Alert, oriented, chronically ill-appearing woman in NAD 
 
HEENT: Sclera anicteric, MMM, oropharynx clear without exudates  

Neck: Supple, no cervical or supraclavicular LAD  
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur 
in the apex  
Lungs: Clear to auscultation bilaterally, no wheezes, rales, 
rhonchi  
Abdomen: Soft, non-distended, nontender, bowel sounds present, 
no rebound or guarding  
Ext: Warm, well perfused, no edema  
Neuro: Alert and oriented x 3, CNII-XII intact  
Skin: no rashes  

 

###RESPONSE: Vitals {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, fatigued {Fatigue}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, dry mucous membranes {Mucous membrane dryness}, oropharynx clear {Pharynx normal}, exudates {Exudate}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, cervical {Cervical lymphadenopathy}, supraclavicular {Supraclavicular lymphadenopathy}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmur {Murmur}, apex {Structure of apex of heart}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-distended {Normal abdominal contour}, tenderness {Tenderness}, lower 
abdomen {Lower abdomen structure}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, edema {Edema}, Neuro {Neurological examination}, Alert {Mentally alert}, oriented {Orientated}, CNII {Optic nerve structure}, XII intact {Intact hypoglossal nerve}, Skin {Examination of skin}, rashes {Eruption of skin}, VS {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Oriented to person}, ill-appearing {Looks ill}, NAD {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, exudates {Exudate}, Neck {Neck structure}, Supple {Normal movement of neck}, cervical {Cervical lymphadenopathy}, supraclavicular {Supraclavicular lymphadenopathy}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 + S2 {Heart sounds normal}, systolic murmur {Systolic murmur}, apex {Structure of apex of heart}, Lungs {Lung structure}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-distended {Normal abdominal contour}, nontender {Tenderness}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, edema {Edema}, Neuro {Neurological examination}, Alert {Mentally alert}, oriented x 3 {Oriented to person, time and place}, CNII {Optic nerve structure}, XII intact {Intact hypoglossal nerve}, Skin {Examination of skin}, rashes {Eruption of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Labs on Admission:
------------------
___ 05:00PM   WBC-7.0 RBC-3.99* HGB-11.8* HCT-34.8* MCV-87 
MCH-29.7 MCHC-34.0 RDW-15.0
___ 05:00PM   NEUTS-59 BANDS-0 ___ MONOS-14* EOS-0 
BASOS-1 ATYPS-2* ___ MYELOS-0
___ 05:00PM   PLT SMR-NORMAL PLT COUNT-175
___ 05:00PM   HYPOCHROM-NORMAL ANISOCYT-NORMAL 
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL 
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
___ 05:00PM   GLUCOSE-92 UREA N-23* CREAT-1.5* SODIUM-137 
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-22 ANION GAP-25*
___ 05:00PM   ALT(SGPT)-39 AST(SGOT)-111* ALK PHOS-155* TOT 
BILI-0.3
___ 05:00PM   ALBUMIN-3.2* CALCIUM-9.1 PHOSPHATE-4.4 
MAGNESIUM-1.6
___ 05:00PM   LIPASE-57
___ 05:17PM   LACTATE-1.8

Micro Data:
-----------
All stool cultures, stains, O&P were negative.
Blood culturtes negative to date. Urine cx negative to date.
Cryptococcal antigen and toxoplasma IgG negative.
CMV Viral Load (Final ___: 984 IU/mL. 
C.difficile negative.
Cryptosporidium/ giardia negative.

Imaging Reports:
----------------
CT Abdomen/ Pelvis with contrast:
1. Small amount of free fluid in the pelvis, which may be 
physiologic. 
2. No GI abnormality to explain the patient's diarrhea 
3. Postcholecystectomy 
4. Degenerative disc L4-5 

EGD/ Colonoscopy Report:
EGD ___:
Small white plaques in mid-esophagus, ? of mild candidiasis. 
(biopsy)
Erythema and petechiae in the whole stomach compatible with mild 
gastritis (biopsy)
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum

Colonoscopy ___:
Diverticulosis of the scattered throughout the colon
Erythema and small erosions in the left colon (biopsy)
The terminal ileum mucosa appeared normal. (biopsy)
Otherwise normal colonoscopy to cecum and terminal ileum

EGD/ COLONOSCOPY PATHOLOGY REPORT:
1. Mid esophagus:
- Active esophagitis with numerous intraepithelial lymphocytes 
and scattered eosinophils and
neutophils.
- GMS stain for fungal organisms is negative with satisfactory 
control.
2.. Gastric/stomach:
- Corpus/antral mucosa with mild chronic inactive gastritis.
- Immunostain for Helicobacter species is in progress and the 
results will be reported in a revised
report.
3. Duodenum:
- Duodenal mucosa, within normal limits.
4. Terminal ileum:
- Small intestinal mucosa, within normal limits.
5. Random colon:
- Colonic mucosa, within normal limits.
Addendum yet to be finalized by pathology at time of discharge: 
evidence of CMV on esophageal biopsies; no evidence of CMV on 
clononic biopsies.

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, PHOS {Phosphate, total measurement}, TOT 
BILI {Bilirubin, total measurement}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium measurement}, stool cultures {Stool culture}, O&P {Finding of presence of ova cysts and parasites}, Blood culturtes {Blood culture}, Urine cx {Urine culture}, IgG {Immunoglobulin G measurement}, Viral Load {Viral load}, pelvis {Structure of pelvis}, GI {Gastrointestinal tract finding}, diarrhea {Diarrhea}, Degenerative {Degenerative abnormality}, L4 {Bone structure of L4}, 5 {Bone structure of L5}, EGD {Esophagogastroduodenoscopy}, plaques {Plaque}, esophagus {Esophageal structure}, candidiasis {Candidiasis}, biopsy {Biopsy}, Erythema {Erythema}, petechiae {Petechia}, stomach {Stomach structure}, gastritis {Gastritis}, biopsy {Biopsy}, mucosa {Vaginal mucous membrane structure}, duodenum {Duodenal structure}, biopsy {Biopsy}, EGD {Esophagogastroduodenoscopy}, third part of the duodenum {Structure of inferior portion of duodenum}, Diverticulosis {Diverticulosis of colon}, colon {Colon structure}, Erythema {Erythema}, erosions {Superficial ulcer}, left colon {Left colon structure}, biopsy {Biopsy}, terminal ileum {Structure of distal portion of ileum}, mucosa {Vaginal mucous membrane structure}, biopsy {Biopsy}, colonoscopy {Colonoscopy}, cecum {Cecum structure}, terminal ileum {Structure of distal portion of ileum}, esophagus {Esophageal structure}, esophagitis {Esophagitis}, fungal {Mycosis}, Corpus {Gastric corpus structure}, antral {Pyloric antrum structure}, mucosa {Vaginal mucous membrane structure}, chronic {Chronic gastritis}, gastritis {Gastritis}, Duodenal mucosa {Duodenal mucous membrane structure}, Small {Structure of small intestine}, intestinal mucosa {Intestinal mucous membrane structure}, Colonic mucosa {Colonic mucous membrane structure}, CMV {Cytomegalovirus infection}, esophageal biopsies {Biopsy of esophagus}, no evidence {No abnormality detected}, CMV {Cytomegalovirus infection}, clononic biopsies {Biopsy of colon}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ with HIV/AIDS with poor medication compliance(CD4 24(3%), 
HIV VL 70K ___, depression, and hx of seizures, who was 
recently admitted with fever, non-bloody diarrhea, and ___ 
(___), who now re-presets with similar symptoms.  

# Fevers/ Diarrhea: Most likely secondary to CMV given she had a 
positive CMV viral load to >900. Given her low CD4 status, 
differential was broad and included other opportunistic 
infections as well as non-opportunistic infections.  Less likely 
to be ischemic or inflammatory. ___ with evidence of 
esophagitis with concern for contribution from ?___ as well 
as some mild colitis in left colon, biopsies taken, revealing 
evidence of CMV in the esophagus, however, no evidence of CMV in 
the colon. She was started on IV  gancyclovir and transitioned 
to PO valgancyclovir, to complete a ___ week course, to be 
determined by outpatient ID. Also started a 14 day course of 
fluconazole, for ___ esophagitis. Ophthalmology was 
consulted, and patient was without evidence of CMV retinitis. 
All other workup, including stool studies, clultures and serum 
cryptococcal antigen were negative. Her diarrhea and fevers 
resolved and her diet was advanced without issues. Of note, 
discontinued empiric CTX/flagyl that were initially started in 
the ED given low concern for bacterial infection. All of the 
above was done in consultation with the infectious disease 
service.  
 
# Fevers: As above unifying diagnosis would be infectious 
colitis possibly from an opportunistic infection as described 
above. However given her AIDS and CMV viremia, fever could also 
represent other systemic infection. CXR without any 
consolidations. The patient did not appear septic. Infectious 
workup results detailed above. Discharged on valgancyclovir and 
fluconazole as above.  

# ___: Baseline Cr 1 which was elevated to 1.5 on admission. 
Most likely pre-renal vs ATN in the setting of diarrhea and poor 
po intake, however, given that she has remained in the 1.4 to 
1.5 range on a subacute time period, this may represent a new 
baseline. Renally dosed all medications, with changes made to 
include HIV meds that were less nephrotoxic. Avoided NSAIDS, 
contrast and other nephrotoxic meds as much as possible. 
Discharge creatinine was 1.4. 

# HIV AIDS: History of med non-complaince however currently 
reports taking her HIV meds. Cannot use Stribild given ___ For 
HIV: Discontinued Stribild. Continued with dolutegravir 50mg 
daily, darunavir 800mg PO daily, cobicistat 100mg daily, 
lamivudine 150mg PO daily per ID recs. Darunavir and cobicistat 
were prescribed as a combination pill at time of discharge. Of 
note, she does have a history of non-adherence to HAART; in the 
setting of depression she states she became tired of taking the 
medications and self-discontinued them. Her mother and brother 
are unaware of her diagnosis; sister is aware and per pt, 
provides support.   

***TRANSITIONAL ISSUES***
- history of poor adherence to HAART
- Patient should have at least yearly dilated eye exams, sooner
if any issues and this was discussed with the patient. She can
follow up at ___ or by an outside ophthalmologist.
- to complete 14 day course of PO fluconazole, end date 
___.
- to complete ___ week course of valgancyclovir (exact course to 
be determined by outpatient ID physician) (trsnaitioned to PO on 
___.
- patient with anemia, and borderline low B12, should have MMA 
checked as an outpatient (likely effect of HAART therapy). 

 

###RESPONSE: HIV {Human immunodeficiency virus infection}, AIDS {Acquired immune deficiency syndrome}, HIV {Human immunodeficiency virus infection}, depression {Depressive disorder}, seizures {Seizure}, fever {Fever}, bloody diarrhea {Hemorrhagic diarrhea}, Fevers {Fever}, Diarrhea {Diarrhea}, CMV {Cytomegalovirus infection}, CMV {Cytomegalovirus infection}, viral load {Viral load}, infections {Infectious disease}, infections {Infectious disease}, ischemic {Ischemia}, inflammatory {Inflammatory disorder}, esophagitis {Esophagitis}, colitis {Colitis}, left colon {Left colon structure}, biopsies {Biopsy}, CMV {Cytomegalovirus infection}, esophagus {Esophageal structure}, no evidence {No abnormality detected}, CMV {Cytomegalovirus infection}, colon {Colon structure}, IV {Administration of drug or medicament via intravenous route}, ID {Infectious disease}, esophagitis {Esophagitis}, CMV retinitis {Cytomegaloviral retinitis}, stool studies {Stool microscopy}, clultures {Stool culture}, diarrhea {Diarrhea}, fevers {Fever}, resolved {Problem resolved}, diet {Normal diet}, CTX {Contraction of uterus during labor}, bacterial infection {Bacterial infectious disease}, infectious disease 
service {Infectious diseases service}, Fevers {Fever}, infectious 
colitis {Infectious colitis}, infection {Infectious disease}, AIDS {Acquired immune deficiency syndrome}, CMV viremia {Cytomegalovirus viremia}, fever {Fever}, systemic infection {Sepsis}, CXR {Plain chest X-ray}, consolidations {Consolidation}, septic {Sepsis}, Infectious {Infectious disease}, Baseline {Baseline state}, Cr {Finding of creatinine level}, elevated {Serum creatinine above reference range}, renal {Kidney structure}, ATN {Acute tubular necrosis}, diarrhea {Diarrhea}, poor 
po intake {Decrease in appetite}, baseline {Baseline state}, HIV {Human immunodeficiency virus infection}, creatinine {Creatinine measurement}, HIV {Human immunodeficiency virus infection}, AIDS {Acquired immune deficiency syndrome}, non-complaince {Drug compliance poor}, HIV {Human immunodeficiency virus infection}, HIV {Human immunodeficiency virus infection}, ID {Infectious diseases service}, depression {Depressive disorder}, dilated {Dilated pupil}, eye {Structure of eye proper}, exams {Ophthalmic examination and evaluation}, ID {Infectious disease}, anemia {Anemia}, low B12 {Cobalamin deficiency}, therapy {Therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atovaquone Suspension 1500 mg PO DAILY 
2. Azithromycin 600 mg PO 2X/WEEK (WE,SA) 
3. Darunavir 800 mg PO DAILY 
4. Prochlorperazine 5 mg PO DAILY PRN nausea 
5. Stribild 1 TAB PO DAILY 
6. camphor-menthol 0.5 % topical bid:prn 
7. Ensure (food supplemt, lactose-reduced) 1 can oral daily 
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 

 
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY 
2. Azithromycin 600 mg PO 2X/WEEK (WE,SA) 
3. Dolutegravir 50 mg PO DAILY 
RX *dolutegravir [___] 50 mg 1 tablet(s) by mouth daily Disp 
#*30 Tablet Refills:*1
RX *dolutegravir [___] 50 mg 1 tablet(s) by mouth daily Disp 
#*30 Tablet Refills:*1
4. Fluconazole 200 mg PO Q24H 
RX *fluconazole [Diflucan] 200 mg 1 tablet(s) by mouth daily 
Disp #*11 Tablet Refills:*0
5. LaMIVudine 150 mg PO DAILY 
RX *lamivudine [Epivir] 150 mg 1 tablet(s) by mouth daily Disp 
#*30 Tablet Refills:*1
6. camphor-menthol 0.5 % topical bid:prn 
7. Ensure (food supplemt, lactose-reduced) 1 can oral daily 
8. Prochlorperazine 5 mg PO DAILY PRN nausea 
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 
10. ValGANCIclovir 450 mg PO Q12H 
RX *valganciclovir 450 mg 1 tablet(s) by mouth twice a day Disp 
#*60 Tablet Refills:*0
11. darunavir-cobicistat 800-150 mg-mg oral DAILY 
RX *darunavir-cobicistat [Prezcobix] 800 mg-150 mg 1 tablet(s) 
by mouth daily Disp #*30 Tablet Refills:*1

 

###RESPONSE: mg {Blood magnesium measurement}, mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis:
------------------
- CMV viremia
- ___ and CMV esophagitis
- fevers and diarrhea

SECONDARY DIAGNOSES:
--------------------
-AIDS

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: CMV viremia {Cytomegalovirus viremia}, CMV esophagitis {Esophagitis caused by Cytomegalovirus}, fevers {Fever}, diarrhea {Diarrhea}, AIDS {Acquired immune deficiency syndrome}, Mental Status {Neurological mental status determination}, Clear {Normal breath sounds}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,

It was a pleasure taking care of you during your hospital stay 
at ___. You came in because you 
were having fevers and diarrhea. Our infectious disease doctors 
___ and recommended a complete infectious workup. Our 
lab tests revealed that you had a virus in your blood, called 
cytomegalovirus, that may have been causing your symptoms. We 
treated you with an antiviral, called valgancyclovir, a 
medication which you should continue to take for three to six 
weeks (your doctor ___ tell you how long exactly). You should 
also continue to take fluconazole for two weeks. Your symptoms 
have resolved and it is now safe for you to be discharged. 
Please be sure to take ALL of your medications as prescribed and 
keep your follow-up appointments. We wish you the very best!

Sincerely,

Your ___ Team
 

###RESPONSE: fevers {Fever}, diarrhea {Diarrhea}, infectious disease {Infectious disease}, infectious {Infectious disease}, cytomegalovirus {Cytomegalovirus infection}, medication {Patient medication education}, resolved {Problem resolved}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Adenocarcinoma of the bile duct 
 
Major Surgical or Invasive Procedure:
___: 
1. Diagnostic laparoscopy
2. Pancreaticoduodenectomy with extended bile duct resection
3. Open cholecystectomy
4. Placement of Golden Fiducials for Cyperknife therapy

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, Adenocarcinoma of the bile duct {Primary adenocarcinoma of bile duct}, laparoscopy {Laparoscopy}, Pancreaticoduodenectomy {Pancreaticoduodenectomy}, bile duct resection {Resection of extrahepatic bile duct}, cholecystectomy {Cholecystectomy}, Placement {Implantation procedure}, therapy {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: History of Present Illness:
Mr. ___ is a ___ year old with PMH of HTN and BPH who 
initially presented with 1 week of diarrhea, a few days of dark 
colored urine and pruritus, found to have an elevated T 
bilirubin, abnormal abdominal ultrasound and CT scan which 
showed a 25 mm gallstone as well as intrahepatic and common 
hepatic duct
dilatation, concerning for possible malignancy. MRCP was 
performed which confirmed a 3.5cm segment of distal common 
hepatic and proximal come bile duct with irregular enhancement 
with necrotic periportal ___ s/f nodal involvement. 
He then underwent ERCP on ___ which confirmed a 
malignant-appearing stricture in the proximal CBD with plastic 
stent placement. His ampullar was normal and cholangiogram 
demonstrated a 2cm long, malignant appearing stricture in the
proximal CBD.  Cytology from the ERCP brushings were consistent 
for  adenocarcinoma.  He will undergo a whipple procedure.  

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, BPH {Benign prostatic hyperplasia}, diarrhea {Diarrhea}, dark 
colored urine {Urine looks dark}, pruritus {Itching of skin}, elevated T 
bilirubin {Total bilirubin above reference range}, abnormal abdominal ultrasound {Ultrasonography of abdomen abnormal}, CT scan {Computed tomography of abdomen abnormal}, gallstone {Gallbladder calculus}, intrahepatic {Intrahepatic biliary tract structure}, common 
hepatic duct {Structure of common hepatic duct}, dilatation {Dilatation}, malignancy {Malignant neoplasm}, MRCP {Magnetic resonance cholangiopancreatography}, distal common 
hepatic {Structure of common bile duct, distal}, proximal come bile duct {Structure of common bile duct, proximal}, necrotic {Necrosis}, ERCP {Endoscopic retrograde cholangiopancreatography}, stricture {Stricture}, proximal CBD {Structure of common bile duct, proximal}, stent placement {Placement of stent}, cholangiogram {Cholangiogram}, stricture {Stricture}, proximal CBD {Structure of common bile duct, proximal}, ERCP {Endoscopic retrograde cholangiopancreatography}, adenocarcinoma {Adenocarcinoma}, whipple procedure {Pancreaticoduodenectomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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
- BPH
- Arthritis
- Prior Carpal Tunnel Surgery R Wrist
 

###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, BPH {Benign prostatic hyperplasia}, Arthritis {Arthritis}, Carpal Tunnel {Carpal tunnel syndrome}, Surgery {Surgical procedure}, R Wrist {Structure of right wrist region}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
father - CAD
mother - pancreatic cancer
brother - HTN

 
Physical ___:
Prior To Discharge:
VS: 98.6, 68, 134/71, 18, 94% RA
GEN: Pleasant male without acute distress 
HEENT: NC/AT, PERRL, EOMI, no scleral icterus
CV: RRR
PULM: CTAB
ABD: Bilateral subcostal incision open to air with staples and 
c/d/I. RLQ with old JP site x 2, lateral with single suture, 
medial open to air 
EXTR: Warm, no c/c/e
 

###RESPONSE: CAD {Coronary arteriosclerosis}, pancreatic cancer {Malignant tumor of pancreas}, HTN {Hypertensive disorder, systemic arterial}, VS {Vital signs finding}, GEN {General examination of patient}, distress {Distress}, NC {Normal head}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, scleral icterus {Scleral icterus}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, ABD {Examination of abdomen}, subcostal incision {Subcostal incision}, RLQ {Structure of right lower quadrant of abdomen}, EXTR {Examination of limb}, Warm {Warm skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
RECENT LABS:

___ 05:25AM BLOOD WBC-8.4 RBC-3.76* Hgb-11.7* Hct-35.5* 
MCV-94 MCH-31.1 MCHC-33.0 RDW-16.2* RDWSD-55.7* Plt ___
___ 05:25AM BLOOD Glucose-143* UreaN-12 Creat-0.6 Na-144 
K-3.9 Cl-102 HCO3-31 AnGap-11
___ 04:40PM ASCITES Amylase-8
___ 04:40PM ASCITES Amylase-8

MICROBIOLOGY:
___ 2:00 pm SWAB      BILE CULTURE. 
      Fluid should not be sent in swab transport media.  Submit 
fluids in a
      capped syringe (no needle), red top tube, or sterile cup. 
                  **FINAL REPORT ___

GRAM STAIN (Final ___: 
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR 
LEUKOCYTES. 
      NO MICROORGANISMS SEEN. 

WOUND CULTURE (Final ___: 
      ESCHERICHIA COLI.    SPARSE GROWTH. 
         Cefazolin interpretative criteria are based on a dosage 
regimen of
         2g every 8h. 
      ESCHERICHIA COLI.    SPARSE GROWTH. 
         Cefazolin interpretative criteria are based on a dosage 
regimen of
         2g every 8h.  SECOND MORPHOLOGY. 

                              SENSITIVITIES: MIC expressed in 
MCG/ML
                      
_________________________________________________________
                             ESCHERICHIA COLI
                             |          ESCHERICHIA COLI
                             |          |   
AMPICILLIN------------   <=2 S        4 S
AMPICILLIN/SULBACTAM--   <=2 S      <=2 S
CEFAZOLIN-------------   <=4 S      <=4 S
CEFEPIME--------------   <=1 S      <=1 S
CEFTAZIDIME-----------   <=1 S      <=1 S
CEFTRIAXONE-----------   <=1 S      <=1 S
CIPROFLOXACIN---------<=0.25 S   <=0.25 S
GENTAMICIN------------   <=1 S      <=1 S
MEROPENEM-------------<=0.25 S   <=0.25 S
PIPERACILLIN/TAZO-----   <=4 S      <=4 S
TOBRAMYCIN------------   <=1 S      <=1 S
TRIMETHOPRIM/SULFA----   <=1 S      <=1 S

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, 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}, CULTURE {Microbial culture}, GRAM STAIN {Gram stain method}, WOUND CULTURE {Wound microscopy, culture and sensitivities}, SENSITIVITIES {Antimicrobial susceptibility test}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
The patient with biopsy proven adenocarcinoma was admitted to 
the HPB Surgical Service on ___ for elective operation. On 
___, the patient underwent pylorus-preserving 
pancreaticoduodenectomy (Whipple) and open cholecystectomy, 
intraoperative patient spiked a fever and was continued on Zosyn 
for empiric coverage post operative, bile and blood cultures 
were sent (please see the Operative Note for details). After a 
brief, uneventful stay in the PACU, the patient arrived on the 
floor NPO with an NG tube, on IV fluids, with a foley catheter 
and a JP drain x 2 in place, and epidural catheter for pain 
control.  The patient was hemodynamically stable.
The ___ hospital course was uneventful and followed the 
Whipple Clinical Pathway without major deviations. 
Post-operative pain was initially well controlled with epidural 
analgesia, which was converted to oral pain medication when 
tolerating clear liquids. The NG tube was discontinued on POD# 
2, and the foley catheter discontinued at midnight of POD# 4. 
The patient subsequently voided without problem. The patient was 
started on sips of clears on POD# 3, which was progressively 
advanced as tolerated to a regular diet by POD# 6.  JP amylase 
was sent in the evening of  POD#6; the posterior JP was 
discontinued on POD# 6, and anterior JP was discontinued on POD 
7 as the output and amylase level were low. Patient was 
transitioned from Zosyn to PO Cipro on POD 4 to complete 7 days 
total. Patient remained afebrile with WBC within normal limits 
prior to discharge. 
During this hospitalization, the patient ambulated early and 
frequently, was adherent with respiratory toilet and incentive 
spirrometry, and actively participated in the plan of care. The 
patient received subcutaneous heparin and venodyne boots were 
used during this stay. He was transitioned to ___ Lovenox prior 
to discharge. The patient's blood sugar was monitored regularly 
throughout the stay; no insulin was required on discharge. 
At the time of discharge on ___, 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: biopsy {Biopsy}, adenocarcinoma {Adenocarcinoma}, elective operation {Optional surgery}, pylorus-preserving 
pancreaticoduodenectomy {Pylorus-sparing Whipple operation}, cholecystectomy {Cholecystectomy}, fever {Fever}, post operative {Postoperative state}, blood cultures {Blood culture}, NPO {Nil by mouth}, IV fluids {Administration of intravenous fluids}, foley catheter {Urinary catheter in situ}, pain 
control {Pain control}, hemodynamically stable {Hemodynamically stable}, Post-operative pain {Postoperative pain}, epidural 
analgesia {Epidural anesthesia}, oral {Administration of drug or medicament via oral route}, pain medication {Administration of analgesic}, voided without problem {Normal micturition}, regular diet {Normal diet}, amylase level {Amylase measurement}, incentive 
spirrometry {Incentive spirometry}, blood sugar {Glucose measurement, blood}, 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}, 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:
Lisinopril-HCTZ ___ QD
Finasteride 5 QD
Pravastatin 20 QD
 
Discharge Medications:
1.  Acetaminophen ___ mg PO Q8H:PRN Pain - Mild 
do not exceed more then 3000 mg/day  
2.  Docusate Sodium 100 mg PO BID 
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day 
Disp #*60 Capsule Refills:*0 
3.  Enoxaparin Sodium 40 mg SC DAILY 
RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*30 
Syringe Refills:*0 
4.  lisinopril-hydrochlorothiazide ___ mg oral DAILY  
5.  Metoclopramide 10 mg PO QIDACHS 
RX *metoclopramide HCl 10 mg 1 tab by mouth QIDACHS Disp #*56 
Tablet Refills:*0 
6.  OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - 
Moderate 
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp 
#*20 Tablet Refills:*0 
7.  Pantoprazole 40 mg PO Q24H 
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 
Tablet Refills:*11 
8.  Senna 8.6 mg PO BID  
9.  Finasteride 5 mg PO DAILY  
10.  Pravastatin 20 mg PO QPM  

 

###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:
Locally advanced cholangiocarcinoma 

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: cholangiocarcinoma {Cholangiocarcinoma}, Mental Status {Neurological mental status determination}, Clear {Chest clear}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Mr. ___, 
You were admitted to the surgery service at ___ for surgical 
resection of your biliary duct mass. You have done well in the 
post operative period and are now safe to return home to 
complete your recovery with the following instructions:
.
Please call Dr. ___ office at ___ or Office RNs at 
___ if you have any questions or concerns. 
.
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.
*If you have staples, they will be removed at your follow-up 
appointment.

 

###RESPONSE: surgical 
resection {Surgical removal}, biliary duct {Bile duct structure}, mass {Mass of pancreas}, post operative {Postoperative state}, increased pain {Increased pain}, swelling {Swelling}, redness {Redness of skin over lesion}, drainage {Discharge}, incision 
site {Surgical incision wound}, 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: 
Cefaclor / Aspirin
 
Attending: ___.
 
Chief Complaint:
Feeling hot/cold, paresthesias
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: Aspirin {Allergy to aspirin}, Feeling hot/cold {Sensation of hot and cold}, paresthesias {Paresthesia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 presented to ___ for his fourth ___ visit for a 
strange constellation of symptoms including a strange feeling 
like water in his stomach, abdominal pain, a feeling of fecal 
urgency, and warm tingling up into his chest and down his leg.  
He reported a total duration of about three weeks for these 
symptoms.  His most dramatic symptom had been a strange 
sensation of hot and cold.  He reported he would have a very 
cold feeling in his abdomen associated with some pain that was 
most intense in the right upper quadrant.  This would be 
followed by a warm, dry feeling in his chest.  He reported after 
these symptoms he would have a feeling of fecal urgency and 
almost invariably have a bowel movement.   Additionally, 
associated with these episodes he endorsed shortness of breath, 
mild chest pain, diaphoresis, and a presyncopal feeling.  He 
acknowledged these symptoms would lead to a great deal of 
anxiety, which would make him feel worse, but was very insistent 
the anxiety developed after and in response to the symptoms.  He 
denied actually syncope.  He did report various areas of 
paresthesia as part of these spells in a band down his arm or 
leg.  These symptoms led to at least three previous ___ 
evaluations and he had a CT Abdomen (reportedly benign), 
multiple ECG's and multiple sets of labs with attempts to 
empirically treat for PNA, asthma flare, and influenza.  There 
had been some discussion of sending urine metanephrines and both 
his PCP and an ___ physician at ___ recommended this but it was 
deferred as he was completing a steroid course.  He reported 
none of these symptoms had improved with any of the measures 
recommended at other hospitals and he continued to be very 
worried something dangerous was occurring.  Over the last three 
days preceding his presentation these symptoms had been more 
marked and he had a chronic sensation of discomfort in his 
abdomen.  When he awoke on the morning of presentation he had a 
right frontal headache as well as his other symptoms so he 
called ___ and the physician on call, Dr ___ him to 
the ___ for further work up.   

In the ___ VS 99. 100 132/87 18 100%.  Physical exam was notable 
for wheezing so he received albuterol inhaler.  He also received 
buprenorphine-naloxone ___.  He had a benign head CT and was 
admitted to the floor.  

REVIEW OF SYSTEMS: + per HPI.  Also positive for cough and URI 
symptoms.  Negative for constipation, ememesis, melena, 
hematochezia, palpitations, dysuria, hematuria, confusion, 
syncope.
 

###RESPONSE: stomach {Stomach structure}, abdominal pain {Abdominal pain}, fecal 
urgency {Urgent desire for stool}, warm {Sensation of being warm}, tingling {Tingling of skin}, chest {Thoracic structure}, leg {Lower limb structure}, sensation of hot and cold {Sensation of hot and cold}, cold feeling {Sensation of being cold}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, pain {Chest pain}, right upper quadrant {Structure of right upper quadrant of abdomen}, warm {Sensation of being warm}, dry {Xeroderma}, chest {Thoracic structure}, fecal urgency {Urgent desire for stool}, shortness of breath {Dyspnea}, chest pain {Chest pain}, diaphoresis {Excessive sweating}, presyncopal {Near syncope}, anxiety {Anxiety}, anxiety {Anxiety}, syncope {Syncope}, paresthesia {Paresthesia}, arm {Upper limb structure}, leg {Lower limb structure}, evaluations {Evaluation procedure}, CT Abdomen {Computed tomography of abdomen}, ECG {Electrocardiographic procedure}, PNA {Pneumonia}, asthma {Asthma}, influenza {Influenza}, steroid {Steroid therapy}, improved {Patient's condition improved}, discomfort in his 
abdomen {Abdominal discomfort}, frontal headache {Frontal headache}, work up {Evaluation procedure}, VS {Vital signs finding}, wheezing {Wheezing}, head CT {Computed tomography of head}, cough {Cough}, URI {Upper respiratory infection}, constipation {Constipation}, melena {Melena}, hematochezia {Hematochezia}, palpitations {Palpitations}, dysuria {Dysuria}, hematuria {Blood in urine}, confusion {Clouded consciousness}, syncope {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:
-Cerbral palsy
-Asthma
-Hep C positive
-Anxiety
-History of substance abuse on naloxone
-S/P left shoulder surgeries * 2
-He reports an episode of acute kidney injury during his period 
of substance abuse, he reports he not require dialysis but this 
was discussed
 

###RESPONSE: Cerbral palsy {Cerebral palsy}, Asthma {Asthma}, Hep C {Viral hepatitis type C}, Anxiety {Anxiety}, substance abuse {Substance abuse}, left shoulder {Structure of left shoulder region}, surgeries {Surgical procedure}, acute kidney injury {Acute kidney injury}, substance abuse {Substance abuse}, dialysis {Dialysis 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: 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:
Didn't know his father but heard something about an adrenal 
tumor in him.  Mother had brain aneurysm and has had cardiac 
stents in ___ (mother is currently actively using drugs).  
 

###RESPONSE: adrenal 
tumor {Neoplasm of adrenal gland}, brain {Brain structure}, aneurysm {Aneurysm}, stents {Insertion of arterial stent}, using drugs {Drug abuse}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
On Admission:
VS: T 98.1, P 76, BP 128/95, RR 18, O2 99% on RA
Gen: Anxious young man in NAD, diaphoretic
HEENT: Normocephalic, anicteric, MMM, OP clear without lesions
Neck: No masses or thyroid nodules appreciated
CV: RRR, no M/R/G; there is no jugular venous distension 
appreciated
Pulm: Resps unlabored, bilateral expiratory wheezes, good air 
movement.  
Abd: Mild abdominal tenderness diffusely but no guarding or 
rebound, no organomegaly or masses appreciated
Extrem: Warm and well perfused, no C/C/E
Neuro: A and O*3, CNII-XII exam showed normal movement, 
complained decreased sensation V2-V3 on R side, strength ___ in 
all extremities
Psych: Very anxious affect

On Discharge:
Neuro: Right V2-V3 sensation normal, but new left face numb 
sensation.
Anal: Skin abrasion around anus, but no vesicles, condyloma, 
erythema, or fluctuance.
 

###RESPONSE: VS {Vital signs finding}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, RA {Breathing room air}, Gen {General examination of patient}, Anxious {Anxiety}, NAD {No abnormality detected}, diaphoretic {Excessive sweating}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, anicteric {White sclera}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, lesions {Lesion}, Neck {Physical examination procedure}, masses {Mass of neck}, thyroid nodules {Thyroid nodule}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, no M/R/G {Heart sounds normal}, jugular venous distension {Jugular venous engorgement}, Pulm {Examination of respiratory system}, Resp {Examination of respiratory system}, unlabored {Breathing easily}, wheezes {Wheezing}, good air 
movement {Breath normal}, Abd {Examination of abdomen}, tenderness {Tenderness}, guarding {Abdominal guarding}, rebound {Rebound tenderness}, organomegaly {Abdominal organomegaly}, masses {Abdominal mass}, Extrem {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, Neuro {Neurological examination}, CNII-XII {Cranial nerve finding}, decreased sensation {Hypesthesia}, all extremities {All extremities}, Psych {Neurological mental status determination}, anxious {Anxiety}, affect {Mood finding}, Neuro {Neurological examination}, sensation normal {Normal sensation}, left face {Structure of left half of face}, numb {Numbness}, Skin {Examination of skin}, abrasion {Abrasion}, anus {Anal structure}, vesicles {Vesicle}, condyloma {Condyloma}, erythema {Erythema}, fluctuance {Fluctuant}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
===================
LABORATORY RESULTS
===================
On Presentation:
Na 140, K 4.6, Cl 101, HCO3 28, BUN 16, Cr 0.7, Glu 121
WBC 10, Hb 15.5, Hct 43.3, MCV 83, Plt 290
--N 65.2, L 30.8, M 2.6, E 0.2, B 1.1
___ 15.4, PTT 30.1, INR 1.3
Ca ___, Mg 2.1, P 3.6
TropT< 0.01
ALT 19, AST 19, AP 41, LDH 184, TBili 0.5
TSH-1.2 T4-10.0 T3-139
Tox: ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

UA: Mod Bact, 30 protein

On Discharge:
WBC-7.2 RBC-4.92 Hgb-14.5 Hct-40.2 MCV-82 RDW-13.2 Plt ___
Glucose-107* UreaN-19 Creat-0.7 Na-138 K-4.3 Cl-101 HCO3-27 

=============
MICROBIOLOGY
=============
Urine Culture ___: No Growth

Monospot ___: Negative

==============
OTHER STUDIES
==============
CT Head W/O Contrast ___:
IMPRESSION: No acute intracranial process. Sphenoid sinus 
disease.

Chest Radiograph ___:
IMPRESSION: No acute intrathoracic process.

ECG: Sinus bradycardia at 83.  Nl axis and intervals.  J point 
elevation anteriorly.  No acute ST or TW abnormalities.  
 

###RESPONSE: RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, RDW {Red cell distribution width determination}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, Urine Culture {Urine culture}, Sphenoid sinus 
disease {Disorder of sphenoidal sinus}, ECG: Sinus bradycardia {Electrocardiogram: sinus bradycardia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 anxiety, substance 
abuse, and asthma presenting with three weeks of strange 
symptoms and multiple ___ evals.

1) Chills/ Warm Sensation/ Paresthesias/ Paresthesias/ 
Presyncope: The patient presented for at least his fourth visit 
for a complicated set of somatic symptoms including feeling hot 
or cold, migrating paresthesias, fecal urgency, and presyncope.  
 His febrile symptoms are, of course, concerning for infection 
and his neurological symptoms and fever raise concern for 
neurogenic or cardiogenic syncope vs seizure.  The patient was 
monitored >24 hours and had multiple episodes of this symptom 
complex.  Vital signs were checked numerous times and he was 
monitored on telemetry.  There were no episodes of concerning 
arrhythmia, hemodynamic instability, fevers, chills, or other 
appreciable physical exam finding with the exception of the 
patient being somewhat diaphoretic and having some mild, diffuse 
tenderness to palpation on his abdomen.  A wide range of labs 
were checked and no significant abnormalities were detected.  
Ultimate diagnosis remains unclear though the team has 
considerable suspicion of anxiety or atypical panic attacks 
given the patient's marked anxiety and the lack of physical 
findings.  Other possible etiologies would be vasovagal (near) 
syncope perhaps initiated by a viral syndrome that caused loose 
stools and nausea (though neither of these GI symptoms were 
reported during this hospitalization).  His CT head was benign 
and pretest probability of stroke or severe intracranial process 
with NO hard neurological deficits on exam in this young, 
healthy man would be very low.   Other much less likely 
diagnostic possibilities would be pheochromocytoma or carcinoid, 
both of which can cause flushing spells (carcinoid would better 
explain fecal urgency) though one would expect at least some 
vital sign abnormalities during the episodes.  Ultimately, the 
very benign nature of the tests and data from monitoring were 
discussed with the patient and Dr ___ at ___ 
___.  Given the difficulties with initiating 24 hour 
urine monitoring and sending send-out tests in an ultimately 
VERY stable looking man tests of 5-HIAA and urine metanephrines 
were deferred.  We explained to the patient that though we were 
unable to give a specific diagnosis findings were suggestive of 
something not immediately dangerous, which he found reassuring.  
The patient was discharged to follow up with his PCP for further 
___ of these symptoms.  

2) Wheezing/ SOB: Patient has history of asthma and was wheezing 
on presentation.  He was given albuterol inhaler in house.  

3) History of substance abuse: He was continued on his home 
buprenorphine-naloxone.

He tolerated a full diet.  He received subcutaneous heparin for 
DVT prophylaxis.  He was full code.  
 

###RESPONSE: anxiety {Anxiety}, substance 
abuse {Substance abuse}, asthma {Asthma}, Chills {Chill}, Warm Sensation {Sensation of being warm}, Paresthesias {Paresthesia}, Paresthesias {Paresthesia}, Presyncope {Near syncope}, feeling hot 
or cold {Sensation of hot and cold}, paresthesias {Paresthesia}, fecal urgency {Urgent desire for stool}, presyncope {Near syncope}, febrile {Fever}, infection {Infectious disease}, neurological symptoms {Neurological symptom}, fever {Fever}, cardiogenic syncope {Cardiac syncope}, seizure {Seizure}, telemetry {Cardiac telemetry}, arrhythmia {Cardiac arrhythmia}, hemodynamic instability {Hemodynamic instability}, fevers {Fever}, chills {Chill}, diaphoretic {Excessive sweating}, tenderness to palpation {Abdominal tenderness}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, no significant abnormalities {No abnormality detected}, anxiety {Anxiety}, panic attacks {Panic attack}, anxiety {Anxiety}, vasovagal {Vasovagal syncope}, near) 
syncope {Near syncope}, viral syndrome {Nonspecific syndrome suggestive of viral illness}, loose 
stools {Loose stool}, nausea {Nausea}, GI symptoms {Gastrointestinal symptom}, CT head {Computed tomography of head}, stroke {Cerebrovascular accident}, neurological deficits {Neurological deficit}, pheochromocytoma {Pheochromocytoma}, carcinoid {Carcinoid syndrome}, flushing {Flushing}, fecal urgency {Urgent desire for stool}, stable {Patient's condition stable}, reassuring {Reassuring}, follow up {Follow-up arranged}, Wheezing {Wheezing}, SOB {Dyspnea}, asthma {Asthma}, wheezing {Wheezing}, substance abuse {Substance abuse}, heparin {Heparin therapy}, DVT prophylaxis {Prevention of deep vein thrombosis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Buprenorphine-Naloxone ___ mg PO QAM, ___ mg PO QPM 
 
Discharge Medications:
1. buprenorphine-naloxone ___ mg Tablet, Sublingual Sig: One (1) 
Tablet Sublingual QAM (once a day (in the morning)).  
2. Suboxone ___ mg Tablet, Sublingual Sig: Two (2) tabs 
Sublingual at bedtime.  
3. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed for fever, pain.  
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnoses:
--Somatic symptoms NOS, suspected viral syndrome vs vasovagal
--Asthma

Secondary Diagnosis:
-History of opiate addiction on suboxone maintenance
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 

###RESPONSE: Somatic symptoms {Somatic pain}, viral syndrome {Nonspecific syndrome suggestive of viral illness}, vasovagal {Vasovagal syncope}, Asthma {Asthma}, addiction {Addiction}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted due to concerns about the symptoms you have 
been having including sensation of hot and cold, urgency to go 
to the bathroom, abdominal discomfort, shortness of breath, and 
feeling as if you might pass out.  You were admitted and  
monitored overnight.  You have had no vital sign abnormalities, 
dangerous cardiac rhythms, and your labs were unremarkable.  A 
CT scan showed no major intracranial process.  It is unclear 
what is causing your symptoms.  Most likely you had a viral 
syndrome that exacerbated your asthma and perhaps is causing 
something called vasovagal episodes, during which you may feel 
lightheaded.  There are a few other rare illnesses that could 
cause some of these symptoms but these require 24 hour urine 
corrections and take some time to return.  These were deferred 
as an inpatient but will be pursued as an outpatient by your 
PCP.  

Your medications have not been changed.  Please continue to take 
your Suboxone as prescribed.  
 

###RESPONSE: sensation of hot and cold {Sensation of hot and cold}, abdominal discomfort {Abdominal discomfort}, shortness of breath {Dyspnea}, cardiac rhythms {Finding of heart rhythm}, unremarkable {No abnormality detected}, CT scan {Computed tomography}, viral 
syndrome {Nonspecific syndrome suggestive of viral illness}, asthma {Asthma}, vasovagal {Vasovagal syncope}, lightheaded {Lightheadedness}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: 
Codeine
 
Attending: ___.
 
Chief Complaint:
diarrhea
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: Codeine {Allergy to codeine}, 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: History of Present Illness:
The patient is a ___ w/ no significant PMH who presents with 3 
days diarrhea. She has not had F/C/N/V/NS. She had increasing 
abdominal pain overnight and bloody diarrhea this morning. She 
was sent in by ___ for evaluation.

In the ED she was afebrile, 98.9, 59, 115/70, 15, 100% RA. She 
was given IV Cipro and Flagyl. CT abd showed pancolitis with 
rectal sparing. She was admitted to medicine for further 
management.

ROS:
-Constitutional: []WNL []Weight loss []Fatigue/Malaise []Fever 
[]Chills/Rigors []Nightsweats []Anorexia
-Eyes: []WNL []Blurry Vision []Diplopia []Loss of Vision 
[]Photophobia
-ENT: []WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose 
[]Tinnitus []Sinus pain []Sore throat
-Cardiac: []WNL []Chest pain []Palpitations ___ edema 
[]Orthopnea/PND []DOE
-Respiratory: []WNL []SOB []Pleuritic pain []Hemoptysis []Cough
-Gastrointestinal: []WNL []Nausea []Vomiting []Abdominal pain 
[]Abdominal Swelling []Diarrhea []Constipation []Hematemesis 
[]Hematochezia []Melena
-Heme/Lymph: []WNL []Bleeding []Bruising []Lymphadenopathy
-GU: []WNL []Incontinence/Retention []Dysuria []Hematuria 
[]Discharge []Menorrhagia
-Skin: []WNL []Rash []Pruritus
-Endocrine: []WNL []Change in skin/hair []Loss of energy 
[]Heat/Cold intolerance
-Musculoskeletal: []WNL []Myalgias []Arthralgias []Back pain
-Neurological: []Numbness of extremities []Weakness of 
extremities []Parasthesias []Dizziness/Lightheaded []Vertigo 
[]Confusion []Headache
-Psychiatric: []WNL []Depression []Suicidal Ideation
-Allergy/Immunological: [] WNL []Seasonal Allergies

 

###RESPONSE: diarrhea {Diarrhea}, F/C {Fever with chills}, N/V {Nausea and vomiting}, abdominal pain {Abdominal pain}, bloody diarrhea {Hemorrhagic diarrhea}, evaluation {Evaluation procedure}, afebrile {Fever}, RA {Breathing room air}, CT abd {Computed tomography of abdomen}, pancolitis {Ulcerative pancolitis}, rectal {Rectum structure}, WNL {No abnormality detected}, Weight loss {Weight loss}, Fatigue {Fatigue}, Malaise {Malaise}, Fever {Fever}, Chills {Chill}, Rigors {Rigor}, Nightsweats {Night sweats}, Anorexia {Loss of appetite}, Eyes {Ophthalmic examination and evaluation}, WNL {No abnormality detected}, Blurry Vision {Blurring of visual image}, Diplopia {Diplopia}, Loss of Vision {Functional visual loss}, Photophobia {Photophobia}, ENT {Ear, nose and throat examination}, WNL {No abnormality detected}, Dry Mouth {Mucous membrane dryness}, Oral ulcers {Ulcer of mouth}, Bleeding gums {Bleeding gums}, nose {Bleeding from nose}, Tinnitus {Tinnitus}, Sinus {Nasal sinus structure}, pain {Pain}, Sore throat {Sore throat}, Cardiac {Cardiovascular physical examination}, WNL {No abnormality detected}, Chest pain {Chest pain}, Palpitations {Palpitations}, edema {Edema}, Orthopnea {Orthopnea}, PND {Paroxysmal nocturnal dyspnea}, DOE {Dyspnea on exertion}, Respiratory {Examination of respiratory system}, WNL {No abnormality detected}, SOB {Dyspnea}, Pleuritic pain {Pleuritic pain}, Hemoptysis {Hemoptysis}, Cough {Cough}, Gastrointestinal {Examination of digestive system}, WNL {No abnormality detected}, Nausea {Nausea}, Vomiting {Vomiting}, Abdominal pain {Abdominal pain}, Abdominal Swelling {Swollen abdomen}, Diarrhea {Diarrhea}, Constipation {Constipation}, Hematemesis {Hematemesis}, Hematochezia {Hematochezia}, Melena {Melena}, Lymph {Lymphatic system physical examination}, WNL {No abnormality detected}, Bleeding {Bleeding}, Bruising {Contusion}, Lymphadenopathy {Lymphadenopathy}, GU {Examination of genitourinary system}, WNL {No abnormality detected}, Incontinence {Incontinence}, Retention {Retention of urine}, Dysuria {Dysuria}, Hematuria {Blood in urine}, Menorrhagia {Menorrhagia}, Skin {Examination of skin}, WNL {No abnormality detected}, Rash {Eruption of skin}, Pruritus {Itching of skin}, WNL {No abnormality detected}, skin {Skin structure}, hair {Hair structure}, Loss of energy {Lack of energy}, Heat {Intolerant of heat}, Cold intolerance {Intolerant of cold}, Musculoskeletal {Musculoskeletal system physical examination}, WNL {No abnormality detected}, Myalgias {Muscle pain}, Arthralgias {Joint pain}, Back pain {Backache}, Neurological {Neurological examination}, Numbness {Numbness}, extremities {All extremities}, Weakness {Asthenia}, extremities {All extremities}, Parasthesias {Paresthesia}, Dizziness {Dizziness}, Lightheaded {Lightheadedness}, Vertigo {Vertigo}, Confusion {Clouded consciousness}, Headache {Headache}, Psychiatric {Psychiatry procedure or service}, WNL {No abnormality detected}, Depression {Depressive disorder}, Suicidal Ideation {Suicidal thoughts}, WNL {No abnormality detected}, Seasonal Allergies {Seasonal allergy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
None
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
Grandfather with colon CA. No h/o IBD.
 

###RESPONSE: colon CA {Malignant neoplasm of colon}, IBD {Inflammatory bowel 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: Physical Exam:

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Appearance: NAD
Vitals: T: 99.4 BP: 114/79 HR: 58 RR: 18 O2: 99% RA
Eyes: EOMI, PERRL, conjunctiva clear, noninjected, anicteric, no 
exudate
ENT: Moist
Neck: No JVD, no LAD
Cardiovascular: RRR, nl S1/S2, no m/r/g
Respiratory: CTA bilaterally, comfortable, no wheezing, no 
ronchi, no rales
Gastrointestinal: soft, tender in umbilical and hypogastric 
region, non-distended, no hepatosplenomegaly, normal bowel 
sounds
Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint 
swelling, no edema in the bilateral extremities
Neurological: Alert and oriented x3, fluent speech, sensation 
WNL, moves all four extremities
Integument: warm, no rash, no ulcer
Psychiatric: appropriate, pleasant

 

###RESPONSE: Physical Exam {Physical examination procedure}, Appearance {Finding of general observation of appearance}, NAD {No abnormality detected}, Vitals {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 {Oxygen saturation measurement}, RA {Breathing room air}, Eyes {Ophthalmic examination and evaluation}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, conjunctiva clear {Conjunctiva normal}, anicteric {White sclera}, exudate {Exudate}, ENT {Abdominal tenderness}, Moist {Moist oral mucosa}, Neck {Physical examination procedure}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, Cardiovascular {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, no m/r/g {Heart sounds normal}, Respiratory {Examination of respiratory system}, CTA {Normal breath sounds}, wheezing {Wheezing}, ronchi {Wheeze - rhonchi}, rales {Respiratory crackles}, Gastrointestinal {Examination of digestive system}, soft {Abdomen soft}, tender {Abdominal tenderness}, umbilical {Umbilical region structure}, hypogastric 
region {Hypogastric region structure}, non-distended {Normal abdominal contour}, hepatosplenomegaly {Hepatosplenomegaly}, normal bowel 
sounds {Normal bowel sounds}, Musculoskeletal {Musculoskeletal system physical examination}, Extremities {Examination of limb}, clubbing {Clubbing}, cyanosis {Cyanosis}, joint 
swelling {Joint swelling}, edema {Edema}, extremities {Examination of limb}, Neurologic {Neurological examination}, Alert {Mentally alert}, oriented {Orientated}, fluent speech {Finding of fluency of speech}, sensation 
WNL {Normal sensation}, moves all four extremities {Does move all four limbs}, Integument {Examination of skin}, warm {Warm skin}, rash {Eruption of skin}, ulcer {Ulcer}, Psychiatric {Psychiatry procedure or service}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 11:00AM   GLUCOSE-90 UREA N-10 CREAT-0.9 SODIUM-143 
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15
___ 11:00AM   ALT(SGPT)-26 AST(SGOT)-29 ALK PHOS-107 TOT 
BILI-0.4
___ 11:00AM   LIPASE-30
___ 11:00AM   WBC-6.3 RBC-4.18* HGB-12.6 HCT-35.7* MCV-85 
MCH-30.1 MCHC-35.2* RDW-13.2
___ 11:00AM   PLT COUNT-217
___ 12:50PM URINE  COLOR-Yellow APPEAR-Clear SP ___
___ 12:50PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 
LEUK-SM
___ 12:50PM URINE  ___ BACTERIA-FEW YEAST-NONE 
___

CT abd/pelvis: Pancolitis, worst along the cecum. Findings may 
be secondary to infectious or inflammatory process. 

 

###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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, PHOS {Phosphate, total measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, COLOR {Color finding}, PROTEIN {Measurement of protein in urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, AST {Aspartate aminotransferase measurement}, cecum {Cecum structure}, infectious {Infectious disease}, inflammatory {Inflammatory disorder}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
A/P: ___ w/ no significant PMH presents with 3 days diarrhea, 1 
day worsening abdominal pain.

## diarrhea/abdominal pain: colitis identified on CT, most 
likely infectious, especially given occupational risk factor, 
but cannot rule out inflammatory bowel disease. Stool was sent 
for culture including C. diff. Her diarrhea improved with 
empiric Cipro/Flagyl, and she tolerated clears. Her pain 
improved with Tylenol and oxycodone x1. As she was tolerating 
clears and PO meds and her diarrhea was improving, she was 
discharged home with strong recommendations to followup in 
Healthcare Associates within the week. She will be contacted if 
the stool cultures return positive and indicate a change in 
therapy. her her symptoms do not improve with a 7-day course of 
Abx, a flex sig in GI clinic would be considered to evaluate for 
evidence of IBD.

 

###RESPONSE: diarrhea {Diarrhea}, worsening {Increased pain}, abdominal pain {Abdominal pain}, diarrhea {Diarrhea}, abdominal pain {Abdominal pain}, colitis {Colitis}, CT {Computed tomography}, infectious {Infectious disease}, inflammatory bowel disease {Inflammatory bowel disease}, Stool was sent 
for culture {Stool culture}, diarrhea {Diarrhea}, improved {Patient's condition improved}, pain 
improved {Sensation of pain reduced}, diarrhea {Diarrhea}, improving {Patient's condition improved}, stool cultures {Stool culture}, Abx {Antibiotic therapy}, IBD {Inflammatory bowel disease}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
multivitamin
 
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H 
(every 12 hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 
8 hours) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
3. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed.  

 

###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: colitis of presumed infectious origin

 
Discharge Condition:
good, stable, tolerating liquids

 

###RESPONSE: colitis {Colitis}, infectious {Infectious disease}, good {Patient's condition satisfactory}, stable {Patient's condition stable}, tolerating liquids {Tolerating oral fluid}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 evaluated for diarrhea and abdominal cramping and were 
found to have inflammation of the colon (colitis) on CT scan. 
This is most likely due to an infection, although inflammatory 
bowel disease is also possible. As your diarrhea improved and 
you were able to keep down fluids, you should be safe for 
discharge home. Some stool culture results were pending at the 
time of discharge, and you should follow up early next week at 
Healthcare Associates for results and consideration of further 
testing depending on your symptoms.

Take antibiotics (Flagyl and Cipro) as directed.

If you have worsening abdominal pain, lightheadedness, 
significant blood in your stool, inability to keep down food or 
liquid, fevers or chills, see ___ Health Services or come 
to the emergency room.
 

###RESPONSE: diarrhea {Diarrhea}, abdominal cramping {Stomach cramps}, inflammation {Inflammatory disorder}, colon {Colon structure}, colitis {Colitis}, CT scan {Computed tomography}, infection {Infectious disease}, inflammatory 
bowel disease {Inflammatory bowel disease}, diarrhea {Diarrhea}, improved {Patient's condition improved}, keep down fluids {Tolerating oral fluid}, stool culture {Stool culture}, antibiotics {Antibiotic therapy}, worsening {Increased pain}, abdominal pain {Abdominal pain}, lightheadedness {Lightheadedness}, blood in your stool {Hematochezia}, fevers {Fever}, chills {Chill}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Bilaterally heel pain
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Drugs {Allergy to drug}, heel pain {Heel pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ y.o. male with history of hypertrophic cardiomyopathy 
presents from outside hospital with bilateral calcaneus 
fractures.  The patient reports that earlier today he was up on 
a ladder, approximately 8 feet off of the ground.  The bottom of 
the ladder started to slide backwards, and the ladder fell to 
the ground.  He landed on his feet, and felt immediate heel pain 
bilaterally. The patient denies head strike, LOC, or back pain.  


He reports no other pain or injury.  He was seen at ___ 
___ and had plain films of his bilateral ankle/feet which 
revealed bilateral comminuted heel fractures.  He was 
transferred to ___ for further management.

He denies recent fever, cough, chest pain, shortness of breath, 
n/v/d, and abodminal pain.

 

###RESPONSE: hypertrophic cardiomyopathy {Hypertrophic cardiomyopathy}, calcaneus 
fractures {Fracture of calcaneus}, fell {Falls}, feet {Foot structure}, heel pain {Heel pain}, head strike {Injury of head}, LOC {Loss of consciousness}, back pain {Backache}, pain {Pain}, injury {Traumatic or non-traumatic injury}, plain films {Plain radiography}, bilateral ankle {Both ankles}, feet {Both feet}, comminuted {Fracture, comminuted}, heel fractures {Fracture of calcaneus}, fever {Fever}, cough {Cough}, chest pain {Chest pain}, shortness of breath {Dyspnea}, n/v/d {Nausea, vomiting and diarrhea}, abodminal pain {Abdominal pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
(1) Hypertrophic Cardiomyopathy
(2) Depression

 

###RESPONSE: Hypertrophic Cardiomyopathy {Hypertrophic cardiomyopathy}, Depression {Depressive disorder}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
non-contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
General Evaluation Exam
Sensorium:           Awake (x) Awake impaired () Unconscious ()
Airway:              Intubated () Not intubated (x)
Breathing:           Stable (x) Unstable ()
Circulation:         Stable (x)   Unstable ()

Musculoskeletal Exam
Neck   Normal (x)  Abnormal ()   Comments:
Spine  Normal (x)  Abnormal ()   Comments:
Clavicle
     R Normal (x)  Abnormal ()   Comments:
     L Normal (x)  Abnormal ()   Comments:
Shoulder
     R Normal (x)  Abnormal ()   Comments:
     L Normal (x)  Abnormal ()   Comments:
Arm
     R Normal (x)  Abnormal ()   Comments:
     L Normal (x)  Abnormal ()   Comments:
Elbow
     R Normal (x)  Abnormal ()   Comments:
     L Normal (x)  Abnormal ()   Comments:
Forearm
     R Normal (x)  Abnormal ()   Comments:
     L Normal (x)  Abnormal ()   Comments:
Wrist
     R Normal (x)  Abnormal ()   Comments:
     L Normal (x)  Abnormal ()   Comments:
Hand
     R Normal ()  Abnormal (x)   Comments: superficial abrasions
over dorsum of right hand.
     L Normal (x)  Abnormal ()   Comments:
Pelvis
     R Normal (x)  Abnormal ()    Comments:
     L Normal (x)  Abnormal ()    Comments:
Hip
     R Normal (x)  Abnormal ()    Comments:
     L Normal (x)  Abnormal ()    Comments:
Thigh
     R Normal (x)  Abnormal ()    Comments:
     L Normal (x)  Abnormal ()    Comments:
Knee
     R Normal (x)  Abnormal ()    Comments:
     L Normal (x)  Abnormal ()    Comments:
Leg
     R Normal (x)  Abnormal ()    Comments:
     L Normal (x)  Abnormal ()    Comments:
Ankle
     R Normal ()  Abnormal (x)    Comments: mild edema,
tenderness to palpation of the heel, plantar surface. No 
palpable
deformity. 2+ ___ pulses. Normal sensation, normal capillary
refill.
     L Normal ()  Abnormal (x)    Comments: moderate edema,
tenderness to palpation of the heel, plantar surface. No 
palpable
deformity. 2+ ___ pulses. Normal sensation, normal capillary
refill.
Foot
     R Normal ()  Abnormal (x)    Comments: see above
     L Normal ()  Abnormal (x)    Comments: see above

Vascular:
Radial   R Palpable (x) Non-palpable () Doppler ()
         L Palpable (x) Non-palpable () Doppler ()
Ulnar    R Palpable (x) Non-palpable () Doppler ()
         L Palpable (x) Non-palpable () Doppler ()
DP       R Palpable (x) Non-palpable () Doppler ()
         L Palpable (x) Non-palpable () Doppler ()
___       R Palpable (x) Non-palpable () Doppler ()
         L Palpable (x) Non-palpable () Doppler ()

Neuro:
Deltoid    R (5) L (5)
Biceps     R (5) L (5)
Triceps    R (5) L (5)
Wrist Flx  R (5) L (5)
Wrist Ext  R (5) L (5)
Finger Flx R (5) L (5)
Finger Ext R (5) L (5)
Thumb Ext  R (5) L (5)
___ DIP    R (5) L (5)
Index Abd  R (5) L (5)
Thumd Add  R (5) L (5)
Quad       R (5) L (5)
Ant Tib    R (5) L (5)
___        R ___ limited by pain) L ___, limited by pain)
Peroneal   R ___ limited by pain) L ___ limited by pain)
___         R ___ limited by pain) L ___ limited by pain)

 

###RESPONSE: General {General examination of patient}, Sensorium {Structure of sensory nervous system}, Awake {Awake}, Awake {Awake}, Unconscious {Unconscious}, Airway {Airway structure}, Intubated {Intubation}, intubated {Intubation}, Breathing {Examination of respiratory system}, Stable {Patient's condition stable}, Unstable {Patient's condition unstable}, Circulation {Cardiovascular examination and evaluation}, Stable {Patient's condition stable}, Unstable {Patient's condition unstable}, Musculoskeletal Exam {Musculoskeletal system physical examination}, Spine {Structure of vertebral column}, Clavicle {Bone structure of clavicle}, Shoulder {Structure of right shoulder region}, R {Structure of right shoulder region}, L {Structure of left shoulder region}, Arm {Upper limb structure}, R {Right upper arm structure}, L {Left upper arm structure}, Elbow {Elbow region structure}, R {Right elbow region structure}, L {Left elbow region structure}, Forearm {Forearm structure}, R {Structure of right forearm}, L {Structure of left forearm}, Wrist {Structure of left wrist region}, R {Structure of right wrist region}, L {Structure of left wrist region}, Hand {Hand structure}, R {Structure of right hand}, superficial abrasions {Abrasion}, dorsum of right hand {Structure of dorsum of right hand}, L {Structure of left hand}, Pelvis {Structure of pelvis}, L {Structure of left half of pelvis}, Hip {Hip region structure}, R {Right hip region structure}, L {Left hip region structure}, Thigh {Thigh structure}, R {Structure of right thigh}, L {Structure of left thigh}, Knee {Structure of left knee region}, R {Structure of right knee region}, L {Structure of left knee region}, Leg {Lower limb structure}, R {Structure of right lower leg}, L {Structure of left lower leg}, Ankle {Ankle region structure}, R {Structure of right ankle}, mild {Symptom mild}, edema {Edema}, tenderness {Tenderness}, palpation {Palpation}, heel {Heel structure}, palpable {Finding by palpation}, deformity {Deformity}, pulses {Normal pulse}, Normal sensation {Normal sensation}, capillary
refill {Capillary refill}, L {Structure of left ankle}, moderate {Symptom moderate}, edema {Edema}, tenderness {Tenderness}, palpation {Palpation}, heel {Heel structure}, palpable {Finding by palpation}, deformity {Deformity}, pulses {Normal pulse}, Normal sensation {Normal sensation}, capillary
refill {Capillary refill}, Foot {Foot structure}, R {Structure of right foot}, L {Structure of left foot}, Radial {Structure of radial artery}, R {Structure of right radial artery}, Palpable {Finding by palpation}, palpable {Finding by palpation}, L {Structure of left radial artery}, Palpable {Finding by palpation}, palpable {Finding by palpation}, Ulnar {Structure of ulnar vessel}, R {Structure of right ulnar artery}, Palpable {Finding by palpation}, palpable {Finding by palpation}, L {Structure of left ulnar artery}, Palpable {Finding by palpation}, palpable {Finding by palpation}, R {Structure of right dorsalis pedis artery}, Palpable {Finding by palpation}, palpable {Finding by palpation}, L {Structure of left dorsalis pedis artery}, Palpable {Finding by palpation}, palpable {Finding by palpation}, Palpable {Finding by palpation}, palpable {Finding by palpation}, Neuro {Neurological examination}, Deltoid {Structure of deltoid muscle}, Biceps {Biceps brachii muscle structure}, R {Structure of right biceps brachii muscle}, L {Structure of left biceps brachii muscle}, Triceps {Triceps brachii muscle structure}, Wrist {Structure of left wrist region}, Flx {Structure of flexor of wrist joint}, Wrist {Structure of left wrist region}, Finger {Finger structure}, Finger {Finger structure}, Thumb {Thumb structure}, DIP {Structure of distal interphalangeal joint}, Index {Index finger structure}, Abd {Structure of adductor muscle}, Thumd {Thumb structure}, Add {Structure of adductor muscle}, Quad {Structure of quadriceps femoris muscle}, Ant Tib {Tibialis anterior muscle structure}, pain {Pain}, pain {Pain}, Peroneal {Structure of peroneal artery}, pain {Pain}, pain {Pain}, pain {Pain}, pain {Pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:40PM   GLUCOSE-91 UREA N-11 CREAT-0.9 SODIUM-140 
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-27 ANION GAP-17
___ 06:40PM   WBC-10.2 RBC-4.39* HGB-14.0 HCT-40.1 MCV-91 
MCH-31.8 MCHC-34.9 RDW-13.7
___ 06:40PM   NEUTS-74.6* LYMPHS-16.6* MONOS-7.0 EOS-1.1 
BASOS-0.7
 

###RESPONSE: GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Mr. ___ was evaluated in the emergency room by the 
orthopaedic trauma service and found to have bilateral calcaneal 
fractures. He was admitted to ortho for pain control and 
bilateral bulky ___ casts were placed.  He was evaluated by 
physical therapy during his hospital stay.

On the floor he was given a regular diet with PO pain meds.  At 
the time of discharge he was afebrile with stable vital signs, 
tolerating a regular diet, voiding spontaneously, and with his 
pain well controled.

 

 

###RESPONSE: trauma {Traumatic injury}, calcaneal 
fractures {Fracture of calcaneus}, pain control {Pain control}, casts {Cast}, placed {Implantation procedure}, evaluated by 
physical therapy {Physical therapy management}, regular diet {Normal diet}, pain {Pain}, afebrile {Fever}, stable vital signs {Normal vital signs}, regular diet {Normal diet}, voiding spontaneously {Normal micturition}, pain well controled {Demonstrates adequate pain control}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
(1) Atenolol 50mg PO daily
(2) Paxil 20mg PO daily

 
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) injection 
Subcutaneous once a day for 4 weeks.
Disp:*28 1* Refills:*0*
4. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
5. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
6. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) 
as needed for Pain.
Disp:*90 Tablet(s)* Refills:*0*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Bilateral calcaneal fractures

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: calcaneal fractures {Fracture of calcaneus}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Wound Care: 
- Keep Incision clean and dry. 
- Do not soak the incision in a bath or pool. 

Activity: 
- Continue to be non-weight bearing on both of your legs.

Other Instructions
- Resume your regular diet. 
- Avoid nicotine products to optimize healing. 
- Resume your home medications. Take all medications as 
instructed. 
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control 
your pain. Please allow 72 hours ___ through ___, 9am to 
4pm) for refill of narcotic prescriptions, so plan ahead. There 
will be no prescription refils on ___, or 
holidays. You can either have them mailed to your home or pick 
them up at the clinic located on ___. We are not allowed 
to call in narcotic (oxycontin, oxycodone, percocet) 
prescriptions to the pharmacy. In addition, we are only allowed 
to write for pain medications for 90 days from the date of 
surgery.
- Narcotic pain medication may cause drowsiness. Do not drink 
alcohol while taking narcotic medications. Do not operate any 
motor vehicle or machinery while taking narcotic pain 
medications. Taking more than recommended may cause serious 
breathing problems.

If you have questions, concerns or experience any of the below 
danger signs then please call your doctor at ___ or go 
to your local emergency room.
 

###RESPONSE: Wound Care {Wound care}, Incision {Incision}, soak {Soak}, incision {Incision}, Activity {Functional activity education}, non-weight bearing {Non-weight-bearing}, legs {Lower limb structure}, regular diet {Normal diet}, medications {Patient medication education}, medications {Patient medication education}, blood clots {Blood clot}, Medications {Patient medication education}, pain {Pain}, narcotic {Narcotherapy}, prescriptions {Prescription}, prescription {Prescription}, narcotic {Narcotherapy}, prescriptions {Prescription}, pain medications {Administration of analgesic}, surgery {Surgical procedure}, Narcotic {Narcotherapy}, pain medication {Administration of analgesic}, drowsiness {Drowsy}, Do not drink 
alcohol {Education about alcohol consumption}, while taking narcotic {Narcotherapy}, medications {Patient medication education}, while taking narcotic {Narcotherapy}, pain 
medications {Administration of analgesic}, breathing problems {Abnormal breathing}, signs {Sign}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Penicillins / Bactrim / Prochlorperazine / Sulfa (Sulfonamide 
Antibiotics) / Quinolones / Pineapple / Erythromycin Base / 
Metoclopramide
 
Attending: ___.
 
Chief Complaint:
Abdominal Pain 
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Penicillins {Allergy to penicillin}, Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, Prochlorperazine {Allergy to prochlorperazine}, Sulfonamide 
Antibiotics {Allergy to sulfonamide antibiotic}, Pineapple {Allergy to pineapple}, Erythromycin {Allergy to erythromycin}, Metoclopramide {Allergy to metoclopramide}, Abdominal Pain {Abdominal pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ is a ___ year old female with a h/o kidney stones who 
presents with several days of RUQ/flank pain and a distended 
abdomen. The pain began ___ after eating when she started 
having nausea and then vomited. Over the next few days she had 
what she describes as a ""belly ache"" with some associated nausea 
and one episode of emesis on ___. During the week she was 
able to tolerate po's then noted an increase in urinary 
frequency and thought she could feel a kidney stone passing, but 
when the pain didn't improve she called her PCP's office on 
___. She was seen by her PCP for evaluation of her 
abdominal pain, who was concerned about a kidney stone vs. 
gallbladder pathology so she had a noncontrast abdominal CT scan 
done. The CT scan showed a 17mm likely cyst in her liver and two 
kidney stones on the left, but since the cyst had increased in 
size and she continued to have pain she was referred to the ER 
for further evaluation.  
.  
In the ED, initial vs were: 98.6, 77, 125/80, 18, 100% on RA. 
Patient was given morphine x 2 for pain, which improved her pain 
but did not last that long, had an ultrasound of her abdomen 
that showed a left sided 5mm non-obstructing kidney stone and 
two likely liver hemangiomas. Labs showed all LFT's within 
normal limits, lipase of 44, HCT of 34.2, u/a with a small 
amount of blood, and was admitted for further work up of her 
abdominal pain.  
.  
On the floor initial VS were: 96.2, 110/80, 88, 18, 99% on RA, 
currently her pain is ___, improved to ___ with morphine. 
Describes the belly pain as diffuse and dull, flank pain is 
sharp.  
.  
Review of systems:  
(+) Per HPI  
(-) Denies fever, chills, night sweats, recent weight loss or 
gain. Denies headache, sinus tenderness, rhinorrhea or 
congestion. Denied cough, shortness of breath. Denied chest pain 
or tightness, palpitations. Denied nausea, vomiting, diarrhea, 
constipation. No recent change in bowel habits. No dysuria. 
Denied arthralgias or myalgias.  

 

###RESPONSE: kidney stones {Kidney stone}, RUQ {Right upper quadrant pain}, flank pain {Flank pain}, distended 
abdomen {Swollen abdomen}, pain {Abdominal pain}, nausea {Nausea}, vomited {Vomiting}, belly ache {Stomach ache}, nausea {Nausea}, emesis {Vomiting}, increase in urinary 
frequency {Increased frequency of urination}, kidney stone {Kidney stone}, pain {Pain}, evaluation {Evaluation procedure}, abdominal pain {Abdominal pain}, kidney stone {Kidney stone}, gallbladder {Gallbladder structure}, noncontrast abdominal CT scan {Computed tomography of abdomen without contrast}, CT scan {Computed tomography of abdomen without contrast}, cyst in her liver {Cyst of liver}, kidney stones {Kidney stone}, left {Left kidney structure}, cyst {Cyst of liver}, pain {Pain}, evaluation {Evaluation procedure}, RA {Breathing room air}, improved {Patient's condition improved}, pain {Pain}, ultrasound of her abdomen {Ultrasonography of abdomen}, left {Left kidney structure}, kidney stone {Kidney stone}, liver hemangiomas {Hemangioma of liver}, LFT's within 
normal limits {Liver function tests within reference range}, u/a {Urinalysis}, abdominal pain {Abdominal pain}, RA {Breathing room air}, pain {Abdominal pain}, improved {Patient's condition improved}, belly pain {Abdominal pain}, diffuse {Diffuse pain}, dull {Dull pain}, flank pain {Flank pain}, sharp {Sharp pain}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, headache {Headache}, sinus {Nasal sinus structure}, tenderness {Tenderness}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, cough {Cough}, shortness of breath {Dyspnea}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, nausea, vomiting {Nausea and vomiting}, diarrhea {Diarrhea}, constipation {Constipation}, change in bowel habits {Altered bowel function}, dysuria {Dysuria}, arthralgias {Joint pain}, myalgias {Muscle pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
(per patient and atrius records)  
Kidney Stones  
Asthma  
Anemia  
Sickle cell trait  
hx hematuria  
endometriosis
Hx Abnormal Pap

 

###RESPONSE: Kidney Stones {Kidney stone}, Asthma {Asthma}, Anemia {Anemia}, Sickle cell trait {Sickle cell trait}, hematuria {Blood in urine}, endometriosis {Endometriosis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother with HTN, DM, RA and interstitial cystitis  
Two maternal aunts with breast cancer  
One paternal aunt with colon cancer  

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, RA {Rheumatoid arthritis}, interstitial cystitis {Chronic interstitial cystitis}, breast cancer {Malignant neoplasm of breast}, colon cancer {Malignant neoplasm of colon}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Vitals: T: 98 BP: 102/68 P: 77 (70-80s) R: 18 O2: 99% on RA  
General: WDWN young AA female, appearing in mild discomfort  
HEENT: NCAT, EOMI, MMM, OP clear  
Neck: supple  
Lungs: Clear to auscultation bilaterally, no wheezes, rales, 
ronchi  
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, 
gallops  
Abdomen: soft, mildly distended, TTP in epigastric region, RUQ 
and RLQ, no rebound tenderness or guarding  
Back: no spinal tenderness, +right CVA tenderness  
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  

 

###RESPONSE: Vitals {Vital signs finding}, BP {Blood pressure finding}, RA {Breathing room air}, General {General examination of patient}, WDWN {Well nourished}, mild {Symptom mild}, discomfort {Discomfort}, HEENT {Physical examination procedure}, NC {Normal head}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, ronchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, distended {Swollen abdomen}, TTP {Tenderness}, epigastric region {Tenderness of epigastrium}, RUQ {Tenderness of right upper quadrant of abdomen}, RLQ {Tenderness of right lower quadrant of abdomen}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, spinal {Structure of vertebral column}, tenderness {Tenderness}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Laboratory Findings
___ 08:33PM BLOOD WBC-5.4# RBC-3.95* Hgb-12.1 Hct-34.2*# 
MCV-87 MCH-30.6 MCHC-35.3* RDW-13.0 Plt ___
___ 08:33PM BLOOD Neuts-48.5* ___ Monos-6.8 
Eos-5.2* Baso-0.5
___ 08:33PM BLOOD Glucose-88 UreaN-10 Creat-0.6 Na-141 
K-3.6 Cl-110* HCO3-23 AnGap-12
___ 08:33PM BLOOD ALT-15 AST-22 AlkPhos-58 TotBili-0.4
___ 08:33PM BLOOD Albumin-4.2
___ 10:05AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.8
___ 06:50AM BLOOD WBC-4.6 RBC-3.84* Hgb-11.9* Hct-33.3* 
MCV-87 MCH-30.9 MCHC-35.7* RDW-12.7 Plt ___
___ 06:50AM BLOOD Glucose-84 UreaN-9 Creat-0.7 Na-139 K-3.7 
Cl-107 HCO3-23 AnGap-13

----------------
Microbiology:
----------------
___ 08:33PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:33PM URINE Blood-SM Nitrite-NEG Protein-NEG 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG
___ 08:33PM URINE ___ Bacteri-MOD Yeast-NONE 
___
URINE CULTURE (Final ___:    <10,000 organisms/ml. (final 
report)

----------------
Imaging
----------------
Abdominal Ultrasound ___:
There is normal echogenicity of the liver. There is no extra- or 

intra-hepatic biliary duct dilatation. There are two hyperechoic 
lesions in the liver with no convincing vascularity, one 
measuring 1.8 x 2.1 x 2 cm and second one measuring 8 x 8 x ___ile duct measures 3 mm. The portal vein is 
patent. The left kidney measures 10.2 cm. There is a 5-mm 
nonobstructing stone in the upper pole of the left kidney. The 
right kidney measures 10 cm. There is no evidence of 
hydronephrosis. There is no free fluid. The spleen is normal 
measuring 7.3 cm. Evaluation of pancreas is slightly suboptimal 
due to overlapping bowel gas; however, no gross abnormality of 
the pancreatic head. Urinary bladder appears within normal 
limits.   
IMPRESSION: 
1. Two hyperechoic liver lesions in the right liver lobe, with 
no convincing vascularity, with imaging characteristics most 
suggestive of liver hemangioma. 
2. 5-mm nonobstructive stone in the upper pole of the left 
kidney. No 
hydronephrosis. 
3. Patent main portal vein. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, liver {Liver structure}, intra-hepatic biliary duct {Intrahepatic biliary tract structure}, dilatation {Dilatation}, lesions {Lesion}, liver {Liver structure}, ile duct {Bile duct structure}, portal vein {Portal vein structure}, left kidney {Left kidney structure}, stone {Calculus}, upper pole of the left kidney {Structure of upper pole of left kidney}, right kidney {Right kidney structure}, no evidence {No abnormality detected}, hydronephrosis {Hydronephrosis}, free fluid {Effusion}, spleen {Splenic structure}, pancreas {Pancreatic structure}, no gross abnormality {No abnormality detected}, pancreatic head {Structure of head of pancreas}, Urinary bladder {Urinary bladder structure}, liver lesions {Lesion of liver}, right liver lobe {Structure of right lobe of liver}, liver hemangioma {Hemangioma of liver}, stone {Calculus}, upper pole of the left 
kidney {Structure of upper pole of left kidney}, hydronephrosis {Hydronephrosis}, portal vein {Portal vein structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
This is a ___ year old female with a history of kidney stones who 
presents with a one week history of right sided crampy abdominal 
pain, found to have a left-sided kidney stone and liver cyst on 
abdominal ultrasound.  

.  
# Abdominal Pain: No clear etiology, but felt to be most likely 
related to passage of a kidney stone on the right.  The patient 
described a crampy abdominal pain located on the right, and had 
right and left CVA tenderness on examination.  She was started 
on tamsulosin given the presence of a 5mm stone on that side.  
However, she experienced dizziness, so this medication was 
stopped.  Additionally, the patient mentioned experiencing a 
painful big toe during a prior episode of passing a kidney 
stone. While she did not pass a stone that could be collected 
for laboratory evaluation, the possibility of hyperuricemia and 
concurrent gout was considered, and the patient was given 
information regarding a low uric acid diet.  Her pain resolved 
spontaneously during the admission, and she was able to tolerate 
a regular diet at discharge.  She was instructed to contact her 
PCP regarding further workup for her kidney stones.
.  
# Liver lesions: Outpatient CT records were obtained, which 
noted growth of a liver lesion ___ 7 mm to 17 mm since ___. 
The report did not specify whether this lesion was consistent 
with a cyst or hemangioma, and suggested MRI for further 
characterization.  An ultrasound during admission identified 
cysts consistent with hemangiomas.  This lesion was felt to be 
unrelated to her current episode of abdominal pain.  The patient 
preferred to undergo MRI as an outpatient, and was instructed to 
contact her PCP regarding scheduling this test on discharge.
.
# Migraine HA: The patient reported a history of migraine 
headaches, for which she had taken fioricet in the past, 
although this had been discontinued by her PCP for unknown 
reasons.  While admitted, she did experience a migraine that was 
partially relieved with acetaminophen and tramadol.  She 
requested a trial of motrin for headaches, and was discharged 
with a prescription for several doses of Motrin 800 mg.  She was 
instructed to discuss this medication further with her PCP if 
effective and she would like to continue.
.
# Asthma: The patient denied any asthmatic symptoms, and was 
continued on her home dose of flovent and albuterol prn.  
  

 

###RESPONSE: kidney stones {Kidney stone}, right sided {Right sided abdominal pain}, crampy {Stomach cramps}, abdominal 
pain {Abdominal pain}, kidney stone {Kidney stone}, liver cyst {Cyst of liver}, abdominal ultrasound {Ultrasonography of abdomen}, Abdominal Pain {Abdominal pain}, kidney stone {Kidney stone}, right {Right kidney structure}, crampy {Stomach cramps}, abdominal pain {Abdominal pain}, right {Structure of right half of abdomen lateral to midsagittal plane}, CVA tenderness {Renal angle tenderness}, stone {Calculus}, dizziness {Dizziness}, painful {Pain in toe}, big toe {Great toe structure}, kidney 
stone {Kidney stone}, stone {Calculus}, hyperuricemia {Hyperuricemia}, gout {Inflammatory disorder due to increased blood urate level}, pain resolved {No present pain}, regular diet {Normal diet}, workup {Evaluation procedure}, kidney stones {Kidney stone}, Liver lesions {Lesion of liver}, CT {Computed tomography of abdomen}, liver lesion {Lesion of liver}, lesion {Lesion}, cyst {Cyst}, hemangioma {Hemangioma}, MRI {Magnetic resonance imaging}, ultrasound {Ultrasonography}, cysts {Cyst}, hemangiomas {Hemangioma}, lesion {Lesion}, abdominal pain {Abdominal pain}, MRI {Magnetic resonance imaging}, Migraine HA {Migraine}, migraine 
headaches {Migraine}, migraine {Migraine}, headaches {Headache}, Asthma {Asthma}, asthmatic {Asthma}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Flovent 2puffs daily  
Albuterol PRN  

 
Discharge Medications:
1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff 
Inhalation DAILY (Daily).  
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 
___  Inhalation every six (6) hours as needed for shortness of 
breath or wheezing.  
3. Motrin 800 mg Tablet Sig: One (1) Tablet PO once a day as 
needed for headache.
Disp:*10 Tablet(s)* Refills:*0*
4. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed for pain, headache.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnoses:
Nephrolithiasis
Liver cysts
Migraine headaches

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Nephrolithiasis {Kidney stone}, Liver cysts {Cyst of liver}, Migraine headaches {Migraine}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,

You were admitted to the hospital for severe abdominal pain.  
You underwent an abdominal ultrasound that showed a cyst in your 
liver and a kidney stone on the left.  We think that you likely 
passed a kidney stone on the right, which caused your pain.  You 
should call your PCP on ___ to discuss scheduling an MRI to 
better evaluate your liver cyst.

We made the following changes to your medications:
-Start Motrin to use for headache for the next several days.  If 
you would like to continue with this medication, please discuss 
it with your PCP.
 

###RESPONSE: abdominal pain {Abdominal pain}, abdominal ultrasound {Ultrasonography of abdomen}, cyst in your 
liver {Cyst of liver}, kidney stone {Kidney stone}, left {Left kidney structure}, kidney stone {Kidney stone}, right {Right kidney structure}, pain {Abdominal pain}, MRI {Magnetic resonance imaging}, liver cyst {Cyst of liver}, headache {Headache}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                      Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: NEUROLOGY
 

###RESPONSE: NEUROLOGY {Neurological examination}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
stroke
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, stroke {Cerebrovascular accident}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms ___ is a lovely ___ yo woman with PMH significant for
Alzheimer dementia, HTN, HLD, and hypothyroid who presents after
subacute stroke was found on out patient MRI. The patient lives
in an assisted living in ___. She started acting ""more
confused"" this past ___ (10 days PTA). Most notable she
walked into several other apartments when she was looking for 
her
own. She went to see his PCP on ___ and was found to have a
positive UA and was started on ___ (started on ___. Over
this weekend she was at a wedding with her daughter and kept
asking for someone to bring her food, while there was an
untouched plate sitting in front of her. on ___ she did the
same with a glass of juice. The patient's daughter asked her PCP
to order an MRI which was done and showed a subacute infarct on
the right.  

On neuro ROS: the pt denies headache, loss of vision, blurred
vision, diplopia, oscilopsia, dysarthria, dysphagia, drop
attacks, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, paresthesias. No bowel
or bladder incontinence or retention. Denies difficulty with
gait. 

On general ROS: the pt denies recent fever or chills. No night
sweats or recent weight loss or gain. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
 

###RESPONSE: Alzheimer dementia {Alzheimer's disease}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, hypothyroid {Hypothyroidism}, stroke {Cerebrovascular accident}, MRI {Magnetic resonance imaging of brain}, confused {Clouded consciousness}, positive {Detected by measurement}, UA {Urine examination}, MRI {Magnetic resonance imaging}, infarct {Infarct}, right {Structure of right half of body}, neuro {Neurological examination}, headache {Headache}, loss of vision {Functional visual loss}, blurred
vision {Blurring of visual image}, diplopia {Diplopia}, oscilopsia {Finding of movement of visual image}, dysarthria {Dysarthria}, dysphagia {Dysphagia}, drop
attacks {Drop attack}, lightheadedness {Lightheadedness}, vertigo {Vertigo}, tinnitus {Tinnitus}, hearing
difficulty {Hearing difficulty}, difficulties producing or comprehending
speech {Difficulty comprehending speech}, weakness {Asthenia}, numbness {Numbness}, paresthesias {Paresthesia}, bowel {Incontinence of feces}, bladder incontinence {Urinary incontinence}, retention {Retention}, difficulty with
gait {Abnormal gait}, general {General examination of patient}, fever {Fever}, chills {Chill}, night
sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, Denies cough {Does not cough}, shortness of
breath {Dyspnea}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, change in bowel {Altered bowel function}, bladder habits {Alteration in patterns of urinary elimination}, dysuria {Dysuria}, arthralgias {Joint pain}, myalgias {Muscle pain}, rash {Eruption of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Dementia 
hypothyroidism 
HTN
HLD 

 

###RESPONSE: Dementia {Dementia}, hypothyroidism {Hypothyroidism}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
non-contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:
T: 97 HR: 84 BP: 158/80 RR: 18 Sat: 99%

GENERAL MEDICAL EXAMINATION:
General appearance: alert, in no apparent distress
HEENT: Neck is supple. Sclera are non-injected. Mucous membranes
are moist. No carotid bruit 
CV: Heart rate is regular
Lungs: Clear to auscultation bilaterally without wheezing or
crackles. 
Abdomen: soft, non-tender
Extremities: No evidence of deformities. No contractures. 
Skin: No visible rashes. Warm and well perfused.

NEUROLOGICAL EXAMINATION:
Mental Status: Awake and alert. oriented to ___ and
___, location was ""a place for head problems"". she was able
to repeat that she was at ___ (where her
daughter works) but could not recall this moments later. She
could also not recall that she was here due to a stroke despite
several explanations. Inattentive with slow DOWB. Language is
fluent and appropriate with intact comprehension, repetition and
naming of both high and low frequency objects. Normal prosody.
There were no paraphasic errors. Speech was not dysarthric. Able
to follow both midline and appendicular commands. No neglect,
left/right confusion or finger agnosia.  No apraxia for salute 
or
brush your teeth. + palomental on left. no grasp. 

Cranial Nerves:
I: not tested
II: dense homonymous hemianopsia on left. could not visualize
fundi. 
III-IV-VI: pupils equally round, reactive to light - small. 
Eyes were eso deviated. With both eyes open left eye did not
cross midline to the left. when tested separately EOMI. could 
not
test saccads as patient had difficulty finding objects in space.
she denies diplopia. 
V: Symmetric perception of LT in V1-3 
VII: Face is symmetric at rest and with activation; symmetric
speed and excursion with smile.
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug and head rotation ___ bl 
XII: No tongue deviation or fasciculations

Pt only describes the R side of the stroke cards. She lists
details in the scene (drawers, water, dish) but can not describe
the whole image at all. She seem to do the same when asked to
look at my face (eyes, neck, mouth, nose...) but does not seem 
to
see my face. she has trouble locating objects in space both by
sight and sound, event when placed in her good field. 

Motor: Normal muscle bulk and tone throughout. No pronator drift
or rebound
Strength:
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L  5    ___   ___  5   5    5  5     5     5   5
R  5    ___   ___  5   5    5  5     5     5   5

Reflexes:
  Bi Tri ___ Pat Ach
L  2  2    2    2   1
R  2  2    2    2   1
Toes are down going bilaterally.

Sensory: normal and symmetric perception of pinprick, light
touch, vibration and temperature. Proprioception is intact. No
agraphesthesia or astereognosis. No extinction to DSS.

Coordination: Finger to nose without dysmetria bilaterally. No
intention tremor. RAM were symmetric with regard to cadence and
speed, no dysdiadochokinesia noted.

Gait: not tested. 
========================================================
DISCHARGE PHYSICAL EXAM:
NEUROLOGICAL EXAMINATION:
Mental Status: Awake and alert. Very hard of hearing. She cannot 
say why she is in the hospital. Language is fluent and 
appropriate with intact comprehension, repetition and naming of 
both high and low frequency objects. Normal prosody. There were 
no paraphasic errors. Speech was not dysarthric. Able to follow 
both midline and appendicular commands. Left sided neglect.  

Cranial Nerves:
I: not tested
II: dense homonymous hemianopsia on left. could not visualize
fundi. 
III-IV-VI: pupils equally round, reactive to light, EOMI. 
V: Symmetric perception of LT in V1-3 
VII: Face is symmetric at rest and with activation; symmetric
speed and excursion with smile.
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug and head rotation ___ bl 
XII: No tongue deviation or fasciculations

Motor: Normal muscle bulk and tone throughout. No pronator drift
or rebound
Strength:
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L  5    ___   ___  5   5    5  5     5     5   5
R  5    ___   ___  5   5    5  5     5     5   5

Reflexes:
  Bi Tri ___ Pat Ach
L  2  2    2    2   1
R  2  2    2    2   1
Toes are down going bilaterally.

Sensory: normal and symmetric perception of pinprick, light
touch, vibration and temperature. Proprioception is intact. No
agraphesthesia or astereognosis. No extinction to DSS.

Coordination: Finger to nose without dysmetria bilaterally. 

Gait: not tested. 

 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, T {Body temperature finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, Sat {Finding of oxygen saturation}, General {General examination of patient}, appearance {Finding of general observation of appearance}, alert {Mentally alert}, distress {Distress}, HEENT {Physical examination procedure}, Neck {Neck structure}, supple {Normal movement of neck}, Sclera {Scleral structure}, Mucous membranes
are moist {Moist oral mucosa}, carotid bruit {Carotid bruit}, CV {Cardiovascular physical examination}, Heart rate is regular {Normal heart rate}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezing {Wheezing}, crackles {Respiratory crackles}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, Extremities {Examination of limb}, No evidence {No abnormality detected}, deformities {Deformity}, contractures {Contracture}, Skin {Examination of skin}, rashes {Eruption of skin}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, Mental Status {Neurological mental status determination}, Awake {Awake}, alert {Mentally alert}, oriented {Orientated}, head {Head structure}, problems {Problem}, stroke {Cerebrovascular accident}, fluent {Does speak fluently}, intact {Normal sensation}, comprehension {Does comprehend language}, repetition {Verbal repetition}, naming of both high and low frequency objects {Able to recognize objects}, Normal prosody {Able to use prosody in speech}, paraphasic {Paraphasia}, Speech {Speech finding}, dysarthric {Dysarthria}, neglect {Hemi-neglect}, left/right confusion {Right-left disorientation}, finger agnosia {Finger agnosia}, apraxia {Apraxia}, II {Optic nerve structure}, homonymous hemianopsia on left {Left homonymous hemianopsia}, could not visualize
fundi {Inadequate visualization of fundus of eye}, III {Oculomotor nerve structure}, IV {Trochlear nerve structure}, VI {Abducens nerve structure}, pupils equally round {Pupil size and shape normal}, reactive to light {Finding of pupil reaction to light}, small {Constricted pupil}, Eyes were eso deviated {Esotropia}, both eyes {Structure of both eyes}, left eye {Left eye structure}, EOMI {Normal ocular motility}, test saccads {Saccadic velocity test}, difficulty finding objects in space {Cognitive deficit in visuospatial function}, diplopia {Diplopia}, V {Trigeminal nerve structure}, Symmetric {Facial symmetry}, perception {Psychological finding of perception}, VII {Facial nerve structure}, Face {Face structure}, symmetric {Facial symmetry}, symmetric {Facial symmetry}, smile {Smiles}, VIII {Vestibulocochlear nerve structure}, Hearing intact {Hearing normal}, finger rub bl {Hearing examination}, IX {Glossopharyngeal nerve structure}, X {Vagus nerve structure}, Palate elevates {Does elevate soft palate}, XI {Accessory nerve structure}, Shoulder {Shoulder region structure}, head {Head structure}, XII {Hypoglossal nerve structure}, tongue {Tongue structure}, deviation {Displacement}, fasciculations {Fasciculation of tongue}, stroke {Cerebrovascular accident}, cards {Cardiology service}, trouble locating objects in space {Cognitive deficit in visuospatial function}, Motor {Motor testing}, Normal muscle bulk {Skeletal muscle size normal}, tone {Normal tone in skeletal muscle}, pronator drift {Downward drift of outstretched supinated arm}, rebound {Rebound tenderness}, Delt {Structure of deltoid muscle}, Bic {Biceps brachii muscle structure}, Tri {Triceps brachii muscle structure}, WrE {Structure of extensor of wrist joint}, FFl {Structure of flexor digitorum superficialis muscle of hand}, FE {Structure of extensor of interphalangeal joint of finger}, IO {Inferior oblique muscle structure}, IP {Interphalangeal joint structure}, Quad {Structure of quadriceps femoris muscle}, Ham {Posterior muscle of thigh structure}, TA {Tibialis anterior muscle structure}, Bi {Biceps brachii muscle structure}, Tri {Triceps brachii muscle structure}, Toes {Structure of all toes}, Sensory {Sensory testing}, normal {No abnormality detected}, symmetric {Facial symmetry}, perception {Psychological finding of perception}, pinprick {Normal pin prick discrimination}, light
touch {Light touch sensation present}, vibration {Finding of vibration sense}, temperature {Finding of temperature sense}, Proprioception is intact {Normal joint position sense}, agraphesthesia {Graphesthesia finding}, astereognosis {Tactile agnosia}, Coordination {Finding related to coordination / incoordination}, Finger to nose {Finger-to-nose test}, dysmetria {Dysmetria}, intention tremor {Intention tremor}, dysdiadochokinesia {Dysdiadochokinesis}, Gait {Gait normal}, NEUROLOGICAL EXAMINATION {Neurological examination}, Mental Status {Neurological mental status determination}, Awake {Awake}, alert {Mentally alert}, hard of hearing {Hearing loss}, fluent {Does speak fluently}, intact {Normal sensation}, comprehension {Able to comprehend language}, repetition {Verbal repetition}, naming of 
both high and low frequency objects {Able to recognize objects}, Normal {No abnormality detected}, prosody {Able to use prosody in speech}, paraphasic {Paraphasia}, Speech {Speech finding}, dysarthric {Dysarthria}, Left sided neglect {Hemi-neglect}, Cranial Nerves {Cranial nerve structure}, I {Olfactory nerve structure}, II {Optic nerve structure}, homonymous hemianopsia on left {Left homonymous hemianopsia}, could not visualize
fundi {Inadequate visualization of fundus of eye}, III {Oculomotor nerve structure}, IV {Trochlear nerve structure}, VI {Abducens nerve structure}, pupils equally round {Pupil size and shape normal}, reactive to light {Finding of pupil reaction to light}, EOMI {Normal ocular motility}, V {Trigeminal nerve structure}, Symmetric {Facial symmetry}, perception {Psychological finding of perception}, VII {Facial nerve structure}, Face {Face structure}, symmetric {Facial symmetry}, symmetric {Facial symmetry}, smile {Smiles}, VIII {Vestibulocochlear nerve structure}, Hearing intact {Hearing normal}, finger rub bl {Hearing examination}, IX {Glossopharyngeal nerve structure}, X {Vagus nerve structure}, Palate elevates {Does elevate soft palate}, XI {Accessory nerve structure}, Shoulder {Structure of right shoulder region}, head {Head structure}, XII {Hypoglossal nerve structure}, tongue {Tongue structure}, deviation {Displacement}, fasciculations {Fasciculation of tongue}, Motor {Motor testing}, Normal muscle bulk {Skeletal muscle size normal}, tone {Normal tone in skeletal muscle}, pronator drift {Downward drift of outstretched supinated arm}, rebound {Rebound tenderness}, Strength {Examination of muscle power}, Delt {Structure of deltoid muscle}, Bic {Biceps brachii muscle structure}, Tri {Triceps brachii muscle structure}, WrE {Structure of extensor of wrist joint}, FFl {Structure of flexor digitorum superficialis muscle of hand}, FE {Structure of extensor of interphalangeal joint of finger}, IO {Inferior oblique muscle structure}, IP {Interphalangeal joint structure}, Quad {Structure of quadriceps femoris muscle}, Ham {Posterior muscle of thigh structure}, TA {Tibialis anterior muscle structure}, Reflexes {Reflex finding}, Bi {Biceps brachii muscle structure}, Tri {Triceps brachii muscle structure}, Toes {Structure of all toes}, Sensory {Sensory testing}, normal {No abnormality detected}, symmetric {Facial symmetry}, perception {Psychological finding of perception}, pinprick {Normal pin prick discrimination}, light
touch {Light touch sensation present}, vibration {Finding of vibration sense}, temperature {Finding of temperature sense}, Proprioception is intact {Normal joint position sense}, agraphesthesia {Graphesthesia finding}, astereognosis {Tactile agnosia}, Coordination {Finding related to coordination / incoordination}, Finger to nose {Finger-to-nose test}, dysmetria {Dysmetria}, Gait {Gait normal}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 07:00PM BLOOD WBC-5.7 RBC-4.37 Hgb-12.6 Hct-40.2 MCV-92 
MCH-28.8 MCHC-31.3* RDW-13.6 RDWSD-46.2 Plt ___
___ 07:00PM BLOOD Neuts-58.6 ___ Monos-10.2 Eos-3.0 
Baso-0.5 Im ___ AbsNeut-3.32 AbsLymp-1.55 AbsMono-0.58 
AbsEos-0.17 AbsBaso-0.03
___ 07:00PM BLOOD ___ PTT-32.0 ___
___ 07:00PM BLOOD Glucose-93 UreaN-22* Creat-1.0 Na-141 
K-5.4* Cl-104 HCO3-26 AnGap-16
___ 12:53PM BLOOD ALT-9 AST-16 AlkPhos-68 TotBili-1.0
___ 12:53PM BLOOD Albumin-4.4 Calcium-10.0 Phos-3.6 Mg-2.4
___ 12:53PM BLOOD %HbA1c-5.9 eAG-123
___ 12:53PM BLOOD TSH-3.6

IMAGING:
MRI BRAIN ___:
1.  Moderate-sized acute infarction involving the right 
parietotemporal 
region, with associated small internal microhemorrhages. 
2.  Additional findings of moderate global cerebral atrophy and 
small vessel ischemic disease. 
3.  A punctate susceptibility focus of the left occipital 
parietal lobe, which may represent prior microhemorrhage. 

CTA HEAD AND NECK ___ (PRELIM):
NCHCT: Hypodensity in the right temporoparietal lobe corresponds 
to the areas of restricted diffusion on the patients recent MRI, 
consistent with patients known infarction. 
  
CTA: No definite vascular abnormalities identified in the region 
of the known infarction in the right temporoparietal region. No 
aneurysms identified. 

TTE ___:
The left atrium is normal in size. No left atrial mass/thrombus 
seen (best excluded by transesophageal echocardiography). There 
is mild symmetric left ventricular hypertrophy with normal 
cavity size and regional/global systolic function (LVEF>55%). 
Diastolic function could not be assessed. Right ventricular 
chamber size and free wall motion are normal. The aortic valve 
leaflets (3) are mildly thickened but aortic stenosis is not 
present. Mild (1+) aortic regurgitation is seen. The mitral 
valve leaflets are mildly thickened. The estimated pulmonary 
artery systolic pressure is normal. There is no pericardial 
effusion. 

IMPRESSION: Suboptimal image quality. No cardiac source of 
embolism identified. Mild symmetric left ventricular hypertrophy 
with preserved regional/global systolic function. Mild aortic 
regurgitation.  

DISCHARGE LABS:
___ 12:53PM BLOOD WBC-6.2 RBC-4.63 Hgb-13.4 Hct-42.3 MCV-91 
MCH-28.9 MCHC-31.7* RDW-13.6 RDWSD-45.4 Plt ___
___ 12:53PM BLOOD ___ PTT-33.9 ___
___ 12:53PM BLOOD Glucose-73 UreaN-18 Creat-1.1 Na-142 
K-4.4 Cl-103 HCO3-26 AnGap-17
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, eAG {Glucose measurement estimated from glycated hemoglobin}, TSH {Thyroid stimulating hormone measurement}, MRI BRAIN {Magnetic resonance imaging of brain}, Moderate {Symptom moderate}, infarction {Infarct}, right 
parietotemporal 
region {Right temporal and parietal lobes (combined site)}, small internal microhemorrhages {Silent micro-hemorrhage of brain}, moderate {Symptom moderate}, cerebral atrophy {Cerebral atrophy}, small vessel {Structure of small blood vessel (organ)}, ischemic disease {Ischemia}, left occipital 
parietal lobe {Left parietal and occipital lobes (combined site)}, NCHCT {Computed tomography of head without contrast}, Hypodensity {Decreased radiologic density}, right temporoparietal lobe {Right temporal and parietal lobes (combined site)}, MRI {Magnetic resonance imaging of brain}, infarction {Infarct}, CTA {Computed tomography angiography of head with contrast}, vascular {Blood vessel structure}, abnormalities {No abnormality detected}, infarction {Infarct}, right temporoparietal region {Right temporal and parietal lobes (combined site)}, aneurysms {Aneurysm}, left atrium {Left atrial structure}, normal in size {Normal size}, left atrial {Left atrial structure}, mass {Mass}, thrombus {Thrombus}, transesophageal echocardiography {Transesophageal echocardiography}, mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, normal 
cavity {Normal size cardiac chamber}, regional/global systolic function {Normal left ventricular systolic function and wall motion}, Right ventricular 
chamber {Right cardiac ventricular structure}, wall motion are normal {Normal ventricular wall motion}, aortic valve 
leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, Mild (1+) aortic regurgitation {Mild mitral valve regurgitation}, mitral 
valve leaflets are mildly thickened {Thickened mitral leaflet}, pulmonary 
artery {Pulmonary artery structure}, systolic pressure is normal {Normal systolic arterial pressure}, pericardial 
effusion {Pericardial effusion}, cardiac {Heart structure}, embolism {Embolism}, Mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, regional/global systolic function {Normal left ventricular systolic function and wall motion}, aortic 
regurgitation {Aortic valve regurgitation}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Ms ___ is an ___ yo woman with PMH significant for Alzheimer 
dementia, HTN, HLD, and hypothyroidism who presented with left 
sided neglect with acute right temporoparietal infarct. 

# Right temporoparietal infarct: Patient presented with left 
sided neglect and possible left sided field cut. She was placed 
on aspirin 325mg and atorvastatin 40mg and MRI confirmed acute 
infarction involving the right parietotemporal 
region, with associated small internal microhemorrhages. CTA was 
unremarkable. She was monitored on telemetry but there were no 
episodes of atrial fibrillation to account for stroke. HbA1C and 
lipid panel were within normal limits. TTE did not show any 
evidence of left atrial thrombus or PFO. Given her age and 
mental status, it was decided not to pursue long term cardiac 
monitoring for evaluation of atrial fibrillation. Patient had 
difficulty tolerating telemetry monitors while hospitalized and 
it would not change management as the team decided they would 
not start anti-coagulation in this patient even if atrial 
fibrillation was found. She will continue on aspirin as an 
outpatient and follow-up with stroke neurology as ab outpatient. 
  

# UTI: Patient was found to have a UTI on admission and treated 
with 3 days of Ciprofloxacin HCl 250 mg PO/NG Q12H.  

# Hypothyroidism: She was continued on Levothyroxine Sodium 75 
mcg PO/NG DAILY. 

# HTN: She was continued on Lisinopril 5 mg PO/NG DAILY.  

Transitional issues: 
-continue on aspirin 81mg 
-HCP: ___ (daughter) ___ 
-currently Full code, continue to address goals of care
 

###RESPONSE: Alzheimer 
dementia {Alzheimer's disease}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, hypothyroidism {Hypothyroidism}, left 
sided neglect {Hemi-neglect}, right temporoparietal {Right temporal and parietal lobes (combined site)}, infarct {Infarct}, Right temporoparietal {Right temporal and parietal lobes (combined site)}, infarct {Infarct}, left 
sided neglect {Hemi-neglect}, left sided field cut {Visual field defect of left eye}, aspirin {Administration of aspirin}, MRI {Magnetic resonance imaging of brain}, infarction {Infarct}, right parietotemporal 
region {Right temporal and parietal lobes (combined site)}, small internal microhemorrhages {Silent micro-hemorrhage of brain}, CTA {Computed tomography angiography with contrast}, unremarkable {No abnormality detected}, monitored {Monitoring procedure}, telemetry {Electroencephalogram telemetry}, atrial fibrillation {Atrial fibrillation}, stroke {Cerebrovascular accident}, within normal limits {Measurement finding within reference range}, TTE {Transthoracic echocardiography}, left atrial thrombus {Thrombus of left atrium}, PFO {Patent foramen ovale}, mental status {Altered mental status}, cardiac 
monitoring {Cardiac monitoring}, evaluation {Evaluation procedure}, atrial fibrillation {Atrial fibrillation}, telemetry monitors {Telehealth monitoring}, anti-coagulation {Anticoagulant therapy}, atrial 
fibrillation {Atrial fibrillation}, stroke {Cerebrovascular accident}, neurology {Neurological examination}, UTI {Urinary tract infectious disease}, UTI {Urinary tract infectious disease}, Hypothyroidism {Hypothyroidism}, HTN {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY 
2. melatonin 3 mg oral QHS:PRN insomnia 
3. Levothyroxine Sodium 75 mcg PO DAILY 
4. Lisinopril 5 mg PO DAILY 
5. Lovastatin 40 mg oral QHS 

 
Discharge Medications:
1. Levothyroxine Sodium 75 mcg PO DAILY 
2. Lisinopril 5 mg PO DAILY 
3. melatonin 3 mg oral QHS:PRN insomnia 
4. Lovastatin 40 mg ORAL QHS 
5. Aspirin 325 mg PO DAILY 

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
___ Diagnosis:
Primary diagnosis:
Right parietotemporal stroke

Secondary diagnosis:
Urinary Tract Infection

 
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: Right parietotemporal {Right temporal and parietal lobes (combined site)}, stroke {Cerebrovascular accident}, Urinary Tract Infection {Urinary tract infectious disease}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___, 

You were admitted to ___ with a stroke. Your heart rhythm was 
monitored but there was no evidence of an abnormal rhythm 
causing the stroke. You did not have any evidence of clot in 
your heart on ultrasound so the cause of your stroke remains 
unclear. You should continue to take aspirin and you will 
follow-up with neurology at the appointments scheduled below. 

It was a pleasure taking care of you, 
Your ___ Neurologists
 

###RESPONSE: stroke {Cerebrovascular accident}, heart rhythm {Finding of heart rhythm}, no evidence {No abnormality detected}, abnormal rhythm {Cardiac arrhythmia}, stroke {Cerebrovascular accident}, clot {Blood clot}, heart {Heart structure}, ultrasound {Ultrasonography}, stroke {Cerebrovascular accident}, follow-up with neurology {Follow-up neurological assessment}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___              Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
chest pain
 
Major Surgical or Invasive Procedure:
cardiac catheterization
 

###RESPONSE: chest pain {Chest pain}, cardiac catheterization {Cardiac catheterization}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mr. ___ is a ___ with h/o diabetes, HTN, HLD, DM who 
presented to OSH for chest pain and was transferred for trop 
elevation .08.

Mr. ___ in normal state of health until 1 week prior to 
presentation when he started experiencing recurrent episodes of 
chest pain.  Pain is typically on the left side of his chest and 
sometimes radiates to his neck, left arm and back. Described as 
a tightness or squeezing. Pain sometimes goes away after ___
minutes but most recently has been persistent for ___ hours. He 
endorses significant fatigue over the past week as well, night 
sweats for the past 2 days, prominent cough of 7 days' duration 
and loose stools for the past ___ days.  He endorses one episode 
of nausea/emesis on ___. Denies diaphoresis.  He has not been 
very active over the past week though notes no relation to
exertion. 2 weeks ago he was able to play hockey as he often 
does with no issue. Also with some DOE.  Reports if was cutting 
the lawn would have to take breaks. 

He presented to ___, where he was found to have elevated 
trop at 0.08. Otherwise, labs were unremarkable and chest X-ray 
showed no abnormality. He had CTA chest that showed no PE and no 
dissection. He was treated with aspirin (325) and was 
transferred for consideration for cath.

In the ED here, he had stable vital signs. His troponin here was 
negative. EKG showed normal sinus rhythm at 66bpm, normal axis 
and intervals, early R wave progression, without any ST 
elevations/depressions, T wave inversions, or Q waves. He was 
given sublingual nitro with no resolution of symptoms. He was
also given 12.5mg metoprolol tartrate, atorvastatin 80mg, and 
started on a heparin gtt.
 
On arrival to the cardiology ward, patient corroborates the 
above history.  He currently is experiencing ___ chest pain and 
notes no relief of his last dose of sublingual nitrogen.  He is 
no longer having sweats or shortness of breath but it does 
endorse increased frequency of stool. 
 
 

###RESPONSE: diabetes {Diabetes mellitus}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, chest pain {Chest pain}, trop {Troponin measurement}, elevation {Measurement finding above reference range}, recurrent {Recurrent disease}, chest pain {Chest pain}, Pain {Pain}, left side of his chest {Structure of left half of chest wall}, radiates {Radiating pain}, neck {Pain radiating to neck}, left arm {Pain radiating to left arm}, tightness {Tight chest}, squeezing {Squeezing chest pain}, Pain {Pain}, fatigue {Fatigue}, night 
sweats {Night sweats}, cough {Cough}, loose stools {Loose stool}, nausea {Nausea}, emesis {Vomiting}, diaphoresis {Excessive sweating}, not been 
very active {Physical deconditioning}, exertion {Finding related to exertion}, play hockey {Physically active}, DOE {Dyspnea on exertion}, elevated 
trop {Troponin I above reference range}, labs {Laboratory test}, unremarkable {No abnormality detected}, chest X-ray {Plain chest X-ray}, no abnormality {Imaging result normal}, CTA chest {Computed tomography angiography of chest with contrast}, PE {Pulmonary embolism}, dissection {Dissection of aorta}, aspirin {Administration of aspirin}, cath {Cardiac catheterization}, stable vital signs {Normal vital signs}, troponin {Troponin measurement}, negative {No pathologic diagnosis}, EKG {Electrocardiographic procedure}, normal sinus rhythm {Electrocardiogram: normal sinus rhythm}, normal {Electrocardiogram normal}, axis {Electrocardiographic axis finding}, intervals {Finding of electrocardiogram waveform}, R wave progression {Electrocardiographic R wave abnormal}, ST 
elevations {ST segment elevation}, depressions {ST segment depression}, T wave inversions {Inverted T wave}, Q waves {Finding of electrocardiogram Q wave}, no resolution of symptoms {Symptom not changed}, started {New medication added}, cardiology {Cardiology service}, chest pain {Chest pain}, relief {Pain relief}, last dose {Evaluation of response to medications}, sweats {Sweating}, shortness of breath {Dyspnea}, increased frequency of stool {Increased frequency of defecation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1. CARDIAC RISK FACTORS  
- Diabetes  
- Hypertension  
- Dyslipidemia  
2. CARDIAC HISTORY  
- CAD - mid 50% LAD - no intervention 
3. OTHER PAST MEDICAL HISTORY
- Appendectomy
- Diverticulitis
 
 

###RESPONSE: CARDIAC RISK FACTORS {Assessment for risk of cardiovascular disease}, Diabetes {Diabetes mellitus}, Hypertension {Hypertensive disorder, systemic arterial}, Dyslipidemia {Dyslipidemia}, CAD {Coronary arteriosclerosis}, LAD {Structure of anterior descending branch of left coronary artery}, Appendectomy {Excision of appendix}, Diverticulitis {Diverticulitis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
FatherAliveHad an ' irrgeular heart rate and had ICD or
pacemaker placed'
MotherAliveNo Significant Medical History
SisterAliveNo Significant Medical History
 

###RESPONSE: irrgeular heart rate {Pulse irregular}, ICD {Implantation of automatic cardiac defibrillator}, pacemaker placed {Implantation of cardiac pacemaker}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAMINATION:  
=====================  
VS: Temp 98.0 BP 139 / 87 HR 68 RR 17SaO2 96%Ra
GENERAL: NAD, well appearin man in NAD. Ruddy complexion
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs. JVD < 10 cm at 90 
degrees
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably 
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no 
rebound/guarding, no hepatosplenomegaly
EXTREMITIES:trace edema b/l, at baseline per patient
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face 
symmetric
DERM: warm and well perfused, no excoriations or lesions, no 
rashes

Discharge Exam: 
GENERAL: NAD, well appearing man in NAD. Ruddy complexion
HEENT: AT/NC, anicteric sclera
NECK: supple, no LAD, no elevated JVD
CV: RRR, S1/S2, no murmurs, gallops, or rubs. 
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably 
without use of accessory muscles
GI: abdomen soft, nondistended, nontender, no hepatosplenomegaly
EXTREMITIES: no edema b/l, right arm with dressing over cath 
site without strike through, bruit, and with perfusion of distal 
extremities, no evidence hematoma 
Neuro: sensation to light touch in right hand, strength ___ in 
B/l hands, movement of bilateral fingers with intention. 
 

###RESPONSE: PHYSICAL EXAMINATION {Physical examination procedure}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, GENERAL {General examination of patient}, NAD {No abnormality detected}, well appearin {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, anicteric sclera {White sclera}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, JVD {Jugular venous engorgement}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, breathing comfortably {Breathing easily}, accessory muscles {Accessory skeletal muscle}, GI {Examination of digestive system}, soft {Abdomen soft}, nondistended {Normal abdominal contour}, nontender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, hepatosplenomegaly {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, edema {Edema}, baseline {Baseline state}, radial pulses {Radial pulse present}, NEURO {Neurological examination}, Alert {Mentally alert}, moving all 4 extremities {Does move all four limbs}, face 
symmetric {Facial symmetry}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Lesion}, rashes {Eruption of skin}, GENERAL {General examination of patient}, NAD {No abnormality detected}, well appearing {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, anicteric sclera {White sclera}, NECK {Physical examination procedure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, breathing comfortably {Breathing easily}, accessory muscles {Accessory skeletal muscle}, GI {Examination of digestive system}, soft {Abdomen soft}, nondistended {Normal abdominal contour}, nontender {Abdominal tenderness}, hepatosplenomegaly {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, edema {Edema}, right arm {Structure of right upper limb}, cath 
site {Vascular catheter insertion site}, bruit {Bruit}, perfusion {Normal tissue perfusion}, distal 
extremities {Structure of distal lower limb artery}, no evidence {No abnormality detected}, hematoma {Hematoma}, Neuro {Neurological examination}, sensation to light touch {Light touch sensation present}, right hand {Structure of right hand}, B/l hands {Both hands}, bilateral {Both hands}, fingers {Finger structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION
___ 11:20PM   WBC-5.6 RBC-4.45* HGB-14.8 HCT-41.5 MCV-93 
MCH-33.3* MCHC-35.7 RDW-12.1 RDWSD-41.4
___ 11:20PM   NEUTS-41.7 ___ MONOS-11.2 EOS-1.8 
BASOS-1.1* AbsNeut-2.35 AbsLymp-2.49 AbsMono-0.63 AbsEos-0.10 
AbsBaso-0.06
___ 11:20PM   ___ PTT-27.1 ___
___ 11:20PM   GLUCOSE-98 UREA N-12 CREAT-1.0 SODIUM-139 
POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-21* ANION GAP-15
___ 11:20PM   ALT(SGPT)-42* AST(SGOT)-34 CK(CPK)-72 ALK 
PHOS-63 TOT BILI-0.5
___ 11:20PM   LIPASE-44
___ 11:20PM   cTropnT-<0.01
___ 11:20PM   CK-MB-<1
___ 11:20PM   ALBUMIN-3.9
___ 10:45PM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 10:45PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR* 
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 
LEUK-NEG
___ 10:45PM URINE  RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE 
EPI-<1
 
PERTINENT STUDIES:
___ CATH
Coronary Anatomy
Right dominant
LM: No disease.
LAD: Focal 50% eccentric stenosis in mid vessel.
LCx: No significant disease.
RCA: No significant disease.
 
Impressions:
Intermediate mid LAD disease.
 
Recommendations
Med Rx. If patient has persistent angina or evidence of 
ischemia, could do mid LAD PCI in future.

Discharge Labs: 

___ 06:33AM BLOOD WBC-6.6 RBC-4.86 Hgb-15.7 Hct-45.6 MCV-94 
MCH-32.3* MCHC-34.4 RDW-12.1 RDWSD-42.3 Plt ___
___ 06:33AM BLOOD Plt ___
___ 06:33AM BLOOD Glucose-123* UreaN-15 Creat-1.1 Na-141 
K-4.8 Cl-102 HCO3-28 AnGap-11
___ 06:33AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.___ year old man with PMHx DM2, HTN, HLD, who presented with 
chest pain at rest and found to have NSTEMI with moderate 
coronary artery disease on cardiac catheterization, not thought 
to be contributing to chest pain and no intervention was done. 
Patient was started on aspirin, high dose atorvastatin and PRN 
sublingual nitroglycerin and discharged with Cardiology follow 
up.

Active Issues
# NSTEMI:
Presented with chest pain at rest concern for unstable angina. 
Etiology unclear as underwent coronary angiogram and had only 
moderate 50% mid LAD disease not thought to be responsible for 
his chest pain. Patient started on ___, high dose statin and 
PRN SL NTG and discharged with Cardiology follow up.
 
Chronic Issues
# HTN: continued home felodipine
# HLD: increased atorvastatin
# Depression: continued home citalopram
# Anxiety: continued home lorazepam
 
Transitional Issues:
[ ] new diagnosis of CAD: started on ASA 81, high dose 
atorvastatin, PRN SL NTG
[ ] please obtain TTE as outpatient

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PTT {Partial thromboplastin time, activated}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, CK(CPK {Creatine kinase measurement}, ALK 
PHOS {Alkaline phosphatase measurement}, TOT BILI {Bilirubin, total measurement}, LIPASE {Triacylglycerol lipase measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, ALBUMIN {Albumin measurement}, COLOR {Color finding}, APPEAR-Clear {Urine looks clear}, NEG {No abnormality detected}, PROTEIN {Measurement of protein in urine}, GLUCOSE-NEG {Urine glucose not detected}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, NEG {No abnormality detected}, UROBILNGN {Urobilinogen measurement, urine}, NEG {No abnormality detected}, PH {pH measurement}, LEUK-NEG {Urine leukocytes not detected}, URINE {Evaluation of urine specimen}, RBC {Red blood cell count}, WBC {White blood cell count}, AST {Aspartate aminotransferase measurement}, CATH {Cardiac catheterization}, Coronary Anatomy {Coronary artery finding}, Right dominant {Right dominant coronary system}, No disease {No abnormality detected}, LAD {Structure of anterior descending branch of left coronary artery}, stenosis {Stenosis of mid portion of anterior descending branch of left coronary artery}, mid vessel {Structure of mid portion of anterior descending branch of left coronary artery}, No significant disease {No abnormality detected}, RCA {Right coronary artery structure}, No significant disease {No abnormality detected}, mid LAD disease {Stenosis of mid portion of anterior descending branch of left coronary artery}, angina {Angina}, ischemia {Ischemia}, mid LAD {Structure of mid portion of anterior descending branch of left coronary artery}, PCI {Percutaneous coronary intervention}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, DM2 {Diabetes mellitus type 2}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, chest pain at rest {Chest pain at rest}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, moderate {Symptom moderate}, coronary artery disease {Coronary arteriosclerosis}, cardiac catheterization {Cardiac catheterization}, chest pain {Chest pain}, started {New medication added}, aspirin {Administration of aspirin}, nitroglycerin {Administration of prophylactic glyceryl trinitrate}, Cardiology {Cardiology service}, follow 
up {Follow-up arranged}, chest pain at rest {Chest pain at rest}, unstable angina {Preinfarction syndrome}, coronary angiogram {Angiography of coronary artery}, mid LAD disease {Stenosis of mid portion of anterior descending branch of left coronary artery}, chest pain {Chest pain}, started {New medication added}, NTG {Administration of prophylactic glyceryl trinitrate}, Cardiology {Cardiology service}, follow up {Follow-up arranged}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, increased {Increasing dosage of medication}, Depression {Depressive disorder}, Anxiety {Anxiety}, CAD {Coronary arteriosclerosis}, started {New medication added}, ASA {Administration of aspirin}, NTG {Administration of prophylactic glyceryl trinitrate}, TTE {Transthoracic echocardiography}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 
2. Citalopram 20 mg PO DAILY 
3. Atorvastatin 40 mg PO QPM 
4. Zolpidem Tartrate 10 mg PO QHS:PRN Insomnia 
5. LORazepam 1 mg PO BID:PRN Anxiety 
6. Felodipine 10 mg PO DAILY 

 
Discharge Medications:
1.  Aspirin 81 mg PO DAILY  
2.  Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually Q5minutes Disp 
#*25 Tablet Refills:*0 
3.  Atorvastatin 80 mg PO QPM  
4.  Citalopram 20 mg PO DAILY  
5.  Felodipine 10 mg PO DAILY  
6.  LORazepam 1 mg PO BID:PRN Anxiety  
7.  MetFORMIN XR (Glucophage XR) 500 mg PO DAILY  
8.  Zolpidem Tartrate 10 mg PO QHS:PRN Insomnia  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
# Coronary artery disease
# Non-ST elevation myocardial infarction

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 

###RESPONSE: Coronary artery disease {Coronary arteriosclerosis}, Non-ST elevation myocardial infarction {Acute non-ST segment elevation myocardial infarction}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___,  
 
It was a pleasure taking care of you at the ___ 
___!  
 
WHY WAS I IN THE HOSPITAL?  
==========================  
- You were admitted because you had chest pain
 
WHAT HAPPENED IN THE HOSPITAL?  
==============================  
- You were admitted to the hospital because you had chest pain. 
You were found to have had a heart attack. Your heart arteries 
were examined (cardiac catheterization) which showed a blockage 
of one of the arteries. This blockage was not enough to limit 
the flow in your artery and was not thought to be the reason for 
your pain.
- We increased your home medications to take the stress off the 
heart
  
WHAT SHOULD I DO WHEN I GO HOME?  
================================  
- Please take your medications as prescribed
- Please follow up with your primary care doctor
- Please return to hospital if you have chest pain that does not 
go away or gets worse when you are being active.

Thank you for allowing us to be involved in your care, we wish 
you all the best!  
 
Your ___ Healthcare Team  
 

 

###RESPONSE: chest pain {Chest pain}, chest pain {Chest pain}, heart attack {Myocardial infarction}, heart arteries {Coronary artery structure}, cardiac catheterization {Cardiac catheterization}, blockage {Coronary artery stenosis}, arteries {Coronary artery structure}, blockage {Coronary artery stenosis}, artery {Structure of intracranial artery}, pain {Pain}, increased {Increased pain}, medications {Administration of drug or medicament}, heart {Heart structure}, take your medications as prescribed {Recommendation to continue with drug treatment}, follow up {Follow-up arranged}, primary care {Primary care management}, chest pain {Chest pain}, worse {Increased pain}, active {Physically active}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___            Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
chest pain, dizziness
 
Major Surgical or Invasive Procedure:
none 

 

###RESPONSE: chest pain {Chest pain}, dizziness {Dizziness}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ year old woman with a history of HTN who presents with one 
week of chest pain.  She describes the chest pain as a constant, 
___, left-sided burning sensation that radiates to the back. 
Pain has been progressively worsening over the week. It is worst 
in the mornings, when pain is associated with weakness and 
fatigue.  It is also worse when she exerts her left arm (e.g. 
cutting vegtables), but not with generalized exertion.  She 
states current pain is distinct from heartburn symptoms which 
she had experienced in the past.  Associated symptoms include 
general weakness, fatigue, and mild DOE throughout the week. She 
denies nausea, or diaphoresis.  No fevers, sweats or rigors but 
did have some chills today.  
.
She went to see her PCP today due to her ongoing symptoms.  At 
the PCP's office SL NG was administered with almost immediate 
relief within seconds. She also recieved Aspirin 325mg. She was 
referred to the ED for further workup.  
.  
Of note:  Patient has prior history of admission to ___ ___ years 
ago with chest pain similar to current pain. At the time, pain 
developed acutely while was shoveling snow and was stronger than 
current complaints but similar in distribution and quality. She 
says she spent several days in the hospital and was told her 
heart was ""damaged"". No PTCA was done. She says she had a second 
admission to ___ ___ years ago for difficult to control HTN.  She 
takes her BP meds regularly.
. 
In the ED, initial Vitals: 99.2 66 185/88 18 99% 2L.  Labs were 
notable for absence of leukocytosis and Hct 33.  The patient was 
ruled out for MI by cardiac enzymes x 2 and EKG.  The patient 
underwent CXR that showed left basilar atelectasis versus 
infiltrate.  CTA chest ruled out aortic dissection and 
demonstrated extensive bronchiectasis in the right middle lobe 
and bilateral lower lobes.  Levoquin was administered prior to 
admission for possible infiltrate.  Prior to transfer, VS: 97.8, 
180/70, 57, 17, 98% ra.   
.  
On the floor, patient feels well.  She states her pain had 
resolved completley after NG at ___'s office. She has no further 
complaints.  She denies any recent or past known aspiration 
events. She had no recent travel, no sick or animal exposures 
and denies any history of TB or industrial exposures.  
 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, chest pain {Chest pain}, chest pain {Chest pain}, constant {Constant pain}, left-sided {Left sided chest pain}, burning sensation {Burning sensation}, radiates {Radiating pain}, Pain {Pain}, worsening {Increased pain}, pain {Pain}, weakness {Asthenia}, fatigue {Fatigue}, worse {Patient's condition worsened}, left arm {Left upper arm structure}, exertion {Chest pain on exertion}, pain {Pain}, heartburn {Heartburn}, general weakness {Asthenia}, fatigue {Fatigue}, mild {Symptom mild}, DOE {Dyspnea on exertion}, nausea {Nausea}, diaphoresis {Excessive sweating}, No fevers {Temperature normal}, sweats {Sweating}, rigors {Rigor}, chills {Chill}, PCP {Primary care management}, PCP {Primary care management}, relief {Pain relief}, Aspirin {Administration of aspirin}, referred to the ED {Referral to accident and emergency service}, workup {Evaluation procedure}, chest pain {Chest pain}, pain {Pain}, pain {Pain}, heart {Heart structure}, PTCA {Percutaneous transluminal coronary angioplasty}, difficult to control HTN {Poor hypertension control}, Vitals {Vital signs finding}, Labs {Laboratory test}, leukocytosis {Leukocytosis}, cardiac enzymes {Finding of cardiac enzyme levels}, EKG {Electrocardiographic procedure}, CXR {Plain chest X-ray}, left basilar {Structure of lower lobe of left lung}, atelectasis {Atelectasis}, infiltrate {Infiltration}, CTA chest {Computed tomography of chest}, aortic dissection {Dissection of aorta}, bronchiectasis {Bronchiectasis}, right middle lobe {Structure of middle lobe of right lung}, bilateral {Both lungs}, lower lobes {Structure of lower lobe of lung}, infiltrate {Infiltration}, patient feels well {Patient feels well}, pain {Pain}, resolved {Problem resolved}, aspiration {Aspiration}, travel {Travel abroad}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- HTN  
- Pneumonia ___ years ago treated as out patient  
- ? of cardiac ""event"" - see HPI.  
- s/p left salpingectomy > ___ years ago.  

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, Pneumonia {Pneumonia}, cardiac {Heart disease}, left salpingectomy {Left salpingectomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
- Mother died of ""heart attack"" at age ___  
- Father had MI at age ___  
- no siblings or biological children  

 

###RESPONSE: died {Dead}, heart attack {Myocardial infarction}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Admission 
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:  
VS - Temp 96.1 F, 161/79 BP , HR 57 , R 18 , 97 O2-sat % RA  
GENERAL - well-appearing in NAD, comfortable, appropriate  
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear  
NECK - supple, no thyromegaly, no JVD, no carotid bruits  
CHEST: some reproducible pain in left paravertebral area, mild 
scoliosis  
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp 
unlabored, no accessory muscle use  
HEART - PMI is hyperdynamic but not displaced, RRR, no MRG, a 
third heart sound is heard possibly S4.  
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no 
rebound/guarding  
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) 
 
SKIN - no rashes or lesions  
LYMPH - no cervical, axillary, or inguinal LAD  
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength 
___ throughout, sensation grossly intact throughout, DTRs 2+ and 
symmetric, cerebellar exam intact.  
. 
Discharge Physical Exam:  
VS: 97.3 136/74 55 18 97%RA  
GENERAL - well-appearing in NAD, comfortable  
NECK - supple, no JVD, no carotid bruits  
CHEST: non-tender to palpation  
LUNGS - mild dry crackles in bases, good air movement, resp 
unlabored  
HEART - RRR, no MRG  
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no 
rebound/guarding  
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) 
 
SKIN - no rashes or lesions  
LYMPH - no cervical, axillary, or inguinal LAD  
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength 
___ throughout, sensation grossly intact throughout, DTRs 2+ and 
symmetric, cerebellar exam intact.  

 

###RESPONSE: Physical Exam {Physical examination procedure}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, O2-sat {Oxygen saturation measurement}, RA {Breathing room air}, GENERAL {General examination of patient}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, comfortable {Comfortable appearance}, HEENT {Physical examination procedure}, NC {Normal head}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, sclerae anicteric {White sclera}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, NECK {Physical examination procedure}, supple {Normal movement of neck}, thyromegaly {Goiter}, JVD {Jugular venous engorgement}, carotid bruits {Carotid bruit}, pain {Pain}, left {Structure of left half of chest wall}, paravertebral {Structure of paravertebral region}, mild {Symptom mild}, scoliosis {Scoliosis deformity of spine}, LUNGS {Examination of respiratory system}, CTA {Normal breath sounds}, rh/wh {Wheeze - rhonchi}, good air movement {Breath normal}, resp 
unlabored {Breathing easily}, accessory muscle {Accessory skeletal muscle}, HEART {Cardiovascular physical examination}, PMI {Finding of apex beat}, hyperdynamic {Hyperdynamic circulation}, displaced {Apex beat displaced}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, third heart sound {Third heart sound}, ABDOMEN {Examination of abdomen}, NABS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, no c/c/e {No abnormality detected}, 2+ peripheral pulses {Peripheral pulse present}, radials {Radial pulse present}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, cervical {Cervical lymphadenopathy}, axillary {Axillary lymphadenopathy}, LAD {Lymphadenopathy}, NEURO {Neurological examination}, awake {Awake}, Ox3 {Oriented to person, time and place}, grossly intact {Normal nervous system function}, muscle strength {Normal muscle function}, sensation grossly intact {Normal sensation}, DTRs 2 {Normal tendon reflex}, exam {Physical examination procedure}, Physical Exam {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, comfortable {Comfortable appearance}, NECK {Physical examination procedure}, supple {Normal movement of neck}, JVD {Jugular venous engorgement}, carotid bruits {Carotid bruit}, non-tender {Abdominal tenderness}, palpation {Palpation}, LUNGS {Examination of respiratory system}, mild {Symptom mild}, crackles {Respiratory crackles}, bases {Structure of base of lung}, good air movement {Breath normal}, resp 
unlabored {Breathing easily}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, ABDOMEN {Examination of abdomen}, NABS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, no c/c/e {No abnormality detected}, 2+ peripheral pulses {Peripheral pulse present}, radials {Radial pulse present}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, cervical {Cervical lymphadenopathy}, axillary {Axillary lymphadenopathy}, LAD {Lymphadenopathy}, NEURO {Neurological examination}, awake {Awake}, Ox3 {Oriented to person, time and place}, grossly intact {Normal nervous system function}, muscle strength {Normal muscle function}, sensation grossly intact {Normal sensation}, DTRs 2 {Normal tendon reflex}, exam {Physical examination procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Admission Labs:  
___ 07:06PM BLOOD WBC-5.4 RBC-3.72* Hgb-11.2* Hct-33.6* 
MCV-90 MCH-30.0 MCHC-33.3 RDW-13.2 Plt ___
___ 04:32PM BLOOD Glucose-125* UreaN-20 Creat-1.1 Na-141 
K-4.0 Cl-104 HCO3-26 AnGap-15
___ 04:32PM BLOOD LD(LDH)-186
___ 10:45PM BLOOD Cholest-204*
___ 10:45PM BLOOD Triglyc-67 HDL-63 CHOL/HD-3.2 LDLcalc-128
___ 04:32PM BLOOD %HbA1c-5.5 eAG-111
___ 07:20PM BLOOD Lactate-1.0
. 
Discharge Labs:  
___ 06:25AM BLOOD WBC-5.6 RBC-3.65* Hgb-11.1* Hct-32.8* 
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.1 Plt ___
___ 06:25AM BLOOD Glucose-94 UreaN-32* Creat-1.1 Na-144 
K-3.5 Cl-108 HCO3-28 AnGap-12
___ 06:25AM BLOOD Calcium-9.2 Phos-4.4 Mg-1.8
. 
Cardiac Enzyme trend:  
___ 04:32PM BLOOD cTropnT-<0.01
___ 10:45PM BLOOD cTropnT-<0.01
___ 06:25AM BLOOD CK-MB-2 cTropnT-<0.01
. 
Urine:  
___ 04:33PM URINE Color-Straw Appear-Clear Sp ___
___ 04:33PM URINE Blood-NEG Nitrite-NEG Protein-NEG 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 4:33 pm URINE CULTURE (Final ___:    NO GROWTH. 
. 
CXR ___:  
Findings: PA and lateral view of the chest, no prior. There is 
subtle left 
basilar opacity, potentially atelectasis, however, infiltrate is 
not excluded. In addition, there is a 7-mm nodular opacity 
projecting in the suprahilar region on the left. Elsewhere, the 
lungs are grossly clear, costophrenic angles are sharp. The 
cardiomediastinal silhouette is within normal limits.  Osseous 
and soft tissue structures are unremarkable. 
IMPRESSION: Left basilar atelectasis versus infiltrate. Possible 
left 
suprahilar nodule. These findings can be followed up on the 
upcoming chest 
CT, which has been ordered. 
. 
CTA chest/abdomen/pelvis ___:  
1. No evidence of aortic dissection. 
2. Bilateral adrenal nodules measuring 10 mm on the left and 8 
mm on the 
right, incompletely characterized on this single phase study. 
Further 
evaluation could be performed with an adrenal protocol CT or MR. 

3. Extensive bronchiectasis with associated reticulation and 
ground glass 
opacity in the basilar aspects of the right middle lobe and both 
lower lobes, possibly secondary to chronic aspiration or prior 
infection, although an intrinsic lung process, such as 
non-specific interstitial fibrosis, cannot be excluded. 
4. Right renal simple cyst. Additional left renal tiny 
hypodensities are too small to characterize, but are 
statistically simple cysts. 
5. Small quantity of free fluid in the dependent portion of the 
pelvis is a nonspecific finding, but not typically seen in a 
female patient of this age. 
6. Moderate lumbar spinal stenosis at L3-L4 and L4-L5. 
. 
Cardiac Perfusion Persantine ___:  
The image quality is adequate but limited due to soft tissue and 
breast 
attenuation. There is activity adjacent to the heart in the 
stress images. 
Left ventricular cavity size is normal.  Rest and stress 
perfusion images reveal uniform tracer uptake throughout the 
left ventricular myocardium.  
Gated images reveal normal wall motion.  The calculated left 
ventricular ejection fraction is 57% with an EDV of 102 ml. 
. 
Stress Portion ___:  No anginal type symptoms or ischemic ECG 
changes. 
. 
MRI head ___:  
1. There is no evidence of acute or subacute intracranial 
pathology. 
2. A few foci of high signal intensity are identified in the 
subcortical 
white matter of the right frontal region, which are nonspecific 
and may 
represent chronic microvascular ischemic changes. 
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, LDH {Lactate dehydrogenase measurement}, Cholest {Cholesterol measurement}, Triglyc {Triglycerides measurement}, HDL {High density lipoprotein measurement}, CHOL/HD {Cholesterol/High density lipoprotein ratio measurement}, LDLcalc {Calculated low density lipoprotein cholesterol level}, HbA1c {Hemoglobin A1c measurement}, eAG {Glucose measurement estimated from glycated hemoglobin}, Lactate {Lactic acid measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Cardiac Enzyme {Cardiac enzymes/isoenzymes measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, Urine {Urinalysis}, URINE Color-Straw {Normal urine color}, Appear-Clear {Urine looks clear}, URINE Blood {Urine blood test}, NEG {No abnormality detected}, Nitrite-NEG {Nitrite not detected in urine}, Protein-NEG {Urine protein not detected}, Glucose-NEG {Urine glucose not detected}, Ketone-NEG {Urine ketones not detected}, NEG {No abnormality detected}, Urobiln-NEG {Urine urobilinogen not detected}, pH {pH measurement}, Leuks-NEG {Urine leukocytes not detected}, URINE CULTURE {Urine culture}, NO GROWTH {No organism isolated by microbiologic culture}, CXR {Plain chest X-ray}, PA and lateral view of the chest {Plain chest X-ray}, left 
basilar {Structure of lower lobe of left lung}, opacity {Abnormally opaque structure}, atelectasis {Atelectasis}, infiltrate {Infiltration}, nodular {Nodule of lung}, opacity {Abnormally opaque structure}, region on the left {Structure of hilar lymph node}, lungs {Lung structure}, clear {Normal lung}, costophrenic angles {Structure of costophrenic angle}, cardiomediastinal {Mediastinal structure}, normal {No abnormality detected}, Osseous {Bone structure}, soft tissue {Structure of soft tissue}, unremarkable {Imaging result normal}, Left basilar {Structure of lower lobe of left lung}, atelectasis {Atelectasis}, infiltrate {Infiltration}, left {Left lung structure}, nodule {Nodule}, abdomen/pelvis {Computed tomography of abdomen and pelvis}, No evidence {No abnormality detected}, aortic dissection {Dissection of aorta}, Bilateral adrenal {Bilateral adrenal glands}, nodules {Nodule}, left {Structure of left adrenal gland}, right {Structure of right adrenal gland}, study {Evaluation procedure}, evaluation {Evaluation procedure}, bronchiectasis {Bronchiectasis}, opacity {Abnormally opaque structure}, basilar {Structure of base of lung}, right middle lobe {Structure of middle lobe of right lung}, lower lobes {Structure of lower lobe of lung}, chronic {Chronic disease}, aspiration {Aspiration pneumonia}, infection {Infectious disease}, lung {Lung structure}, interstitial fibrosis {Interstitial fibrosis}, Right {Right kidney structure}, renal {Kidney structure}, simple cyst {Simple cyst}, left renal {Left kidney structure}, simple cysts {Simple cyst}, free fluid {Effusion}, pelvis {Structure of pelvis}, Moderate {Symptom moderate}, lumbar spinal stenosis {Spinal stenosis of lumbar region}, L4-L5 {Intervertebral disc structure of fourth lumbar vertebra}, soft tissue {Structure of soft tissue}, breast {Breast structure}, heart {Heart structure}, stress {Radionuclide myocardial perfusion stress study}, Left ventricular cavity {Structure of cavity of left cardiac ventricle}, size is normal {Normal size}, stress 
perfusion images {Radionuclide myocardial perfusion stress study}, left ventricular myocardium {Structure of myocardium of left ventricle}, normal wall motion {Normal ventricular wall motion}, left 
ventricular {Left cardiac ventricular structure}, Stress {Radionuclide myocardial perfusion stress study}, anginal {Angina}, ischemic {Ischemia}, ECG {Electrocardiographic procedure}, MRI head {Magnetic resonance imaging of head}, no evidence {No abnormality detected}, intracranial {Intracranial structure}, white matter {Cerebral white matter structure}, right frontal region {Right frontal lobe structure}, chronic {Chronic disease}, microvascular {Structure of small blood vessel (organ)}, ischemic changes {Ischemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ year old woman with a history of HTN admitted with 1 week of 
chest pain, hospitalization complicated by dizziness.  
.  
# Chest pain: Patient presented to the emergency department with 
a week of left-sided stabbing, burning chest pain that radiates 
to the back.  In the emergency department, she was ruled out for 
myocardial infarction by enzymes and EKG.  She underwent CTA 
chest/abdomen/pelvis, that did not show evidence of pulmonary 
embolism or aortic dissection.  Stress test was performed given 
the patient's risk factors that showed normal myocardial 
perfusion and function, and absence of cardiac symptoms with 
stress.  CT did show extensive bronchiectasis and ground glass 
opacities, likely representing ___ syndrome in the 
context of the patient's chest pain, associated with fatigue and 
malaise.  Given absence of fevers and cough, there is no 
indication for antibiotic therapy.  The patient should undergo 
follow-up CT in 3 months to evaluate for evolving ground glass 
opacities.   
.  
# Dizziness: During admission, patient endorsed 2 weeks of 
dizziness that occurred with sudden onset.  She had no focal 
neurologic deficits on exam.  MRI brain did not show evidence of 
an acute cerebral process.  Orthostatics were negative and the 
patient was not bradycardic.  However, given the patient's 
description of symptoms and borderline-low blood pressure, 
labetalol was decreased to 200 mg BID.  The patient was seen by 
physical therapy, and was found to be safe to discharge home.  
.  
# Bilateral adrenal nodules: Incidental finding on CT. ___ be of 
concern given history of difficult-to-control hypertension.  The 
patient will need dedicated adrenal imaging as an outpatient.  
___ consider functional adrenal studies to evaluate for cause of 
poorly-controlled hypertension.  
.  
# normocytic anemia: Patient admitted with mild normocytic 
anemia without known baseline.  Anemia remained stable 
throughout admission.  No evidence of bleed.  The patient should 
follow up with her primary care physician regarding her anemia.  

.
# HTN: chronic.  The patient was normotensive to mildly 
hypotensive during admission on home regimen of lisinopril and 
labetalol.  Prior to discharge, the patient's labetalol was 
decreased to 200 mg BID.  She remained normotensive.  She should 
follow up with her PCP for ___ blood pressure check on discharge.  

.  
# CODE: full code  
================================================================
TRANSITIONAL ISSUES:
# Patient should undergo repeat CT chest in 3 months (___) to 
evaluate ground glass opacities 
# Patient should undergo dedicated adrenal imaging to evaluate 
bilateral adrenal nodules.  ___ consider functional studies of 
nodules.   
# Patient should follow up with PCP for BP check, as labetalol 
was decreased on admission.  
 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, chest pain {Chest pain}, dizziness {Dizziness}, Chest pain {Chest pain}, emergency {Emergency treatment management}, left-sided {Left sided chest pain}, stabbing {Stabbing pain}, burning chest pain {Burning chest pain}, radiates {Radiating pain}, emergency {Emergency treatment management}, myocardial infarction {Myocardial infarction}, EKG {Electrocardiographic procedure}, CTA 
chest {Computed tomography angiography of chest with contrast}, abdomen/pelvis {Computed tomography of abdomen and pelvis}, pulmonary 
embolism {Pulmonary embolism}, aortic dissection {Dissection of aorta}, Stress test {Radionuclide myocardial perfusion stress study}, normal myocardial 
perfusion {Myocardial perfusion normal}, cardiac {Heart structure}, stress {Radionuclide myocardial perfusion stress study}, bronchiectasis {Bronchiectasis}, ground glass 
opacities {Ground glass lung opacity}, syndrome {Disease}, chest pain {Chest pain}, fatigue {Fatigue}, malaise {Malaise}, fevers {Fever}, cough {Cough}, antibiotic therapy {Antibiotic therapy}, follow-up {Follow-up arranged}, evaluate {Evaluation procedure}, ground glass 
opacities {Ground glass lung opacity}, Dizziness {Dizziness}, dizziness {Dizziness}, neurologic deficits {Neurological deficit}, exam {Evaluation procedure}, MRI brain {Magnetic resonance imaging of brain}, Orthostatics {Orthostatic hypotension}, negative {No pathologic diagnosis}, bradycardic {Bradycardia}, low blood pressure {Low blood pressure}, physical therapy {Physical therapy procedure}, Bilateral adrenal {Bilateral adrenal glands}, nodules {Nodule}, difficult-to-control hypertension {Poor hypertension control}, adrenal imaging {Adrenal imaging}, studies {Evaluation procedure}, evaluate {Evaluation procedure}, poorly-controlled hypertension. {Poor hypertension control}, normocytic anemia {Normocytic anemia}, mild {Symptom mild}, normocytic 
anemia {Normocytic anemia}, baseline {Baseline state}, Anemia {Anemia}, stable {Patient's condition stable}, No evidence {No abnormality detected}, bleed {Hemorrhage}, follow up {Follow-up arranged}, primary care {Primary care management}, anemia {Anemia}, HTN {Hypertensive disorder, systemic arterial}, chronic {Chronic disease}, normotensive {Normal blood pressure}, hypotensive {Low blood pressure}, regimen {Therapeutic regimen}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, normotensive {Normal blood pressure}, follow up {Follow-up arranged}, PCP {Primary care management}, blood pressure {Finding of increased blood pressure}, CT chest {Computed tomography of chest}, evaluate {Evaluation procedure}, ground glass opacities {Ground glass lung opacity}, adrenal imaging {Adrenal imaging}, evaluate {Evaluation procedure}, bilateral adrenal {Bilateral adrenal glands}, nodules {Nodule}, studies {Evaluation procedure}, nodules {Thyroid nodule}, follow up {Follow-up arranged}, PCP {Primary care management}, BP check {Blood pressure monitoring}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
1. Lisinopril 40mg daily  
2. Labetolol 400mg BOD  
3. Aspirin 81mg daily 

 
Discharge Medications:
1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
2. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).
Disp:*180 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) 
Tablet, Delayed Release (E.C.) PO once a day.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
PRIMARY DIAGNOSIS:  atypical chest pain, dizziness   
SECONDARY DIAGNOSIS: Hypertension, bilateral adrenal nodules, 
normocytic anemia 

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: atypical chest pain {Atypical chest pain}, dizziness {Dizziness}, Hypertension {Hypertensive disorder, systemic arterial}, bilateral adrena {Bilateral adrenal glands}, nodules {Nodule}, normocytic anemia {Normocytic anemia}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Ms. ___, 
.
You were admitted to the hospital with two weeks of left-sided 
chest pain.  On CT scan, you were found to have changes in your 
lung, concerning for an infection that does not need treatment 
with antibiotics at this time.  You were also found to have 
small nodules in your adrenal glands.  Your chest pain resolved. 
 You should follow up with your primary care physician for ___ 
repeat CT scan in 3 months to evaluate for changes in your lung 
findings and adrenal glands.  You had a stress test that showed 
no acute problems with your heart.  During your hospitalization, 
you were also noted to have dizziness and a feeling of weakness 
in your left leg.  We did not note any weakness on physical 
exam.  You underwent an MRI that showed no evidence of acute 
stroke.  You were seen by physical therapy who recommended that 
you walk with a walker (given to you during admission) at all 
times.  You should follow up with your PCP on discharge.  
. 
Medications changed this admission:  
DECREASE labetalol to 200 mg twice daily   
 

###RESPONSE: left-sided 
chest pain {Left sided chest pain}, CT scan {Computed tomography}, lung {Lung structure}, infection {Infectious disease}, antibiotics {Antibiotic therapy}, nodules {Nodule}, adrenal glands {Bilateral adrenal glands}, chest {Chest pain}, pain resolved {No present pain}, primary care {Primary care management}, CT scan {Computed tomography}, evaluate {Evaluation procedure}, lung 
findings {Lung finding}, adrenal glands {Bilateral adrenal glands}, stress test {Cardiovascular stress testing}, no acute {No abnormality detected}, problems {Problem}, heart {Heart structure}, dizziness {Dizziness}, weakness {Asthenia}, left leg {Structure of left lower limb}, weakness {Asthenia}, physical 
exam {Physical examination procedure}, MRI {Magnetic resonance imaging of head}, no evidence {No abnormality detected}, stroke {Cerebrovascular accident}, physical therapy {Physical therapy procedure}, walker {Uses zimmer frame}, PCP {Primary care management}, Medications changed {Change of medication}, DECREASE {Medication decreased}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
Chest pain
 
Major Surgical or Invasive Procedure:
Cardiac catheterization with two DES ___

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Chest pain {Chest pain}, Cardiac catheterization {Cardiac catheterization}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ is ___ ___ with history of HTN, HLD p/w exertional 
chest pain. 

She first noticed central chest burning with walking 2 weeks 
ago. Since then she has had chest burning with exertion almost 
every day. No associated dyspnea, diaphoresis, nausea. She was 
evaluated at ___'s office today and was found to have new ECG 
changes (poor R wave progression, T wave flattening V4,5,6). She 
received got full dose ASA and was sent to ED for further 
evaluation. 

Of not she has no previous history of chest pain. No recent 
fevers/chills, abdominal pain, or dyspnea. 

In the ED, intial vitals were: 98.3 67 135/94 16 98% RA  
Labs/studies notable for: Trop 0.02

UA notable for leukocytosis with 17 WBCs. Normal CBC and 
electrolytes. Guaiac negative. 

Atrius on call cardiology was consulted from the ED. Per their 
recommendations, she was started on heparin drip and admitted to 
cardiology for unstable angina, consideration of cardiac 
catheterization. 

Of note, she is followed by Dr. ___. Previous ECG in 
___ showed LVH and small inferior Q waves. She had stress 
echo ___ with exercise duration of 9:27 without angina (beta 
blocker was held by patient for the test). ECG response was 
non-diagnostic without ischemia. Mild LVH was noted.
 
On the floor she reported no chest pain.  

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, exertional 
chest pain. {Chest pain on exertion}, chest burning {Burning chest pain}, chest burning {Burning chest pain}, dyspnea {Dyspnea}, diaphoresis {Excessive sweating}, nausea {Nausea}, evaluation {Evaluation procedure}, chest pain {Chest pain}, fevers {Fever}, chills {Chill}, abdominal pain {Abdominal pain}, dyspnea {Dyspnea}, UA {Urinalysis}, leukocytosis {Leukocytosis}, unstable angina {Preinfarction syndrome}, cardiac 
catheterization {Cardiac catheterization}, stress 
echo ___ {Stress echocardiography}, exercise {Exercises}, angina {Angina}, ischemia {Ischemia}, chest pain {Chest pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
HTN
h/o diverticulitis 
Glaucoma

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, diverticulitis {Diverticulitis}, Glaucoma {Glaucoma}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Diabetes mother, father.
Maternal grandmother CAD/PVD; Diabetes - Unknown Type; 
Hyperlipidemia; Hypertension; Stroke
Sister breast cancer  
 

###RESPONSE: Diabetes {Diabetes mellitus}, CAD {Coronary arteriosclerosis}, Diabetes {Diabetes mellitus}, Hyperlipidemia {Hyperlipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, Stroke {Cerebrovascular accident}, breast cancer {Malignant neoplasm of breast}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAMINATION:  
VS: 98.2 160/90 74 18 99%ra  wt 71kg 
GENERAL: NAD. Oriented x3. Mood, affect appropriate.  
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were 
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.  

NECK: no elev JVP  
CARDIAC: PMI located in ___ intercostal space, midclavicular 
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, 
lifts. 
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp 
were unlabored, no accessory muscle use. No crackles, wheezes or 
rhonchi.  
ABDOMEN: Soft, NTND. No HSM or tenderness.  
EXTREMITIES: No c/c/e. No femoral bruits.  
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.  
PULSES:  Distal pulses palpable and symmetric

DISCHARGE PHYSICAL EXAMINATION:  
VS: 99.4 98.7 113/68 80 20 98RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.  
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were 
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.  

NECK: no elev JVP  
CARDIAC: PMI located in ___ intercostal space, midclavicular 
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, 
lifts. 
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp 
were unlabored, no accessory muscle use. No crackles, wheezes or 
rhonchi.  
ABDOMEN: Soft, NTND. No HSM or tenderness.  
EXTREMITIES: No c/c/e. No femoral bruits.  
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. 
PULSES:  Distal pulses palpable and symmetric
 

###RESPONSE: PHYSICAL EXAMINATION {Physical examination procedure}, VS {Vital signs finding}, GENERAL {General examination of patient}, NAD {No abnormality detected}, Oriented x3 {Oriented to person, time and place}, Mood {Level of mood - normal}, affect {Mood finding}, HEENT {Physical examination procedure}, NC {Normal head}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva {Conjunctival structure}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthelasma {Xanthelasma}, NECK {Physical examination procedure}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, intercostal space {Structure of intercostal space}, midclavicular 
line {Midclavicular line}, RR {Finding of rate of respiration}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, thrills {Thrill}, LUNGS {Examination of respiratory system}, chest wall deformities {Deformity of chest wall}, scoliosis {Scoliosis deformity of spine}, kyphosis {Kyphosis deformity of spine}, Resp {Examination of respiratory system}, accessory muscle {Accessory skeletal muscle}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, EXTREMITIES {Examination of limb}, femoral bruits {Femoral bruit}, SKIN {Examination of skin}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, pulses {Normal pulse}, PHYSICAL EXAMINATION {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, NAD {No abnormality detected}, Oriented x3 {Oriented to person, time and place}, Mood {Level of mood - normal}, affect {Mood finding}, HEENT {Physical examination procedure}, NC {Normal head}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva {Conjunctival structure}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthelasma {Xanthelasma}, NECK {Physical examination procedure}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, intercostal space {Structure of intercostal space}, midclavicular 
line {Midclavicular line}, RR {Finding of rate of respiration}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, thrills {Thrill}, LUNGS {Examination of respiratory system}, chest wall deformities {Deformity of chest wall}, scoliosis {Scoliosis deformity of spine}, kyphosis {Kyphosis deformity of spine}, Resp {Examination of respiratory system}, accessory muscle {Accessory skeletal muscle}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, EXTREMITIES {Examination of limb}, femoral bruits {Femoral bruit}, SKIN {Examination of skin}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, pulses {Normal pulse}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
SELECTED LABORATORY TESTS:
___ 04:56PM BLOOD WBC-5.0 RBC-4.67 Hgb-13.0 Hct-38.9 MCV-83 
MCH-27.9 MCHC-33.4 RDW-13.8 Plt ___
___ 05:10AM BLOOD WBC-5.3 RBC-4.41 Hgb-12.2 Hct-36.3 MCV-82 
MCH-27.7 MCHC-33.6 RDW-13.4 Plt ___
___ 04:56PM BLOOD Neuts-30.4* Lymphs-61.4* Monos-4.8 
Eos-2.5 Baso-0.9
___ 04:56PM BLOOD ___ PTT-29.8 ___
___ 04:56PM BLOOD Glucose-162* UreaN-14 Creat-0.9 Na-142 
K-3.9 Cl-103 HCO3-25 AnGap-18
___ 05:10AM BLOOD Glucose-102* UreaN-19 Creat-0.9 Na-141 
K-4.0 Cl-105 HCO3-26 AnGap-14
___ 05:10AM BLOOD CK(CPK)-131
___ 04:56PM BLOOD cTropnT-0.02*
___ 05:10AM BLOOD CK-MB-2 cTropnT-0.02*
___ 11:00AM BLOOD cTropnT-0.01
___ 07:15PM BLOOD CK-MB-6 cTropnT-0.08*
___ 05:05AM BLOOD CK-MB-25* MB Indx-8.5* cTropnT-0.17*
___ 11:00AM BLOOD CK-MB-21* MB Indx-6.8* cTropnT-0.19*
___ 05:10AM BLOOD CK-MB-7 cTropnT-0.23*
___ 05:10AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.1

CXR ___: No acute cardiopulmonary abnormality
 

###RESPONSE: LABORATORY TESTS {Laboratory test}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, CXR {Plain chest X-ray}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Ms. ___ is ___ ___ with history of HTN, HLD now presenting with 
exertional chest pain. 

She had increasing frequency of exertional chest pain, with 
office EKG showing T wave flattening. Troponin 0.02 in ED. She 
underwent cardiac catheterization on ___. She was noted to have 
proximal RCA 100% focal stenosis, (3.8x18 DES) and mid RCA 80% 
tubular stenosis (3x30 DES). Catheterization also demonstrated 
LAD ___ proximal stenosis, first diagonal 50-60% proximal 
stenosis. She was subsequently continued on clopidogrel, 
aspirin, atorvastatin, and atenolol. Troponin and CK-MB was 
elevated in the post-procedural setting with subsequent 
normalization of CK-MB suggesting resolving cardiac injury.

TRANSITION ISSUES:
- She will need close followup in the post-procedural setting 
for unstable angina
- She will benefit from cardiac rehabilitation

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, exertional chest pain {Chest pain on exertion}, exertional chest pain {Chest pain on exertion}, cardiac catheterization {Cardiac catheterization}, stenosis {Stenosis}, stenosis {Stenosis}, Catheterization {Catheterization}, LAD {Structure of anterior descending branch of left coronary artery}, stenosis {Stenosis}, stenosis {Stenosis}, injury {Traumatic or non-traumatic injury}, unstable angina {Preinfarction syndrome}, cardiac rehabilitation {Cardiac rehabilitation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY 
2. Atenolol 50 mg PO DAILY 
3. Atorvastatin 20 mg PO QPM 

 
Discharge Medications:
1. Atenolol 50 mg PO DAILY 
2. Atorvastatin 80 mg PO QPM 
RX *atorvastatin 80 mg 1 tablet(s) by mouth Once every evening 
Disp #*30 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY 
RX *aspirin 81 mg 1 tablet(s) by mouth Once a day Disp #*30 
Tablet Refills:*0
4. Clopidogrel 75 mg PO DAILY 
RX *clopidogrel 75 mg 1 tablet(s) by mouth Once a day Disp #*30 
Tablet Refills:*0
5. Lisinopril 2.5 mg PO DAILY 
RX *lisinopril 2.5 mg 1 tablet(s) by mouth Once a day Disp #*30 
Tablet Refills:*0

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Unstable angina, complete occlusion of RCA

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Unstable angina {Preinfarction syndrome}, occlusion {Complete obstruction}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,

It was a pleasure being part of your care at ___. You were 
admitted to the hospital due to chest pain and concerning 
findings on EKG. You had cardiac catheterization which showed 
blockage of the blood vessels in the heart. A stent was placed. 
You were monitored after the procedure and were found to be safe 
for discharge.

After discharge please follow up with your outpatient providers 
as described below.
 

###RESPONSE: chest pain {Chest pain}, cardiac catheterization {Cardiac catheterization}, blood vessels {Blood vessel structure}, heart {Heart structure}, procedure {Procedure}, follow up {Follow-up status}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___.             Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Penicillins / Darvon / lisinopril
 
Attending: ___
 
Chief Complaint:
Dyspnea
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: Penicillins {Allergy to penicillin}, Darvon {Allergy to dextropropoxyphene}, lisinopril {Non-allergic hypersensitivity to angiotensin-converting enzyme inhibitor}, Dyspnea {Dyspnea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ with PMHx of COPD, OSA on CPAP, current smoker, and HTN 
presenting with increasing shortness of breath, cough, and chest 
tightness similar to prior COPD exacerbations.

Patient was in her USOH until a couple of weeks ago when she 
developed a cold (rhinorrhea, cough, sinus pressure, etc.). She 
reports that at that time she also started to have some 
worsening dyspnea and whezzing. She called her pulmonologist 
(Dr. ___ and was prescribed a short course of prednisone. She 
got slightly better when she again noticed the return of her 
symptoms over the last week. She also noted that her cough which 
is usually dry or productive of clear/white sputum had become 
productive of yellow/green sputum. She also developed worsening 
wheezing and chest tightness. Compounding her issues, she ran 
out of her home nebulizer treatments which she thought had been 
helping to keep her symptoms at bay. Denied fevers, abdominal 
pain, vomiting, diarrhea, constipation, or myalgias. Reports 
mild chills and nausea. She then decided to come into the ___ 
ED for evaluation.  
 
In the ED:  
Initial vital signs were notable for T 98.9, HR 86, BP 142/96, 
RR 40, O2 92% on RA.  

Labs were notable for:  
- WBC 12.9, Hbg 10.6  
- VBG pH 7.39, pCO2 51, O2sat 95  
- Chemistries, renal function wnl, troponin neg x 1 CXR showed a 
subtle increase in opacity at the right lung base, which could 
be due to overlapping structures, but could not exclude definite 
consolidation.  

Patient was given:  
- 500mg IV azithromycin  
- 40mg PO prednisone  
- Duonebs  

The pt triggered in the ED for tachypnea and chest tightness, 
with respiratory rates in the ___. Both the pt's tachypnea and 
symptoms improved after administration of duonebs. She was 
admitted to the medicine service for further management.  

Upon arrival to the floor, the patient was breathing comfortably 
and said that her SOB seemed to have improved after the 
nebulizer treatments in the ED. She was hungry and requested 
dinner. 
 
Regarding the pt's relevant pulmonary history, recent pulmonary 
function tests demonstrate features of moderate obstruction. She 
has an FEV1 of 42% predicted with an FVC of 53% predicted ratio 
62%. She continues to smoke cigarettes daily but is down to 
about one cig every other day.  
 

###RESPONSE: COPD {Chronic obstructive lung disease}, OSA {Obstructive sleep apnea syndrome}, CPAP {Continuous positive airway pressure ventilation treatment}, current smoker {Smoker}, HTN {Hypertensive disorder, systemic arterial}, increasing {Patient's condition worsened}, shortness of breath {Dyspnea}, cough {Cough}, chest 
tightness {Tight chest}, COPD exacerbations {Acute exacerbation of chronic obstructive airways disease}, cold {Common cold}, rhinorrhea {Nasal discharge}, cough {Cough}, sinus pressure {Sensation of nasal sinus pressure}, worsening {Patient's condition worsened}, dyspnea {Dyspnea}, whezzing {Wheezing}, called {Informing doctor}, cough {Cough}, dry {Dry cough}, clear {Productive cough -clear sputum}, white sputum {White sputum}, yellow {Productive cough-yellow sputum}, green sputum {Productive cough -green sputum}, worsening {Patient's condition worsened}, wheezing {Wheezing}, chest tightness {Tight chest}, nebulizer treatments {Nebulizer therapy}, fevers {Fever}, abdominal 
pain {Abdominal pain}, vomiting {Vomiting}, diarrhea {Diarrhea}, constipation {Constipation}, myalgias {Muscle pain}, mild {Symptom mild}, chills {Chill}, nausea {Nausea}, evaluation {Evaluation procedure}, vital signs {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, O2 {Oxygen saturation measurement}, RA {Breathing room air}, WBC {White blood cell count}, Hbg {Measurement of total hemoglobin concentration}, VBG {Blood gases, venous measurement}, pH {pH measurement}, pCO2 {Measurement of venous partial pressure of carbon dioxide}, O2sat {Venous oxygen saturation measurement}, renal function wnl {Renal function tests within reference range}, troponin {Troponin measurement}, neg {No abnormality detected}, CXR {Plain chest X-ray}, opacity {Abnormally opaque structure}, right lung base {Structure of base of right lung}, overlapping structures {Overriding structures}, consolidation {Lung consolidation}, azithromycin {Antibiotic therapy}, tachypnea {Tachypnea}, chest tightness {Tight chest}, respiratory rates {Finding of rate of respiration}, tachypnea {Tachypnea}, improved {Patient's condition improved}, breathing comfortably {Breathing easily}, SOB {Dyspnea}, improved {Patient's condition improved}, nebulizer treatments {Nebulizer therapy}, hungry {Hungry}, pulmonary {Respiratory tract structure}, pulmonary 
function tests {Measurement of respiratory function}, moderate {Symptom moderate}, obstruction {Finding of respiratory obstruction}, smoke {Smoker}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
 - DMII  
 - HTN  
 - COPD  
 - Asthma  
 - Anxiety/Depression  
 - Osteoarthritis  
 - IBS  
 - Seasonal allergies  
 - Hx of EtOH use disorder
 - Obesity  
 - OSA  
 - Thyroid mass 
 

###RESPONSE: DMII {Diabetes mellitus type 2}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, Asthma {Asthma}, Anxiety/Depression {Mixed anxiety and depressive disorder}, Osteoarthritis {Osteoarthritis}, IBS {Irritable bowel syndrome}, Seasonal allergies {Seasonal allergy}, EtOH use disorder {Alcoholism}, Obesity {Obesity}, OSA {Obstructive sleep apnea syndrome}, Thyroid mass {Mass of thyroid gland}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
- Mother with T2DM 
- Father with T2DM
- Sister with HTN  
- Unknown cancers in grandparents on both sides 
 

###RESPONSE: T2DM {Diabetes mellitus type 2}, T2DM {Diabetes mellitus type 2}, HTN {Hypertensive disorder, systemic arterial}, cancers {Malignant neoplasm of colon}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.1 137 / 85 76 18 96 2L nc   
GENERAL: Pleasant F in NAD. At times w/ some dyspnea while 
speaking during interview 
HEENT: NCAT, MMM 
CARDIAC: Heart sounds distant, RRR, no m/r/g  
LUNGS: Decreased breath sounds throughout, no significant 
wheezing   
ABDOMEN: Obese, soft, NT/ND, BS+
EXTREMITIES: WWP, no c/c/e  
NEUROLOGIC: AAOx3, grossly intact

DISCHARGE PHYSICAL EXAM:
========================
GENERAL: Sitting on edge of bed in NAD
HEENT: NCAT, MMM, R lobe of thyroid enlarged 
CARDIAC: RRR, no m/r/g  
LUNGS: coarse breath sounds b/l, no wheezes, breathing
comfortably on room air
ABDOMEN: obese, soft, NT/ND, BS+
EXTREMITIES: WWP, bilateral 2+ nonpitting edema L>R
NEUROLOGIC: AAOx3, no focal deficits

 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VITALS {Vital signs finding}, 2L nc {Oxygen administration by nasal cannula}, GENERAL {General examination of patient}, NAD {No abnormality detected}, dyspnea {Dyspnea}, HEENT {Physical examination procedure}, NC {Normal head}, MMM {Moist oral mucosa}, CARDIAC {Cardiovascular physical examination}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, LUNGS {Examination of respiratory system}, Decreased breath sounds {Decreased breath sounds}, wheezing {Wheezing}, ABDOMEN {Examination of abdomen}, Obese {Obese}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, BS+ {Normal bowel sounds}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, no c/c/e {No abnormality detected}, NEURO {Neurological examination}, GI {Examination of digestive system}, Ox3 {Oriented to person, time and place}, grossly intact {Normal nervous system function}, RA {Breathing room air}, Sitting {Sitting position}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NCAT {Normal head}, MMM {Moist oral mucosa}, R lobe {Structure of right lobe of thyroid gland}, thyroid enlarged {Goiter}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, LUNGS {Examination of respiratory system}, breath sounds {Finding of breath sounds}, wheezes {Wheezing}, breathing
comfortably on room air {Breathing easily}, ABDOMEN {Examination of abdomen}, obese {Obese}, soft {Abdomen soft}, BS+ {Normal bowel sounds}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, bilateral {Edema of bilateral lower limbs}, edema {Edema}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, no focal deficits {Normal nervous system function}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
===============
___ 04:49PM BLOOD WBC-12.9* RBC-4.36 Hgb-10.6* Hct-36.8 
MCV-84 MCH-24.3* MCHC-28.8* RDW-16.7* RDWSD-51.1* Plt ___
___ 04:49PM BLOOD Neuts-68.6 ___ Monos-7.8 Eos-2.6 
Baso-0.3 Im ___ AbsNeut-8.84* AbsLymp-2.59 AbsMono-1.01* 
AbsEos-0.34 AbsBaso-0.04
___ 04:49PM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-143 K-5.0 
Cl-103 HCO3-29 AnGap-11
___ 04:49PM BLOOD cTropnT-<0.01
___ 04:59PM BLOOD ___ pO2-132* pCO2-51* pH-7.39 
calTCO2-32* Base XS-5
___ 04:59PM BLOOD O2 Sat-95

PERTINENT LABS:
===============
___ 08:31AM BLOOD proBNP-35

IMAGING:
========
___ CXR Portable
IMPRESSION:  
Subtle increase in opacity at the right lung base may be due to 
overlap of 
structures, but underlying consolidation is difficult to 
exclude. Consider 
dedicated PA and lateral views if/when patient able, for better 
evaluation.

___ CXR PA/Lateral
IMPRESSION:  
Cardiomediastinal silhouette is within normal limits.  On the 
prior study, there was suggestion of an opacity at the right 
base; however, on today's study, this is not present.  There is 
mild prominence of the pulmonary interstitial markings 
suggestive of mild pulmonary edema.  No definite consolidation 
or pneumothoraces are seen.

___ LENIs
IMPRESSION:  
No evidence of deep venous thrombosis in the right or left lower 
extremity veins. No evidence of medial popliteal fossa (___) 
cyst. 

___ Thyroid Ultrasound
IMPRESSION:
1. Numerous confluent nodules in the right lobe suggest an 
overall stable 
appearance although specific measurements are difficult to 
obtain due to 
differences in scanning technique. 
2. Two left lobe nodules are minimally increased in size 
compared to the prior ultrasound.  No new worrisome nodule is 
identified within the thyroid gland. 

MICRO:
======
___ BCx x2: NGTD

DISCHARGE LABS:
===============
___ 05:30AM BLOOD WBC-16.8* RBC-3.92 Hgb-9.4* Hct-33.1* 
MCV-84 MCH-24.0* MCHC-28.4* RDW-16.9* RDWSD-51.9* Plt ___
___ 05:30AM BLOOD Glucose-157* UreaN-19 Creat-0.8 Na-141 
K-4.6 Cl-102 HCO3-30 AnGap-9*
___ 05:30AM BLOOD Calcium-10.7* Phos-3.5 Mg-2.1
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Plt {Platelet count}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, pO2 {Measurement of partial pressure of oxygen in blood}, pCO2 {Measurement of partial pressure of carbon dioxide in blood}, pH {pH measurement}, calTCO2 {Blood total carbon dioxide (calculated)}, Base XS {Delta base, blood}, O2 Sat {Oxygen saturation measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, CXR {Plain chest X-ray}, Portable {Portable X-ray}, opacity {Abnormally opaque structure}, right lung base {Structure of base of right lung}, consolidation {Lung consolidation}, lateral {Diagnostic radiography of chest, lateral}, evaluation {Evaluation procedure}, CXR PA/Lateral {Diagnostic radiography of chest, combined posteroanterior and lateral}, Cardiomediastinal {Mediastinal structure}, normal {Normal appearance}, study {Evaluation procedure}, opacity {Abnormally opaque structure}, right 
base {Structure of base of right lung}, study {Evaluation procedure}, mild {Symptom mild}, pulmonary {Lung structure}, mild {Symptom mild}, pulmonary edema {Pulmonary edema}, consolidation {Lung consolidation}, pneumothoraces {Pneumothorax}, No evidence {No abnormality detected}, deep venous thrombosis {Deep venous thrombosis}, right {Structure of vein of right lower limb}, left lower 
extremity veins {Structure of vein of left lower limb}, No evidence {No abnormality detected}, medial {Structure of medial aspect of knee}, popliteal fossa {Popliteal fossa structure}, cyst {Cyst}, Thyroid Ultrasound {Ultrasound scan of thyroid}, nodules {Thyroid nodule}, right lobe {Structure of right lobe of thyroid gland}, stable 
appearance {Patient's condition stable}, measurements {Measurement procedure}, left lobe {Structure of left lobe of thyroid gland}, nodules {Thyroid nodule}, increased in size {Increased size}, ultrasound {Ultrasonography}, nodule {Thyroid nodule}, thyroid gland {Thyroid structure}, BCx {Blood culture}, NGTD {No abnormality detected}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Plt {Platelet count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of COPD, OSA 
on CPAP, current smoking, and HTN who presented with increasing 
shortness of breath, cough, and chest tightness similar to prior 
COPD exacerbations. 
 
ACUTE ISSUES:  
============== 
#COPD EXACERBATION: 
Ms. ___ presented with dyspnea, cough with changes in 
sputum production, and chest tightness consistent with her prior 
COPD exacerbations. This episode was likely triggered by a 
recent URI and unfortunately exacerbated by her running out of 
her home nebulizer treatments. CXR PA/lateral did not 
demonstrate overlying pneumonia and flu swab was negative. She 
was initiated on a 5 day course of PO prednisone 40mg and 
azithromycin (___), treated with duonebs and albuterol, and 
managed symptomatically for her cough.

#LOWER EXTREMITY EDEMA:
Ms. ___ also endorsed bilateral non-pitting edema, left 
worse than right, for one week. LENIs were negative for DVT or 
popliteal fossa cyst. There were no other signs of volume 
overload on exam, and her BNP was 35. The edema could be an 
amlodipine side effect, though would not expect asymmetry and 
she has been on this medication (at the same dosage) for 
multiple years.

STABLE ISSUES:  
===============  
#THYROID MASS:
Previously noted to be benign per biopsy results at ___, however 
increasing in size per review of OMR. Ms. ___ was due to 
have repeat thyroid U/S roughly 6 months ago, but had yet to 
receive it in the outpatient setting. Therefore the study was 
performed while the patient was admitted. This demonstrated 
""Numerous confluent nodules in the right lobe suggest an overall 
stable appearance although specific measurements are difficult 
to obtain due to differences in scanning technique. Two left 
lobe nodules are minimally increased in size compared to the 
prior ultrasound.  No new worrisome nodule is identified within 
the thyroid gland."" Patient to follow up with PCP regarding 
these findings.

#CODE: Full (presumed)  
#CONTACT: ___ (sister) - ___

TRANSITIONAL ISSUES:
=====================
[ ] Requires PCP ___ of thyroid ultrasound findings
[ ] Can consider discontinuing amlodipine to see if lower 
extremity edema resolves.
 

###RESPONSE: COPD {Chronic obstructive lung disease}, OSA {Obstructive sleep apnea syndrome}, CPAP {Continuous positive airway pressure ventilation treatment}, smoking {Smoker}, HTN {Hypertensive disorder, systemic arterial}, increasing {Patient's condition worsened}, shortness of breath {Dyspnea}, cough {Cough}, chest tightness {Tight chest}, COPD exacerbations {Acute exacerbation of chronic obstructive airways disease}, COPD EXACERBATION {Acute exacerbation of chronic obstructive airways disease}, dyspnea {Dyspnea}, cough {Cough}, sputum production {Productive cough}, chest tightness {Tight chest}, COPD exacerbations {Acute exacerbation of chronic obstructive airways disease}, URI {Upper respiratory infection}, nebulizer treatments {Nebulizer therapy}, CXR PA/lateral {Diagnostic radiography of chest, combined posteroanterior and lateral}, pneumonia {Pneumonia}, negative {No pathologic diagnosis}, azithromycin {Antibiotic therapy}, cough {Cough}, bilateral {Edema of bilateral lower limbs}, non-pitting edema {Non-pitting edema}, left {Structure of left lower limb}, worse {Patient's condition worsened}, right {Structure of right lower limb}, negative {No pathologic diagnosis}, DVT {Deep venous thrombosis}, popliteal fossa {Popliteal fossa structure}, cyst {Cyst}, signs {Sign}, volume 
overload {Hypervolemia}, exam {Cardiovascular investigation}, BNP {Brain natriuretic peptide measurement}, edema {Edema}, side effect {Medication side effects present}, medication {Administration of drug or medicament}, benign {Benign neoplasm of thyroid gland}, biopsy {Biopsy of thyroid}, increasing in size {Increased size}, thyroid U/S {Ultrasound scan of thyroid}, study {Evaluation procedure}, nodules {Thyroid nodule}, right lobe {Structure of right lobe of thyroid gland}, stable appearance {Patient's condition stable}, measurements {Measurement procedure}, left 
lobe {Structure of left lobe of thyroid gland}, nodules {Thyroid nodule}, increased in size {Increased size}, ultrasound {Ultrasound scan of thyroid}, nodule {Thyroid nodule}, thyroid gland {Thyroid structure}, PCP {Primary care management}, thyroid {Ultrasound scan of thyroid}, ultrasound findings {Ultrasound scan finding}, lower 
extremity edema {Edema of lower extremity}, resolves {Problem resolved}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY 
2. Atorvastatin 40 mg PO QPM 
3. Fluticasone-Salmeterol Diskus (500/50)  1 INH IH BID 
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheeze 
5. Losartan Potassium 100 mg PO DAILY 
6. Sertraline 125 mg PO DAILY 
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough/wheezing 
8. ammonium lactate 12 % topical DAILY 
9. BuPROPion XL (Once Daily) 150 mg PO DAILY 
10. diclofenac sodium 1 % topical BID 
11. Gabapentin 300 mg PO TID 
12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 
13. Tiotropium Bromide 1 CAP IH DAILY 
14. Aspirin 81 mg PO DAILY 

 
Discharge Medications:
1.  Benzonatate 100 mg PO TID:PRN Cough 
RX *benzonatate 100 mg 1 capsule(s) by mouth Three times per day 
Disp #*45 Capsule Refills:*0 
2.  Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN Cough 
RX *dextromethorphan-guaifenesin [Adult Cough Formula DM Max] 
200 mg-10 mg/5 mL 5 mL by mouth Every 6 hours as needed Disp #*1 
Bottle Refills:*0 
3.  Albuterol Inhaler ___ PUFF IH Q4H:PRN cough/wheezing 
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs IH every 4 
to 6 hours Disp #*1 Inhaler Refills:*0 
4.  Amlodipine 10 mg PO DAILY  
5.  ammonium lactate 12 % topical DAILY  
6.  Aspirin 81 mg PO DAILY  
7.  Atorvastatin 40 mg PO QPM  
8.  BuPROPion XL (Once Daily) 150 mg PO DAILY  
9.  diclofenac sodium 1 % topical BID  
10.  Fluticasone-Salmeterol Diskus (500/50)  1 INH IH BID  
11.  Gabapentin 300 mg PO TID  
12.  Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheeze  
13.  Losartan Potassium 100 mg PO DAILY  
14.  MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 
Do Not Crush  
15.  Sertraline 125 mg PO DAILY  
16.  Tiotropium Bromide 1 CAP IH DAILY  

 

###RESPONSE: mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis:
#Chronic Obstructive Pulmonary Disease Exacerbation

Secondary Diagnosis:
#Thyroid Mass
#Bilateral Lower Extremity Edema

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Chronic Obstructive Pulmonary Disease Exacerbation {Acute exacerbation of chronic obstructive airways disease}, Thyroid Mass {Mass of thyroid gland}, Bilateral Lower Extremity Edema {Edema of bilateral lower limbs}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,

It was a pleasure taking care of you at the ___ 
___.

Why did you come to the hospital?
- You came to the hospital because you were having a cough and 
shortness of breath.

What did you receive in the hospital?
- You were treated for a COPD exacerbation with steroids and 
antibiotics.
- You had an ultrasound of your thyroid which did not show any 
new worrisome nodules.

What should you do once you leave the hospital?
- Please take all of your medications as prescribed and attend 
all of your follow up appointments as scheduled.

We wish you all the best!
- Your ___ Care Team
 

###RESPONSE: cough {Cough}, shortness of breath {Dyspnea}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, steroids {Steroid therapy}, antibiotics {Antibiotic therapy}, ultrasound of your thyroid {Ultrasound scan of thyroid}, nodules {Thyroid nodule}, take all of your medications as prescribed {Patient medication education}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Levofloxacin / gabapentin
 
Attending: ___.
 
Chief Complaint:
cough, dyspnea
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: Levofloxacin {Allergy to levofloxacin}, gabapentin {Allergy to gabapentin}, cough {Cough}, dyspnea {Dyspnea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mr. ___ is an ___ y/o M with a PMHx of COPD not on home O2, 
CKD baseline Cr 2.8, CAD, heart block with pacemaker placement, 
BPH and NIDDM who p/w with shortness of breath for ___ days. 
Patient notes a productive cough with greenish sputum as well as 
malaise. At baseline he is able to ambulate long distances but 
recently, has been slowly getting short of breath, which got 
worse on day of admission when even getting to the bathroom was 
taxing. He reports chills but no fever or rigors. He checked his 
temperature at home which was not elevated. He denies chest 
pain, abdominal pain, dysuria, rhinorrhea, myalgias or 
headaches. In the ED, initial VS were 98.9 75 183/70 18 100% RA. 
Exam significant for diffuse wheezing with good air movement and 
oxygen saturations in 97-100% on 3L. Labs significant for K 5.4, 
Cr 3.1 (baseline 2.8), WBC 9.6, H/H 12.3/36.8. Flu A/B PCR 
positive for Influenza A. CXR significant for possible 
superimposed consolidation at the right lung base. The patient 
received albuterol/ipatropium nebs, ceftriaxone 1 g IV, 
azithromycin 500 mg PO, and 60 mg PO prednisone. On transfer to 
the floor, patient was febrile to 100.6 80 185/75 18 98% 2L 
Nasal Cannula. On arrival to the floor, his dyspnea is improved 
after breathing treatments. Patient reports significant cough 
even at rest. He reports getting winded just talking for long 
periods of time.   

 

###RESPONSE: COPD {Chronic obstructive lung disease}, home O2 {Home oxygen therapy}, CKD {Chronic kidney disease}, baseline {Baseline state}, Cr {Creatine measurement}, CAD {Coronary arteriosclerosis}, heart block {Heart block}, pacemaker placement {Implantation of cardiac pacemaker}, BPH {Benign prostatic hyperplasia}, NIDDM {Diabetes mellitus type 2}, shortness of breath {Dyspnea}, productive cough {Productive cough}, greenish sputum {Productive cough -green sputum}, malaise {Malaise}, baseline {Baseline state}, able to ambulate {Able to walk}, short of breath {Dyspnea}, worse {Patient's condition worsened}, chills {Chill}, no fever {Temperature normal}, rigors {Rigor}, checked his 
temperature {Monitoring of patient temperature}, not elevated {Temperature normal}, chest 
pain {Chest pain}, abdominal pain {Abdominal pain}, dysuria {Dysuria}, rhinorrhea {Nasal discharge}, myalgias {Muscle pain}, headaches {Headache}, Exam {Physical examination procedure}, wheezing {Wheezing}, good air movement {Breath normal}, oxygen saturations {Finding of oxygen saturation}, Labs {Laboratory test}, K {Blood potassium measurement}, Cr {Creatine measurement}, baseline {Baseline state}, WBC {White blood cell count}, H/H {Measurement of total hemoglobin concentration and hematocrit}, Flu A/B PCR {Analysis using quantitative fluorescent polymerase chain reaction technique}, Influenza A {Influenza A virus present}, CXR {Plain chest X-ray}, consolidation {Lung consolidation}, right lung base {Structure of base of right lung}, nebs {Nebulizer therapy}, azithromycin {Antibiotic therapy}, prednisone {Steroid therapy}, febrile {Fever}, Nasal Cannula {Oxygen administration by nasal cannula}, dyspnea {Dyspnea}, improved {Patient's condition improved}, breathing treatments {Inhalation therapy procedure}, cough {Cough}, at rest {Cough at rest}, winded {Winded}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
DM (diabetes mellitus), type 2, uncontrolled, with renal 
complications  
Abdominal aortic aneurysm  
Back pain  
Hypertension  
Pacemaker for heart block  
Vitamin B 12 deficiency  
Chronic kidney disease (CKD), stage IV (severe)  
SPINAL STENOSIS, UNSPEC SITE  
CORONARY ARTERY DISEASE, UNSPEC VESSEL TYPE  
COPD 
BPH
GERD
Hypercholesterolemia
Asbestosis
Macular degeneration
Iron deficiency anemia
s/p left TKR
s/p carotid endarterectomy

 

###RESPONSE: DM (diabetes mellitus), type 2, uncontrolled {Type II diabetes mellitus uncontrolled}, renal 
complications {Renal disorder due to type 2 diabetes mellitus}, Abdominal aortic aneurysm {Abdominal aortic aneurysm}, Back pain {Backache}, Hypertension {Hypertensive disorder, systemic arterial}, Pacemaker {Implantation of cardiac pacemaker}, heart block {Heart block}, Vitamin B 12 deficiency {Cobalamin deficiency}, Chronic kidney disease {Chronic kidney disease}, CKD), stage IV {Chronic kidney disease stage 4}, SPINAL STENOSIS {Spinal stenosis}, CORONARY ARTERY DISEASE {Coronary arteriosclerosis}, COPD {Chronic obstructive lung disease}, BPH {Benign prostatic hyperplasia}, GERD {Gastroesophageal reflux disease}, Hypercholesterolemia {Hypercholesterolemia}, Asbestosis {Asbestosis}, Macular degeneration {Degenerative disorder of macula}, Iron deficiency anemia {Iron deficiency anemia}, left TKR {Total replacement of left knee joint}, carotid endarterectomy {Carotid endarterectomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
non-contributory 
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:  
VS - 98.0 165/63 (165-183/63-79) 71 22 98% 2L NC 
I/O: -500mL
GENERAL: Alert and oriented x 3. NAD  
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae, 
patent nares, MMM, good dentition, nontender supple neck, no 
LAD, no JVD  
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs  
LUNG: Faint expiratory wheezes with good air entry. Decreased 
breath sounds in right lung base. 
ABDOMEN: obese, nontender, nondistended, normoactive BS 
EXTREMITIES: 1+ pretibial edema. moving all extremities well, no 
cyanosis,or clubbing PULSES: 2+ DP pulses bilaterally  
NEURO: CN II-XII intact  
SKIN: warm and well perfused, no excoriations or lesions, no 
rashes  

DISCHARGE PHYSICAL EXAM:
Objective:  
VS - 98.3 70 18 161/76 96 on 0.5% 
BG ___ 181
Wt 92.9<-92.9
___ 
GENERAL: Alert and oriented x 3. NAD  
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae, 
patent nares, MMM, good dentition, nontender supple neck, no 
LAD, no JVD  
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs  
LUNG: CTAB. No wheezes, rhonchi. 
ABDOMEN: obese, nontender, nondistended, normoactive BS 
EXTREMITIES: 2+ pitting edema to ankles; moving all extremities 
well, no cyanosis,or clubbing 
PULSES: 2+ DP pulses bilaterally  
NEURO: CN II-XII intact  
SKIN: warm and well perfused, no excoriations or lesions, no 
rashes
 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, NC {Normal head}, I/O {Measuring intake and output}, GENERAL {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclerae {White sclera}, pink conjunctivae {Conjunctiva normal}, nares {Structure of anterior naris}, MMM {Moist oral mucosa}, good dentition {Normal dentition}, nontender {Abdominal tenderness}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, LUNG {Examination of respiratory system}, wheezes {Wheezing}, good {Normal breath sounds}, air entry {Audible inspiration}, Decreased 
breath sounds {Decreased breath sounds}, right lung base {Structure of base of right lung}, ABDOMEN {Examination of abdomen}, obese {Obese}, nontender {Abdominal tenderness}, nondistended {Normal abdominal contour}, normoactive BS {Normal bowel sounds}, EXTREMITIES {Examination of limb}, edema {Edema}, all extremities {All extremities}, cyanosis {Cyanosis}, clubbing {Clubbing}, PULSES {Pulse finding}, 2+ DP pulses {Dorsalis pulse present}, NEURO {Neurological examination}, CN II-XII intact {Normal central nervous system}, SKIN {Examination of skin}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Lesion}, rashes {Eruption of skin}, VS {Vital signs finding}, RA {Breathing room air}, Alert {Mentally alert}, oriented x 3 {Oriented to person, time and place}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, AT/NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclerae {White sclera}, pink conjunctivae {Conjunctiva normal}, nares {Structure of anterior naris}, MMM {Moist oral mucosa}, good dentition {Normal dentition}, nontender {Tenderness of neck}, supple neck {Normal movement of neck}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, S1/S2 {Heart sounds normal}, murmurs {Heart murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, LUNG {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, obese {Obese}, nontender {Abdominal tenderness}, nondistended {Normal abdominal contour}, normoactive BS {Normal bowel sounds}, EXTREMITIES {Examination of limb}, edema {Edema}, ankles {Ankle edema}, moving all extremities {Does move all four limbs}, cyanosis {Cyanosis}, clubbing {Clubbing}, PULSES {Pulse finding}, 2+ DP pulses {Dorsalis pulse present}, NEURO {Neurological examination}, CN II-XII intact {Normal central nervous system}, SKIN {Examination of skin}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Skin lesion}, rashes {Eruption of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 02:55PM BLOOD WBC-9.6 RBC-4.05* Hgb-12.3* Hct-36.8* 
MCV-91 MCH-30.5 MCHC-33.6 RDW-14.3 Plt ___
___ 02:55PM BLOOD Neuts-91.8* Lymphs-3.3* Monos-2.6 Eos-2.0 
Baso-0.2
___ 02:55PM BLOOD Glucose-164* UreaN-45* Creat-3.1* Na-142 
K-5.4* Cl-107 HCO3-24 AnGap-16
___ 07:30AM BLOOD proBNP-3750*
___ 07:30AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.8

IMAGING:
___ CXR  
Calcified pleural plaques. Although there is no prior to assess 
for interval change, there is suspected superimposed 
consolidation at the right lung base which could represent 
pneumonia. Correlation with prior exams would be helpful to 
assess for interval change. Followup will be necessary.  

EKG ___ per Atrius  
Underlying sinus rhythm with 1st degree AV block  

PFTS ___  
FEV1/FVC .62 (87% predicted) 

___ RENAL ULTRASOUND: IMPRESSION: Preliminary 
Report:Slightly increased parenchymal echogenicity bilaterally 
may be seen in the setting of chronic renal disease. No 
hydronephrosis. 

DISCHARGE LABS:

___ 06:20AM BLOOD WBC-7.1 RBC-3.85* Hgb-11.8* Hct-34.4* 
MCV-89 MCH-30.5 MCHC-34.2 RDW-14.0 Plt ___
___ 06:20AM BLOOD Glucose-127* UreaN-70* Creat-3.7* Na-139 
K-4.5 Cl-105 HCO3-23 AnGap-16
___ 06:20AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.___ year old male with hx of COPD p/w with increased shortness of 
breath. He was found to have influenza, COPD exacerbation, ___ 
on CKD and lower extremity edema. He was treated with 
oseltamivir, prednisone, and azithromcyin. He left against 
medical advice one day prior to planned discharge. 

# Influenza/pneumonia: Patient presented with fever, cough with 
green sputum and flu positivity with CXR suggesting right lung 
consolidation. Patient received ceftriaxone and azithromycin in 
the ED for bacterial pneumonia/COPD exacerbation and was started 
on Oseltamivir for influenza. Given that patient appeared 
clinically well without elevated wbc, ceftriaxone was 
discontinued (as bacterial pneumonia was less suspected). His 
cough improved with treatment. He was unable to be weaned off of 
supplemental O2 (ambulatory saturation on discharge 86%) and he 
was discharged with supplemental O2. Lingering O2 requirment 
likely due to infection in setting of COPD. 

# Acute on chronic kidney injury: Most likely due to obstruction 
secondary to BPH. Admission creatinine was 3.1, up from a 
baseline of 2.8. FeNA was 11%, consistent with obstruction. 
Patient had good urine output, so he did not have foley placed. 
Renal ultrasound showed no hydronephrosis. Cr continued to 
uptrend and stabilized at 3.7. FeUrea on day of discharge was 
53%, suggestive of more of an intrinsic pathology - likely ATN 
secondary to obstructive acute kidney injury. He also had 
increased UOP, suggestive of post-ATN diuresis. 

 # Lower extremity edema: Patient presented with 3+ pitting 
edema to the knees bilaterally. He does not have a history of 
congestive heart failure but BNP was elevated to 3750, which is 
consistent with heart failure diagnosis. Patient received IVFs 
on admission which may have further exacerbated the issue. No 
evidence to suggest heart failure causing his dyspnea symptoms. 
No lasix was given due to ___, however, patient autodiuresed and 
swelling was minimal on discharge. He should have outpatient 
echocardiogram. 

# Nausea: Patient had onset of nausea and difficulty tolerating 
PO. He reported that this sometimes occurs at home. He was given 
reglan and a GI cocktail with little effect. Most likely due to 
oseltamivir side effect vs, less likely, gastroparesis. Patient 
was tolerating clears when he left against medical advice. 

# COPD with acute exacerbation: Patient has a history of COPD 
not on home O2. His presentation was also consistent with a COPD 
exacerbation. He received steroids and azithromycin in the ED. 
He continued PO prednisone for a planned 5 day total course. He 
was unable to be weaned off of supplemental O2 (ambulatory 
saturation on discharge 86%) and he was discharged with 
supplemental O2. Lingering O2 requirment likely due to infection 
in setting of COPD. 

# Hyperkalemia: Likely from CKD. This was within normal limits 
on discharge. 

# Type 2 DM (diabetes mellitus), noninsulin dependent: Last 
HbA1C 6.5 in ___. Patient on glimepiride at home. 
Glimepiride was held on admission but restarted on discharge.  

# Hypertension: He continued home labetalol and amlodipine. 

# CAD: He continued home aspirin and statin.  

# BPH: He continued home finasteride and tamsulosin 

TRANSITIONAL ISSUES:
-Discharge weight: 92.9 kg
-Needs TTE to evaluate new CHF
-Patient will continue prednisone 40mg, azithromycin and 
oseltamivir until ___ need to increase Tamsulosin given symptoms of BPH causing 
___
-Patient's blood glucoses elevated while on prednisone 
-Patient was started on preventative COPD medications
-Patient will need oxygen on discharge given drop in sats while 
ambulating.
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Plt {Platelet count}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, CXR {Plain chest X-ray}, Calcified {Pathologic calcification, calcified structure}, pleural plaques {Pleural plaque}, consolidation {Lung consolidation}, right lung base {Structure of base of right lung}, pneumonia {Pneumonia}, exams {Evaluation procedure}, EKG {Electrocardiographic procedure}, sinus rhythm {Sinus rhythm}, 1st degree AV block {First degree atrioventricular block}, PFTS {Measurement of respiratory function}, FVC {Finding of forced vital capacity}, RENAL ULTRASOUND {Echography of kidney}, chronic renal disease {Chronic kidney disease}, hydronephrosis {Hydronephrosis}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Plt {Platelet count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, COPD {Chronic obstructive lung disease}, increased {Patient's condition worsened}, shortness of 
breath {Dyspnea}, influenza {Influenza}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, CKD {Chronic kidney disease}, lower extremity edema {Edema of lower extremity}, prednisone {Steroid therapy}, azithromcyin {Antibiotic therapy}, left against 
medical advice {Left against medical advice}, Influenza {Influenza}, pneumonia {Pneumonia}, fever {Fever}, cough {Productive cough}, green sputum {Productive cough -green sputum}, CXR {Plain chest X-ray}, right {Right lung structure}, lung 
consolidation {Lung consolidation}, azithromycin {Antibiotic therapy}, bacterial pneumonia {Bacterial pneumonia}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, started {New medication added}, influenza {Influenza}, elevated wbc {White blood cell count outside reference range}, discontinued {Recommendation to stop drug treatment}, bacterial pneumonia {Bacterial pneumonia}, cough {Cough}, improved with treatment {Good therapeutic response}, O2 {Oxygen therapy}, saturation {Finding of oxygen saturation}, O2 {Oxygen therapy}, infection {Infectious disease}, COPD {Chronic obstructive lung disease}, Acute on chronic kidney injury {Acute-on-chronic renal failure}, obstruction {Urinary tract obstruction}, BPH {Benign prostatic hyperplasia}, creatinine {Creatinine measurement}, baseline {Baseline state}, FeNA {Measurement of fractional excretion of sodium}, obstruction {Urinary tract obstruction}, good urine output {Increased urine output}, foley placed {Catheterization of urinary bladder}, Renal ultrasound {Echography of kidney}, hydronephrosis {Hydronephrosis}, Cr {Creatine measurement}, uptrend {Serum creatinine above reference range}, ATN {Acute tubular necrosis}, obstructive {Urinary tract obstruction}, acute kidney injury {Acute kidney injury}, increased UOP {Increased urine output}, ATN {Acute tubular necrosis}, diuresis {Diuresis}, Lower extremity edema {Edema of lower extremity}, 3+ pitting 
edema {3+ pitting edema}, knees {Edema of knee}, congestive heart failure {Congestive heart failure}, BNP {Brain natriuretic peptide measurement}, elevated {Complement level above reference range}, heart failure {Heart failure}, IVFs {Administration of intravenous fluids}, No 
evidence {No abnormality detected}, heart failure {Heart failure}, dyspnea {Dyspnea}, lasix {Diuretic therapy}, autodiuresed {Increased urine output}, swelling {Swelling}, minimal {Symptom mild}, echocardiogram {Echocardiography}, Nausea {Nausea}, nausea {Nausea}, tolerating {Tolerating diet}, side effect {Medication side effects present}, gastroparesis {Gastroparesis}, tolerating clears {Tolerating oral fluid}, left against medical advice {Left against medical advice}, COPD {Chronic obstructive lung disease}, acute exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD {Chronic obstructive lung disease}, home O2 {Home oxygen therapy}, COPD 
exacerbation {Acute exacerbation of chronic obstructive airways disease}, steroids {Steroid therapy}, azithromycin {Antibiotic therapy}, prednisone {Steroid therapy}, O2 {Oxygen therapy}, saturation {Finding of oxygen saturation}, O2 {Oxygen therapy}, infection {Infectious disease}, COPD {Chronic obstructive lung disease}, Hyperkalemia {Hyperkalemia}, CKD {Chronic kidney disease}, normal {Serum potassium level within reference range}, Type 2 DM (diabetes mellitus) {Diabetes mellitus type 2}, HbA1C {Hemoglobin A1c measurement}, held {Recommendation to stop drug treatment}, restarted {Restart of medication}, Hypertension {Hypertensive disorder, systemic arterial}, CAD {Coronary arteriosclerosis}, aspirin {Administration of aspirin}, statin {Administration of prophylactic statin}, BPH {Benign prostatic hyperplasia}, weight {Weight finding}, TTE {Transthoracic echocardiography}, evaluate {Evaluation procedure}, CHF {Congestive heart failure}, prednisone {Steroid therapy}, azithromycin {Antibiotic therapy}, BPH {Benign prostatic hyperplasia}, blood glucoses elevated {Glucose in blood specimen above reference range}, prednisone {Steroid therapy}, started {New medication added}, COPD {Chronic obstructive lung disease}, drop in sats {Oxygen saturation below reference range}, ambulating {Fully mobile}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.25 mcg PO EVERY OTHER DAY 
2. Labetalol 200 mg PO BID 
3. Pantoprazole 40 mg PO Q12H 
4. Pravastatin 40 mg PO QPM 
5. Amlodipine 5 mg PO DAILY 
6. Tamsulosin 0.4 mg PO DAILY 
7. glimepiride 1 mg oral BID 
8. Finasteride 5 mg PO DAILY 
9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain 
10. Cyanocobalamin 1000 mcg PO DAILY 
11. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 
mg-unit-mg-mg oral daily 
12. Aspirin 81 mg PO DAILY 

 
Discharge Medications:
1. Amlodipine 5 mg PO DAILY 
2. Aspirin 81 mg PO DAILY 
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY 
4. Cyanocobalamin 1000 mcg PO DAILY 
5. Finasteride 5 mg PO DAILY 
6. Labetalol 200 mg PO BID 
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain 
8. Pantoprazole 40 mg PO Q12H 
9. Pravastatin 40 mg PO QPM 
10. Tamsulosin 0.4 mg PO DAILY 
11. Azithromycin 250 mg PO Q24H 
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1 
Tablet Refills:*0
12. OSELTAMivir 30 mg PO Q24H Duration: 4 Days 
RX *oseltamivir [Tamiflu] 30 mg 1 capsule(s) by mouth daily Disp 
#*1 Capsule Refills:*0
13. PredniSONE 40 mg PO DAILY Duration: 4 Days 
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*2 Tablet 
Refills:*0
14. Tessalon Perles (benzonatate) 100 mg ORAL TID:PRN cough 
RX *benzonatate 100 mg 1 capsule(s) by mouth TID PRN Disp #*30 
Capsule Refills:*0
15. glimepiride 1 mg ORAL BID 
16. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 
mg-unit-mg-mg oral daily 
17. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation 
inhalation BID 
RX *budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/actuation 
1 160 mcg-4.5 mcg inhaled twice a day Disp #*1 Inhaler 
Refills:*0
18. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath, 
wheezing 
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inhaled Q4H 
PRN Disp #*1 Inhaler Refills:*0

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary diagnosis:
Influenza
Pneumonia

Secondary diagnosis:
___ on CKD
Lower extremity edema
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 

###RESPONSE: Home With Service {Home health aide service management}, Influenza {Influenza}, Pneumonia {Pneumonia}, CKD {Chronic kidney disease}, Lower extremity edema {Edema of lower extremity}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___, 

You were admitted to ___ with shortness of breath and cough 
and found to have the flu with superimposed pneumonia. You also 
had a COPD exacerbation. You were treated for these and your 
symptoms improved. You also had acute kidney injury which was 
thought to be from your enlarged prostate. 

Given the swelling in your legs, there is concern for a 
condition in your heart called congestive heart failure. You 
should talk to your primary care doctor about the next steps in 
treatment. You may need to get an ultrasound of your heart to 
get a better look at your heart. 

It is very important that you finish taking all of your 
medications and follow-up with your primary care doctor on ___. 


Despite our recommendation to stay an extra night in the 
hospital, you left ___ against our medical advice. 

It was a pleasure taking care of you, 
Your ___ Doctors
 
___ Instructions:
___

###RESPONSE: shortness of breath {Dyspnea}, cough {Cough}, pneumonia {Pneumonia}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, improved {Patient's condition improved}, acute kidney injury {Acute kidney injury}, enlarged prostate {Large prostate}, swelling {Edema of lower extremity}, legs {Lower limb structure}, heart {Heart structure}, congestive heart failure {Congestive heart failure}, primary care {Primary care management}, ultrasound of your heart {Echocardiography}, heart {Heart structure}, finish taking all of your 
medications {Patient medication education}, follow-up {Follow-up arranged}, primary care {Primary care management}, recommendation to {Recommendation to continue with treatment}, against our medical advice {Left against medical advice}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___           Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Chest Pain
 
Major Surgical or Invasive Procedure:
___: Left heart cath

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Chest Pain {Chest pain}, Left heart cath {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:
The majority of the history of obtained through the patient's 
son and chart review as the patient does not speak ___.  
Mr. ___ is a ___ year old gentleman with history of CAD s/p 
3v CABG in ___, HTN, HLD, DM type II who presents with chest 
pain.  
Substernal chest pain, ___, per patient's son similar to the 
pain that lead to his CABG started last night associated with 
palpitations, diaporesis and dyspnea. The severe pain lasted ___ 
hrs. It improved overnight to ___. He was having difficulty 
sleeping last night because of the pain. He didn't tell anyone 
until his son came back home from work today. Today he tried to 
go down some stairs in his 2 story house and became very 
dyspenic and felt palpitations.  
His son took him to ___ where initial vitals were 
97.3, 76, ___. Significant labs include WBC 13.3. 
BUN/Cr ___. Trop I 0.160 (ref range ___, BNP 58. CXR 
there without acute processes. EKG shows LVH but otherwise no 
evidence of ischemia. He was given ASA 325mg, Nitro SL x 2 and 
Nitro paste with resolution of symptoms and correction of 
hypertension. Vital sign prior to transfer to ___ 134/86 64 16 
100%RA.  
In the ED intial vitals were: 96.9 70 150/78 18 99% 0  
Labs: 11.3 WBC with 12.7% eos. BUN/Cr ___.  
Patient was given: nitro SL x2 with and nitro paste at the OSH 
and morphine 5mg IV once in the ED. Trop <0.01.  
Vitals on transfer: 98 72 120/72 16 97% RA  
On the floor patient currently without chest pain.  
 

###RESPONSE: does not speak {Does not speak}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, DM type II {Diabetes mellitus type 2}, chest 
pain {Chest pain}, Substernal chest pain {Retrosternal pain}, pain {Pain}, CABG {Coronary artery bypass grafting}, palpitations {Palpitations}, diaporesis {Excessive sweating}, dyspnea {Dyspnea}, severe pain {Severe pain}, improved {Patient's condition improved}, difficulty 
sleeping {Difficulty sleeping}, pain {Pain}, dyspenic {Dyspnea}, palpitations {Palpitations}, labs {Laboratory test}, WBC {White blood cell count}, BUN/Cr {Blood urea nitrogen/creatinine ratio}, Trop I {Troponin I measurement}, BNP {Brain natriuretic peptide measurement}, CXR {Plain chest X-ray}, EKG {Electrocardiographic procedure}, LVH {Left ventricular hypertrophy}, no 
evidence of ischemia {Electrocardiogram: no myocardial ischemia}, ASA {Administration of aspirin}, resolution {Problem resolved}, hypertension {Hypertensive disorder, systemic arterial}, Vital sign {Vital signs finding}, vitals {Vital signs finding}, Labs {Laboratory test}, WBC {White blood cell count}, BUN/Cr {Blood urea nitrogen/creatinine ratio}, Trop {Troponin measurement}, Vitals {Vital signs finding}, 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: Diabetes, Dyslipidemia, Hypertension  
2. CARDIAC HISTORY:  
- CABG: 3v CABG in ___. LIMA graft to the LAD and vein grafts 
to a circumflex marginal and the distal right coronary artery.  
- PERCUTANEOUS CORONARY INTERVENTIONS: None  
- PACING/ICD: None  
3. OTHER PAST MEDICAL HISTORY:  
CAD - 3 vessel disease s/p CABG  
HTN  
DM type II  
HLD  
___ disease  
Macroscopic hematuria  
Proteinuria  
cataracts s/p removal of in ___ c/b enucleated eye  
urinary incontinence  
 

###RESPONSE: CARDIAC RISK FACTORS {Assessment for risk of cardiovascular disease}, Diabetes {Diabetes mellitus}, Dyslipidemia {Dyslipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, CABG {Coronary artery bypass grafting}, 3v CABG {Coronary artery bypass grafts x 3}, LIMA graft {Internal mammary-coronary artery bypass graft}, LAD {Structure of anterior descending branch of left coronary artery}, vein grafts {Venous graft}, circumflex marginal {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, distal right coronary artery {Structure of distal portion of right coronary artery}, PERCUTANEOUS CORONARY INTERVENTIONS {Percutaneous coronary intervention}, PACING {Cardiac pacing}, ICD {Automatic implantable cardiac defibrillator in situ}, CAD {Coronary arteriosclerosis}, 3 vessel disease {Triple vessel disease of the heart}, CABG {Coronary artery bypass grafting}, HTN {Hypertensive disorder, systemic arterial}, DM type II {Diabetes mellitus type 2}, HLD {Hyperlipidemia}, Macroscopic hematuria {Frank hematuria}, Proteinuria {Proteinuria}, cataracts {Cataract}, urinary incontinence {Urinary incontinence}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father with ?MI at unknown age. Otherwise no known history of 
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise 
non-contributory.  
 

###RESPONSE: MI {Myocardial infarction}, arrhythmia {Cardiac arrhythmia}, cardiomyopathies {Cardiomyopathy}, sudden cardiac death {Sudden cardiac death}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAMINATION:  
VS: 97.8 77 176/91 20 100%RA  
GENERAL: NAD  
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were 
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.  

NECK: Supple with JVP of 8 cm.  
CARDIAC: PMI located in ___ intercostal space, midclavicular 
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or 
S4.  
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp 
were unlabored, no accessory muscle use. CTAB, no crackles, 
wheezes or rhonchi.  
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not 
enlarged by palpation. No abdominal bruits.  
EXTREMITIES: No c/c/e. 

 
 

###RESPONSE: PHYSICAL EXAMINATION {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, 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}, xanthelasma {Xanthelasma}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, 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}, S4 {Fourth heart sound, S>4<, 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}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, Abd {Examination of abdomen}, enlarged {Enlargement}, palpation {Palpation}, abdominal bruits {Abdominal bruit}, EXTREMITIES {Examination of 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: Pertinent Results:
Admission Labs
___ 12:15AM BLOOD WBC-11.3* RBC-4.98 Hgb-13.8* Hct-41.3 
MCV-83 MCH-27.8 MCHC-33.5 RDW-14.6 Plt ___
___ 12:15AM BLOOD Neuts-64.1 ___ Monos-3.6 
Eos-12.7* Baso-0.7
___ 12:15AM BLOOD ___ PTT-38.8* ___
___ 12:15AM BLOOD Glucose-146* UreaN-27* Creat-1.4* Na-138 
K-5.1 Cl-105 HCO3-22 AnGap-16
___ 12:15AM BLOOD CK(CPK)-98
___ 12:15AM BLOOD CK-MB-5
___ 12:15AM BLOOD cTropnT-0.01
___ 06:00AM BLOOD cTropnT-<0.01
___ 12:15AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.3

Discharge LAbs: 

Pertinent 
###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}, CK(CPK {Creatine kinase measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac 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:
CT Abd/Pelvis ___
IMPRESSION: 
1. Small retroperitoneal hematoma with hemorrhage extending into 
a right inguinal hernia sac and alongside the right spermatic 
cord.
2. Small hiatal hernia.
3. Calcifications within the pancreas, likely sequela of chronic 
pancreatitis.

Echo ___:
The left atrium is normal in size. The estimated right atrial 
pressure is ___ mmHg. There is mild symmetric left ventricular 
hypertrophy with normal cavity size and regional/global systolic 
function (LVEF>55%). Right ventricular chamber size and free 
wall motion are normal. The diameters of aorta at the sinus, 
ascending and arch levels are normal. The aortic valve leaflets 
(3) appear structurally normal with good leaflet excursion and 
no aortic stenosis or aortic regurgitation. The mitral valve 
leaflets are mildly thickened. Trivial mitral regurgitation is 
seen. There is borderline pulmonary artery systolic 
hypertension. There is no pericardial effusion. 

IMPRESSION: Normal biventricular size and global systolic 
function. Mild to moderate tricuspid regurgitation.

Compared with the prior study (images reviewed) of ___, 
the basal inferior wall has normal function on the current 
study. 

L Heart Cath: 
Report pending, please see finalized report when available
 

###RESPONSE: CT Abd/Pelvis {Computed tomography of abdomen and pelvis}, retroperitoneal hematoma {Retroperitoneal hematoma}, hemorrhage {Hemorrhage}, right inguinal hernia {Right inguinal hernia}, sac {Hernia sac}, right spermatic 
cord {Structure of right spermatic cord}, hiatal hernia {Hiatal hernia}, Calcifications {Pathologic calcification, calcified structure}, pancreas {Pancreatic structure}, chronic 
pancreatitis {Chronic pancreatitis}, left atrium {Left atrial structure}, normal in size {Normal size}, right atrial {Right atrial structure}, mild symmetric left ventricular 
hypertrophy {Mild left ventricular hypertrophy}, normal cavity size {Normal size}, regional/global systolic 
function {Normal left ventricular systolic function and wall motion}, Right ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Normal ventricular wall motion}, aorta at the sinus {Structure of sinus of Valsalva}, ascending {Ascending aorta structure}, arch {Aortic arch structure}, normal {Normal size}, aortic valve leaflets {Structure of cardiac valve leaflet}, structurally normal {Aortic valve normal}, aortic 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}, biventricular {Cardiac ventricular structure}, size {Normal size}, systolic 
function {Normal left ventricular systolic function and wall motion}, Mild {Mild tricuspid valve regurgitation}, moderate tricuspid regurgitation {Moderate tricuspid valve regurgitation}, inferior wall {Structure of myocardium of diaphragmatic region}, normal function {Normal cardiac function}, L Heart Cath {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: Brief Hospital Course:
___ w/ hx of CAD s/p CABG in ___ transferred from OSH for chest 
pain and shortness of breath. 

Active Issues:
#Chest pain: Negative trops but found to have V5-V6 depression 
on subsequent EKG, concerning for new ischemia. He was diuresed 
given his shortness of breath with improvement and taken to cath 
lab where angiogram showed occluded SVG to OM, appearing chronic 
in nature. Medically optimized and continued on nitro gtt post 
procedure for blood pressure control as symptoms had resolved 
prior to cath. Echo showed Normal biventricular size and global 
systolic function. Mild to moderate tricuspid regurgitation.

#Hematoma: Patient complained of groin pain at cath site, though 
no tenderness to palpation or signs of hematoma. He was found to 
have a small RP hematoma which was not significant in size and 
therefore was managed expectantly. 

Chronic Issues:
# CAD. s/p 3V CABG in ___. LIMA graft to the LAD and vein 
grafts to a circumflex marginal and the distal right coronary 
artery. Continued on ASA, metoprolol, and  Atorvastatin.  

# CKD. Patient's Cr 1.4 appears to be baseline. Cr 1.3 in ___ 
and per PCP note, recent admission to ___ Cr was 1.4  

# HTN: continued amlodipine at home dose 2.5 BID

# DM type II: continued on home lantus 40mg QHS, held 70/30 
whiel inpatient and given ISS with adequate control of blood 
glucose.  

# HLD: Atorvasatin as above was continued. 

# Esosinophillia. Patient has had chronic esosinophilla. Given 
country of origin, sent Strongyloides IgG, pending at time of 
discharge.  

# ___ disease: continued on home dose Carbidopa-Levodopa. 
 

Transitional Issues
#Consider transitioning to metoprolol succinate as an 
outpatient, and uptitration as needed. Could consider carvedilol 
for better HTN and rate control
#Imdur uptitrated to assist with angina, cont as needed as an 
outpatient
___ not used given hx of hyperkalemia
 

###RESPONSE: CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, chest 
pain {Chest pain}, shortness of breath {Dyspnea}, Chest pain {Chest pain}, trops {Troponin measurement}, V5 {Lead site V5}, V6 {Lead site V6}, EKG {Electrocardiographic procedure}, ischemia {Ischemia}, diuresed {Diuretic therapy}, shortness of breath {Dyspnea}, improvement {Patient's condition improved}, angiogram {Angiography}, occluded {Complete obstruction}, SVG {Aortocoronary artery bypass graft with saphenous vein graft}, OM {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, chronic {Chronic total occlusion of coronary artery}, cath {Cardiac catheterization}, Echo {Echocardiography}, biventricular {Cardiac ventricular structure}, size {Normal size}, systolic function {Normal left ventricular systolic function and wall motion}, Mild {Mild tricuspid valve regurgitation}, moderate tricuspid regurgitation {Moderate tricuspid valve regurgitation}, Hematoma {Hematoma}, groin pain {Inguinal pain}, cath site {Vascular catheter insertion site}, tenderness to palpation {Abdominal tenderness}, signs {Sign}, hematoma {Hematoma}, RP hematoma {Retroperitoneal hematoma}, CAD {Coronary arteriosclerosis}, 3V CABG {Coronary artery bypass grafts x 3}, LIMA graft {Coronary artery bypass grafting using free left internal thoracic artery graft}, LAD {Structure of anterior descending branch of left coronary artery}, vein 
grafts {Venous graft}, circumflex marginal {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, distal right coronary 
artery {Structure of distal portion of right coronary artery}, CKD {Chronic kidney disease}, Cr {Finding of creatinine level}, Cr {Finding of creatinine level}, Cr {Finding of creatinine level}, HTN {Hypertensive disorder, systemic arterial}, DM type II {Diabetes mellitus type 2}, HLD {Hyperlipidemia}, Esosinophillia {Eosinophil count above reference range}, esosinophilla {Eosinophil count above reference range}, HTN {Hypertensive disorder, systemic arterial}, angina {Angina}, hyperkalemia {Hyperkalemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 
2. Metoprolol Tartrate 50 mg PO BID 
3. Aspirin 81 mg PO DAILY 
4. Docusate Sodium 200 mg PO DAILY 
5. Senna 17.2 mg PO BID:PRN constipation 
6. Atorvastatin 40 mg PO QPM 
7. Amlodipine 2.5 mg PO BID 
8. Carbidopa-Levodopa (___) 2 TAB PO TID 
9. 70/30 25 Units Breakfast
70/30 25 Units Dinner
Humalog 40 Units Bedtime

 
Discharge Medications:
1. Amlodipine 2.5 mg PO BID 
2. Aspirin 81 mg PO DAILY 
3. Atorvastatin 40 mg PO QPM 
4. Carbidopa-Levodopa (___) 2 TAB PO TID 
5. Docusate Sodium 200 mg PO DAILY 
6. 70/30 25 Units Breakfast
70/30 25 Units Dinner
Humalog 40 Units Bedtime
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp 
#*30 Tablet Refills:*0
8. Metoprolol Tartrate 50 mg PO BID 
9. Senna 17.2 mg PO BID:PRN constipation 
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually q5min:prn Disp 
#*100 Tablet Refills:*0
11. Cane
LENGTH OF NEED: 13 MONTHS
EQUIPMENT: STANDARD CANE

 

###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:
Chest pain
Coronary ARtery Disease
Secondary Diagnoses:
Chronic Kidney Disease
DIabetes Mellitus, Type 2
Hypertension
Hyperlipidemia
___ Disease
 
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}, Chest pain {Chest pain}, Coronary ARtery Disease {Coronary arteriosclerosis}, Chronic Kidney Disease {Chronic kidney disease}, DIabetes Mellitus, Type 2 {Diabetes mellitus type 2}, Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___,

You were admitted for chest pain in the presence of complex 
coronary disease.  You had changes in your EKG which was 
concerning for new blockage and were taken for a cardiac 
catherization.  You were found to have a chronically occluded 
vessel from your previous coronary bypass surgery.  An echo was 
ordered, but was not obtained to monitor your heart function and 
should be ordered by your primary cardiologist if desired.  You 
were having groin pain which kept you in the hospital for one 
additional night and was controlled.

We have increased your dose of imdur. You should continue your 
remaining medications.

Please follow up with your PCP/cardiologist next week. Please 
call your PCP on the next business day to make an appointment.  
He is aware of your hospitalization.

Please be well.

Your ___ Team
 

###RESPONSE: chest pain {Chest pain}, coronary disease {Coronary arteriosclerosis}, EKG {Electrocardiographic procedure}, blockage {Coronary occlusion}, cardiac 
catherization {Cardiac catheterization}, occluded 
vessel {Coronary artery bypass graft occlusion}, coronary bypass surgery {Coronary artery bypass grafting}, echo {Echocardiography}, groin pain {Inguinal pain}, increased {Increasing dosage of medication}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Aspirin
 
Attending: ___.
 
Chief Complaint:
Chest Discomfort
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Aspirin {Allergy to aspirin}, Chest Discomfort {Chest discomfort}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
EVENTS / HISTORY OF PRESENTING ILLNESS: The pt is a ___ F with 
PMH of Asthma admitted with complains of sub-scapular chest pain 
radiating to the back for the past week. Pain has been constant 
in nature, with cramping. No numbness/tingling in the arms and 
legs. Pt Pt reports her symptoms began two weeks ago after 
breaking into fever, did not take temp., and night sweats. She 
then developed diffuse muscles aches greatest over her breasts, 
chest wall and upper extremities b/l. Denies changes with 
position. States it is mildly worse with deep inspiration. She 
does report increased physical activity over the past two weeks 
with ___ cleaning. Denies pain at rest. She denies recent 
sick contacts. No travel history. Reports night sweats for past 
two weeks. The pt does relate significant EtOH history, drinking 
approx 1 glass of wine every other day, then on the weeks she 
drinks one bottle on ___, then ___ gladsses on ___. 
Reports remote cocaine history, clean for past ___ years. Pt 
reports history of asthma, no change is symptoms and no increase 
in albuterol usage, reports no change of symptoms with exertion, 
does have occassional dyspnea.  
.  
In the ED, Vitals T 98.4, HR 72, RR 18, BP 121/98, Sat 95% RA. 
She was given aspirin 325mg daily and motrin 600mg once. On 
arrival to the floor the patient is resting comfortably and in 
no acute distress.  
.

.  
.  
On review of systems, she denies any prior history of stroke, 
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the 
time of surgery, joint pains, cough, hemoptysis, black stools or 
red stools. She denies exertional buttock or calf pain. All of 
the other review of systems were negative.  
.  
Cardiac review of systems is notable for absence of chest pain, 
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, 
ankle edema, palpitations, syncope or presyncope. 
 

###RESPONSE: Asthma {Asthma}, chest pain {Chest pain}, radiating {Radiating pain}, Pain {Pain}, constant {Constant pain}, cramping {Cramping pain}, numbness/tingling {Numbness and tingling sensation of skin}, arms {Upper limb structure}, legs {Lower limb structure}, fever {Fever}, temp {Body temperature finding}, night sweats {Night sweats}, diffuse {Diffuse pain}, muscles aches {Muscle pain}, breasts {Breast structure}, chest wall {Chest wall structure}, upper extremities {Upper limb structure}, position {Pain provoked by movement}, worse {Increased pain}, increased physical activity {Increased physical activity}, pain at rest {Pain provoked by rest}, travel {Travel abroad}, night sweats {Night sweats}, EtOH {Alcohol abuse}, drinking {Current drinker of alcohol}, drinks {Current drinker of alcohol}, cocaine {Cocaine abuse}, asthma {Asthma}, exertion {Dyspnea on exertion}, dyspnea {Dyspnea}, Vitals {Vital signs finding}, aspirin {Administration of aspirin}, comfortably {Breathing easily}, no acute {No abnormality detected}, distress {Distress}, 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}, joint pains {Joint pain}, cough {Cough}, hemoptysis {Hemoptysis}, black stools {Dark stools}, red stools {Red stools}, exertional {Pain provoked by exertion}, buttock {Pain in buttock}, calf pain {Pain in calf}, review of systems {Review of systems}, negative {No pathologic diagnosis}, Cardiac review of systems {Cardiovascular physical examination}, chest pain {Chest pain}, dyspnea on exertion {Dyspnea on exertion}, paroxysmal nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, ankle edema {Ankle edema}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
HTN  
Obesity  
Endometriosis  
Asthma  
Stress Incontinence  
Cardiac Risk Factors: Hypertension  
 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, Obesity {Obesity}, Endometriosis {Endometriosis}, Asthma {Asthma}, Stress Incontinence {Genuine stress incontinence}, Cardiac Risk Factors {Assessment for risk of cardiovascular disease}, Hypertension {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
There is a family history of father MI age ___.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VS - T 98.8, HR 76, BP 134/62, O2 98%2L  
Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect 
appropriate.  
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were 
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.  

Neck: Supple with flat JVP.  
CV: PMI located in ___ intercostal space, midclavicular line. 
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.  
Chest: No chest wall deformities, scoliosis or kyphosis. Resp 
were unlabored, no accessory muscle use. CTAB, no crackles, 
wheezes or rhonchi.  
TTP over left breast, substernal chest tenderness to palp, also 
tenderness over shoulders and triceps  
Abd: Soft, NT/ND. No HSM or tenderness. Abd aorta not enlarged 
by palpation. No abdominial bruits.  
Ext: No c/c/e. No femoral bruits.  
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.  
.  
Pulses:  
Right: Carotid 2+ Femoral 2+ DP 2+ ___ 2+  
Left: Carotid 2+ Femoral 2+ DP 2+ ___ 2+  

 

###RESPONSE: VS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, Gen {General examination of patient}, WDWN {Well nourished}, middle aged {Middle-age}, NAD {No abnormality detected}, Oriented x3 {Oriented to person, time and place}, Mood {Level of mood - normal}, affect {Mood finding}, HEENT {Physical examination procedure}, NC {Normal head}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva were 
pink {Conjunctiva normal}, pallor {Pallor of skin of face}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthalesma {Xanthelasma}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, CV {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}, Chest {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}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, TTP {Tenderness}, left breast {Left breast structure}, substernal {Structure of substernal region}, tenderness {Tenderness}, palp {Palpation of abdomen}, tenderness {Tenderness}, shoulders {Shoulder region structure}, triceps {Triceps brachii muscle structure}, Abd {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, Abd {Examination of abdomen}, enlarged {Enlargement}, palpation {Palpation}, abdominial bruits {Abdominal bruit}, Ext {Examination of limb}, No c/c/e {No abnormality detected}, femoral bruits {Femoral bruit}, Skin {Examination of skin}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, Carotid 2 {Normal carotid arterial pulse}, 2+ DP {Dorsalis pulse present}, Carotid 2 {Normal carotid arterial pulse}, 2+ DP {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:
___ 03:20PM   WBC-4.1# RBC-3.98* HGB-11.6* HCT-34.8* MCV-87 
MCH-29.2 MCHC-33.5 RDW-14.0
___ 03:20PM   NEUTS-19* BANDS-0 LYMPHS-66* MONOS-10 EOS-4 
BASOS-0 ATYPS-1* ___ MYELOS-0
___ 03:20PM   PLT SMR-NORMAL PLT COUNT-309
___ 03:20PM   ___ PTT-26.1 ___
___ 03:20PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG 
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:20PM   TSH-0.90
___ 03:20PM   ALT(SGPT)-33 AST(SGOT)-46* CK(CPK)-936* ALK 
PHOS-38* TOT BILI-0.2
___ 03:20PM BLOOD ALT-33 AST-46* CK(CPK)-936* AlkPhos-38* 
TotBili-0.2
___ 03:20PM BLOOD CK-MB-9 cTropnT-0.03*
___ 09:32PM BLOOD CK(CPK)-777*
___ 09:32PM BLOOD CK-MB-7 cTropnT-0.02*
___ 06:00AM BLOOD CK-MB-5 cTropnT-0.01
___ 06:00AM BLOOD CK(CPK)-609*
.
CXR ___
FINDINGS: Lung volumes are diminished. No consolidation or 
superimposed edema is evident. Mild tortuosity of the thoracic 
aorta is again demonstrated. The cardiac silhouette is within 
normal limits for size accounting for patient and technical 
factors. No effusion or pneumothorax is noted. The visualized 
osseous structures are unremarkable.

IMPRESSION: Low lung volumes, but otherwise, no superimposed 
acute process.
.
EKG demonstrated NSR, Nl axis and intervals, low voltage in AVF, 
TWF V5 and V6 with no significant change compared with prior 
dated ___.  

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PLT {Platelet count}, NORMAL {No abnormality detected}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}, ASA {Aspirin specific immunoglobulin E antibody measurement}, NEG {No abnormality detected}, ETHANOL {Blood ethanol measurement}, NEG {No abnormality detected}, ACETMNPHN {Acetaminophen measurement}, NEG {No abnormality detected}, bnzodzpn {Benzodiazepine measurement}, NEG {No abnormality detected}, barbitrt {Barbiturates measurement}, NEG {No abnormality detected}, tricyclic {Tricyclic antidepressant measurement}, NEG {No abnormality detected}, TSH {Thyroid stimulating hormone measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, CK(CPK {Creatine kinase measurement}, ALK 
PHOS {Alkaline phosphatase measurement}, TOT BILI {Bilirubin, total measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, CK(CPK {Creatine kinase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total 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}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK(CPK {Creatine kinase measurement}, CXR {Plain chest X-ray}, Lung volumes {Finding of respiratory volume}, consolidation {Consolidation}, edema {Edema}, Mild {Symptom mild}, tortuosity {Tortuosity}, thoracic 
aorta {Thoracic aorta structure}, cardiac {Heart structure}, normal {Normal size}, size {Normal size}, effusion {Pleural effusion}, pneumothorax {Pneumothorax}, osseous structures {Bone structure}, unremarkable {Imaging result normal}, lung volumes {Finding of respiratory volume}, EKG {Electrocardiographic procedure}, NSR {Normal sinus rhythm}, axis {Electrocardiographic axis finding}, intervals {Finding of electrocardiogram waveform}, AVF {aVF}, TWF {Flattened T wave}, no significant {No abnormality detected}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Patient is a ___ F with PMH of Asthma admitted with complains 
of diffuse muscle aches including sub-scapular chest pain 
radiating to the back for the past week, found to have elevated 
CK to 936  
.  
#. Diffuse Musculoskeletal Pain - Pt presented with complaints 
of diffuse musculoskeletal pain, worse with movement and found 
to have elevated CK to 900s. In reviewing labs pt with 
chronically elevated CK of unclear etiology. Etiology may be 
recent overuse at home in the setting of deconditioning vs viral 
myositis. Pt had recent fever/chills prior to onset of muscle 
pain, could be consistent with infectious etiology. Pt may also 
have myositis related to EtOH use. She ruled out for myocardial 
ischemia with three sets of negative cardiac enzymes. She was 
discharged home with close outpatient follow up for further 
management. 
.  
#. Rhythm - NSR  
.  
#. Asthma - pt denies symptoms of dyspnea currently, no wheezing 
on exam. Continued on outpatient regimen of advair and albuterol 
 
.  
#. HTN - continue HCTZ  
.  
 

###RESPONSE: Asthma {Asthma}, diffuse {Diffuse pain}, muscle aches {Muscle pain}, chest pain {Chest pain}, radiating {Radiating pain}, elevated 
CK {Creatine kinase level above reference range}, Diffuse {Diffuse pain}, Musculoskeletal Pain {Musculoskeletal pain}, diffuse {Diffuse pain}, musculoskeletal pain {Musculoskeletal pain}, worse {Increased pain}, elevated CK {Creatine kinase level above reference range}, labs {Laboratory test}, elevated CK {Creatine kinase level above reference range}, viral 
myositis {Viral myositis}, fever {Fever}, chills {Chill}, muscle 
pain {Muscle pain}, infectious {Infectious disease}, myositis {Myositis}, EtOH use {Finding of alcohol intake}, myocardial 
ischemia {Myocardial ischemia}, negative cardiac enzymes {Cardiac enzymes within reference range}, outpatient follow up {Follow-up arranged}, Rhythm {Normal sinus rhythm}, NSR {Normal sinus rhythm}, Asthma {Asthma}, dyspnea {Dyspnea}, wheezing {Wheezing}, exam {Physical examination procedure}, regimen {Therapeutic regimen}, HTN {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
CURRENT MEDICATIONS:  
Albuterol Sulfate - 0.083 % (0.83 mg/mL) Solution for  
Nebulization - 1 vial po every six (6) hours as needed for SOB  
Albuterol Sulfate - 90 mcg HFA Aerosol Inhaler - 2 puffs po 
every  
six (6) hours as needed for SOB  
Citalopram - 40 mg Tablet - 1 and ___ Tablet(s) by mouth once a  

day  
Fluticasone-Salmeterol [Advair Diskus] - 500 mcg-50 mcg/Dose 
Disk  
with Device - one puff disk twice a day  
Hydrochlorothiazide - 25 mg Tablet - 1 (One) Tablet(s) by mouth  

once a day  
Montelukast [Singulair] - 10 mg Tablet - 1 Tablet(s) by mouth  
once a day  
Medications - OTC  
Omeprazole Magnesium [Prilosec OTC] - 20 mg Tablet, Delayed  
Release (E.C.) - 1 Tablet(s) by mouth once a day  
 
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: 
One (1)  Inhalation Q6H (every 6 hours) as needed for 
wheeze/SOB.  
2. Albuterol 90 mcg/Actuation Aerosol Sig: One (1)  Inhalation 
every ___ hours as needed for shortness of breath or wheezing.  
3. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)  
Inhalation once a day.  
4. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day.  
5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO 
DAILY (Daily).  
6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
7. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) 
Tablet, Delayed Release (E.C.) PO once a day.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary:
1. Myositis

 
Discharge Condition:
Afebrile, VSS, ambulating without assistance

 

###RESPONSE: Myositis {Myositis}, Afebrile {Fever}, VSS {Vital signs finding}, ambulating without assistance {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 with diffuse muscle pain. You have undergone 
bloodwork that has demonstrated no evidence of damage to your 
heart as a cause of this pain. Your bloodwork did show an 
elevation of a muscle enyme called creatine kinase. You will 
follow up with Dr. ___ as an outpatient for continued workup.
.
Your medications have not changed. Please continue to take your 
medications as directed. 
.
Please return or call your primary care physician if you develop 
worsening musculoskeletal pain, or if you develop chest pain or 
shortness of breath. 
 

###RESPONSE: diffuse {Diffuse pain}, muscle pain {Muscle pain}, no evidence {No abnormality detected}, damage {Damage}, heart {Heart structure}, pain {Pain}, elevation {Measurement finding above reference range}, muscle {Skeletal and/or smooth muscle structure}, called {Informing doctor}, creatine {Creatine measurement}, follow up {Follow-up arranged}, workup {Evaluation procedure}, changed {Change of medication}, primary care {Primary care management}, worsening {Increased pain}, musculoskeletal pain {Musculoskeletal pain}, chest pain {Chest pain}, shortness of breath {Dyspnea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
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: 
Ativan / Amoxicillin / Bactrim / Codeine / ibuprofen / Lamictal 
/ naproxen / Tetanus Toxoid,Fluid / Cephalexin / Peanuts / Sulfa 
(Sulfonamide Antibiotics) / golytely / citrate of magnesia / 
Lithium
 
Attending: ___.
 
Chief Complaint:
diverticulitis
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: Amoxicillin {Allergy to amoxicillin}, Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, Codeine {Allergy to codeine}, ibuprofen {Allergy to ibuprofen}, Tetanus {Tetanus}, Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, diverticulitis {Diverticulitis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ with multiple medical problems, including ESRD ___ lithium 
toxicity on PD , admitted to ___ on ___ with abdominal 
pain and fever to 102 at home. She had a prior admission on 
___ with similar symptoms; at that time the workup was 
negative and she was give levofloxacin x5 days for presumptive 
pneumonia. On representation to ___, her WBC was elevated 
to 16.5. Peritoneal fluid was sent and demosntrated ___ WBC with 
no organisms on gram stain. A CT scan was obtained with 
demonstrated diverticulitis and likely contained perforation 
with concern for pelvic abscess. She was started on levaquin and 
flagyl and recommended for percutanous drainage. However given 
her extensive past surgical history here at ___, the family 
requested transfer to ___ for further work up and 
management.

ROS: Endorses 20lb wt loss over the past few months
 

###RESPONSE: problems {Problem}, ESRD {End-stage renal disease}, lithium 
toxicity {Lithium poisoning}, abdominal 
pain {Abdominal pain}, fever {Fever}, workup {Evaluation procedure}, pneumonia {Pneumonia}, gram stain {Gram stain method}, CT scan {Computed tomography}, diverticulitis {Diverticulitis}, perforation {Perforation}, pelvic abscess {Pelvic abscess}, drainage {Drainage procedure}, surgical {Surgical procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
PMH: tracheostomy ___ for prolonged respiratory failure, 
hyponatremic seizure following GoLytely prep ___, ESRD for 
lithium toxicity, on HD, bipolar, GERD, HTN, breast cancer, 
diverticulosis 

PSH: parathyroidectomy with reimplantation in left arm, left 
foot surgery in ___, right knee surgery in ___, lumpectomy for 
breast cancer (DCIS), status post radiation, repeat mammograms 
were all negative, history of tonsillectomy in the past. 

 

###RESPONSE: tracheostomy {Exteriorization of trachea}, respiratory failure {Respiratory failure}, seizure {Seizure}, ESRD {End-stage renal disease}, lithium toxicity {Lithium poisoning}, HD {Hemodialysis}, GERD {Gastroesophageal reflux disease}, HTN {Hypertensive disorder, systemic arterial}, breast cancer {Malignant neoplasm of breast}, diverticulosis {Diverticulosis of large intestine}, parathyroidectomy {Parathyroidectomy}, reimplantation {Reimplantation}, left arm {Left upper arm structure}, left 
foot {Structure of left foot}, surgery {Surgical procedure}, right knee {Structure of right knee region}, surgery {Surgical procedure}, lumpectomy {Excision of mass}, breast cancer {Malignant neoplasm of breast}, radiation {Radiation oncology AND/OR radiotherapy}, mammograms {Mammography}, tonsillectomy {Tonsillectomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother with ovarian CA
Father with CAD

 

###RESPONSE: ovarian {Malignant tumor of ovary}, 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:
VS: 99.1  73  117/64  18  100%ra
PE:
 Gen: A&Ox3, NAD, pleasant and comfortable appearing
 CV: RRR
 Pulm: CTAB, easy WOB
 Abd: abd soft, mildly distended. PD catheter site in RLQ. 
Mildly
TTP RUQ/LUQ/LLQ, worst in LLQ.
 Ext: WWP, trace periph edema bilat, L > R
 

###RESPONSE: VS {Vital signs finding}, Gen {General examination of patient}, Ox3 {Oriented to person, time and place}, NAD {No abnormality detected}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, Pulm {Examination of respiratory system}, CTAB {Normal breath sounds}, WOB {Breathing easily}, Abd {Examination of abdomen}, abd soft {Abdomen soft}, distended {Swollen abdomen}, RLQ {Right lower quadrant pain}, TTP {Thrombotic thrombocytopenic purpura}, RUQ {Structure of right upper quadrant of abdomen}, LUQ {Structure of left upper quadrant of abdomen}, LLQ {Structure of left lower quadrant of abdomen}, LLQ {Structure of left lower quadrant of abdomen}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 09:15PM   GLUCOSE-87 UREA N-52* CREAT-10.1*# 
SODIUM-132* POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-29 ANION GAP-14
___ 09:15PM   ALT(SGPT)-17 AST(SGOT)-15 ALK PHOS-311* TOT 
BILI-0.2
___ 09:15PM   ALBUMIN-2.5* CALCIUM-7.6* PHOSPHATE-4.3 
MAGNESIUM-1.6
___ 09:15PM   LITHIUM-0.9
___ 09:15PM   WBC-5.4 RBC-2.32*# HGB-7.4*# HCT-25.1*# 
MCV-108* MCH-31.9 MCHC-29.4* RDW-19.1*
___ 09:15PM   NEUTS-77.4* LYMPHS-12.7* MONOS-7.0 EOS-2.7 
BASOS-0.1
___ 09:15PM   ___ PTT-31.5 ___
 

###RESPONSE: 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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, PHOS {Phosphate, total measurement}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, PTT {Partial thromboplastin time, activated}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. ___ was admitted to the Transplant Surgery Service 
under the care of Dr. ___ on ___. She 
was transferred from ___ in ___ with 
a colonic microperforation in the setting of diverticulitis. 
This was of particular concern given her concurrent use of 
peritoneal dialysis for renal replacement therapy for her long 
standing history of ESRD. Upon admission, physical exam and 
vital signs were un concerning for systemic infection. She was 
afebrile, did not have evidence of cellulitis around her PD 
catheter exit site, and did not have leukocytosis.

Levofloxacin and metronidazole were administered to treat Ms. 
___ diverticulitis. She was kept NPO. Abdominal pain 
resolved. Nephrology followed and managed the peritoneal 
dialysis adding heparin for fibrin in dialysate. Diet was 
resumed and well tolerated. 

Throughout the course of her admission, Ms. ___ home 
medications to treat her psychiatric and medical co morbidities 
were continued. Vital signs remained stable, she was pain free 
and was oob to chair with assist. 

She will f/u with her local nephrologist. Vitamin D and 
calcitriol were started and Cinacalcet stopped. Atenolol and 
Nifedipine were also stopped for SBPs in ___. Heart rates ranged 
between ___. She was instructed to f/u with her 
nephrologist. 
 

###RESPONSE: colonic microperforation in the setting of diverticulitis {Diverticulitis of colon with perforation}, peritoneal dialysis {Peritoneal dialysis}, renal replacement therapy {Continuous renal replacement therapy}, ESRD {End-stage renal disease}, vital signs {Vital signs finding}, systemic infection {Sepsis}, cellulitis {Cellulitis}, catheter exit site {Catheter exit site}, leukocytosis {Leukocytosis}, diverticulitis {Diverticulitis}, NPO {Nil by mouth}, Abdominal pain {Abdominal pain}, peritoneal 
dialysis {Peritoneal dialysis}, Diet {Dietary finding}, medications {Administration of drug or medicament}, psychiatric {Psychiatric symptom}, Vital signs {Vital signs finding}, stable {Normal vital signs}, Heart rates {Finding of heart rate}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
fluoxetine 20 qam, lithium 150 qam 150qpm prn, goal level 0.7. 
antenerol 25 qpm. zyprexa 10mg qpm, ___ prn for agitation, 
dialyvite 800 qam, iron 65mg qd, prilosec 20mg BID, topiramate 
25mg qpm, colace 100mg BID, procrit 40,000 ___, sensipar 30mg 
qd, senna prn, renvela TID with meals
 
Discharge Medications:
1. Docusate Sodium 100 mg PO BID 
2. Fluoxetine 20 mg PO DAILY 
3. Lithium Carbonate 150 mg PO DAILY 
4. OLANZapine 10 mg PO DAILY 
additional doses PRN agitation 
5. Omeprazole 20 mg PO BID 
6. Calcitriol 0.25 mcg PO DAILY 
RX *calcitriol 0.25 mcg 1 capsule(s) by mouth once a day Disp 
#*30 Capsule Refills:*2
7. Heparin Flush (1000 units/mL) 1000 UNIT DWELL QID 
each 1 liter dwell IP for fibrin  
8. Lactulose 30 mL PO BID 
RX *lactulose 20 gram/30 mL 30 ml by mouth twice a day Disp #*1 
Bottle Refills:*2
9. Levofloxacin 250 mg PO Q24H Duration: 8 Days 
RX *levofloxacin [Levaquin] 250 mg 1 tablet(s) by mouth once a 
day Disp #*8 Tablet Refills:*0
10. Lorazepam 1 mg PO HS:PRN insomnia 
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H 
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 
eight (8) hours Disp #*24 Tablet Refills:*0
12. Miconazole Powder 2% 1 Appl TP BID 
13. Tucks Hemorrhoidal Oint 1% 1 Appl PR PRN hemorrhoidal pain 
14. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 
RX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit 1 
capsule(s) by mouth once a week Disp #*12 Capsule Refills:*0
15. Epoetin Alfa 40,000 units SC Q ___ 
16. Senna 1 TAB PO BID:PRN constipation 
17. OLANZapine 5 mg PO ASDIR 
Please assess patient for leg tingling, restlessness and give 
this additional dose. Will likely need while doing CAPD 
18. Topiramate (Topamax) 25 mg PO DAILY 
19. DIALYVITE 800 *NF* (B complex-C-folic acid-Zn) 0.8 mg Oral 
Daily 
20. Ferrous Sulfate 325 mg PO DAILY 

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
diverticulitis
colonic microperforation
ESRD

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: diverticulitis {Diverticulitis}, colonic {Colon structure}, ESRD {End-stage renal disease}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - requires assistance or aid {Finding of walking aid use}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Please call Dr. ___ office ___ if you have 
any of the following: temperature of 101 or greater, chills, 
increased abdominal pain, nausea, vomiting, peritoneal effluent 
appears cloudy or bloody, or has a foul smell, bloody stool or 
diarrhea
-continue with peritoneal dialysis
-finish antibiotics as prescribed
-atenolol and nifedipine stopped for low blood pressure
 

###RESPONSE: chills {Chill}, abdominal pain {Abdominal pain}, nausea, vomiting {Nausea and vomiting}, peritoneal effluent 
appears cloudy or bloody {Peritoneal fluid abnormal}, bloody stool {Hematochezia}, diarrhea {Diarrhea}, peritoneal dialysis {Peritoneal dialysis}, antibiotics {Antibiotic therapy}, low blood pressure {Low blood pressure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   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: 
vancomycin in D5W
 
Attending: ___.
 
Chief Complaint:
lightheadedness
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: lightheadedness {Lightheadedness}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mr. ___ is a ___ male with the past medical
history of COPD on 2L NC, CAD s/p CABG, DM, afib s/p ablation,
who presents with lightheadedness.

Per patient, he notes that he ""felt like I was having a stroke"".
He said that just prior to presentation he got up out of the car
and felt like he was going to fall down and that the ground was
rushing up at him.  He sat back down in the car and the feeling
subsided in ___ minutes.  He denies a spinning sensation or a
disequilibrium type feeling.  No chest pain, SOB, palpitations,
f/c/s.  No numbness, tingling, LOS or weakness anywhere.

He reports he has similar episodes ___, in which he
experiences symptoms like he is being ""electrocuted.""  He calls
these mini-strokes, though he does not have a h/o CVA.  He has
not seen a neurologist for these given infrequency; he has
discussed this with his PCP.  

Currently he feels well without complaints or concerns.  No
further episodes.  Denies current dizziness, headache, fevers,
cough, chest pain, abd pain, N/V/D, or double vision.  He checks
his fingersticks weekly and they have been running between
120-140s. No recent medication changes. 

In the ED, VSS.  He had a head CT which was wnl.  Labs were
notable for Cr 2.1, elevated from his baseline, so he received 1
liter of LR in the ED.  He also had positive orthostatics while
there.  

 

###RESPONSE: COPD {Chronic obstructive lung disease}, 2L NC {Oxygen administration by nasal cannula}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, DM {Diabetes mellitus}, afib {Atrial fibrillation}, ablation {Catheter ablation of arrhythmogenic focus}, lightheadedness {Lightheadedness}, spinning sensation {Vertigo}, chest pain {Chest pain}, SOB {Dyspnea}, palpitations {Palpitations}, numbness, tingling {Numbness and tingling sensation of skin}, LOS {Loss of consciousness}, weakness {Asthenia}, CVA {Cerebrovascular accident}, feels well {Well in self}, dizziness {Dizziness}, headache {Headache}, fevers {Fever}, cough {Cough}, chest pain {Chest pain}, abd pain {Abdominal pain}, N/V/D {Nausea, vomiting and diarrhea}, double vision {Diplopia}, medication changes {Change of medication}, VSS {Vital signs finding}, head CT {Computed tomography of head}, baseline {Baseline state}, orthostatics {Orthostatic body position}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Asthma/COPD
CAD status post CABG
Atrial fibrillation status post ablation
PVD status post subclavian artery stent
Right shoulder osteoarthritis
Cataracts
Osteoporosis
Chronic kidney injury
Diabetes mellitus
Hypertension
Cholelithiasis
Allergic rhinitis
History of alcohol misuse
History of cognitive deficits
History of depression
 

###RESPONSE: Asthma {Asthma}, COPD {Chronic obstructive lung disease}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, Atrial fibrillation {Atrial fibrillation}, ablation {Catheter ablation of arrhythmogenic focus}, PVD {Peripheral vascular disease}, subclavian artery stent {Insertion of stent into subclavian artery}, Right shoulder {Structure of right shoulder region}, osteoarthritis {Osteoarthritis}, Cataracts {Cataract}, Osteoporosis {Osteoporosis}, Chronic kidney injury {Chronic kidney disease}, Diabetes mellitus {Diabetes mellitus}, Hypertension {Hypertensive disorder, systemic arterial}, Cholelithiasis {Calculus in biliary tract}, Allergic rhinitis {Allergic rhinitis}, alcohol misuse {Alcohol abuse}, cognitive deficits {Impaired cognition}, depression {Depressive disorder}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother with lung cancer and father with CVA.
 

###RESPONSE: lung cancer {Malignant tumor of lung}, CVA {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 EXAM:
VITALS: Afebrile and vital signs stable except for SBP 180s
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma. 
Oropharynx without visible lesion, erythema or exudate, MM
slightly dry. 
CV: Heart regular, no murmur, no S3, no S4.  No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally.  Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation.  Bowel
sounds present.  No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with 
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect

DISCHARGE EXAM:
VITALS: Afebrile and vital signs stable except for SBP 180s
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma. 
Oropharynx without visible lesion, erythema or exudate, MM
slightly dry. 
CV: Heart regular, no murmur, no S3, no S4.  No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally.  Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation.  Bowel
sounds present.  No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with 
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
 

###RESPONSE: VITALS {Vital signs finding}, vital signs {Vital signs finding}, stable {Normal vital signs}, SBP {Blood pressure finding}, GENERAL {General examination of patient}, Alert {Mentally alert}, distress {Distress}, Anicteric {White sclera}, pupils equally round {Pupil size and shape normal}, ENT {Abdominal tenderness}, Ears {Ear structure}, nose {Nasal structure}, erythema {Erythema}, masses {Mass of body structure}, trauma {Traumatic injury}, Oropharynx {Oropharyngeal structure}, lesion {Lesion}, erythema {Erythema}, exudate {Exudate}, MM
slightly dry {Mucous membrane dryness}, CV {Cardiovascular physical examination}, Heart {Cardiovascular physical examination}, murmur {Murmur}, no S3 {Third heart sound, S>3<, inaudible}, no S4 {Fourth heart sound, S>4<, inaudible}, JVD {Jugular venous engorgement}, RESP {Examination of respiratory system}, Lungs {Examination of respiratory system}, GI {Examination of digestive system}, soft {Abdomen soft}, non-distended {Normal abdominal contour}, non-tender {Abdominal tenderness}, palpation {Palpation}, Bowel
sounds present {Normal bowel sounds}, HSM {Hepatosplenomegaly}, GU {Examination of genitourinary system}, suprapubic {Hypogastric region structure}, tenderness {Tenderness}, palpation {Palpation}, supple {Normal movement of neck}, all extremities {All extremities}, symmetric bilaterally in all limbs {Normal bilateral upper limbs and bilateral lower limbs}, SKIN {Examination of skin}, rashes {Eruption of skin}, ulcerations {Ulcer}, NEURO {Neurological examination}, Alert {Mentally alert}, oriented {Orientated}, face symmetric {Facial symmetry}, EOMI {Normal ocular motility}, speech fluent {Does speak fluently}, moves all limbs {Does move all four limbs}, sensation to light touch grossly
intact {Normal light touch sensation}, affect {Mood finding}, VITALS {Vital signs finding}, vital signs {Vital signs finding}, stable {Normal vital signs}, GENERAL {General examination of patient}, Alert {Mentally alert}, distress {Distress}, Anicteric {White sclera}, pupils equally round {Pupil size and shape normal}, ENT {Ear, nose and throat examination}, Ears {Ear structure}, nose {Nasal structure}, erythema {Erythema}, masses {Mass of body structure}, trauma {Traumatic injury}, Oropharynx {Oropharyngeal structure}, lesion {Lesion}, erythema {Erythema}, exudate {Exudate}, CV {Cardiovascular physical examination}, Heart regular {Normal sinus rhythm}, murmur {Heart murmur}, no S3 {Third heart sound, S>3<, inaudible}, no S4 {Fourth heart sound, S>4<, inaudible}, RESP {Examination of respiratory system}, Lungs clear to auscultation {Normal breath sounds}, GI {Examination of digestive system}, Abdomen soft {Abdomen soft}, non-distended {Normal abdominal contour}, tender to palpation {Abdominal tenderness}, Bowel
sounds present {Normal bowel sounds}, HSM {Hepatosplenomegaly}, GU {Examination of genitourinary system}, suprapubic {Hypogastric region structure}, tenderness to palpation {Tenderness}, moves all extremities {Does move all four limbs}, symmetric bilaterally in all limbs {Normal bilateral upper limbs and bilateral lower limbs}, SKIN {Examination of skin}, rashes {Eruption of skin}, ulcerations {Ulcer}, NEURO {Neurological examination}, Alert {Mentally alert}, oriented {Oriented to person}, face symmetric {Facial symmetry}, EOMI {Normal ocular motility}, speech fluent {Does speak fluently}, moves all limbs {Does move all four limbs}, sensation to light touch grossly
intact {Normal light touch sensation}, appropriate affect {Appropriate affect}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 11:20AM BLOOD WBC-8.0 RBC-4.44* Hgb-14.3 Hct-44.3 
MCV-100* MCH-32.2* MCHC-32.3 RDW-13.3 RDWSD-48.7* Plt ___
___ 11:20AM BLOOD Neuts-56.5 ___ Monos-13.0 Eos-6.1 
Baso-0.9 Im ___ AbsNeut-4.53 AbsLymp-1.87 AbsMono-1.04* 
AbsEos-0.49 AbsBaso-0.07
___ 11:20AM BLOOD Glucose-125* UreaN-35* Creat-2.1* Na-139 
K-4.6 Cl-104 HCO3-18* AnGap-17
___ 11:20AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.4
___ 11:40AM BLOOD Lactate-2.4*

DISCHARGE LABS:
___ 06:22AM BLOOD Glucose-113* UreaN-29* Creat-1.5* Na-141 
K-4.9 Cl-109* HCO3-18* AnGap-14
___ 06:22AM BLOOD WBC-7.3 RBC-4.29* Hgb-14.3 Hct-43.1 
MCV-101* MCH-33.3* MCHC-33.2 RDW-13.1 RDWSD-48.0* Plt ___

NCHCT: There is a large CSF density lesion in the right middle 
cranial fossa 
unchanged from prior and most likely representing a large 
arachnoid cyst.  
There is no intra-axial or extra-axial hemorrhage, edema, shift 
of normally 
midline structures, or evidence of acute major vascular 
territorial 
infarction.  Age related involutional changes are again noted.  
Ventricles are 
stable in size.  Minimal periventricular white matter 
hypodensities are again 
noted consistent with chronic microvascular ischemic disease.  
The imaged bony 
structures are intact.  Imaged paranasal sinuses, mastoid air 
cells and middle 
ear cavities appear well aerated.  Dense carotid siphon 
calcification is 
noted. 
  
IMPRESSION:  
  
No acute intracranial process.  Large arachnoid cyst within the 
right middle 
cranial fossa. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, 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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, NCHCT {Computed tomography of head without contrast}, density {Abnormally opaque structure}, lesion {Lesion}, middle 
cranial fossa {Structure of middle fossa of cranial cavity}, arachnoid cyst {Arachnoid cyst}, intra-axial or extra-axial hemorrhage {Cerebral hemorrhage}, edema {Edema}, shift 
of normally 
midline structures {Midline shift of brain}, vascular 
territorial {Vascular structure within brain}, infarction {Infarct}, Ventricles {Brain ventricle structure}, periventricular white matter {Structure of periventricular white matter}, chronic {Chronic disease}, ischemic disease {Ischemia}, paranasal sinuses {Nasal sinus structure}, mastoid air 
cells {Structure of mastoid cell}, middle 
ear cavities {Middle ear structure}, carotid siphon {Structure of carotid siphon}, calcification {Pathologic calcification, calcified structure}, arachnoid cyst {Arachnoid cyst}, middle 
cranial fossa {Structure of middle fossa of cranial cavity}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Mr. ___ is a ___ male with PMH of COPD on 2L NC, 
CAD s/p CABG, DM, Afib s/p ablation, who presents with 
lightheadedness and was found to have ___ and orthostatic 
hypotension.

ACUTE/ACTIVE PROBLEMS:
# Lightheadedness/presyncope: Neuro exam was normal on 
admission. He did not have arrhythmias or signs of ischemia on 
EKG and telemetry overnight was without arrhythmia. NCHCT was 
normal, without evidence of stroke/bleed. Based on history, his 
episode appeared more consistent with presyncope, and 
orthostatic vital signs support this diagnosis. He also had ___ 
that improved with IVF which is evidence of dehydration though 
he denies that he has had reduced intake. Even though ___ 
improved, he continued to have orthostatic VS with SBP going 
from 160 to 100 from lying to standing. Could possibly have 
autonomic dysfunction as he does not appear dehydrated anymore.

# ___ on CKD stage III - His Cr was elevated at 2.1 which 
improved to 1.5 with 1L IVF which is his baseline. Losartan was 
held on admission but restarted at discharge.

#Orthostatic hypotension: Patient had positive orthostatic vital 
signs on admission and also after IVF, concerning for some 
possible autonomic dysfunction versus medication effect. Now 
that Cr is improved, will discharge on losartan for HTN, but 
will hold amlodipine as it can worsen orthostatic hypotension.

#Metabolic acidosis: Bicarb was 18 even with improvement in ___. 
Based on prior nephrology note, has history of metabolic 
acidosis which had been attributed to his CKD. Continue to 
monitor and follow up with ___ clinic.

#Macrocytic anemia: Has normal Hgb but with MCV elevated to low 
100s. VitB12 and folate in the past few years have been normal. 
Could possibly be due to alcohol intake. No diagnosis of liver 
disease, but hasn't had an ultrasound in ___ records. MDS is 
also on differential.

CHRONIC/STABLE PROBLEMS:
# CAD s/p CABG - continued ASA, ezetimibe 
# COPD on 2L - continued advair, albuterol prn, loratidine
# Afib - s/p ablation
# DM - ___ qid, placed on SS in hospital, held Januvia. Restarted 
Januvia on discharge.

TRANSITIONAL ISSUES:
- For syncope work up, could consider TTE as outpatient, though 
no evidence of valvular abnormality on cardiac exam. Last TTE 
was ___.
- Follow up BP and increase medications as needed, but would 
avoid CCB and beta blockers due to potential to worsen 
orthostatic hypotension
- Should have evaluation for macrocytic anemia. Consider liver 
ultrasound. Has follow up with hematology in ___.
- Repeat Cr at next clinic visit.
 

###RESPONSE: COPD {Chronic obstructive lung disease}, 2L NC {Oxygen administration by nasal cannula}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, DM {Diabetes mellitus}, Afib {Atrial fibrillation}, ablation {Catheter ablation of arrhythmogenic focus}, lightheadedness {Lightheadedness}, orthostatic 
hypotension {Orthostatic hypotension}, Lightheadedness {Lightheadedness}, presyncope {Near syncope}, Neuro exam was normal {Normal nervous system function}, arrhythmias {Cardiac arrhythmia}, signs {Sign}, ischemia {Ischemia}, EKG {Electrocardiographic procedure}, telemetry {Electroencephalogram telemetry}, arrhythmia {Cardiac arrhythmia}, NCHCT {Computed tomography of head without contrast}, stroke {Cerebrovascular accident}, bleed {Hemorrhage}, presyncope {Near syncope}, orthostatic {Orthostatic body position}, vital signs {Vital signs finding}, improved {Patient's condition improved}, IVF {Administration of intravenous fluids}, dehydration {Dehydration}, improved {Patient's condition improved}, orthostatic {Orthostatic body position}, dehydrated {Dehydration}, CKD stage III {Chronic kidney disease stage 3}, improved {Patient's condition improved}, IVF {Administration of intravenous fluids}, baseline {Baseline state}, Orthostatic hypotension {Orthostatic hypotension}, orthostatic {Orthostatic body position}, vital 
signs {Vital signs finding}, IVF {Administration of intravenous fluids}, improved {Patient's condition improved}, HTN {Hypertensive disorder, systemic arterial}, orthostatic hypotension {Orthostatic hypotension}, Metabolic acidosis {Metabolic acidosis}, metabolic 
acidosis {Metabolic acidosis}, CKD {Chronic kidney disease}, Macrocytic anemia {Macrocytic anemia}, normal Hgb {Hemoglobin within reference range}, MCV elevated {Mean corpuscular volume above reference range}, liver 
disease {Disorder of liver}, ultrasound {Ultrasonography}, MDS {Myelodysplastic syndrome}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, COPD {Chronic obstructive lung disease}, Afib {Atrial fibrillation}, ablation {Catheter ablation of arrhythmogenic focus}, DM {Diabetes mellitus}, syncope {Syncope}, TTE {Transthoracic echocardiography}, no evidence {No abnormality detected}, valvular abnormality {Valvular insufficiency}, cardiac exam {Cardiovascular physical examination}, TTE {Transthoracic echocardiography}, orthostatic hypotension {Orthostatic hypotension}, evaluation {Evaluation procedure}, macrocytic anemia {Macrocytic anemia}, liver {Disorder of liver}, ultrasound {Ultrasonography}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Losartan Potassium 25 mg PO DAILY 
2. BuPROPion XL (Once Daily) 150 mg PO BID 
3. Mirtazapine 15 mg PO QHS 
4. Ezetimibe 10 mg PO DAILY 
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergy 
symptoms 
6. amLODIPine 5 mg PO DAILY 
7. Atorvastatin 80 mg PO QPM 
8. Multivitamins 1 TAB PO DAILY 
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 
10. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH BID 
11. Aspirin 325 mg PO DAILY 
12. Loratadine 10 mg PO DAILY 
13. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 

 
Discharge Medications:
1.  albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN  
2.  Aspirin 325 mg PO DAILY  
3.  Atorvastatin 80 mg PO QPM  
4.  BuPROPion XL (Once Daily) 150 mg PO BID  
5.  Ezetimibe 10 mg PO DAILY  
6.  Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergy 
symptoms  
7.  Fluticasone-Salmeterol Diskus (250/50)  1 INH IH BID  
8.  Loratadine 10 mg PO DAILY  
9.  Losartan Potassium 25 mg PO DAILY  
10.  Mirtazapine 15 mg PO QHS  
11.  Multivitamins 1 TAB PO DAILY  
12.  Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain  

 

###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 kidney injury
Pre-syncope
Orthostatic hypotension versus autonomic dysfunction

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Acute kidney injury {Acute kidney injury}, Pre-syncope {Near syncope}, Orthostatic hypotension {Orthostatic hypotension}, Mental Status {Neurological mental status determination}, Clear {Normal breath sounds}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___,

You were admitted to ___ for an episode of feeling like you 
were going to pass out.

You were found to have acute kidney injury, likely due to 
dehydration. You received IV fluids and your kidney function 
improved back to normal.

You were also found to have orthostatic hypotension, which means 
that your blood pressure gets low when you stand. You need to go 
from sitting to standing very slowly and walk carefully when you 
are out of the hospital so you do not pass out/faint.

Sincerely,
Your ___ Team
 

###RESPONSE: acute kidney injury {Acute kidney injury}, dehydration {Dehydration}, IV fluids {Administration of intravenous fluids}, kidney function 
improved back to normal {Normal renal function}, orthostatic hypotension {Orthostatic hypotension}, blood pressure {Finding of increased blood pressure}, stand {Does stand}, sitting {Sitting position}, standing {Orthostatic body position}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: CARDIOTHORACIC
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Chest pain
 
Major Surgical or Invasive Procedure:
CABG ___ 

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, Chest pain {Chest pain}, CABG {Coronary artery bypass grafting}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 ___ year old man with a history of diabetes, 
hyperlipidemia, hypertension, and smoking. Over the past two 
weeks, he noted multiple episodes of chest pain mostly occuring 
at rest. He described the pain as retrosternal, radiating to his 
face and left jaw, lasting minutes to an hour, and occuring ___ 
times per day. On the morning of presentation, he had more of a 
grabbing/pressure like pain in his left chest. He also endorsed 
headache and shortness of breath. He presented to the emergency 
department for further evaulation. A CTA was performed to rule 
out dissection and was negative. Initial troponin was positive 
at 0.24. An EKG demonstrated a right bundle branch block and ST 
depressions in leads V4-V6. Cardiology was consulted in the ER 
and he was started on IV heparin with plan for cardiac 
catheterization. Cardiac catheterization revealed multivessel 
coronary artery disease and he was referred to cardiac surgery 
for evaluation.
 

###RESPONSE: diabetes {Diabetes mellitus}, hyperlipidemia {Hyperlipidemia}, hypertension {Hypertensive disorder, systemic arterial}, smoking {Smoker}, chest pain {Chest pain}, pain {Pain}, retrosternal {Retrosternal pain}, radiating {Radiating pain}, face {Face structure}, jaw {Pain radiating to jaw}, pressure {Tight chest}, pain {Chest pain}, left chest {Structure of left half of chest wall}, headache {Headache}, shortness of breath {Dyspnea}, evaulation {Evaluation procedure}, CTA {Computed tomography angiography with contrast}, EKG {Electrocardiographic procedure}, right bundle branch block {Right bundle branch block}, ST 
depressions {ST segment depression}, leads V4 {Lead site V4}, V6 {Lead site V6}, cardiac 
catheterization {Cardiac catheterization}, Cardiac catheterization {Cardiac catheterization}, coronary artery disease {Coronary arteriosclerosis}, evaluation {Evaluation procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
PMHx:
1. Hypertension, essential [401.9] ___ new RBBB on routine EKG. 
___: adenosine MIBI neg for ischemia.
2. DM (diabetes mellitus), type 2 with neurological 
complications [250.60]
3. Hypercholesterolemia [272.0] ___
4. OBESITY UNSPEC [278.00] ___
5. GAIT ABNMLTY [781.2] ___
6. IMPOTENCE DUE TO ERECTILE DYSFUNCTION [607.84] ___
7. SLEEP APNEA - OBSTRUCTIVE [327.23] ___. Stopped CPAP
8. MENIERE'S DISEASE, UNSPEC [386.00]
9. DERMATITIS - SEBORRHEIC, UNSPEC [690.10]
10. CHRONIC DAILY HEADACHE
PSHx:
• ___ pilonidal sinus/cyst ___
• ___ 2.1-3 cm
lipoma on back
• Tarsal tunnel release ___
left foot with partial plantar fasciectomy & spur removal
• ___ ___
left thumb CMC jt
CAD-s/p CABG ___
 

###RESPONSE: Hypertension, essential {Essential hypertension}, RBBB on routine EKG {Electrocardiographic right bundle branch block}, MIBI {Radionuclide myocardial perfusion study}, ischemia {Ischemia}, DM {Diabetes mellitus}, diabetes mellitus), type 2 {Diabetes mellitus type 2}, neurological 
complications {Disorder of nervous system due to diabetes mellitus}, Hypercholesterolemia {Hypercholesterolemia}, OBESITY {Obesity}, GAIT ABNMLTY {Abnormal gait}, ERECTILE DYSFUNCTION {Erectile dysfunction}, SLEEP APNEA - OBSTRUCTIVE {Obstructive sleep apnea syndrome}, CPAP {Continuous positive airway pressure ventilation treatment}, MENIERE'S DISEASE {Ménière's disease}, DERMATITIS {Seborrheic dermatitis}, DAILY HEADACHE {Daily headache}, pilonidal sinus {Hair sinus}, cyst {Pilonidal cyst}, lipoma {Lipoma}, back {Structure of back of trunk}, Tarsal tunnel release {Tarsal tunnel release}, left foot {Structure of left foot}, partial plantar fasciectomy {Partial fasciectomy of plantar fascia}, left thumb {Structure of left thumb}, CMC jt {Carpometacarpal joint structure}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Non-contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Vitals-  98.1, 142/81, 65, 18, 99% RA
General: NAD, sitting comfortably in bed, jovial and pleasant
HEENT: MMM, EOMI, no icterus
Cardiac: Normocardic, regular, no MRG
Vascular: JVP visible 2-3cm above sternal angle with HOB at 30 
degr. Extr wwp with 2+ radial, dp/pt pulses. 
Lungs: no incr WOB sitting upright. minimal bibasilar crackles, 
incr RR with lying flat but no increase in subjective dyspnea 
Abdomen: obese, nontender - otherwise limited by habitus 
GU: no foley 
Neuro: AOX3, grossly nonfocal
Skin: dry skin on LEs with absent hair, otherwise no lesions

 

###RESPONSE: Vitals {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, NAD {No abnormality detected}, sitting {Sitting position}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, EOMI {Normal ocular motility}, icterus {Jaundice}, Cardiac {Cardiovascular physical examination}, regular {Normal heart rate}, no MRG {Heart sounds normal}, JVP {Finding of jugular venous pressure}, sternal angle {Structure of sternal angle}, Extr {Limb structure}, 2+ radial {Normal radial pulse}, Lungs {Examination of respiratory system}, WOB {Labored breathing}, sitting {Sitting position}, crackles {Respiratory crackles}, RR {Finding of rate of respiration}, dyspnea {Dyspnea}, Abdomen {Examination of abdomen}, obese {Obese abdomen}, nontender {Abdominal tenderness}, GU {Examination of genitourinary system}, foley {Urinary catheter in situ}, Neuro {Neurological examination}, Skin {Examination of skin}, dry skin {Xeroderma}, absent hair {Hair absent}, lesions {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:
TEE ___:
Findings  
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the 
___ or the RA/RAA. 
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or 
color Doppler. 
LEFT VENTRICLE: Mild symmetric LV hypertrophy with normal cavity 
size, and global systolic function (biplane LVEF>55%). 
RIGHT VENTRICLE: Normal RV chamber size and free wall motion. 
AORTA: Normal aortic diameter at the sinus level. Focal 
calcifications in aortic root. Normal ascending aorta diameter. 
Focal calcifications in ascending aorta. Normal aortic arch 
diameter. 
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. 
Trace AR. 
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial 
MR. 
___ VALVE: Normal tricuspid valve leaflets with trivial 
TR. 
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. 
No PS. Physiologic PR. 
PERICARDIUM: No pericardial effusion. 

PRE-BYPASS: 
No spontaneous echo contrast or thrombus is seen in the body of 
the left atrium/left atrial appendage or the body of the right 
atrium/right atrial appendage. No atrial septal defect is seen 
by 2D or color Doppler. Mild symmetric left ventricular 
hypertrophy with normal cavity size, and global systolic 
function (biplane LVEF = 55 %). Right ventricular chamber size 
and free wall motion are normal. The aortic valve leaflets (3) 
are mildly thickened but aortic stenosis is not present. Trace 
aortic regurgitation is seen. The mitral valve leaflets are 
mildly thickened. Trivial mitral regurgitation is seen. There is 
no pericardial effusion. POST-BYPASS: 
Preserved biventricular systolic function.
LVEF 55%.
Intact thoracic aorta.
No other new findings.   

___ 07:24AM BLOOD WBC-15.7* RBC-4.37* Hgb-13.5* Hct-38.6* 
MCV-88 MCH-31.0 MCHC-35.1* RDW-15.2 Plt ___
___ 07:10AM BLOOD WBC-13.6* RBC-4.27* Hgb-13.3* Hct-37.7* 
MCV-88 MCH-31.2 MCHC-35.3* RDW-15.1 Plt ___
___ 07:05AM BLOOD WBC-10.3 RBC-3.83* Hgb-12.0* Hct-34.2* 
MCV-89 MCH-31.3 MCHC-35.1* RDW-15.1 Plt ___
___ 12:50PM BLOOD Na-133 K-4.4 Cl-95*
___ 07:24AM BLOOD Glucose-155* UreaN-25* Creat-1.2 Na-133 
K-5.2* Cl-95* HCO3-22 AnGap-21*
___ 12:50PM BLOOD UreaN-21* Creat-1.1 Na-133 K-4.9 Cl-96 
HCO3-26 AnGap-16
___ 07:05AM BLOOD Glucose-114* UreaN-21* Creat-1.1 Na-136 
K-5.0 Cl-99 HCO3-25 AnGap-17
___ 06:30AM BLOOD Glucose-85 UreaN-26* Creat-1.1 Na-136 
K-4.2 Cl-98 HCO3-28 AnGap-14
___ 05:05AM BLOOD Glucose-144* UreaN-27* Creat-0.9 Na-135 
K-4.0 Cl-99 HCO3-27 AnGap-13
 

###RESPONSE: TEE {Transesophageal echocardiography}, thrombus {Thrombus}, RA {Right atrial structure}, RA {Right atrial structure}, ASD {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, LV hypertrophy {Left ventricular hypertrophy}, RV chamber {Structure of cavity of right cardiac ventricle}, free wall motion {Normal ventricular wall motion}, AORTA {Aortic structure}, aortic {Aortic structure}, Focal 
calcifications {Focal calcium deposition, calcified structure}, aortic root {Supraaortic valve area structure}, ascending aorta {Ascending aorta structure}, Focal calcifications {Focal calcium deposition, calcified structure}, ascending aorta {Ascending aorta structure}, aortic arch {Aortic arch structure}, AORTIC VALVE {Aortic valve structure}, Mildly thickened {Increased thickness}, aortic valve leaflets {Structure of cusp of aortic valve}, AS {Aortic valve stenosis}, AR {Aortic valve regurgitation}, Mildly thickened {Increased thickness}, mitral valve leaflets {Structure of leaflet of mitral valve}, MR {Mitral valve regurgitation}, tricuspid valve leaflets {Structure of leaflet of tricuspid valve}, PULMONIC VALVE {Pulmonary valve structure}, PULMONARY ARTERY {Pulmonary artery structure}, pulmonic valve leaflet {Structure of cusp of pulmonic valve}, PS {Pulmonic valve stenosis}, PR {Pulmonic valve regurgitation}, PERICARDIUM {Pericardial structure}, pericardial effusion {Pericardial effusion}, thrombus {Thrombus}, left atrium {Left atrial structure}, left atrial appendage {Entire left auricular appendage}, right 
atrium {Right atrial structure}, right atrial appendage {Structure of right auricular appendage}, atrial septal defect {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, Mild symmetric left ventricular 
hypertrophy {Mild left ventricular hypertrophy}, normal cavity {Normal size cardiac chamber}, Right ventricular chamber {Structure of cavity of right cardiac ventricle}, wall motion are normal {Normal ventricular wall motion}, aortic valve leaflets {Structure of cusp of aortic valve}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve leaflets are 
mildly thickened {Thickened mitral leaflet}, mitral regurgitation {Mitral valve regurgitation}, pericardial effusion {Pericardial effusion}, biventricular {Cardiac ventricular structure}, thoracic aorta {Thoracic aorta structure}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, 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}, 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}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
He underwent routine preoperative testing and evaluation. 
Carotid ultrasound revealed bilateral carotid artery stenosis, 
right > left. The vascular surgery service was consulted. Given 
that he is asypmtomatic, recommendation is to follow up with Dr. 
___ as an outpatient for further evaluation. He remained 
hemodynamically stable and was taken to the operating room on 
___. He underwent coronary artery bypass grafting x 3. 
Please see operative note for full details. He tolerated the 
procedure well and was transferred to the CVICU in stable 
condition for recovery and invasive monitoring. 
 
He weaned from sedation, awoke neurologically intact and was 
extubated on POD 1. He was weaned from inotropic and vasopressor 
support. Beta blocker was initiated and he was diuresed toward 
his preoperative weight. His chest tubes were discontinued on 
POD#1 and his epicardial pacing wires were discontinued on 
POD#3.  He had a +UTI and was started on Bactrim. He was started 
on Kefzol for sternal drainage which resolved by the time 
discharge and kefzol was stopped. He remained hemodynamically 
stable and was transferred to the telemetry floor for further 
recovery.  He was evaluated by the physical therapy service for 
assistance with strength and mobility and rehab was recommended. 
By the time of discharge on POD #8 he was ambulating with 
supervision,  the sternal wound was healing without redness or 
drainage, and pain was controlled with oral analgesics. He was 
discharged to ___ Rehab in good condition with appropriate 
follow up instructions.
 

###RESPONSE: evaluation {Evaluation procedure}, Carotid ultrasound {Ultrasonography of carotid artery}, carotid artery stenosis {Carotid artery stenosis}, right {Structure of right carotid artery}, left {Structure of left carotid artery}, asypmtomatic {Asymptomatic}, evaluation {Evaluation procedure}, hemodynamically stable {Hemodynamically stable}, coronary artery bypass grafting {Coronary artery bypass grafting}, stable 
condition {Patient's condition stable}, neurologically intact {Normal nervous system function}, extubated {Removal of endotracheal tube}, vasopressor 
support {Vasopressor therapy}, diuresed {Diuretic therapy}, epicardial pacing {Insertion of epicardial electrode for temporary cardiac pacing}, UTI {Urinary tract infectious disease}, sternal {Structure of sternal region}, drainage {Wound discharge}, hemodynamically 
stable {Hemodynamically stable}, ambulating {Fully mobile}, supervision {Supervision}, sternal {Structure of sternal region}, wound was healing {Wound healing well}, redness {Redness of skin over lesion}, drainage {Discharge}, pain was controlled with oral analgesics {Demonstrates adequate pain control}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO BID 
2. Simvastatin 80 mg PO DAILY 
3. Aspirin 81 mg PO DAILY 
4. Diazepam 5 mg PO PRN nausea 
5. Lisinopril 5 mg PO DAILY 
6. MetFORMIN (Glucophage) 1000 mg PO BID 
7. Glargine 38 Units Dinner
8. fluocinolone acetonide oil 0.01 % otic DAILY 
9. Omeprazole 40 mg PO DAILY 
10. Propranolol LA 60 mg PO DAILY 
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY 
12. TraZODone 100 mg PO QHS:PRN insomnia 
13. Acetaminophen 325-650 mg PO Q6H:PRN pain 

 
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever 
2. Aspirin EC 81 mg PO DAILY 
3. ClonazePAM 1 mg PO BID:PRN anxiety 
RX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*65 
Tablet Refills:*0
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 
5. Glargine 38 Units Dinner
6. MetFORMIN (Glucophage) 1000 mg PO BID 
7. Omeprazole 40 mg PO DAILY 
8. Simvastatin 80 mg PO DAILY 
9. TraZODone 100 mg PO QHS:PRN insomnia 
10. BuPROPion (Sustained Release) 150 mg PO BID 
11. Docusate Sodium 100 mg PO BID 
12. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY 
13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezes 
14. Metoprolol Tartrate 25 mg PO BID 
15. OxycoDONE (Immediate Release)  ___ mg PO Q6H:PRN pain 
RX *oxycodone 5 mg ___ tablet(s) by mouth very 6 hours Disp #*65 
Tablet Refills:*0
16. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days 
17. Furosemide 20 mg PO BID Duration: 5 Days 
18. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days 
19. fluocinolone acetonide oil 0.01 % otic DAILY 
20. Atorvastatin 80 mg PO QPM 
21. Diazepam 5 mg PO PRN nausea 
RX *diazepam 5 mg 1 tablet by mouth prn Disp #*25 Tablet 
Refills:*0
22. Outpatient Lab Work
plaese check BUN/Creat on ___  and if greater than 1.3, please 
continue to follow until off lasix and bactrim and returns to 
baseline of 1.0

 

###RESPONSE: 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: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Primary: NSTEMI
Secondary:
IDDM
HTN
Hyperlipidemia
GERD, s/p gastric ulcer ___ yrs ago
vertigo
chronic back pain
chronic headaches
deaf left ear
coronary artery disease s/p CABG ___
Past Surgical History: prostatectomy ___

 
Discharge Condition:
Alert and oriented x3 nonfocal 
Ambulating with steady gait
Incisional pain managed with Oxycodone 
Incisions: 
Sternal - healing well, no erythema or drainage 
Leg Left - healing well, no erythema or drainage. 
Edema trace
 

 

###RESPONSE: NSTEMI {Acute non-ST segment elevation myocardial infarction}, IDDM {Diabetes mellitus type 1}, HTN {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, GERD {Gastroesophageal reflux disease}, gastric ulcer {Gastric ulcer}, vertigo {Vertigo}, chronic back pain {Chronic back pain}, chronic headaches {Chronic headache disorder}, deaf left ear {Deafness of left ear}, coronary artery disease {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, prostatectomy {Prostatectomy}, Alert {Mentally alert}, oriented x3 {Oriented to person, time and place}, Ambulating {Fully mobile}, steady gait {Gait normal}, Incisional {Surgical incision wound}, pain {Pain}, Incisions {Surgical incision wound}, Sternal {Structure of sternal region}, healing well {Wound healing well}, erythema {Erythema}, drainage {Discharge}, Leg Left {Structure of left lower leg}, healing well {Wound healing well}, erythema {Erythema}, drainage {Discharge}, Edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Please shower daily including washing incisions gently with mild 
soap, no baths or swimming until cleared by surgeon. Look at 
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions 
Each morning you should weigh yourself and then in the evening 
take your temperature, these should be written down on the chart 

No driving for approximately one month and while taking 
narcotics, will be discussed at follow up appointment with 
surgeon when you will be able to drive 
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or 
concerns ___. Answering service will contact on call 
person during off hours**

 

###RESPONSE: incisions {Surgical incision wound}, redness {Redness of skin over lesion}, drainage {Discharge}, 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: 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: 
___
 
Attending: ___.
 
Chief Complaint:
s/p mechanical fall
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: fall {Falls}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ PMHx CAD s/p CABG, 2 prior colon surgeries, presenting as 
transfer from ___ for trauma eval for R ___ rib 
fractures due to mechanical fall. Patient reports trying to get 
into his walker at his ___ this evening, when he tripped and 
fell onto his right side. Denies LOC or headstrike. He sustained 
a laceration to his R forearm and was sent to an OSH. head CT 
head, torso, abdomen, CXR and x-ray R hand, found to have 
non-displaced fractures of ___ to 9th ribs on right.

Upon evaluation in the ED, patient appears comfortable and NAD. 
He is breathing well on room air, although his breaths still 
appear to be shallow. He demonstrates significant pain along his 
right flank.
 

###RESPONSE: CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, colon {Colon structure}, surgeries {Surgical procedure}, trauma {Traumatic injury}, eval {Evaluation procedure}, rib 
fractures {Fracture of multiple ribs}, fall {Falls}, walker {Uses zimmer frame}, fell {Falls}, right side {Structure of right half of body}, LOC {Loss of consciousness}, headstrike {Injury of head}, laceration {Laceration}, R forearm {Structure of right forearm}, head {Head structure}, CT 
head {Computed tomography of head}, torso {Computed tomography of chest}, abdomen {Computed tomography of abdomen}, CXR {Plain chest X-ray}, x-ray R hand {Plain X-ray of right hand}, non-displaced fractures {Undisplaced fracture}, 9th ribs {Bone structure of ninth rib}, evaluation {Evaluation procedure}, comfortable {Comfortable appearance}, NAD {No abnormality detected}, breathing well on room air {Breathing room air}, shallow {Shallow breathing}, pain along his 
right flank {Right flank 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:
PMHx: CHF, CODP, CKD, anemia
 

###RESPONSE: CHF {Congestive heart failure}, CODP {Chronic obstructive lung disease}, CKD {Chronic kidney disease}, anemia {Anemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Non-contributory 
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Admission 
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:|
R ribs TTP along mid-axillary line, most prominent at rib 9. No 
flail chest, no ecchymosis. Lungs clear anteriorly, pt refuses 
to sit up for posterior exam. Head NCAT. R forearm with ~3 x 4 
cm area of denuded skin.

Discharge Physical Exam:
VS: T: 97.4 PO BP: 113/68 L Sitting HR: 79 RR: 16 O2: 96% Ra 
GEN: A+Ox3, NAD
HEENT: atraumatic, MMM
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: wwp, trace edema b/l UE.  RUE abrasions with mepilex 
 

###RESPONSE: Physical Exam {Physical examination procedure}, TTP {Tenderness}, mid-axillary line {Midaxillary line}, rib 9 {Bone structure of ninth rib}, flail chest {Flail chest}, ecchymosis {Ecchymosis}, Lungs {Examination of respiratory system}, NC {Normal head}, R forearm {Structure of right forearm}, denuded skin {Denuded skin}, VS {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 {Oxygen saturation measurement}, Ra {Breathing room air}, GEN {General examination of patient}, A+Ox3 {Oriented to person, time and place}, NAD {No abnormality detected}, atraumatic {No injuries apparent}, MMM {Moist oral mucosa}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, PULM {Examination of respiratory system}, CTA b/l {Normal breath sounds}, ABD {Examination of abdomen}, soft {Abdomen soft}, non-distended {Normal abdominal contour}, tender {Abdominal tenderness}, EXT {Examination of limb}, edema b/l UE {Edema of bilateral upper limbs}, RUE {Structure of right upper limb}, abrasions {Abrasion}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
IMAGING:

OSH Right Hand x-ray ___
Impression - No acute abnormality identified

OSH CT Chest w/ contrast ___
Impression - nondisplaced fractures of the lateral right ___ 
through 9th ribs

OSH CT abd/pelvis w/ contrast ___
Impression - No acute abnormality idenitified

OSH CT C-spine w/o contrast ___
Impression - there are degenerative disc and facet findings. No 
acute abnormality identified

LABS:

___ 09:09PM   GLUCOSE-102* UREA N-20 CREAT-1.2 SODIUM-138 
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-21* ANION GAP-15
___ 09:09PM   CALCIUM-8.4 PHOSPHATE-3.5 MAGNESIUM-2.0
___ 09:09PM   WBC-6.7 RBC-3.03* HGB-11.1* HCT-33.0* 
MCV-109* MCH-36.6* MCHC-33.6 RDW-16.3* RDWSD-65.7*
___ 09:09PM   NEUTS-79.7* LYMPHS-7.6* MONOS-9.3 EOS-2.4 
BASOS-0.4 IM ___ AbsNeut-5.34 AbsLymp-0.51* AbsMono-0.62 
AbsEos-0.16 AbsBaso-0.03
___ 09:09PM   PLT SMR-LOW* PLT COUNT-90*
___ 09:09PM   ___ PTT-31.6 ___
 

###RESPONSE: IMAGING {Imaging}, x-ray {Radiographic imaging procedure}, No acute abnormality {No abnormality detected}, nondisplaced fractures {Undisplaced fracture}, 9th ribs {Bone structure of ninth rib}, No acute abnormality {No abnormality detected}, degenerative disc {Degeneration of intervertebral disc}, facet {Osteoarthritis of spinal facet joint}, No 
acute abnormality {No abnormality detected}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, CALCIUM {Blood calcium measurement}, PHOSPHATE {Phosphate, total measurement}, MAGNESIUM {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PLT {Platelet count}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Mr. ___ is a ___ who presented as transfer from ___ 
for trauma evaluation for right ___ rib fractures s/p 
mechanical fall. The patient was admitted to the trauma surgery 
service for respiratory monitoring and pulmonary toilet. Pain 
was managed with acetaminophen and tramadol. 

The patient was alert and oriented throughout hospitalization.  
The patient remained stable from a cardiovascular and pulmonary 
standpoint. Vital signs were routinely monitored. Good pulmonary 
toilet, early ambulation and incentive spirometry were 
encouraged throughout hospitalization. The patient tolerated a 
regular diet. The patient's fever curves were closely watched 
for signs of infection, of which there were none. The patient's 
blood counts were closely watched for signs of bleeding, of 
which there were none. The patient received subcutaneous heparin 
and ___ dyne boots were used during this stay and was 
encouraged to get up and ambulate as early as possible.

The patient worked with Physical Therapy and ___ recommended 
discharge to home with home physical therapy. At the time of 
discharge, the patient was doing well, afebrile and 
hemodynamically stable.  The patient was tolerating a diet, 
ambulating, voiding without assistance, and pain was well 
controlled.  The patient received discharge teaching and 
follow-up instructions with understanding verbalized and 
agreement with the discharge plan.

 

###RESPONSE: trauma {Traumatic injury}, evaluation {Evaluation procedure}, right {Bone structure of right rib}, rib fractures {Fracture of multiple ribs}, fall {Falls}, respiratory monitoring {Monitoring of respiration}, pulmonary toilet {Airway toilet}, Pain {Pain}, alert {Mentally alert}, oriented {Orientated}, stable {Patient's condition stable}, Vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, pulmonary 
toilet {Airway toilet}, ambulation {Ambulation training}, incentive spirometry {Incentive spirometry}, tolerated a 
regular diet {Tolerating normal diet}, fever {Fever}, watched 
for signs of infection {Monitoring for signs and symptoms of infection}, blood counts {Cell count}, signs {Sign}, bleeding {Bleeding}, subcutaneous heparin {Subcutaneous injection of heparin}, ambulate {Ambulation training}, Physical Therapy {Physical therapy procedure}, physical therapy {Physical therapy procedure}, afebrile {Temperature normal}, hemodynamically stable {Hemodynamically stable}, tolerating a diet {Tolerating diet}, ambulating {Fully mobile}, voiding without assistance {Continence independent}, pain was well 
controlled {Demonstrates adequate pain control}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Tylenol
Diltiazem ER 120mg
Flovent 220mcg HFA BID
Folic acid 1mg
Furosemide 20mg
Guaifensin 10cc q4 prn cough
Ipratropium-albuterol q4 prn
Loperamide 2mg TID prn
Methotrexate 2.5mg (7.5mg weekly on ___
Omeprazole 20mg daily
Pro-air HFA 90mcg inhaler
Procrit 40,000 ___
Spiriva 18mcg
Trazodone 50mg qhs
Vitamin B12 1000mcg daily

 
Discharge Medications:
1.  Acetaminophen ___ mg PO Q6H:PRN Pain - Mild 
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) 
hours Disp #*40 Tablet Refills:*0 
2.  Docusate Sodium 100 mg PO BID:PRN constipation   
3.  Lidocaine 5% Patch 1 PTCH TD DAILY 
apply patch and leave on for 12 hours, and then remove and leave 
off for 12 hours  
RX *lidocaine 5 % Apply one patch to area of rib pain Daily Disp 
#*7 Patch Refills:*0 
4.  TraMADol 25 mg PO Q6H:PRN pain 
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six 
(6) hours Disp #*15 Tablet Refills:*0 
5.  Cyanocobalamin 1000 mcg PO DAILY  
6.  Diltiazem Extended-Release 120 mg PO DAILY  
7.  Epoetin ___ ___  Units SC WEEKLY   
8.  Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID  
9.  FoLIC Acid 1 mg PO DAILY  
10.  Furosemide 20 mg PO DAILY  
11.  Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheezing  
12.  LOPERamide 2 mg PO TID:PRN diarrhea   
13.  Methotrexate 7.5 mg PO 1X/WEEK (___)  
14.  Omeprazole 20 mg PO DAILY  
15.  ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 
Q4H:PRN  
16.  Tiotropium Bromide 1 CAP IH DAILY  
17.  TraZODone 50 mg PO QHS  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___ 
 
Discharge Diagnosis:
-Right ___ rib fractures 

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Right {Bone structure of right rib}, rib fractures {Fracture of rib}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___, 

You were transferred to ___ in 
___ with multiple right-sided rib fractures after a fall.  
You were admitted to the Trauma Surgery Service for pain control 
and to monitor your breathing. While in the hospital, you worked 
with Physical Therapy and it is recommended that you have 
Physical Therapy services come to your home to help you regain 
your strength. You are now ready to be discharged home.  Please 
note the following discharge instructions:

* Your injury caused right-sided rib fractures which can cause 
severe pain and subsequently cause you to take shallow breaths 
because of the pain.
 
* You should take your pain medication as directed to stay ahead 
of the pain otherwise you won't be able to take deep breaths. If 
the pain medication is too sedating take half the dose and 
notify your physician.
 
* Pneumonia is a complication of rib fractures.  In order to 
decrease your risk you must use your incentive spirometer 4 
times every hour while awake.  This will help expand the small 
airways in your lungs and assist in coughing up secretions that 
pool in the lungs.
 
* You will be more comfortable if you use a cough pillow to hold 
against your chest and guard your rib cage while coughing and 
deep breathing.
 
* Symptomatic relief with ice packs or heating pads for short 
periods may ease the pain.
 
* Narcotic pain medication can cause constipation therefore you 
should take a stool softener twice daily and increase your fluid 
and fiber intake if possible.
 
* Do NOT smoke
 
* If your doctor allows, non-steroidal ___ drugs 
are very effective in controlling pain ( ie, Ibuprofen, Motrin, 
Advil, Aleve, Naprosyn) but they have their own set of side 
effects so make sure your doctor approves.
 
* Return to the Emergency Room right away for any acute 
shortness of breath, increased pain or crackling sensation 
around your ribs (crepitus).

 
 

###RESPONSE: right-sided {Bone structure of right rib}, rib fractures {Fracture of multiple ribs}, fall {Falls}, pain control {Pain control}, monitor {Monitoring for signs and symptoms of infection}, injury {Traumatic injury}, right-sided {Bone structure of right rib}, rib fractures {Fracture of multiple ribs}, severe pain {Severe pain}, shallow breaths {Shallow breathing}, pain {Pain}, pain medication {Administration of analgesic}, pain {Pain}, able to take deep breaths {Able to take deep breaths}, pain medication {Administration of analgesic}, Pneumonia {Pneumonia}, rib fractures {Fracture of multiple ribs}, decrease your risk {Preventive procedure}, use your incentive spirometer {Incentive spirometry}, airways {Airway structure}, lungs {Lung structure}, lungs {Lung structure}, chest {Thoracic structure}, rib cage {Thoracic cage structure}, coughing and 
deep breathing {Deep breathing and coughing exercises}, relief {Pain relief}, ice packs {Application of ice}, heating pads {Heat therapy}, pain {Pain}, constipation {Constipation}, take a stool softener {Administration of laxative}, increase your fluid {Fluid intake encouragement}, fiber intake {High fiber diet education}, Do NOT smoke {Smoking cessation education}, controlling pain {Pain control}, shortness of breath {Dyspnea}, increased pain {Increased pain}, crackling {Respiratory crackles}, ribs {Bone structure of rib}, crepitus {Bone crepitus}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
Morphine / Aspirin / Methocarbamol / Meperidine / Hydrocodone
 
Attending: ___.
 
Chief Complaint:
Dyspnea
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: Morphine {Allergy to morphine}, Aspirin {Allergy to aspirin}, 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 of CHF, AAA, and chronic back pain presenting from 
Rehab with confusion and disorientation, found to have a T=101, 
SaO2=88%. She was sent to the emergency room for further 
evaluation. In the emergency room she was somnolent, but 
arousable, and was confused and disoriented. She was transiently 
hypotensive and received ___ of IVF. CXR was consistent with 
pneumonia and she was given Vancomycin, Levofloxacin, and Zosyn. 
She was then transferred to the MICU for further management.
 

###RESPONSE: CHF {Congestive heart failure}, AAA {Abdominal aortic aneurysm}, chronic back pain {Chronic back pain}, confusion {Clouded consciousness}, disorientation {Disorientated}, SaO2 {Finding of oxygen saturation}, emergency {Emergency treatment management}, evaluation {Evaluation procedure}, emergency {Emergency treatment management}, confused {Clouded consciousness}, disoriented {Disorientated}, hypotensive {Low blood pressure}, IVF {Administration of intravenous fluids}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, Vancomycin {Antibiotic therapy}, Levofloxacin {Antibiotic therapy}, transferred to the MICU {Patient transfer to intensive care unit}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
CHF: EF unknown
AAA
Back Pain
GERD
Depression
 

###RESPONSE: CHF {Congestive heart failure}, AAA {Abdominal aortic aneurysm}, Back Pain {Backache}, GERD {Gastroesophageal reflux disease}, Depression {Depressive disorder}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Non-contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
T=95.7  HR=71  BP=99/39  RR=22   SpO2=92%
General: NAD
HEENT: Anicteric
CV: RR, ___ systolic murmur
Pulm: crackles on R>L, dullness at L base
Abd: soft, NTND, positive bowel sounds
Ext: no edema

 

###RESPONSE: HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, SpO2 {Finding of oxygen saturation}, General {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, Anicteric {White sclera}, CV {Cardiovascular physical examination}, RR {Finding of rate of respiration}, murmur {Murmur}, Pulm {Examination of respiratory system}, crackles {Respiratory crackles}, dullness {Chest dull to percussion}, L base {Structure of base of left lung}, Abd {Examination of abdomen}, soft {Abdomen soft}, ND {Swollen abdomen}, Ext {Examination of limb}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:06PM   TYPE-ART RATES-/28 PO2-98 PCO2-53* PH-7.32* 
TOTAL CO2-29 BASE XS-0 INTUBATED-NOT INTUBA
___ 02:07PM   LACTATE-1.2
___ 01:58PM   GLUCOSE-106* UREA N-22* CREAT-1.4* SODIUM-142 
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13
___ 01:58PM   ALT(SGPT)-14 AST(SGOT)-22 ALK PHOS-179* TOT 
BILI-0.6
___ 01:58PM   LIPASE-11
___ 01:58PM   proBNP-___*
___ 01:58PM   WBC-19.4*# RBC-3.26*# HGB-8.8*# HCT-28.9*# 
MCV-89 MCH-26.9* MCHC-30.4* RDW-16.5*
___ 01:58PM   ___ PTT-27.8 ___

___ 07:10PM 
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
6.8 3.55* 9.6* 30.4* 86 27.0 31.6 17.3* 443*

Glucose UreaN Creat Na K Cl HCO3 AnGap
112* 14 1.2* 142 3.6 104 31 11

___ 15:27 ECHO

The left atrium is elongated. No atrial septal defect is seen by 
2D or color Doppler. The right atrial pressure is indeterminate. 
There is mild symmetric left ventricular hypertrophy with normal 
cavity size and regional/global systolic function (LVEF>55%). 
There is no ventricular septal defect. Right ventricular chamber 
size and free wall motion are normal. The diameters of aorta at 
the sinus, ascending and arch levels are normal. The aortic 
valve leaflets (3) are mildly thickened. There is mild aortic 
valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation 
is seen. The mitral valve leaflets are mildly thickened. There 
is no mitral valve prolapse. Trivial mitral regurgitation is 
seen. The tricuspid valve leaflets are mildly thickened. There 
is moderate pulmonary artery systolic hypertension. There is a 
trivial/physiologic pericardial effusion.  

___ CXR
In comparison with the study of ___, there is again 
enlargement
of the cardiac silhouette with evidence of some pulmonary 
vascular congestion. Areas of increased opacification are seen 
at both bases with apparent silhouetting the hemidiaphragm. This 
most likely represents combination of atelectasis and effusion, 
though superimposed pneumonia be definitely excluded.
 

###RESPONSE: PO2 {Oxygen measurement, partial pressure, arterial}, PCO2 {Measurement of arterial partial pressure of carbon dioxide}, PH {pH measurement}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, BASE XS {Delta base, blood}, INTUBATED {Intubation}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, PHOS {Phosphate, total measurement}, TOT 
BILI {Bilirubin, total measurement}, LIPASE {Triacylglycerol lipase measurement}, proBNP {N-terminal pro-brain natriuretic peptide 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}, PTT {Partial thromboplastin time, activated}, WBC {White blood cell count}, RBC {Red blood cell count}, 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}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ECHO {Echocardiography}, left atrium is elongated {Left atrial enlargement}, atrial septal defect {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, right atrial {Right atrial structure}, mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, normal 
cavity size {Normal size}, regional/global systolic function {Normal left ventricular systolic function and wall motion}, ventricular septal defect {Ventricular septal defect}, Right ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Normal ventricular wall motion}, aorta at 
the sinus {Structure of sinus of Valsalva}, ascending {Ascending aorta structure}, arch {Aortic arch structure}, normal {No abnormality detected}, aortic 
valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, mild aortic 
valve stenosis {Mild stenosis of aortic valve}, aortic regurgitation {Aortic valve regurgitation}, mitral valve leaflets are mildly thickened {Thickened mitral leaflet}, mitral valve prolapse {Mitral valve prolapse}, Trivial mitral regurgitation {Mild mitral valve regurgitation}, tricuspid valve leaflets are mildly thickened {Tricuspid leaflet thickened}, moderate pulmonary artery systolic hypertension {Moderate pulmonary hypertension}, pericardial effusion {Pericardial effusion}, CXR {Plain chest X-ray}, study {Evaluation procedure}, enlargement {Enlargement}, cardiac {Heart structure}, pulmonary 
vascular congestion {Pulmonary congestion}, opacification {Abnormally opaque structure}, bases {Structure of base of lung}, atelectasis {Atelectasis}, effusion {Pleural effusion}, pneumonia {Pneumonia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ with PMH of CHF, depression, AAA, GERD presenting with 
altered mental status and hypotension, found to have sepsis 
likely due to a multi-lobar pneumonia admitted to the ICU for 
two days and transferred to medical floor on ___. She did 
not require tracheal intubation in the ICU.

1. Pneumonia: Urine legionella negative, blood cultures (NGTD 
from ___, viral culture negative. Patient improved on 
Vanc/Zosyn with steady improvement in her oxygen saturation to 
normal on RA at the time of discharge. She received an 8day 
course of antibiotics, then they were discontinued.  Oxygen was 
given and eventually weaned off.  Asnoted above, she did not 
require tracheal intubation in the ICU.

2. Dyspnea: Likely multifactorial due to pneumonia, and a 
component of diastolic congestive heart failure with volume 
resuscitation in the ER. Initial BNP elevated, and blood 
tests/EKG did not reveal suggestive myocardial injury. Patient 
responded well to intermittent doses of Lasix 10mg IV. 

3. Hypertension: Pt had episodes of hypotension at presentation; 
on the general medicine floor she remained intermitently 
hypertensive to SBP=180 despite Labetalol 200mg BID, which is 
her home regiment. Elevated values tended to be right before 
next dose of medicine is given; otherwise relatively 
well-controlled.  on discharge =150s/70s

4. Chronic diastolic CHF: TTE obtained this hospitalization 
showed EF>55%, no echocardiographic evidence of diastolic 
dysfunction, only mild LVH on TTE. She was continued on 
Labetalol as above for BP and rate control.

5. Anemia: Hct improved slowly to 31 at the time of discharge, 
MCV=89, baseline unknown. Given MCV, likely due to anemia of 
chronic disease, eval studies were consistent with this.

6. Lumbar disc disease - s/p lumbar surgery.  Back pain was 
slightly worse in hospital and so her Oxycontin to increased to 
40mg BID on ___ with good effect.  Not requireing breakthrough 
pain.  Valium was decreased to 2mg BID, and she's being 
discharged on 2mg once daily prn anxiety. She has not displayed 
high levels of anxiety, though the valium had been given to her 
prior to hospitalization more to help any spasm component of her 
back pain. 

 
 

###RESPONSE: CHF {Congestive heart failure}, depression {Depressive disorder}, AAA {Abdominal aortic aneurysm}, GERD {Gastroesophageal reflux disease}, altered mental status {Altered mental status}, hypotension {Low blood pressure}, sepsis {Sepsis}, lobar pneumonia {Lobar pneumonia}, ICU {Patient transfer to intensive care unit}, tracheal intubation {Insertion of endotracheal tube}, ICU {Patient transfer to intensive care unit}, Pneumonia {Pneumonia}, Urine {Urinalysis}, legionella {Legionella infection}, blood cultures {Blood culture}, viral culture {Viral culture}, improved {Patient's condition improved}, Vanc {Antibiotic therapy}, improvement {Patient's condition improved}, oxygen saturation to 
normal {Oxygen saturation within reference range}, antibiotics {Antibiotic therapy}, discontinued {Recommendation to stop drug treatment}, tracheal intubation {Insertion of endotracheal tube}, ICU {Patient transfer to intensive care unit}, Dyspnea {Dyspnea}, pneumonia {Pneumonia}, diastolic congestive heart failure {Heart failure with normal ejection fraction}, volume 
resuscitation {Oxygen therapy}, BNP {Brain natriuretic peptide measurement}, blood 
tests {Blood test}, EKG {Electrocardiographic procedure}, injury {Traumatic or non-traumatic injury}, responded well {Good therapeutic response}, Lasix {Diuretic therapy}, Hypertension {Hypertensive disorder, systemic arterial}, hypotension {Low blood pressure}, hypertensive {Finding of increased blood pressure}, SBP {Increased systolic arterial pressure}, regiment {Therapeutic regimen}, Elevated {Finding of increased blood pressure}, well-controlled {Disease condition determination, well controlled}, Chronic diastolic CHF {Chronic diastolic heart failure}, TTE {Transthoracic echocardiography}, echocardiographic {Echocardiography}, diastolic 
dysfunction {Diastolic dysfunction}, mild LVH {Mild left ventricular hypertrophy}, TTE {Transthoracic echocardiography}, Anemia {Anemia}, improved {Patient's condition improved}, MCV {Erythrocyte mean corpuscular volume determination}, baseline {Baseline state}, MCV {Erythrocyte mean corpuscular volume determination}, anemia of 
chronic disease {Anemia of chronic disorder}, eval {Evaluation procedure}, studies {Evaluation procedure}, Lumbar disc disease {Disorder of lumbar disc}, Back pain {Backache}, worse {Increased pain}, good effect {Good therapeutic response}, breakthrough 
pain {Breakthrough pain}, anxiety {Anxiety}, levels of anxiety {Level of anxiety}, spasm {Spasm}, 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: Medications on Admission:
Lidoderm patch
Levothyroxine 25mcg po qday
prilosec 20mg po qday
cymbalta 60mg po qday
colace 100mg po bid
labetalol 200mg po bid
xoycontin 30mg po bid
senna 1 tablet po bid
diazepam 5mg po q6h prn anxiety
oxycodone 10mg po q6 prn pain
mvi daily
lyrica 50mg po qday
robitussin prn
 
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed for pain, fever.  
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
5. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) 
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as 
needed for chronic back pain.  
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose 
Injection TID (3 times a day).  
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb 
Inhalation Q6H (every 6 hours) as needed for shortness of breath 
or wheezing.  
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for 
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as 
needed for wheeze, shortness of breath.  
10. Diazepam 2 mg Tablet Sig: One (1) Tablet PO once a day as 
needed for anxiety.  
11. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times 
a day).  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Pneumonia
Congestive Heart Failure (diastolic)
Low Back Pain

 
Discharge Condition:
Improved

 

###RESPONSE: Pneumonia {Pneumonia}, Congestive Heart Failure {Congestive heart failure}, diastolic {Diastolic heart failure}, Low Back Pain {Low back pain}, 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: Discharge Instructions:
You were admitted with pneumonia and sepsis and treated for this 
in the ICU and hospital floor with antibiotics and have 
completed this course.  You had an ultrasound of the heart which 
was normal. Your back pain medication was adjusted for increased 
pain.  If you have fever, cough, shortness of breath, chest pain 
or worsening back pain, please have this evaluated by your 
doctor.
 

###RESPONSE: pneumonia {Pneumonia}, sepsis {Sepsis}, ICU {Patient transfer to intensive care unit}, antibiotics {Antibiotic therapy}, ultrasound {Ultrasonography}, heart {Heart structure}, normal {No abnormality detected}, pain medication {Administration of analgesic}, adjusted {Drug dosage altered}, increased 
pain {Increased pain}, fever {Fever}, cough {Cough}, shortness of breath {Dyspnea}, chest pain {Chest pain}, worsening {Increased pain}, back pain {Backache}, evaluated {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: 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: UROLOGY
 

###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 DS
 
Attending: ___.
 
Chief Complaint:
hematuria, urinary retention
 
Major Surgical or Invasive Procedure:
___ Dr. ___, bladder biopsy

 

###RESPONSE: Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, hematuria {Blood in urine}, urinary retention {Retention of urine}, bladder biopsy {Biopsy of bladder}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mr. ___ is a ___ with a history of BPH.  He states that he saw 
a urologist more than ___ years ago and was started on terazosin. 
 He also underwent urodynamics and cystoscopy around ___ years 
ago and was told that he will likely need an operation.  
Yesterday, he presented to the ED in urinary retention following 
4 days of weak stream.  A foley was placed and he was found to 
have a UTI.  He was discharged with a 7d course of cipro.  Last 
night he noticed blood in his catheter which got progressibly 
darker in appearanced.  He returned to the ED this morning.  His 
catheter was changed to a 3 way foley, he was hand irrigated 
with return of clots and he was placed on CBI.  A few hours 
later his drainage became bloody again and he was hand irrigated 
with further return of clots. 

 

###RESPONSE: BPH {Benign prostatic hyperplasia}, urodynamics {Urodynamic studies}, cystoscopy {Transurethral cystoscopy}, operation {Surgical procedure}, urinary retention {Retention of urine}, weak stream {Poor stream of urine}, foley was placed {Introduction of urinary catheter}, UTI {Urinary tract infectious disease}, blood {Blood in urine}, catheter was changed {Change of urethral catheter}, foley {Catheterization of urinary bladder}, hand irrigated {Manual bladder washout through catheter}, clots {Blood clot}, CBI {Monitoring of continuous bladder irrigation}, s hand irrigated {Manual bladder washout through catheter}, clots {Blood clot}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Diabetes type 2, complicated by retinopathy
h/o syphilis
Angioedema
Glaucoma
BPH
spinal stenosis
s/p laminectomy
Paget's disease
s/p shoulder surgery
gout
lichen planus

 

###RESPONSE: Diabetes type 2 {Diabetes mellitus type 2}, retinopathy {Retinal disorder}, syphilis {Syphilis}, Angioedema {Angioedema}, Glaucoma {Glaucoma}, BPH {Benign prostatic hyperplasia}, spinal stenosis {Spinal stenosis}, laminectomy {Excision of lamina of vertebra}, Paget's disease {Osteitis deformans}, shoulder {Structure of left shoulder region}, surgery {Surgical procedure}, gout {Inflammatory disorder due to increased blood urate level}, lichen planus {Lichen planus}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: Physical Exam:
nad
Abd soft, nt/nd
Foley with clear yellow urine
 

###RESPONSE: nad {No abnormality detected}, soft {Abdomen soft}, Foley {Urinary catheter in situ}, clear yellow urine {Urine looks clear}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 08:30PM   HCT-37.7*
___ 11:00AM   GLUCOSE-238* UREA N-19 CREAT-1.1 SODIUM-142 
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
___ 3:15 pm URINE     Site: CLEAN CATCH

                            **FINAL REPORT ___

   URINE CULTURE (Final ___: 
      KLEBSIELLA PNEUMONIAE.    >100,000 ORGANISMS/ML.. 
         Piperacillin/tazobactam sensitivity testing available 
on request. 

                              SENSITIVITIES: MIC expressed in 
MCG/ML
                      
_________________________________________________________
                             KLEBSIELLA PNEUMONIAE
                             |   
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------    ___ I
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

___ 07:04PM BLOOD WBC-13.4* RBC-3.76* Hgb-11.2* Hct-34.0* 
MCV-90 MCH-29.7 MCHC-32.8 RDW-13.7 Plt ___
___ 07:18AM BLOOD WBC-12.1* RBC-3.62* Hgb-10.6* Hct-32.4* 
MCV-90 MCH-29.4 MCHC-32.8 RDW-13.8 Plt ___
___ 07:18AM BLOOD Glucose-122* UreaN-14 Creat-1.2 Na-139 
K-3.7 Cl-102 HCO3-29 AnGap-12
 

###RESPONSE: HCT {Hematocrit determination}, 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}, URINE {Urine culture}, CATCH {Urine specimen collection, clean catch}, URINE CULTURE {Urine culture}, sensitivity {Antimicrobial susceptibility test}, SENSITIVITIES {Antimicrobial susceptibility test}, 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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
The patient was admitted to Dr. ___ service with 
hematuria.  He underwent conservative management with CBI but 
continued to have hematuria when the CBI was clamped.  On HD3 he 
underwent cystoscopy and bladder biopsy. No obvious bleeding 
source was identified. No concerning intraoperative events 
occurred; please see dictated operative note for details. The 
patient received ___ antibiotic prophylaxis. On POD1 
he underwent a voiding trial but failed and a foley was 
replaced.  The evening of POD1 he developed fevers and chills.  
His WBC was elevated to 13.  Urine and blood cultures were 
obtained and are still pending.  CXR was normal.  He deferveced 
on POD2 and his WBC count was decreasing.  At discharge, 
patient's pain well controlled with oral pain medications, 
tolerating regular diet, ambulating without assistance, and 
urine is clear yellow. He will be discharged with a total 3 week 
course of cipro.  He is given explicit instructions to call Dr. 
___ follow-up next week to have the catheter removed.
 

###RESPONSE: hematuria {Blood in urine}, conservative management {Conservative therapy}, CBI {Irrigation of urinary bladder}, hematuria {Blood in urine}, CBI {Irrigation of urinary bladder}, clamped {Application of clamp}, cystoscopy and bladder biopsy {Cystoscopy and biopsy of bladder}, bleeding {Bleeding}, intraoperative {Intraoperative state}, operative {Surgical procedure}, antibiotic prophylaxis {Administration of prophylactic antibiotic}, voiding {Normal micturition}, foley {Catheterization of urinary bladder}, replaced {Catheterization of urinary bladder}, fevers {Fever}, chills {Chill}, WBC {White blood cell count}, Urine {Urine culture}, blood cultures {Blood culture}, CXR was normal {Standard chest X-ray normal}, WBC count {White blood cell count}, pain well controlled {Demonstrates adequate pain control}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, tolerating {Tolerating diet}, regular diet {Normal diet}, ambulating without assistance {Independent walking}, urine is clear yellow {Urine looks clear}, instructions {Recommendation to}, catheter removed {Removal of urinary system catheter}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
BIMATOPROST [LUMIGAN] - 0.03 % Drops - one drop each eye once a
day
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day
TADALAFIL [CIALIS] - 20 mg Tablet - one Tablet(s) by mouth 60 
min
prior to intercourse Do not take more than once per day.
TERAZOSIN - 5 mg Capsule - 1 Capsule(s) by mouth once a day
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply after shower
every other day
ASPIRIN -  (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] -  (OTC; record) - 
Dosage
uncertain
GARLIC -  (OTC) - Dosage uncertain

 
Discharge Medications:
1. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical 
QID (4 times a day).  
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H 
(every 12 hours) for 16 days.
Disp:*32 Tablet(s)* Refills:*0*
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) 
Tablet PO DAILY (Daily).  
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic DAILY 
(Daily).  
5. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at 
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) 
as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours).  
9. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).  
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: 
hold if diarrhea.
Disp:*60 Capsule(s)* Refills:*2*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
hematuria, BPH

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: hematuria {Blood in urine}, BPH {Benign prostatic hyperplasia}, Mental Status {Neurological mental status determination}, Clear {Normal breath sounds}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
-No vigorous physical activity for 2 weeks. 

 

-Expect to see occasional blood in your urine and to experience 
urgency and frequecy over the next month. 

 

-You may shower and bathe normally. 

 

-Tylenol should be your first line pain medication, a narcotic 
pain medication has been prescribed for breakthough pain >4.  
Replace Tylenol with narcotic pain medication.  Max daily 
Tylenol dose is 4gm, note that narcotic pain medication also 
contains Tylenol (acetaminophen)

 

-Do not drive or drink alcohol while taking narcotics

 

-Colace has been prescribed to avoid post surgical constipation 
and constipation related to narcotic pain medication, 
discontinue if loose stool or diarrhea develops.

 

-Resume all of your home medications, except hold NSAID 
(aspirin,  and ibuprofen containing products such as advil & 
motrin,) until you see your urologist in follow-up

 

 -Resume all of your home medications, but please avoid 
aspirin/advil for one week.   

- Ciprofloxacin has been prescribed.  You will take a total of 3 
week course.
 

-Call Dr. ___ (___) for follow-up AND if you 
have any questions (page Dr. ___ at ___. 

 

 -If you have fevers > 101.5 F, vomiting, severe abdominal pain, 
or inability to urinate, call your doctor or go to the nearest 
emergency room.

 

###RESPONSE: activity {Functional activity education}, blood in your urine {Blood in urine}, urgency {Urgent desire to urinate}, frequecy {Increased frequency of urination}, may shower {Wound treatment education}, Tylenol {Administration of analgesic}, pain medication {Administration of analgesic}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, breakthough pain {Breakthrough pain}, Tylenol {Administration of analgesic}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, Tylenol {Administration of analgesic}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, Tylenol {Administration of analgesic}, Do not drive {Recommendation to avoid activity of daily living}, post surgical {Postoperative state}, constipation {Constipation}, constipation {Constipation}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, loose stool {Loose stool}, diarrhea {Diarrhea}, aspirin {Administration of aspirin}, aspirin {Administration of aspirin}, Ciprofloxacin {Antibiotic therapy}, fevers {Fever}, vomiting {Vomiting}, abdominal pain {Abdominal pain}, inability to urinate {Retention of urine}, call your doctor {Informing doctor}, emergency {Emergency treatment}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
charcot arthropathy
 
Major Surgical or Invasive Procedure:
___
1. Closed treatment right bimalleolar ankle fracture with
    manipulation.
2. Tenotomy, right Achilles tendon.
3. Flexor hallucis longus tendon release.
4. Flexor digitorum longus release.
5. Posterior tibial tendon release.

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, charcot arthropathy {Charcot's arthropathy}, right {Structure of right ankle}, bimalleolar ankle fracture {Bimalleolar fracture of ankle}, manipulation {Manipulation}, Tenotomy {Tenotomy}, right Achilles tendon {Structure of right Achilles tendon}, Flexor hallucis longus tendon {Structure of flexor hallucis longus tendon}, release {Release}, Flexor digitorum longus {Flexor digitorum longus muscle structure}, release {Release}, Posterior tibial tendon {Tendon structure of posterior tibial muscle}, release {Release}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
I am seeing your patient today in the ___ clinic.  I am
seeing this patient today for review.  She has had unfortunately
a fall approximately one and half weeks ago.  She had a twisting
injury.  She has had pain in the ankle since that time.

She does not describe any changes in her health.  Her past
medical history has been documented including diabetes.

I examined her today and found that she has some tenderness on
deep palpation of medial or lateral aspects of her ankle.  No
complaints of any calf pain or calf swelling to suggest deep 
vein
thrombosis or pulmonary embolus.

IMAGING:  I reviewed her x-rays that show evidence of an acute
fracture involving her ankle joint, specifically a bimalleolar
ankle fracture.  She does have underlying Charcot arthropathy.

ASSESSMENT AND PLAN:  I had a discussion today with ___
regarding management.  I am concerned regarding her new 
fracture.
 We have talked about treatment.  We have talked about surgical
intervention to address her deformity; however, I am concerned
about adding additional hardware because of her history of
noncompliance and the risk of deep infection that may require
additional procedures including a possible below-knee 
amputation.

We will go ahead and make the appropriate arrangements for her 
to
have her procedure done to stabilize the ankle and again, we 
will
try to avoid any hardware that would not be removed at a later
date.  She also is aware of the possibility that she may require
a fusion type procedure as if she continues to have instability
involving the ankle.

I have answered all of her questions.  She was given specific
instructions regarding followup.  She is to remain
nonweightbearing.  She understands signs and symptoms associated
with deep vein thrombosis and pulmonary embolus.

 

###RESPONSE: fall {Falls}, twisting
injury {Rotation injury}, pain in the ankle {Ankle pain}, tenderness {Tenderness}, deep palpation {Deep palpation}, medial {Structure of medial aspect of ankle}, lateral aspects {Structure of lateral aspect of ankle}, ankle {Ankle region structure}, No
complaints {No complaints}, calf pain {Pain in calf}, calf swelling {Swollen calf}, deep 
vein
thrombosis {Deep venous thrombosis}, pulmonary embolus {Pulmonary embolism}, IMAGING {Imaging}, x-rays {Radiographic imaging procedure}, fracture {Fracture}, ankle joint {Ankle joint structure}, bimalleolar
ankle fracture {Bimalleolar fracture of ankle}, Charcot arthropathy {Charcot's arthropathy}, fracture {Fracture}, surgical
intervention {Surgical procedure}, deformity {Deformity}, infection {Infectious disease}, procedures {Procedure}, below-knee 
amputation {Amputation of leg through tibia and fibula}, ankle {Ankle region structure}, fusion type procedure {Fusion procedure}, ankle {Ankle region structure}, signs {Sign}, deep vein thrombosis {Deep venous thrombosis}, pulmonary embolus {Pulmonary embolism}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
PMH: 
type 1 DM
alport syndrome
htn
hypercholesterolemia

PSH:
vp shunt 
c-section

 

###RESPONSE: type 1 DM {Diabetes mellitus type 1}, alport syndrome {Alport syndrome}, htn {Hypertensive disorder, systemic arterial}, hypercholesterolemia {Hypercholesterolemia}, shunt {Surgical fistula}, c-section {Cesarean section}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
non contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
splint c/d/i
neurovascularly intact distally
foot wwp
 

###RESPONSE: splint {Application of splint}, neurovascularly intact {Normal peripheral neurovascular function}, foot {Foot structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
none
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and 
was taken to the operating room for above described procedure. 
Please see separately dictated operative report for details. The 
surgery was uncomplicated and the patient tolerated the 
procedure well. Patient received perioperative IV antibiotics.

Otherwise, pain was initially controlled with a PCA followed by 
a transition to oral pain medications on POD#1.  The patient 
received lovenox for DVT prophylaxis starting on the morning of 
POD#1.  The patient was seen daily by physical therapy.   

At the time of discharge the patient was tolerating a regular 
diet and feeling well.  The patient was afebrile with stable 
vital signs.  The patient's  pain was adequately controlled on 
an oral regimen. The operative extremity was neurovascularly 
intact.   The patient is non-weight-bearing on the operative 
lower extremity.
 
She is discharged to home in stable condition with prescriptions 
for oxycodone and lovenox
 

###RESPONSE: surgery {Surgical procedure}, IV antibiotics {Intravenous antibiotic therapy}, pain {Pain}, PCA {Patient controlled analgesia}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, DVT prophylaxis {Prevention of deep vein thrombosis}, physical therapy {Physical therapy procedure}, regular 
diet {Normal diet}, feeling well {Well in self}, afebrile {Fever}, stable 
vital signs {Normal vital signs}, pain was adequately controlled {Demonstrates adequate pain control}, oral {Administration of drug or medicament via oral route}, regimen {Therapeutic regimen}, operative {Operative site}, extremity {Limb structure}, neurovascularly 
intact {Normal peripheral neurovascular function}, non-weight-bearing {Non-weight-bearing}, operative {Operative site}, lower extremity {Lower limb structure}, stable condition {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Medications - Prescription
AMLODIPINE - 10 mg Tablet - take 1 Tablet(s) by mouth once a day
ENALAPRIL MALEATE - 20 mg Tablet - take 1 Tablet(s) by mouth
twice a day
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - use as
directed twice a day
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - use as 
directed
four times a day
PAROXETINE HCL [PAXIL] - 10 mg Tablet - take 1 Tablet(s) by 
mouth
once a day
PRAVASTATIN - 40 mg Tablet - take 1 Tablet(s) by mouth at 
bedtime
SULFAMETHOXAZOLE-TRIMETHOPRIM - 800 mg-160 mg Tablet - take 1
Tablet(s) by mouth twice a day
 
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] -   Strip - use 
as
directed to measure blood glucose four times a day
INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE ULTRA-FINE] - 
30
gauge X ___ Syringe - use as directed 8 times a day as needed
for glucose level

 
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours) as needed for pain.  
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).  

3. enalapril maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2 
times a day).  
4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at 
bedtime).  
5. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) 
as needed for Pain.  
6. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe 
Subcutaneous Q 24H (Every 24 Hours).  

 

###RESPONSE: mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
charcot arthropathy

 
Discharge Condition:
home.  stable.  alert and oriented x3.

 

###RESPONSE: charcot arthropathy {Charcot's arthropathy}, stable {Patient's condition stable}, alert {Mentally alert}, oriented x3 {Oriented to person, time and place}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
1. Please return to the emergency department or notify your 
physician if you experience any of the following: severe pain 
not relieved by medication, increased swelling, decreased 
sensation, difficulty with movement, fevers greater than 101.5, 
shaking chills, increasing redness or drainage from the incision 
site, chest pain, shortness of breath or any other concerns.

2. Please follow up with your primary physician regarding this 
admission and any new medications and refills.  
 
3. Resume your home medications unless otherwise instructed.

 
4. You have been given medications for pain control. Please do 
not drive, operate heavy machinery, or drink alcohol while 
taking these medications. As your pain decreases, take fewer 
tablets and increase the time between doses. This medication can 
cause constipation, so you should drink plenty of water daily 
and take a stool softener (such as colace) as needed to prevent 
this side effect.  Call your surgeons office 3 days before you 
are out of medication so that it can be refilled.  These 
medications cannot be called into your pharmacy and must be 
picked up in the clinic or mailed to your house.  Please allow 
an extra 2 days if you would like your medication mailed to your 
home.

 
5. Please call your surgeon's office to schedule or confirm your 
follow-up appointment in two (2) weeks.

 
6. Please DO NOT take any non-steroidal anti-inflammatory 
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, 
motrin, etc).

 
7. ANTICOAGULATION: Please continue your lovenox for four (4) 
weeks to help prevent deep vein thrombosis (blood clots).  

 
8. CAST CARE: Please keep your cast clean, dry and intact. 

 
9. ACTIVITY: Non-weight bearing on the operative extremity
 

###RESPONSE: severe pain {Severe pain}, swelling {Swelling}, decreased 
sensation {Hypesthesia}, difficulty with movement {Difficulty moving}, fevers {Fever}, shaking {Tremor}, chills {Chill}, redness {Redness of skin over lesion}, drainage {Wound discharge}, incision 
site {Surgical incision wound}, chest pain {Chest pain}, shortness of breath {Dyspnea}, medications {Patient medication education}, medications {Patient medication education}, medications {Patient medication education}, pain control {Pain control}, drink alcohol {Current drinker of alcohol}, while 
taking these medications {Patient medication education}, pain decreases {Sensation of pain reduced}, constipation {Constipation}, take a stool softener {Administration of laxative}, side effect {Medication side effects present}, medication so that it can be refilled {Medication prefill education}, medications {Patient medication education}, medication {Patient medication education}, non-steroidal anti-inflammatory 
medications {Non-steroidal anti-inflammatory agent therapy}, ANTICOAGULATION {Anticoagulant therapy}, prevent deep vein thrombosis {Prevention of deep vein thrombosis}, blood clots {Blood clot}, CAST CARE {Cast care}, cast {Cast}, clean, dry and intact {Wound healing well}, ACTIVITY {Functional activity education}, Non-weight bearing {Non-weight-bearing}, operative {Operative site}, extremity {Limb structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Lincosamides / Penicillins
 
Attending: ___
 
Chief Complaint:
Presentation for TIPS procedure
 
Major Surgical or Invasive Procedure:
TIPS

 

###RESPONSE: Penicillins {Allergy to penicillin}, TIPS procedure {Transjugular intrahepatic portosystemic shunt}, TIPS {Transjugular intrahepatic portosystemic shunt}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ with a PMHx of ___ cirrhosis c/b refractory ascites and 
esophageal varices who presents for direct admission to the ET 
service for TIPS procedure given now weekly need for 
paracenteses and abdominal pain.  Pt dx with NASH in ___ 
following her gastric bypass and had no symptoms until ___ when 
she started to have increased abdominal girth and abd pain.  Pt 
has had weekly paracentesis for refractory ascites, most 
recently ___ where 9L was taken off. She has complaints today of 
dull abd pain given length of time since last tap.  

Pt had EGD on ___ which revealed two lower esophageal 
varices. Had one episode of HE one month ago when she missed her 
lactulose. Pt notes persistent issues with varying constipation 
and diarrhea and requires lactulose for BM's. Had 3 BM's 
yesterday, denies melena/ BRBPR/ hematemesis.

 

###RESPONSE: cirrhosis {Cirrhosis of liver}, refractory ascites {Refractory ascites}, esophageal varices {Esophageal varices}, TIPS procedure {Transjugular intrahepatic portosystemic shunt}, paracenteses {Abdominal paracentesis}, abdominal pain {Abdominal pain}, NASH {Nonalcoholic steatohepatitis}, gastric bypass {Bypass of stomach}, increased abdominal girth {Swollen abdomen}, abd pain {Abdominal pain}, paracentesis {Abdominal paracentesis}, refractory ascites {Refractory ascites}, dull {Dull pain}, abd pain {Abdominal pain}, tap {Abdominal paracentesis}, EGD {Esophagogastroduodenoscopy}, esophageal 
varices {Esophageal varices}, HE {Hepatic encephalopathy}, constipation {Constipation}, diarrhea {Diarrhea}, BM {Defecation care}, BM {Finding of defecation}, melena {Melena}, BRBPR {Hematochezia}, hematemesis {Hematemesis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
NASH cirrhosis with portal hypertension c/b refractory ascites, 
esophageal varices (EGD on ___
ITP
Obesity s/p gastric bypass surgery in ___
CCY in ___
C-section ___

 

###RESPONSE: NASH {Nonalcoholic steatohepatitis}, cirrhosis {Cirrhosis of liver}, portal hypertension {Portal hypertension}, refractory ascites {Refractory ascites}, esophageal varices {Esophageal varices}, EGD {Esophagogastroduodenoscopy}, ITP {Chronic idiopathic thrombocytopenic purpura}, Obesity {Obesity}, gastric bypass {Bypass of stomach}, surgery {Surgical procedure}, CCY {Cholecystectomy}, C-section {Cesarean section}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Great uncle died of ""liver disease"" at age ___, possible HCC

 

###RESPONSE: died {Dead}, liver disease {Disorder of liver}, HCC {Liver cell carcinoma}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Physical exam on admission:
Vitals-  97.9 118/64 83 18 99% RA
General:  Alert, oriented, pleasant, sitting up in bed
HEENT:  NCAT, PERRL, EOMI, MMM, oropharynx clear
Neck:  supple, no JVD, no LAD
CV:  RRR, nl S1 and S2, no m/r/g
Lungs:  CTAB without wheeze or crackles
Abdomen:  obese, distended with + fluid wave, non-tender, no 
appreciable organomegaly
GU:  no foley
Ext:  Warm and dry, 2+ peripheral pulses, trace pedal edema, no 
cyanosis
Neuro:  AOx3, CN2-12 grossly intact, moves all extremities 
freely
Skin:  varicose veins noted on bilateral ___, no rash or lesions

On discharge:

Vitals:  Tm 98.3 Tc 97.9 HR 88 BP 127/67 RR 20 

###RESPONSE: Physical Exam {Physical examination procedure}, Vitals {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, sitting {Sitting position}, HEENT {Physical examination procedure}, NC {Normal head}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, no m/r/g {Heart sounds normal}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, wheeze {Wheezing}, crackles {Respiratory crackles}, Abdomen {Examination of abdomen}, obese {Obese abdomen}, distended {Swollen abdomen}, fluid {Effusion}, non-tender {Abdominal tenderness}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, Ext {Examination of limb}, Warm {Warm skin}, 2+ peripheral pulses {Peripheral pulses normal}, edema {Edema}, cyanosis {Cyanosis}, Neuro {Neurological examination}, AOx3 {Oriented to person, time and place}, 12 {Hypoglossal nerve structure}, grossly intact {Normal nervous system function}, all extremities {All extremities}, Skin {Examination of skin}, varicose veins {Venous varices}, rash {Eruption of skin}, lesions {Lesion}, Vitals {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam: 
Gen: WDWN, no acute distress, sitting in chair
HENT: no scleral icterus
CV: RRR, no m/r/g
Pulm: CTA in all fields, no wheezes or ronchi
Abd: obese, distended, mild tenderness to palpation in RUQ, hard 
enlarged liver palpated. RUQ wound bandaged, clean dry and 
intact.
Ext: 2+ DP pulses bilaterally
Neuro: A&Ox3, fine tremor but no asterixis 

 

###RESPONSE: Physical Exam {Physical examination procedure}, Gen {General examination of patient}, WDWN {Well nourished}, no acute {No abnormality detected}, distress {Distress}, sitting {Sitting position}, HENT {Physical examination procedure}, scleral icterus {Scleral icterus}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, Pulm {Examination of respiratory system}, CTA {Normal breath sounds}, wheezes {Wheezing}, ronchi {Wheeze - rhonchi}, Abd {Examination of abdomen}, obese {Obese abdomen}, distended {Swollen abdomen}, mild {Symptom mild}, tenderness to palpation in RUQ {Tenderness of right upper quadrant of abdomen}, enlarged liver {Large liver}, palpated {Palpation of abdomen}, RUQ {Structure of right upper quadrant of abdomen}, wound {Surgical incision wound}, bandaged {Application of bandage}, clean dry and 
intact {Wound healing well}, Ext {Examination of limb}, 2+ DP pulses {All pulses present in bilateral lower limbs}, Neuro {Neurological examination}, A&Ox3 {Oriented to person, time and place}, fine tremor {Fine tremor}, asterixis {Asterixis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Pertinent labs on admission:

___ 05:11PM BLOOD WBC-3.4* RBC-3.61* Hgb-7.4* Hct-25.8* 
MCV-72* MCH-20.5* MCHC-28.7* RDW-20.7* RDWSD-53.4* Plt Ct-77*
___ 05:11PM BLOOD ___ PTT-30.1 ___
___ 05:11PM BLOOD Glucose-127* UreaN-10 Creat-0.8 Na-132* 
K-3.6 Cl-99 HCO3-23 AnGap-14
___ 05:11PM BLOOD ALT-15 AST-47* AlkPhos-226* TotBili-0.7 
DirBili-0.3 IndBili-0.4
___ 05:11PM BLOOD Albumin-3.0* Calcium-9.0 Phos-3.5 Mg-1.7
___ 05:11PM BLOOD HCG-<5

Reports:
Hepatic ultrasound with doppler studies ___
FINDINGS:  
  
Liver:  The hepatic parenchyma is coarsened and nodular.  
Nofocal liver 
lesions are identified.  There is a moderate amount of ascites. 
Bile ducts:  There is no intrahepatic biliary ductal dilation.  
The common 
hepatic duct measures 2 mm. 
Gallbladder:  The gallbladder surgically absent. 
Pancreas:  The pancreas is largely obscured by overlying bowel 
gas, with 
imaged portions of the pancreas appearing within normal limits. 
Spleen:  The spleen is markedly enlarged, and measures greater 
than 18.3 cm. 
Kidneys:  Limited sagittal views of the right kidney demonstrate 
no evidence 
of hydronephrosis. 
  
Doppler evaluation: 
The main portal vein is patent, with flow in the appropriate 
direction.  The 
right and left portal veins are patent, with antegrade flow. 
The main hepatic artery is patent, with appropriate waveform. 
Right, middle and left hepatic veins are patent, with 
appropriate waveforms. 
  
IMPRESSION: 
  
  
1. Patent hepatic vasculature with appropriate direction of 
flow. 
2. Cirrhosis and sequela of portal hypertension including marked 
splenomegaly 
and a moderate amount of ascites. 
3. Status post cholecystectomy. 

Micro:

Pertinent labs on discharge:

___ 05:45PM BLOOD WBC-2.8* RBC-3.44* Hgb-7.4* Hct-25.6* 
MCV-74* MCH-21.5* MCHC-28.9* RDW-20.5* RDWSD-53.5* Plt Ct-66*
___ 04:33AM BLOOD Glucose-133* UreaN-13 Creat-0.9 Na-129* 
K-4.0 Cl-97 HCO3-23 AnGap-13
___ 04:33AM BLOOD ALT-100* AST-258* AlkPhos-212* 
TotBili-1.4
___ 04:33AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
___ 04:50AM BLOOD Albumin-3.0* Calcium-9.0 Phos-3.9 Mg-1.___ female with ITP and NASH cirrhosis c/b portal HTN resulting 
in refractory ascites requiring large volume (___) paracenteses 
qWeek presenting for TIPS procedure.

#NASH cirrhosis c/b esophageal varicies, refractory ascites and 
hepatic encephalopathy: Pt with persistent disease and symptoms 
since ___. Has been previously evaluated for 
transplant, however, it was decided to undergo TIPS given weekly 
need for large volume paracenteses and abdominal pain.

#NASH cirrhosis c/b esophageal varicies, refractory ascites and 
hepatic encephalopathy: Pt with persistent disease and symptoms 
since ___. Has been previously evaluated for 
transplant, however, it was decided to undergo TIPS given weekly 
need for large volume paracenteses and abdominal pain. 
Complicated TIPS completed ___. Specifically, right hepatic 
vein to right portal vein TIPS placed, complicated by suspected 
dissection of the portal vein and jailing of right PV posterior 
branches. TIPS was extended into main PV with luminex stents, 
dilated to 10 mm. post procedure gradient approx 15, similar to 
preprocedure gradient. 5 L paracentesis. approx 470 cc contrast 
used. Pt reported abd soreness ""like punched"" which improved 
with oxycodone. LFTs and Cr bumped. Creatinine normalized with 
500cc 5% albumin for suspected contrast-induced nephropathy vs 
HRS. Will obtain f/u ultrasound in 1 week post-discharge and f/u 
with hepatology as arranged. Pt was maintained on lactulose 
without evidence of hepatic encephalopathy throughout her stay.

#Hypotension - likely secondary to cirrhosis. Held home lasix, 
spironolactone, nadolol for labile blood pressure and optimizing 
renal blood flow which may be restarted per hepatology as an 
outpatient. 

#Anemia - likely secondary to chronic liver disease
- required 1U pRBC during stay with Hg 6.7 and appropriate rise 
in Hg to 7.4 prior to discharge. 

# History of ITP:
-Stable during hospitalization. Plt ranged 66-103

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Hepatic ultrasound with doppler {Doppler ultrasonography of liver and portal system}, Liver {Liver structure}, hepatic parenchyma {Structure of parenchyma of liver}, nodular {Nodule}, liver 
lesions {Lesion of liver}, ascites {Ascites}, Bile ducts {Bile duct structure}, intrahepatic biliary ductal {Intrahepatic biliary tract structure}, dilation {Dilatation}, common 
hepatic duct {Structure of common hepatic duct}, Gallbladder {Gallbladder structure}, gallbladder surgically absent {Gallbladder not seen}, Pancreas {Pancreatic structure}, pancreas {Pancreatic structure}, bowel {Intestinal structure}, pancreas {Pancreatic structure}, Spleen {Splenic structure}, spleen is markedly enlarged {Splenomegaly}, Kidneys {Kidney structure}, right kidney {Right kidney structure}, no evidence {No abnormality detected}, hydronephrosis {Hydronephrosis}, evaluation {Evaluation procedure}, portal vein {Portal vein structure}, right {Structure of right main branch of portal vein}, left portal veins {Structure of left main branch of portal vein}, hepatic artery {Structure of hepatic artery}, Right {Structure of right main branch of portal vein}, middle {Structure of middle hepatic vein}, left hepatic veins {Structure of left hepatic vein}, hepatic vasculature {Vascular structure of liver}, Cirrhosis {Cirrhosis of liver}, portal hypertension {Portal hypertension}, splenomegaly {Splenomegaly}, ascites {Ascites}, Status post {Postoperative state}, cholecystectomy {Cholecystectomy}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, ITP {Chronic idiopathic thrombocytopenic purpura}, NASH {Nonalcoholic steatohepatitis}, cirrhosis {Cirrhosis of liver}, portal HTN {Portal hypertension}, refractory ascites {Refractory ascites}, paracenteses {Abdominal paracentesis}, TIPS procedure {Transjugular intrahepatic portosystemic shunt}, NASH {Nonalcoholic steatohepatitis}, cirrhosis {Cirrhosis of liver}, esophageal varicies {Esophageal varices}, refractory ascites {Refractory ascites}, hepatic encephalopathy {Hepatic encephalopathy}, disease {Disease}, transplant {Transplantation of liver}, TIPS {Transjugular intrahepatic portosystemic shunt}, paracenteses {Abdominal paracentesis}, abdominal pain {Abdominal pain}, NASH {Nonalcoholic steatohepatitis}, cirrhosis {Cirrhosis of liver}, esophageal varicies {Esophageal varices}, refractory ascites {Refractory ascites}, hepatic encephalopathy {Hepatic encephalopathy}, disease {Disease}, transplant {Transplantation of liver}, TIPS {Transjugular intrahepatic portosystemic shunt}, paracenteses {Abdominal paracentesis}, abdominal pain {Abdominal pain}, TIPS {Transjugular intrahepatic portosystemic shunt}, right hepatic 
vein {Structure of right hepatic vein}, right portal vein {Structure of right main branch of portal vein}, TIPS {Transjugular intrahepatic portosystemic shunt}, placed {Implantation procedure}, dissection {Dissection procedure}, portal vein {Portal vein structure}, right PV {Structure of right main branch of portal vein}, TIPS {Transjugular intrahepatic portosystemic shunt}, PV {Pulmonary valve structure}, stents {Insertion of arterial stent}, dilated {Dilatation}, procedure {Procedure}, paracentesis {Abdominal paracentesis}, abd soreness {Abdominal pain}, improved {Patient's condition improved}, LFTs {Hepatic function panel}, Cr {Finding of creatinine level}, Creatinine normalized {Serum creatinine within reference range}, albumin {Administration of albumin}, contrast-induced nephropath {Acute kidney injury caused by contrast agent}, HRS {Hepatorenal syndrome}, ultrasound {Ultrasonography}, hepatic encephalopathy {Hepatic encephalopathy}, Hypotension {Low blood pressure}, cirrhosis {Cirrhosis of liver}, lasix {Diuretic therapy}, labile blood pressure {Labile blood pressure}, renal {Kidney structure}, restarted {Restart of medication}, Anemia {Anemia}, chronic liver disease {Chronic liver disease}, 1U pRBC {Transfusion of packed red blood cells}, ITP {Chronic idiopathic thrombocytopenic purpura}, Stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY 
2. Lactulose 30 mL PO TID 
3. Nadolol 20 mg PO DAILY 
4. Omeprazole 20 mg PO BID 
5. Spironolactone 150 mg PO DAILY 
6. Vitamin D 400 UNIT PO DAILY 

 
Discharge Medications:
1. Omeprazole 20 mg PO BID 
2. Lactulose 30 mL PO TID 
3. Vitamin D 400 UNIT PO DAILY 
4. OxycoDONE (Immediate Release)  2.5 mg PO Q6H:PRN pain 
RX *oxycodone 5 mg 1 tablet(s) by mouth every six hours Disp #*5 
Tablet Refills:*0

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary diagnosis
NASH cirrhosis s/p TIPS procedure

Secondary diagnoses:
ITP

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: NASH {Nonalcoholic steatohepatitis}, cirrhosis {Cirrhosis of liver}, TIPS procedure {Transjugular intrahepatic portosystemic shunt}, ITP {Chronic idiopathic thrombocytopenic purpura}, Mental Status {Neurological mental status determination}, Clear {Normal breath sounds}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,

It was a pleasure taking part in your care during your recent 
hospitalization at ___. You 
were hospitalized for a TIPS procedure. Your blood pressure was 
low at times during this admission so we stopped your blood 
pressure medications including furosemide, nadolol, and 
spironolactone. Please discuss with your liver doctor when to 
restart these medications.

Please follow-up with all appointments listed below and take 
your medications as prescribed.

Again, it was a pleasure taking part in your care-

-Your ___ Care Team
 
                             ___ MD ___
 
Completed by: ___

###RESPONSE: TIPS procedure {Transjugular intrahepatic portosystemic shunt}, blood pressure {Blood pressure monitoring}, blood 
pressure medications {Antihypertensive therapy}, liver {Liver structure}, medications {Administration of drug or medicament}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___          Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
nausea, vomiting, diarrhea
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ y/o M with a past medical history of hypertension
NIDDM2, HLD, stable angina, hearing loss and metastatic 
pancreatic cancer s/p ___ on palliative chemotherapy 
presenting with 6 days of diarrhea and 2 days of nausea and 
vomiting. He notes ___ episodes of watery, non-bloody diarrhea 
every day for the past 6 days. He also complains of several days 
of nausea and vomiting. He also complains of one episode of 
night sweats and chills on day prior to admission. Notes he has 
been unable to take POs and has been feeling dehydrated and 
lightheaded.  He denies abdominal pain,
fevers, bloody stools, chest pain and SOB. The patient had his 
most recent session of chemotherapy on ___ and his prior 
session was held in the setting of acute illness. He denies any 
recent sick contacts.

Of note, he was recently hospitalized ___ for chest 
pain when he was found to be febrile and have a UTI and GNR 
bacteremia.

ED course:
In the ED, patient was noted to have nausea, vomiting and 
diarrhea. He received 1L IVF, Zofran and morphine for pain 
control. CT A/P showed mild proctitis so he was admitted for 
further workup.

 

###RESPONSE: hypertension {Hypertensive disorder, systemic arterial}, NIDDM2 {Diabetes mellitus type 2}, HLD {Hyperlipidemia}, stable angina {Stable angina}, hearing loss {Hearing loss}, metastatic 
pancreatic cancer {Metastatic carcinoma to head of pancreas}, palliative chemotherapy {Administration of palliative antineoplastic agent}, diarrhea {Diarrhea}, nausea and 
vomiting {Nausea and vomiting}, bloody diarrhea {Hemorrhagic diarrhea}, nausea and vomiting {Nausea and vomiting}, night sweats {Night sweats}, chills {Chill}, dehydrated {Dehydration}, lightheaded {Lightheadedness}, abdominal pain {Abdominal pain}, fevers {Fever}, bloody stools {Hematochezia}, chest pain {Chest pain}, SOB {Dyspnea}, chemotherapy {Chemotherapy}, chest 
pain {Chest pain}, febrile {Fever}, UTI {Urinary tract infectious disease}, GNR 
bacteremia {Bacteremia caused by Gram-negative bacteria}, nausea, vomiting and 
diarrhea {Nausea, vomiting and diarrhea}, IVF {Administration of intravenous fluids}, morphine {Allergy to morphine}, pain 
control {Pain control}, CT A/P {Computed tomography of abdomen and pelvis}, mild {Symptom mild}, proctitis {Proctitis}, workup {Evaluation procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
PAST MEDICAL HISTORY:
T2D,HLD,HTN,stable angina and hearing loss. 

See OMR for detailed oncologic history: Briefly, 

___: dx with pancreatic cancer ___ s/p Whipple
Adjuvant gemcitabine and Abraxane until ___ 
___- additional chemotherapy for metatastatic liver lesions
___- worsening metastatic liver lesions

PAST SURGICAL HISTORY: 
___ ___ 

 

###RESPONSE: T2D {Diabetes mellitus type 2}, HLD {Hyperlipidemia}, HTN {Hypertensive disorder, systemic arterial}, stable angina {Stable angina}, hearing loss {Hearing loss}, pancreatic cancer {Carcinoma of pancreas}, chemotherapy {Chemotherapy}, metatastatic liver {Metastatic malignant neoplasm to liver}, metastatic liver {Metastatic malignant neoplasm to liver}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father prostate cancer, brother liver cancer.
 

###RESPONSE: prostate cancer {Carcinoma of prostate}, liver cancer {Malignant neoplasm of liver}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: ___ 1126 Temp: 98.0 PO BP: 130/72 HR: 88 RR: 18 O2
sat: 99% O2 delivery: RA   
General: Awake, cooperative, NAD.
HEENT: Pupils react normally to light. Oropharynx is clear.
Neck: Supple
Lungs: Clear with no wheezing, rhonchi or rales.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2 no
m/r/g.
Abdomen: soft, tender to palpation in epigastric area.
non-distended. periumbilical surgical scar. No suprapubic
tenderness. There is no 
organomegaly or appreciable mass. Bowel sounds are hyperactive.
Back: No CVA tenderness. 
Extremities: No edema, 2+ pedal pulses
Neurologic: Cranial nerves II through XII are intact. No focal
motor or sensory deficits are noted.

DISCHARGE PHYSICAL EXAM
Vitals:  ___ 2314 Temp: 97.9 PO BP: 155/70 HR: 77 RR: 20 O2
sat: 98% O2 delivery: Ra 
General: Awake, cooperative, NAD.
HEENT: Pupils react normally to light. Oropharynx is clear.
Neck: Supple
Lungs: Clear with no wheezing, rhonchi or rales.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2 no
m/r/g.
Abdomen: soft, non-tender, non-distended. periumbilical surgical
scar. No suprapubic tenderness. There is no 
organomegaly or appreciable mass. normal bowel sounds.
Back: No CVA tenderness. 
Extremities: No edema, 2+ pedal pulses
Neurologic: Cranial nerves II through XII are intact. No focal
motor or sensory deficits are noted.

 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2
sat {Oxygen saturation measurement}, RA {Breathing room air}, General {General examination of patient}, Awake {Awake}, cooperative {Cooperative mental state}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, Pupils react normally to light {Pupil afferent light reaction normal}, Oropharynx is clear {Pharynx normal}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Lungs {Examination of respiratory system}, Clear {Normal breath sounds}, wheezing {Wheezing}, rhonchi {Wheeze - rhonchi}, rales {Respiratory crackles}, Cardiovascular {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, Normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, no
m/r/g {Heart sounds normal}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, tender {Abdominal tenderness}, palpation {Palpation}, epigastric {Epigastric region structure}, non-distended {Normal abdominal contour}, surgical scar {Surgical scar}, suprapubic {Hypogastric region structure}, tenderness {Tenderness}, organomegaly {Abdominal organomegaly}, mass {Abdominal mass}, Bowel sounds are hyperactive {Bowel sounds hyperactive}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, Extremities {Examination of limb}, edema {Edema}, 2+ pedal pulses {Normal foot pulse}, Neurologic {Neurological examination}, Cranial nerves II {Optic nerve structure}, XII {Hypoglossal nerve structure}, motor {Motor testing}, sensory {Sensory testing}, deficits {Neurological deficit}, PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2
sat {Oxygen saturation measurement}, Ra {Breathing room air}, General {General examination of patient}, Awake {Awake}, cooperative {Cooperative mental state}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, Pupils react normally to light {Pupil afferent light reaction normal}, Oropharynx is clear {Pharynx normal}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Lungs {Examination of respiratory system}, Clear {Normal breath sounds}, wheezing {Wheezing}, rhonchi {Wheeze - rhonchi}, rales {Respiratory crackles}, Cardiovascular {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, Normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, no
m/r/g {Heart sounds normal}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, surgical
scar {Surgical scar}, suprapubic {Hypogastric region structure}, tenderness {Tenderness}, organomegaly {Abdominal organomegaly}, mass {Abdominal mass}, normal bowel sounds {Normal bowel sounds}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, Extremities {Examination of limb}, edema {Edema}, 2+ pedal pulses {Normal foot pulse}, Neurologic {Neurological examination}, Cranial nerves II {Optic nerve structure}, XII {Hypoglossal nerve structure}, motor {Motor testing}, sensory {Sensory testing}, deficits {Neurological deficit}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS
___ 11:07PM BLOOD WBC-7.7 RBC-3.31* Hgb-9.8* Hct-32.9* 
MCV-99* MCH-29.6 MCHC-29.8* RDW-16.3* RDWSD-60.0* Plt ___
___ 11:07PM BLOOD Neuts-87.0* Lymphs-10.4* Monos-1.3* 
Eos-0.7* Baso-0.1 Im ___ AbsNeut-6.67* AbsLymp-0.80* 
AbsMono-0.10* AbsEos-0.05 AbsBaso-0.01
___ 11:07PM BLOOD Glucose-195* UreaN-20 Creat-0.9 Na-132* 
K-4.9 Cl-98 HCO3-21* AnGap-13
___ 11:07PM BLOOD ALT-37 AST-26 AlkPhos-859* TotBili-0.9
___ 11:07PM BLOOD Albumin-3.5

DISCHARGE LABS
___ 05:25AM BLOOD WBC-3.0* RBC-2.56* Hgb-7.5* Hct-23.8* 
MCV-93 MCH-29.3 MCHC-31.5* RDW-15.8* RDWSD-53.8* Plt ___
___ 05:25AM BLOOD Neuts-70.2 ___ Monos-3.9* 
Eos-0.7* Baso-0.4 AbsNeut-1.98 AbsLymp-0.68* AbsMono-0.11* 
AbsEos-0.02* AbsBaso-0.01
___ 05:25AM BLOOD Glucose-134* UreaN-9 Creat-0.7 Na-139 
K-3.6 Cl-104 HCO3-22 AnGap-13
___ 05:25AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.9

MICRO

___ 7:43 pm URINE      Source: ___. 

                            **FINAL REPORT ___

   Legionella Urinary Antigen  (Final ___: 
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. 

___ 7:43 pm STOOL     CONSISTENCY: LOOSE      Source: 
Stool. 

                            **FINAL REPORT ___

   C. difficile PCR (Final ___: 
      NEGATIVE. 
___ 7:43 pm STOOL     CONSISTENCY: LOOSE      Source: 
Stool. 

                            **FINAL REPORT ___

   FECAL CULTURE (Final ___:    NO SALMONELLA OR SHIGELLA 
FOUND. 

   CAMPYLOBACTER CULTURE (Final ___:    NO CAMPYLOBACTER 
FOUND. 

   OVA + PARASITES (Final ___: 
      NO OVA AND PARASITES SEEN. 
      . 
      This test does not reliably detect Cryptosporidium, 
Cyclospora or
      Microsporidium. While most cases of Giardia are detected 
by routine
      O+P, the Giardia antigen test may enhance detection when 
organisms
      are rare. 
      . 
      FEW POLYMORPHONUCLEAR LEUKOCYTES. 
___ 12:40 am BLOOD CULTURE      Source: Line-Port. 

   Blood Culture, Routine (Pending):    No growth to date. 

___ 9:05 am STOOL     CONSISTENCY: LOOSE      Source: 
Stool. 

                            **FINAL REPORT ___

   OVA + PARASITES (Final ___: 
      NO OVA AND PARASITES SEEN. 
      . 
      This test does not reliably detect Cryptosporidium, 
Cyclospora or
      Microsporidium. While most cases of Giardia are detected 
by routine
      O+P, the Giardia antigen test may enhance detection when 
organisms
      are rare. 
      . 
      FEW POLYMORPHONUCLEAR LEUKOCYTES. 

___ 9:21 am URINE      Source: ___. 

                            **FINAL REPORT ___

   URINE CULTURE (Final ___: 
      ESCHERICHIA COLI.    >100,000 CFU/mL.  PRESUMPTIVE 
IDENTIFICATION. 
         Cefazolin interpretative criteria are based on a dosage 
regimen of
         2g every 8h. 

                              SENSITIVITIES: MIC expressed in 
MCG/ML
                      
_________________________________________________________
                             ESCHERICHIA COLI
                             |   
AMPICILLIN------------     8 S
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------   0.5 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

___ 6:13 pm BLOOD CULTURE      Source: Line-POC. 

   Blood Culture, Routine (Pending):    No growth to date. 

___ 7:20 pm BLOOD CULTURE      Source: Line-POC. 

   Blood Culture, Routine (Pending):    No growth to date. 

IMAGING
CT ABD/PELVIS ___
1. Likely mild proctitis without a perirectal abscess or bowel 
obstruction. 
2. The known metastatic lesion in the right hepatic lobe 
measuring up to 6.6 cm, is slightly large in size since prior 
exam from ___, when it measured up to 6.2 cm.  The 
adjacent hepatic parenchyma in segment VI and VII enhances 
heterogeneously raising suspicion for satellite metastases. 
Unchanged appearance of occluded right hepatic vein and right 
branch of the portal vein. 
3. Subacute healing pathologic fracture is again seen in the 
left lateral 
tenth rib.  Unchanged compression deformities of the L3-L5 
vertebrae. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, CULTURE {Blood culture}, Blood Culture {Blood culture}, URINE CULTURE {Urine culture}, CULTURE {Blood culture}, Blood Culture {Blood culture}, CULTURE {Blood culture}, Blood Culture {Blood culture}, IMAGING {Imaging}, proctitis {Proctitis}, perirectal abscess {Perirectal abscess}, bowel 
obstruction {Intestinal obstruction}, metastatic {Metastatic malignant neoplasm}, lesion {Lesion}, right hepatic lobe {Structure of right lobe of liver}, hepatic parenchyma {Structure of parenchyma of liver}, metastases {Metastatic malignant neoplasm}, occluded {Complete obstruction}, right hepatic vein {Structure of right hepatic vein}, right 
branch of the portal vein {Structure of right main branch of portal vein}, healing {Structure resulting from tissue repair process}, pathologic fracture {Pathologic fracture}, tenth rib {Bone structure of tenth rib}, compression {Compression}, deformities {Deformity}, L3 {Bone structure of L3}, L5 {Bone structure of L5}, vertebrae {Bone structure of L3}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ y/o M with a past medical history of hypertension NIDDM2, 
HLD, stable angina, hearing loss and metastatic pancreatic 
cancer s/p Whipple on palliative chemotherapy, who presented 
with 6 days of diarrhea and 2 days of nausea and
vomiting likely ___ recent chemotherapy and a urinary tract 
infection.

ACUTE ISSUES
#Complicated urinary tract infection
Despite lack of symptoms, due to a history of recurrent urinary 
infections and ongoing fevers, we sent for a UA and urine 
culture. The patient was found to have a grossly positive UA and 
culture grew pan-sensitive E. Coli. The patient was initially 
placed on Zosyn and was discharged to complete a 7 day course of 
Bactrim DS. Given recurrent urinary tract infections, urology 
was consulted and they recommended continuing prophylactic 
Bactrim SS indefinitely. He will be following up with urology 
outpatient.

#Diarrhea, nausea, vomiting
#Poor PO intake
Patient with one week of diarrhea and several days of nausea and 
vomiting. C4D1 of chemotherapy was ___. Diarrhea is a 
common adverse effect of onivyde. Given patient had a 2 month 
break from chemotherapy, it is possible that this was a rebound 
effect in the setting of drug break. The patient was also 
complaining of chills and sweats concerning for possible 
infectious etiology. During his last admission, he had GNR 
bacteremia and was treated with meropenem and discharged on 
ertapenem with course finishing ___. On this admission, C. 
Diff and Legionella were negative. Nausea and vomiting resolved 
rapidly with symptomatic treatment. He was able to eat, but 
continued to have diarrhea throughout hospital course. It 
resolved prior to discharge with loperamide. Stool, blood and 
urine cultures were all negative to date.

#Proctitis:
CT with mild proctitis. DDx included anal fissures/fistulas, C. 
Diff, diverticulitis, infectious, IBD, traumatic. In this case, 
it was likely due to inflammation from severe diarrhea.

#Hyponatremia:
This was noted on admission and believed to be likely hypotonic 
hypovolemic in the setting of poor PO intake and less likely 
SIADH. Na was noted to be 133 on ___ at appointment prior for 
chemotherapy, and believed to be ___ poor PO intake. Na 138 on 
___.

#Metastatic pancreatic cancer
Followed by oncologist Dr. ___. His current regimen is 
___ which he recently received on ___ for 
palliative chemotherapy. Palliative care was consulted to 
discuss GOC and symptom management. Patient will follow closely 
with Dr. ___ discharge to discuss next steps.

CHRONIC ISSUES
#Anemia
Baseline around ___ at recent admission. Patient remained around 
baseline and did not require any transfusions. 

#Hx of stable angina
EKG on admission with no evidence of ST segment changes. 
Troponins negative x1.

#Hypertension:
He was continued on amlodipine, lisinopril. Metoprolol was held 
during this admission as it was held on discharge at last 
admission. Given blood pressures were slightly elevated while 
inpatient, patient may benefit from restarting metoprolol.

#Diabetes:
Patient placed on insulin sliding scale while inpatient.

TRANSITIONAL ISSUES
[]Last day of Bactrim DS for UTI ___
[]Given recurrent UTIs, urology consulted and recommended 
prophylactic Bactrim SS indefinitely, will need to follow 
closely with urology outpatient
[]Patient has had numerous hospitalizations and poor tolerance 
to chemo, would benefit from conversations with outpatient 
oncologist Dr. ___ plan moving forward
[]Will need ongoing conversations regarding code status
[]Nausea, vomiting and diarrhea resolved with symptomatic 
treatment but will likely require titration of symptomatic 
medications to ensure doesn't become constipated; encourage 
patient to take loperamide for symptomatic relief
[]Patient seems somewhat confused about medication regimen, 
would benefit from clarification or help with medication 
management
[]BPs mostly 140s/60s while inpatient but going up to SBPs 160s 
prior to discharge on amlodipine and lisinopril. metoprolol was 
held on discharge but patient would benefit from ongoing BP 
monitoring and may need to restart metoprolol.
[]Patient would benefit from ongoing follow up with nutrition as 
PO intake appears somewhat poor at baseline and albumin was 3.1.

___) ___ 
#CODE STATUS: FULL 
 

###RESPONSE: hypertension {Hypertensive disorder, systemic arterial}, NIDDM2 {Diabetes mellitus type 2}, HLD {Hyperlipidemia}, stable angina {Stable angina}, hearing loss {Hearing loss}, metastatic pancreatic 
cancer {Metastatic carcinoma to head of pancreas}, Whipple {Pancreaticoduodenectomy}, palliative chemotherapy {Administration of palliative antineoplastic agent}, diarrhea {Diarrhea}, nausea and
vomiting {Nausea and vomiting}, chemotherapy {Chemotherapy}, urinary tract 
infection {Urinary tract infectious disease}, urinary tract infection {Urinary tract infectious disease}, urinary {Urinary tract infectious disease}, infections {Infectious disease}, fevers {Fever}, UA {Urinalysis}, urine 
culture {Urine culture}, UA {Urinalysis}, culture {Microbial culture}, recurrent urinary tract infections {Recurrent urinary tract infection}, Diarrhea {Diarrhea}, nausea, vomiting {Nausea and vomiting}, Poor PO intake {Decrease in appetite}, diarrhea {Diarrhea}, nausea and 
vomiting {Nausea and vomiting}, chemotherapy {Chemotherapy}, Diarrhea {Diarrhea}, chemotherapy {Chemotherapy}, rebound 
effect {Medication rebound effect}, chills {Chill}, sweats {Sweating}, infectious {Infectious disease}, GNR 
bacteremia {Bacteremia caused by Gram-negative bacteria}, Nausea and vomiting {Nausea and vomiting}, resolved {Problem resolved}, able to eat {Able to eat}, diarrhea {Diarrhea}, resolved {Problem resolved}, Stool {Hematochezia}, urine cultures {Urine culture}, CT {Computed tomography}, proctitis {Proctitis}, anal fissures {Anal fissure}, fistulas {Fistula}, diverticulitis {Diverticulitis}, infectious {Infectious disease}, IBD {Inflammatory bowel disease}, traumatic {Traumatic injury}, inflammation {Inflammatory disorder}, severe diarrhea {Severe diarrhea}, hypovolemic {Hypovolemia}, poor PO intake {Decrease in appetite}, SIADH {Syndrome of inappropriate vasopressin secretion}, chemotherapy {Chemotherapy}, poor PO intake {Decrease in appetite}, Metastatic pancreatic cancer {Metastatic carcinoma to pancreas}, regimen {Therapeutic regimen}, palliative chemotherapy {Administration of palliative antineoplastic agent}, symptom management {Symptom management}, Anemia {Anemia}, Baseline {Baseline state}, baseline {Baseline state}, transfusions {Transfusion}, stable angina {Stable angina}, EKG {Electrocardiographic procedure}, ST segment changes {Finding of electrocardiogram ST segment}, Troponins {Troponin measurement}, blood pressures {Blood pressure monitoring}, elevated {Finding of increased blood pressure}, insulin sliding scale {Sliding scale insulin regime}, UTI {Urinary tract infectious disease}, recurrent UTIs {Recurrent urinary tract infection}, chemo {Chemotherapy}, Nausea, vomiting and diarrhea {Nausea, vomiting and diarrhea}, resolved {Problem resolved}, medications {Prescription of drug}, constipated {Constipation}, medication {Prescription of drug}, regimen {Therapeutic regimen}, medication 
management {Procedure related to management of drug administration}, BP 
monitoring {Blood pressure monitoring}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY 
2. Aspirin 81 mg PO DAILY 
3. Atorvastatin 20 mg PO QPM 
4. Creon 12 2 CAP PO QIDWMHS 
5. Finasteride 5 mg PO DAILY 
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 
7. Lisinopril 5 mg PO DAILY 
8. Polyethylene Glycol 17 g PO DAILY 
9. Senna 17.2 mg PO BID 
10. LOPERamide 2 mg PO QID:PRN diarrhea 
11. Magnesium Oxide 400 mg PO DAILY 
12. MetFORMIN (Glucophage) 850 mg PO DAILY 
13. Metoprolol Succinate XL 100 mg PO DAILY 
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 

 
Discharge Medications:
1.  Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days 
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by 
mouth twice a day Disp #*10 Tablet Refills:*0 
2.  Sulfameth/Trimethoprim SS 1 TAB PO DAILY 
Take this medication after you finish Bactrim DS to prevent 
recurrent urinary infection 
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by 
mouth every day Disp #*30 Tablet Refills:*0 
3.  amLODIPine 10 mg PO DAILY  
4.  Aspirin 81 mg PO DAILY  
5.  Atorvastatin 20 mg PO QPM  
6.  Creon 12 2 CAP PO QIDWMHS  
7.  Finasteride 5 mg PO DAILY  
8.  Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY  
9.  Lisinopril 5 mg PO DAILY  
10.  LOPERamide 2 mg PO QID:PRN diarrhea 
RX *loperamide 2 mg 1 tablet by mouth every 6 hours Disp #*60 
Capsule Refills:*0 
11.  MetFORMIN (Glucophage) 850 mg PO DAILY  
12.  Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain  
13.  Polyethylene Glycol 17 g PO DAILY  
14.  Senna 17.2 mg PO BID  
15. HELD- Magnesium Oxide 400 mg PO DAILY  This medication was 
held. Do not restart Magnesium Oxide until your doctor tells you 
to
16. HELD- Metoprolol Succinate XL 100 mg PO DAILY  This 
medication was held. Do not restart Metoprolol Succinate XL 
until your doctor tells you to

 

###RESPONSE: mg {Blood magnesium measurement}, mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Complicated urinary tract infection
Diarrhea

SECONDARY DIAGNOSES
metastatic pancreatic cancer
hyponatremia
proctitis
anemia
hypertension

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Home With Service {Home health aide service management}, urinary tract infection {Urinary tract infectious disease}, Diarrhea {Diarrhea}, metastatic pancreatic cancer {Metastatic carcinoma to pancreas}, hyponatremia {Hyponatremia}, proctitis {Proctitis}, anemia {Anemia}, hypertension {Hypertensive disorder, systemic arterial}, Mental Status {Neurological mental status determination}, Clear {Normal breath sounds}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___, 

It was a pleasure caring for you at ___ 
___.

WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were nauseous and were 
having diarrhea and vomiting all week.

WHAT HAPPENED TO ME IN THE HOSPITAL?
- We gave you lots of fluids through the IV and you felt better
- You were found to have a urinary infection and we gave you 
antibiotics
- We gave you medications for your nausea and diarrhea and you 
felt better
- You were able to eat and stopped having diarrhea so you were 
discharged home

WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Be sure to take the DOUBLE STRENGTH Bactrim until ___ 
after this switch to the SINGLE STRENGTH Bactrim and only take 
one of those tablets daily until you talk to the urologists
- Continue to take all your medicines and keep your 
appointments.
- Please come back to the hospital if you have any worsening of 
your nausea, vomiting, diarrhea, dehydration or if you are 
unable to eat and drink.

We wish you the best!

Sincerely,
Your ___ Team

 

###RESPONSE: nauseous {Nausea}, diarrhea and vomiting {Diarrhea and vomiting}, fluids {Administration of fluid therapy}, IV {Administration of drug or medicament via intravenous route}, urinary infection {Urinary tract infectious disease}, antibiotics {Antibiotic therapy}, medications {Prescription of drug}, nausea {Nausea}, diarrhea {Diarrhea}, able to eat {Able to eat}, diarrhea {Diarrhea}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, dehydration {Dehydration}, unable to eat {Unable to eat}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Morphine
 
Attending: ___.
 
Chief Complaint:
Chest pain 
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Morphine {Allergy to morphine}, Chest pain {Chest pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness: ___ yo man with h/o ""small heart 
attack ___ years ago"", ESRD (on HD for ___ years, urinates 
3x/day), HTN, HLP, DM, presents with chest pain and SOB since 
late afternoon today. He was sitting on his bed when he suddenly 
developed ___ substernal chest heaviness, that may have 
radiated to the back. This was associated with SOB, but no N/V, 
sweats, dizziness, numbness or tingling. There was no 
association of his pain with food, position, breathing, or 
cough. He's never had this pain before. When he had the ""mild 
heart attack"" ___ years ago, he cannot recal if this pain was 
similar. He decided to present to the ED.
.
In the ED, initial vs were: 98 118/48 60 16 99%RA. Patient was 
given . Vitals on transfer were 98.3 55 136/58 14 100%2LNC. ASA 
325mg PO ONCE, morphine 4mg IV ONCE, 1gm tylenol PO ONCE
.
On the floor,
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or 
gain. Denies headache, sinus tenderness, rhinorrhea or 
congestion. Denied cough, shortness of breath. Denied 
palpitations. Denied nausea, vomiting, diarrhea, constipation. 
No recent change in bowel or bladder habits. 
 

###RESPONSE: heart 
attack {Myocardial infarction}, ESRD (on HD {End stage renal failure on dialysis}, urinates {Micturition finding}, HTN {Hypertensive disorder, systemic arterial}, HLP {Hyperlipidemia}, DM {Diabetes mellitus}, chest pain {Chest pain}, SOB {Dyspnea}, sitting {Sitting position}, substernal {Structure of substernal region}, chest heaviness {Tight chest}, radiated {Radiating pain}, back {Structure of back of trunk}, SOB {Dyspnea}, N/V {Nausea and vomiting}, sweats {Sweating}, dizziness {Dizziness}, numbness {Numbness}, tingling {Pins and needles}, pain {Pain}, food {Pain provoked by eating}, position {Pain provoked by movement}, breathing {Pain provoked by breathing}, cough {Pain provoked by coughing}, pain {Pain}, heart attack {Myocardial infarction}, pain {Pain}, Vitals {Vital signs finding}, ASA {Administration of aspirin}, tylenol {Administration of analgesic}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, headache {Headache}, sinus tenderness {Tenderness over frontal sinus}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, cough {Cough}, shortness of breath {Dyspnea}, palpitations {Palpitations}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, change in bowel {Altered bowel function}, bladder habits {Alteration in patterns of urinary elimination}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1) ESRD on HD for ___ years
2) ""Mild heart attack"" at ___ in ___
3) HTN
4) HLP
5) DM
6) ?Dementia 
 

###RESPONSE: ESRD on HD {End stage renal failure on dialysis}, heart attack {Myocardial infarction}, HTN {Hypertensive disorder, systemic arterial}, HLP {Hyperlipidemia}, DM {Diabetes mellitus}, Dementia {Dementia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Patient's father died of an MI in mid ___. No other personal or 
family history of heart disease or blood clot.
 

###RESPONSE: died {Dead}, MI {Myocardial infarction}, heart disease {Heart disease}, blood clot {Blood clot}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Vitals: 96.5 150/68 66 18 100%2LNC
General: Alert, oriented x ___ (says he's in ___, can't recall 
city, says he's in hospital can't recall name, says ___ can't 
recall date) no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales, 
ronchi except bibasilar rhales
CV: Regular rate and rhythm, normal S1 + S2, soft ___ SM at apex 
no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema 
 

###RESPONSE: Vitals {Vital signs finding}, NC {Normal head}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, ronchi {Wheeze - rhonchi}, bibasilar {Structure of base of lung}, rhales {Respiratory crackles}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, soft {Abdomen soft}, apex {Structure of apex of heart}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, Ext {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 02:25PM BLOOD WBC-8.0 RBC-3.74* Hgb-12.1* Hct-36.5* 
MCV-98 MCH-32.4* MCHC-33.2 RDW-16.5* Plt ___
___ 02:25PM BLOOD Neuts-57.8 ___ Monos-5.9 Eos-2.5 
Baso-0.7
___ 02:25PM BLOOD ___ PTT-22.1 ___
___ 02:25PM BLOOD Glucose-137* UreaN-45* Creat-6.4* Na-139 
K-3.1* Cl-91* HCO3-36* AnGap-15
___ 02:25PM BLOOD ALT-4 AST-11 LD(LDH)-110 CK(CPK)-33* 
AlkPhos-58 Amylase-74 TotBili-0.5
___ 02:25PM BLOOD proBNP-699*
___ 02:25PM BLOOD cTropnT-0.02*
___ 11:59PM BLOOD CK-MB-NotDone cTropnT-0.03*
___ 07:10AM BLOOD CK-MB-NotDone cTropnT-0.02*
___ 07:10AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.1
___ 02:25PM BLOOD Albumin-4.0

REPORTS: 

___   Radiology CARDIAC PERFUSION PERSA  Left 
ventricular cavity size is normal. The end-diastolic volume is 
129 ml.
Rest and stress perfusion images reveal a small region of 
decreased tracer
uptake along the inferior wall of the left ventricle, although 
this may be due to artifact generated by adjacent soft tissue. 
There is no change in tracer uptake on stress versus rest 
images.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 68 %.
No prior studies are available for comparison.
IMPRESSION: 1. No reversible myocardial perfusion defect. 2. 
Focal decreased tracer uptake in the left ventricular inferior 
wall is likely due to artifact from adjacent soft tissue; 
alternatively this could represent a mild fixed perfusion 
defect.
     
___   Cardiology STRESS ___: ___ yo 
man with h/o HTN, HL and type II DM requiring
insulin; s/p ""small heart attack"" ___ years ago was referred to 
evaluate
an atypical chest discomfort and shortness of breath. The 
patient was
administered 0.142 mg/kg/min of Persantine over 4 minutes. No 
chest,
back, neck or arm discomforts were reported by the patient 
during the
procedure. No significant ST segment changes were noted. The 
rhythm was
sinus with no ectopy noted. An appropriate heart rate and blood 
pressure
response to the Persantine infusion was noted. Post-infusion, 
the
patient was administered 125 mg Aminophylline IV.
IMPRESSION: No anginal symptoms or ischemic ST segment changes 
to
Persantine. Appropriate heart rate and blood pressure response 
to
Persantine infusion. Nuclear report sent separately.  
 
___   Radiology CHEST (PA & LAT)   
FINDINGS: Lung volumes are mildly diminished. Hazy subsegmental 
atelectasis
is seen in both lung bases. No consolidation or edema is 
evident. The
mediastinum is unremarkable. The cardiac silhouette is 
borderline enlarged
even accounting for patient and technical factors. No effusion 
or
pneumothorax is noted. The osseous structures are grossly 
unremarkable.
IMPRESSION: Low lung volumes with hazy bibasilar atelectasis. 
Otherwise, no
acute pulmonary process.

DISCHARGE LABS: 

___ 06:35AM BLOOD WBC-7.0 RBC-3.83* Hgb-12.5* Hct-37.1* 
MCV-97 MCH-32.6* MCHC-33.6 RDW-15.5 Plt ___
___ 06:35AM BLOOD Glucose-103* UreaN-53* Creat-6.7*# Na-141 
K-3.5 Cl-96 HCO3-31 AnGap-18
___ 06:35AM BLOOD Calcium-9.5 Phos-4.7* Mg-1.___ yo man with h/o ""small heart attack ___ years ago"", ESRD (on HD 
for ___ years, urinates 3x/day), HTN, HLP, DM, presents with 
chest pain and SOB since late afternoon today.
.
# Chest pain: Unclear etiology, ACS thought to be unlikely given 
atypically pain, no EKG changes, negative enzymes, and negative 
PMIBI results. LFTs including amylase/lipase were wnl. CXR 
negative for any acute process. PE unlikely given lack of risk 
factors, such as tachycardia, recent surgery/travel, hemoptysis, 
DVT sx, h/o cancer or DVT/PE. Mild volume overload secondary to 
ESRD was thought to be a possible cause, which was resolved 
after HD. Pt was initially treated with ACS protocol with ASA 
325mg PO daily, Plavix 75mg PO Daily, Atorvastatin 80mg PO 
daily. We continued Metoprolol tartrate 200mg PO HS, Continue 
Cozaar 50mg PO Daily. Once PMIBI was negative plavix was DC'd, 
ASA dropped back to 81 and pt's original simvastatin 40 was 
restarted.  
.
# ESRD: On HD for ___ years. Continued HD ___, with 
renal following. 
.
# HTN: Continued BB and ___ per above
.
# HLP: Atorvastatin per above
.
# DM: Continued home Lantus 28 units plus SSI.
.
# Dementia: Continued carbidopa and levadopa.
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Plt {Platelet count}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Serum total lactate dehydrogenase measurement}, CK(CPK {Creatine kinase measurement}, AlkPhos {Alkaline phosphatase measurement}, Amylase {Amylase measurement}, TotBili {Bilirubin, total measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Albumin {Albumin measurement}, Radiology CARDIAC PERFUSION {Radionuclide myocardial perfusion study}, Left 
ventricular cavity {Structure of cavity of left cardiac ventricle}, size is normal {Normal size}, stress perfusion images {Radionuclide myocardial perfusion stress study}, inferior wall {Structure of myocardium of diaphragmatic region}, left ventricle {Left cardiac ventricular structure}, artifact {Artifact}, soft tissue {Structure of soft tissue}, stress {Radionuclide myocardial perfusion stress study}, normal wall motion {Normal ventricular wall motion}, left ventricular {Structure of myocardium of left ventricle}, studies {Evaluation procedure}, reversible myocardial perfusion defect {Reversible myocardial perfusion defect}, left ventricular {Structure of myocardium of left ventricle}, inferior 
wall {Structure of myocardium of diaphragmatic region}, artifact {Artifact}, soft tissue {Structure of soft tissue}, perfusion 
defect {Myocardial perfusion defect}, HTN {Hypertensive disorder, systemic arterial}, HL {Hyperlipidemia}, type II DM {Diabetes mellitus type 2}, insulin {Insulin regime}, heart attack {Myocardial infarction}, evaluate {Evaluation procedure}, atypical {Atypical chest pain}, chest discomfort {Chest discomfort}, shortness of breath {Dyspnea}, chest {Thoracic structure}, back {Structure of back of trunk}, neck {Neck structure}, arm {Upper limb structure}, discomforts {Discomfort}, procedure {Procedure}, ST segment changes {Electrocardiographic ST segment changes}, rhythm was
sinus {Normal sinus rhythm}, heart rate {Finding of heart rate}, blood 
pressure {Blood pressure finding}, infusion {Infusion}, infusion {Infusion}, anginal symptoms {Angina}, ischemic {Ischemia}, ST segment changes {Electrocardiographic ST segment changes}, heart rate {Finding of heart rate}, blood pressure {Blood pressure finding}, infusion {Infusion}, Radiology CHEST (PA & LAT) {Diagnostic radiography of chest, combined posteroanterior and lateral}, Lung volumes {Finding of respiratory volume}, atelectasis {Atelectasis}, lung bases {Structure of base of lung}, consolidation {Consolidation}, edema {Edema}, mediastinum {Mediastinal structure}, unremarkable {No abnormality detected}, cardiac {Heart structure}, enlarged {Enlargement}, effusion {Pleural effusion}, pneumothorax {Pneumothorax}, osseous structures {Bone structure}, unremarkable {No abnormality detected}, lung volumes {Finding of respiratory volume}, bibasilar {Structure of base of lung}, atelectasis {Atelectasis}, no
acute {No abnormality detected}, pulmonary {Lung structure}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Plt {Platelet count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, heart attack {Myocardial infarction}, ESRD (on HD {End stage renal failure on dialysis}, urinates {Micturition finding}, HTN {Hypertensive disorder, systemic arterial}, HLP {Hyperlipidemia}, DM {Diabetes mellitus}, chest pain {Chest pain}, SOB {Dyspnea}, Chest pain {Chest pain}, ACS {Acute coronary syndrome}, atypically pain {Atypical chest pain}, no EKG changes {Electrocardiogram normal}, negative enzymes {Cardiac enzymes within reference range}, negative {No abnormality detected}, PMIBI {Radionuclide myocardial perfusion study}, LFTs {Hepatic function panel}, amylase {Amylase measurement}, lipase {Serum lipase measurement}, wnl {Liver function tests within reference range}, CXR {Plain chest X-ray}, PE {Pulmonary embolism}, tachycardia {Tachycardia}, surgery {Surgical procedure}, travel {Travel abroad}, hemoptysis {Hemoptysis}, DVT {Deep venous thrombosis}, cancer {Malignant neoplasm}, DVT {Deep venous thrombosis}, PE {Pulmonary embolism}, volume overload {Hypervolemia}, ESRD {End-stage renal disease}, resolved {Problem resolved}, HD {Hemodialysis}, ACS {Acute coronary syndrome}, ASA {Administration of aspirin}, PMIBI {Radionuclide myocardial perfusion study}, negative {No abnormality detected}, ASA {Administration of aspirin}, restarted {Restart of medication}, ESRD {End stage renal failure on dialysis}, HD {Hemodialysis}, HD {Hemodialysis}, HTN {Hypertensive disorder, systemic arterial}, HLP {Hyperlipidemia}, DM {Diabetes mellitus}, SSI {Sliding scale insulin regime}, Dementia {Dementia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
1) Aspirin 81mg PO daily
2) Simvastatin 40mg PO daily
3) Losartan 50mg PO daily
4) Nexium 40mg PO Daily
5) Sevelamer carbonate 800mg PO TID
6) Nephrocaps 1 cap PO Daily
7) Ambien 10mg PO HS
8) Trazadone 100mg PO HS
9) Insulin glargine 28 units daily
10) Sliding scale insulin
11) Carbidopa-Levodopa (___) 2 tab PO TID
12) Metoprolol XL 200mg PO HS 
 
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.  
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO once a day.  
3. Losartan 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).  
4. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).  

5. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at 
bedtime).  
6. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID 
W/MEALS (3 TIMES A DAY WITH MEALS).  
7. Carbidopa-Levodopa ___ mg Tablet Sig: Two (2) Tablet PO 
TID (3 times a day).  
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap 
PO DAILY (Daily).  
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr 
Sig: Two (2) Tablet Sustained Release 24 hr PO HS (at bedtime).  

10. Insulin Glargine 100 unit/mL Solution Sig: ___ (28) 
Units Subcutaneous once a day: Plus sliding scale. .  
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.  


 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
1) Atypical chest pain
2) Musculoskeletal chest pain 
3) End stage renal disease

 
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: Home With Service {Home health aide service management}, Atypical chest pain {Atypical chest pain}, Musculoskeletal chest pain {Musculoskeletal chest pain}, End stage renal disease {End-stage renal disease}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}, walker {Uses zimmer frame}, cane {Uses single walking stick}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
It was a pleasure to take care of you here at ___. You were 
admitted for chest pain. Fortunately, an stress test was 
negative for any evidence of heart disease. Also, our testing 
revealed that you did not have a heart attack. You will be 
discharged home with physical therapy. 

We have not made the any changes to your medications.

 

###RESPONSE: chest pain {Chest pain}, stress test {Radionuclide myocardial perfusion stress study}, negative {No abnormality detected}, heart disease {Heart disease}, heart attack {Myocardial infarction}, physical therapy {Physical therapy procedure}, changes to your medications {Change of medication}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                     Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Keflex / Augmentin / Amoxicillin
 
Attending: ___.
 
Chief Complaint:
Shortness of breath.
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Keflex {Allergy to cefalexin}, Augmentin {Antibiotic therapy}, Amoxicillin {Allergy to amoxicillin}, Shortness of breath {Dyspnea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
 Mrs. ___ is a ___ y.o. female with a past history of 
COPD/Asthma, who reported increased dyspnea over approximately 
one week.  Apparently, her husband came home almost a week ago 
with a ""cold"" and she then developed a non-productive cough, 
malaise, dyspnea on exertion and eventually an inability to 
sleep due to dyspnea.  She denied the presence of fevers, 
chills, or chest pain.  Over the past 3 days her dyspnea 
increased and today she appeared in significant distress.  She 
was brought to the ED.  She has had several admissions in the 
past for dyspnea/COPD exacerbation, has been on BiPAP, never 
been intubated.
.  
In the ED on arrival, VS:  Temp 98.8; BP 129/61; HR 95; RR 28; 
SpO2 80% on RA.  She arrived ambulatory from home with family 
(who reported cough productive with yellow sputum).  Blood gases 
after 3.5 L for 4 minutes revealed hypoxia with PO2 61 and PCO2 
47.  She received 3 combivent nebs with marked improvement. A 
CXR was suggestive of pneumonia.  She was given prednisone and 
levofloxacin and admitted for COPD exacerbation/pneumonia.  On 
transfer to the floor, VS: Temp 98.8; BP 140/47; HR 102; RR 20; 
SpO2 93% on 3L.
.  
Currently, her dyspnea is much better.  She denied chest pain, 
or other symptoms.  Her daughter, a nurse, was with her and able 
to assist with much of the history, as the patient reproted her 
memory was poor.  Her daughter reported that the patient became 
confused during previous admission.
.  
ROS: Denies fever, chills, night sweats, headache, vision 
changes, rhinorrhea, congestion, sore throat, chest pain, 
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, 
melena, hematochezia, dysuria, hematuria.  She refuses to have a 
mammogram or colonoscopy.

 

###RESPONSE: COPD {Chronic obstructive lung disease}, Asthma {Asthma}, increased {Patient's condition worsened}, dyspnea {Dyspnea}, cold {Common cold}, non-productive cough {Dry cough}, malaise {Malaise}, dyspnea on exertion {Dyspnea on exertion}, dyspnea {Dyspnea}, fevers {Fever}, chills {Chill}, chest pain {Chest pain}, dyspnea {Dyspnea}, increased {Patient's condition worsened}, distress {Distress}, dyspnea {Dyspnea}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, BiPAP {Bilevel positive airway pressure titration}, intubated {Insertion of endotracheal tube}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, SpO2 {Finding of oxygen saturation}, RA {Breathing room air}, cough productive {Productive cough}, yellow sputum {Yellow sputum}, Blood gases {Blood gas measurement}, hypoxia {Hypoxia}, PO2 {Measurement of venous partial pressure of oxygen}, PCO2 {Measurement of venous partial pressure of carbon dioxide}, nebs {Nebulizer therapy}, improvement {Patient's condition improved}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, prednisone {Steroid therapy}, levofloxacin {Antibiotic therapy}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, pneumonia {Pneumonia}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, SpO2 {Finding of oxygen saturation}, dyspnea {Dyspnea}, chest pain {Chest pain}, memory was poor. {Memory impairment}, confused {Clouded consciousness}, ROS {Review of systems}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, headache {Headache}, vision 
changes {Visual disturbance}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, sore throat {Sore throat}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, BRBPR {Hematochezia}, melena {Melena}, hematochezia {Hematochezia}, dysuria {Dysuria}, hematuria {Blood in urine}, mammogram {Mammography}, colonoscopy {Colonoscopy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1. COPD/Ashtma
2. Hypertension
3. Hyperlipidemia
4. Type II Diabetes
5. Peripheral Neuropathy
6. s/p MRSA osteomyelitis in right foot with 3 surgical 
debridements
7. s/p MRSA bacteremia in ___. ?Dementia (reported by daughter)
9. Bilateral cataract surgery
 

###RESPONSE: COPD {Chronic obstructive lung disease}, Ashtma {Asthma}, Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, Type II Diabetes {Diabetes mellitus type 2}, Peripheral Neuropathy {Peripheral nerve disease}, MRSA {Methicillin resistant Staphylococcus aureus infection}, surgical {Surgical procedure}, debridements {Debridement}, MRSA bacteremia {Bacteremia caused by Methicillin resistant Staphylococcus aureus}, Dementia {Dementia}, Bilateral cataract surgery {Surgery of cataract of bilateral eyes}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Her father was a smoker and exposed to asbestos, died of lung 
cancer at age ___.  Her mother died form with complications from 
Alzheimer's at age ___.  One sister survived breast CA.
 

###RESPONSE: smoker {Smoker}, died {Dead}, lung 
cancer {Malignant tumor of lung}, died {Dead}, Alzheimer {Alzheimer's disease}, breast CA {Malignant neoplasm of breast}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Vitals - T: 99.3; BP: 128/76; HR: 100; RR: 20; SpO2: 93% on 3L
GENERAL: Pleasant, female with mild respiratory distress.  
Speaks in near full sentences, slight tachypnea.
HEENT: Normocephalic, atraumatic. Conjunctiva moist and pink. No 
scleral icterus. PERRLA, EOMs intact. Mucosa pink and moist. 
Neck Supple, No LAD, No thyromegaly.  
CARDIAC: Regular rhythm, tachy rate. Normal S1, S2. No murmurs, 
rubs or ___. No gross JVD.
LUNGS: Good, equal chest excursion.  Lung sounds with rales and 
rhonchi in right lower lobe, slight in left base.  Scattered 
expiratory wheezes throughout.  No egophony.
ABDOMEN: Protuberant.  Positive bowel sounds.  Soft, non-tender 
to palpation. 
EXTREMITIES: No peripheral edema, positive pain in left calf, 2+ 
dorsalis pedis pulses.  Noted deformed toenails and prior 
surgery on right foot.
SKIN: Pink/hot/dry.  No rashes/lesions, ecchymoses.  
NEURO: A&Ox3. Appropriate, seems slightly confused, refers many 
answers to daughter. CN ___ grossly intact. Sensation and 
moevement grossly intact in all extremities.
PSYCH: Listens and responds to questions appropriately, 
pleasant. 
 

###RESPONSE: Vitals {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, SpO2 {Finding of oxygen saturation}, GENERAL {General examination of patient}, distress {Distress}, Speaks {Does speak}, full sentences {Able to complete sentence in one breath}, tachypnea {Tachypnea}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, Conjunctiva moist and pink {Finding of moistness of eye}, scleral icterus {Scleral icterus}, PERRLA {Pupils equal, react to light and accommodation}, EOMs {Ophthalmic examination and evaluation}, intact {No abnormality detected}, Mucosa pink and moist {Moist oral mucosa}, Supple {Normal movement of neck}, LAD {Lymphadenopathy}, thyromegaly {Goiter}, CARDIAC {Cardiovascular physical examination}, Regular rhythm {Normal sinus rhythm}, tachy {Tachycardia}, rate {Finding of heart rate}, Normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, JVD {Jugular venous engorgement}, LUNGS {Examination of respiratory system}, Good {Normal breath sounds}, chest excursion {Finding of chest expansion}, Lung {Lung structure}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, right lower lobe {Structure of lower lobe of right lung}, left base {Structure of base of left lung}, wheezes {Wheezing}, egophony {Egophony}, ABDOMEN {Examination of abdomen}, Protuberant {Swollen abdomen}, Positive bowel sounds {Normal bowel sounds}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, palpation {Palpation}, EXTREMITIES {Examination of limb}, edema {Edema}, pain {Pain}, left calf {Structure of calf of left lower leg}, 2+ 
dorsalis pedis {Dorsalis pulse present}, pulses {Pulse finding}, right foot {Structure of soft tissue of dorsum of right foot}, SKIN {Examination of skin}, Pink {Pink skin}, hot {Hot skin}, dry {Xeroderma}, rashes {Eruption of skin}, lesions {Lesion}, ecchymoses {Ecchymosis}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, Appropriate {Appropriate affect}, confused {Clouded consciousness}, grossly intact {Normal nervous system function}, Sensation {Finding of sensation by site}, grossly intact {Normal nervous system function}, all extremities {All extremities}, PSYCH {Psychological assessment}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
IMAGING: 
CXR ___ - IMPRESSION: Patchy airspace opacities, most 
notable in the right lung base, but also in the right mid lung 
and likely also left lower lung. Findings are concerning for 
aspiration or pneumonia. 
.
MICROBIOLOGY:  Blood cultures ___ - pending
.
LAB DATA:
LABS ON ADMISSION:
___ 10:45AM BLOOD WBC-19.3* RBC-5.09 Hgb-14.9 Hct-44.3 
MCV-87 MCH-29.3 MCHC-33.7 RDW-14.2 Plt ___
___ 10:45AM BLOOD Neuts-86.3* Lymphs-9.0* Monos-3.8 Eos-0.7 
Baso-0.2
___ 10:45AM BLOOD Plt ___
___ 10:45AM BLOOD Glucose-170* UreaN-24* Creat-1.0 Na-139 
K-4.6 Cl-99 HCO3-28 AnGap-17
___ 10:45AM BLOOD cTropnT-<0.01
___ 10:45AM BLOOD CK-MB-5
___ 10:50AM BLOOD Type-ART pO2-61* pCO2-47* pH-7.40 
calTCO2-30 Base XS-2
___ 10:50AM BLOOD Lactate-1.0
.
LABS ON DISCHARGE:
 

###RESPONSE: IMAGING {Imaging}, CXR {Plain chest X-ray}, opacities {Abnormally opaque structure}, right lung base {Structure of base of right lung}, right mid lung {Structure of middle lobe of right lung}, left lower lung {Structure of lower lobe of left lung}, aspiration {Aspiration pneumonia}, pneumonia {Pneumonia}, MICROBIOLOGY {Microbiology}, Blood cultures {Blood culture}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, ART {Arterial specimen collection for laboratory test}, pH {pH measurement}, calTCO2 {Blood total carbon dioxide (calculated)}, Base XS {Delta base, blood}, Lactate {Lactic acid measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ y.o. woman with a past history of COPD and asthma that 
presented with increasing dyspnea and cough.  
.  
# Dyspnea: Likely due to COPD exacerbation with pneumonia 
suggested by CXR. ___ have occured in the setting of a URI given 
her husband's recent cold symptoms, but may also be due 
COPD/asthma exacerbation alone. Respiratory status has improved 
significantly since she presented to the ED. Infleunza was 
negative Does not appear to be volume overloaded, making CHF 
less likely. PE unlikely given her presentation and response to 
bronchodilators. Given her baseline respiratory dysfunction, she 
will likely need pulmonary rehab prior to returning home. She is 
not a candidate for home oxygen because she continues to smoke.  
If she can quit, she should start on nighttime home oxygen. 
Smoking cessation was discussed.  She had a nicotine patch and 
was discharged on chantix.  She plans not to smoke on this 
medication and knows to watch for depression and altered dreams.
She was discharged with a steroid taper, plan to complete a 10 
day course of antibiotics, and nebs for COPD/Asthma.  She should 
continue oxygen as needed. 
.  
Leukocytosis: Elevated WBC prior to steroids. Decreased during 
admission. Likely related to pneumonia, as suggested by CXR. 
This trended down.  
.  
# Hypertension: Well controlled with home medications. HCTZ, 
metoprolol and norvasc were continued, BP remained stable.  
.  
# Type II Diabetes: Glucose checks qid, standing coverage with 
70/30 and sliding scale.  Her 70/30 was increased while on 
prednisone and she was started on metformin.
.  
# Hyperlipidemia: Continued her simvastatin.  
.  
# Peripheral Neuropathy: Continued with her gabapentin.  
.  
# ? Dementia: Patient is on aricept, she and her daughter 
reported forgetfulness. Aricept was continued and she was 
monitored closely for delerium.  
.  
# CODE: Remains FULL code at this time. Patient did express that 
she may not want to be resuscitated/intubated, but further 
discussion with patient and family is required. She does not 
have a health care proxy.  
.  
# CONTACT: With patient and her daughter.  

 

###RESPONSE: COPD {Chronic obstructive lung disease}, asthma {Asthma}, increasing {Patient's condition worsened}, dyspnea {Dyspnea}, cough {Cough}, Dyspnea {Dyspnea}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, pneumonia {Pneumonia}, CXR {Plain chest X-ray}, URI {Upper respiratory infection}, cold {Common cold}, COPD {Chronic obstructive lung disease}, asthma exacerbation {Exacerbation of asthma}, Respiratory status {Monitoring of respiration}, improved {Patient's condition improved}, Infleunza {Influenza}, negative {No pathologic diagnosis}, volume overloaded {Hypervolemia}, CHF {Congestive heart failure}, PE {Pulmonary embolism}, baseline {Baseline state}, respiratory {Respiratory function finding}, dysfunction {Functional disorder}, pulmonary rehab {Pulmonary rehabilitation}, home oxygen {Home oxygen therapy}, smoke {Smoker}, home oxygen {Home oxygen therapy}, Smoking cessation {Smoking cessation education}, smoke {Smoker}, medication {Administration of drug or medicament}, depression {Depressive disorder}, steroid {Steroid therapy}, taper {Medication decreased}, antibiotics {Antibiotic therapy}, nebs {Nebulizer therapy}, COPD {Chronic obstructive lung disease}, Asthma {Asthma}, oxygen {Oxygen therapy}, Leukocytosis {Leukocytosis}, Elevated WBC {White blood cell count outside reference range}, steroids {Steroid therapy}, pneumonia {Pneumonia}, CXR {Plain chest X-ray}, Hypertension {Hypertensive disorder, systemic arterial}, Well controlled {Disease condition determination, well controlled}, medications {Administration of drug or medicament}, stable {Stable blood pressure}, Type II Diabetes {Diabetes mellitus type 2}, Glucose {Glucose measurement, blood}, sliding scale {Sliding scale insulin regime}, increased {Increasing dosage of medication}, prednisone {Steroid therapy}, started {New medication added}, Hyperlipidemia {Hyperlipidemia}, Peripheral Neuropathy {Peripheral nerve disease}, Dementia {Dementia}, forgetfulness {Forgetful}, monitored {Monitoring procedure}, delerium {Delirium}, resuscitated {Resuscitation}, intubated {Insertion of endotracheal tube}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Albuterol - 90mcg aerosol prn
Citalopram - 10 mg PO daily
Fluticasone-Salmeterol (Advair) - 250 mcg-50 mcg inhaled bid
Gabapentin - 300 mg PO qhs
HCTZ - 25 mg PO daily
Metoprolol Succinatate - 150 mg PO daily
Simvastatin - 40 mg PO qhs
ASA - 81 mg PO daily
Norvasc - 5 mg PO daily
Aricept - 5 mg PO daily
Insulin NPH and Regular (Humulin 70/30) - 32 units, QAM and QPM
 
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day 
for 12 days: 6 tabs for 2 days, then 4 tabs for 2 days, then 3 
tabs for 2 days, then 2 tabs for 2 days, then 1 tab for 2 days 
then ___ tab for 2 days.
Disp:*43 Tablet(s)* Refills:*0*
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 
___  Inhalation every four (4) hours as needed for shortness of 
breath or wheezing.  
3. Chantix 0.5(11)-1(3X14) mg Tablets, Dose Pack Sig: ___ 
Tablets, Dose Packs PO as directed for 11 weeks: 0.5 mg daily 
for 3 days, then 0.5 mg BID for 4 days, then 1 mg BID.
Disp:*1 Tablets, Dose Pack(s)* Refills:*0*
4. Citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.  
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: 
One (1) Disk with Device Inhalation BID (2 times a day).  
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at 
bedtime).  
7. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO 
DAILY (Daily).  
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr 
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.  
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily).  
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at 
bedtime).  
13. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension 
Sig: ___ (32)  Subcutaneous twice a day: Take 40 units 
twice daily for the next ___ days while on prednisone.  
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: 
One (1) Inh Inhalation once a day.
Disp:*QS 1 month unit* Refills:*2*
15. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day 
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
16. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H 
(every 24 hours) for 7 days.  
17. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times 
a day).
Disp:*60 Tablet(s)* Refills:*2*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Priamry: COPD exacerbation, penumonia.
Secondary: Hypertension, Type II Diabetes, Hyperlipidemia, 
Peripheral Neuropathy, Dementia: 

 
Discharge Condition:
Stable
 

###RESPONSE: COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, penumonia {Pneumonia}, Hypertension {Hypertensive disorder, systemic arterial}, Type II Diabetes {Diabetes mellitus type 2}, Hyperlipidemia {Hyperlipidemia}, Peripheral Neuropathy {Peripheral nerve disease}, Dementia {Dementia}, Stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted for shortness of breath.  You were treated a 
COPD exacerbation and pneumonia and were given frequent 
nebulizers, supplemental oxygen, oral steroids and antibiotics 
with improvement in your breathing.  You were also given a 
nicotine patch and encouraged to stop or reduce your smoking, 
which is likely contributing to your condition.  

You were started on a new medication, chantix, to help with 
smoking cessation.  Please watch for depressed mood or strange 
dreams on this medication and report these symptoms to your PCP.

You were started on Spireva for better COPD control as well as a 
taper of prednisone.  You were given increased insulin and 
metformin to help control your blood sugars while on the 
prednisone.  You should comeplete a 10 day course of 
antibiotics.

Please call your primary care physician or come to the emergency 
room if you experience worsening breathing difficulties that do 
not respond to inhalers, fevers, chills, chest pain, or other 
concerning symptoms.

 

###RESPONSE: shortness of breath {Dyspnea}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, pneumonia {Pneumonia}, nebulizers {Nebulizer therapy}, supplemental oxygen {Oxygen therapy support}, oral {Administration of drug or medicament via oral route}, steroids {Steroid therapy}, antibiotics {Antibiotic therapy}, improvement {Patient's condition improved}, reduce your smoking {Smoking cessation education}, started {New medication added}, new medication {New medication commenced}, smoking cessation {Smoking cessation education}, depressed mood {Depressed mood}, medication {Administration of drug or medicament}, PCP {Primary care management}, started {New medication added}, COPD {Chronic obstructive lung disease}, taper {Medication decreased}, prednisone {Steroid therapy}, increased {Increasing dosage of medication}, insulin {Insulin regime}, metformin {Allergy to metformin}, blood sugars {Blood sugar management}, prednisone {Steroid therapy}, antibiotics {Antibiotic therapy}, primary care {Primary care management}, emergency {Emergency treatment management}, breathing difficulties {Difficulty breathing}, fevers {Fever}, chills {Chill}, chest pain {Chest pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                     Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Aspirin / Penicillins / Codeine / Inderal / Isordil Titradose / 
Iodine-Iodine Containing / Celexa / Glucophage / Atorvastatin / 
Dilaudid (PF) / Vioxx / Levofloxacin / Hydralazine And 
Derivatives / Ondansetron / Carbapenem / Lidocaine / 
Nortriptyline / Fosfomycin / Morphine / Trimethoprim / Latex
 
Attending: ___.
 
Chief Complaint:
Chest pain
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Aspirin {Allergy to aspirin}, Penicillins {Allergy to penicillin}, Codeine {Allergy to codeine}, Iodine-Iodine {Allergy to iodine compound}, Atorvastatin {Allergy to atorvastatin}, Levofloxacin {Allergy to levofloxacin}, Morphine {Allergy to morphine}, Latex {Allergy to Hevea brasiliensis latex protein}, Chest pain {Chest pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ is a ___ year old female with CAD, HTN, Type II DM, CKD 
and a history of bradycardia with Wenckebach rhythm, CVA, s/p 
DVT with indwelling IVC filter w/o coumadin, presenting with 
___ substernal chest pressure radiating to the left arm as well 
as jaw while waiting for dermatology appointment.  
In the ED, initial vitals were 98.6 76 150/82 16 98% 2L NC  
Labs and imaging significant for clear CXR, Cr 1.2 (baseline), 
troponin T <0.01  
Patient started on nitro gtt, heparin bolus and gtt, started on 
2L n/c and was transferred to floor for further w/u.  
Vitals on transfer were 97.1, 73, 134/60, 24, 93% 2L  
.  
On arrival to the floor, patient denies CP, states has improved. 
She only notes feeling of general malaise. Denies DOE, SOB, 
cough, F/C/S. She notes that the pain had started at about 
10:45, and remained constant until about 4pm when it improved.  
.  
Pt had admission for chest pain ___, was ruled out for MI 
with echo and CE, felt to have large anxiety component to pain 
at that time.  
REVIEW OF SYSTEMS  
On review of systems, she denies any prior history of pulmonary 
embolism, bleeding at the time of surgery, myalgias, joint 
pains, cough, hemoptysis, black stools or red stools. She denies 
recent fevers, chills or rigors. She denies exertional buttock 
or calf pain. All of the other review of systems were negative.  

.  
Cardiac review of systems is notable for absence of dyspnea on 
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, 
palpitations, syncope or presyncope.  

 

###RESPONSE: CAD {Coronary arteriosclerosis}, HTN {Hypertensive disorder, systemic arterial}, Type II DM {Diabetes mellitus type 2}, CKD {Chronic kidney disease}, bradycardia {Bradycardia}, rhythm {Irregular heart beat}, CVA {Cerebrovascular accident}, DVT {Deep venous thrombosis}, IVC filter {Inferior vena cava filter in situ}, coumadin {Anticoagulant therapy}, chest pressure {Tight chest}, radiating to the left arm {Pain radiating to left arm}, jaw {Pain radiating to jaw}, vitals {Vital signs finding}, NC {Oxygen administration by nasal cannula}, imaging {Imaging}, clear {Chest clear}, CXR {Plain chest X-ray}, baseline {Baseline state}, troponin {Troponin measurement}, heparin {Heparin therapy}, Vitals {Vital signs finding}, CP {Chest pain}, improved {Patient's condition improved}, malaise {Malaise}, DOE {Dyspnea on exertion}, SOB {Dyspnea}, cough {Cough}, F/C {Fever with chills}, pain {Chest pain}, constant {Constant pain}, improved {Patient's condition improved}, chest pain {Chest pain}, MI {Myocardial infarction}, echo {Echocardiography}, anxiety {Anxiety}, pain {Chest pain}, review of systems {Review of systems}, pulmonary 
embolism {Pulmonary embolism}, bleeding {Bleeding}, surgery {Surgical procedure}, myalgias {Muscle pain}, joint 
pains {Joint pain}, cough {Cough}, hemoptysis {Hemoptysis}, black stools {Dark stools}, red stools {Red stools}, fevers {Fever}, chills {Chill}, rigors {Rigor}, buttock {Pain in buttock}, calf pain {Pain in calf}, review of systems {Review of systems}, Cardiac {Heart disease}, review of systems {Review of systems}, dyspnea on 
exertion {Dyspnea on exertion}, paroxysmal nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, ankle edema {Ankle edema}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- CAD: Cardiac cath ___ showed 50% mid LAD, 50% OM1 lesions c/b 

coronary aneurysm
- HTN  
- Diabetes mellitus, type 2
- CRI: baseline creatinine 0.9-1.2
- Asymptomatic bradycardia w/ ___ rhythm in past
- s/p CVA with residual left sided weakness in ___  
- h/o DVT in ___ post-op from back surgery, s/p IVC filter  
- L1-2 discectomy, L5-S1 fusion, R sided L2-3 and L3-4 w/ 
residual right leg weakness, now wheelchair bound when going 
outside but uses a walker at home
- Cervical stenosis on ___ MRI: mild stenosis C3-4, moderate 

stenosis C4-5, C5-6
- Foraminotomy
- Recurrent UTIs, on chronic suppressive methenamine  
- Arthritis  
- Cervical spondylosis  
- Osteoporosis  
- GERD
- s/p: appendectomy, hysterectomy, tonsillectomy, lap 
cholecystectomy in ___, cataract surgery x 2
 

###RESPONSE: CAD {Coronary arteriosclerosis}, Cardiac cath {Cardiac catheterization}, mid LAD {Structure of mid portion of anterior descending branch of left coronary artery}, OM1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, lesions {Lesion}, coronary aneurysm {Aneurysm of coronary vessels}, HTN {Hypertensive disorder, systemic arterial}, Diabetes mellitus, type 2 {Diabetes mellitus type 2}, CRI {Chronic renal insufficiency}, baseline {Baseline state}, creatinine {Creatinine measurement}, Asymptomatic bradycardia {Asymptomatic bradycardia}, rhythm {Irregular heart beat}, CVA {Cerebrovascular accident}, left sided weakness {Left hemiparesis}, DVT {Deep venous thrombosis}, post-op {Postoperative state}, surgery {Surgical procedure}, IVC filter {Inferior vena cava filter in situ}, discectomy {Chondrectomy of spine}, L5-S1 {Structure of intervertebral disc of L5 and S1}, fusion {Spinal arthrodesis}, right leg weakness {Right hemiparesis}, wheelchair bound {Does mobilize using wheelchair}, Cervical stenosis {Spinal stenosis in cervical region}, MRI {Magnetic resonance imaging}, stenosis {Stenosis}, stenosis {Stenosis}, Foraminotomy {Foraminotomy}, Recurrent UTIs {Recurrent urinary tract infection}, Arthritis {Arthritis}, Cervical spondylosis {Cervical spondylosis}, Osteoporosis {Osteoporosis}, GERD {Gastroesophageal reflux disease}, appendectomy {Excision of appendix}, hysterectomy {Hysterectomy}, tonsillectomy {Tonsillectomy}, lap 
cholecystectomy {Laparoscopic cholecystectomy}, cataract surgery {Cataract surgery}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother died at age ___ of CAD. Father died ___ CAD. 2 brothers 
died at ___ of CAD. Sister: ___. Sister: lung cancer. 3 
brothers: diabetes and CAD. 3 daughters: 1 with ""hole in her 
heart"", 1 with learning disability, 1 died of melanoma ___ years 
ago.
 

###RESPONSE: died {Dead}, CAD {Coronary arteriosclerosis}, died {Dead}, CAD {Coronary arteriosclerosis}, died {Dead}, CAD {Coronary arteriosclerosis}, lung cancer {Malignant tumor of lung}, CAD {Coronary arteriosclerosis}, ""hole in her 
heart"" {Atrial septal defect}, learning disability {Developmental academic disorder}, died {Dead}, melanoma {Malignant melanoma of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Admission PE:
GENERAL: ___ F in NAD. Oriented x3. Mood, affect appropriate.  
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were 
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. 
No Carotid Bruits.  
NECK: Supple with JVP of 2 cm.  
CARDIAC: PMI located in ___ intercostal space, midclavicular 
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or 
S4.  
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp 
were unlabored, no accessory muscle use. Few crackles b/l at the 
bases  
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not 
enlarged by palpation. No abdominial bruits.  
EXTREMITIES: No c/c/e. No femoral bruits.  
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.  
PULSES:  
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+  
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+  

Discharge PE:
T 97.6 126/66 HR 78 RR 20 96% RA
GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.  
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were 
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. 
No Carotid Bruits.  
NECK: Supple with JVP of 2 cm.  
CARDIAC: PMI located in ___ intercostal space, midclavicular 
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or 
S4.  
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp 
were unlabored, no accessory muscle use. Few crackles b/l at the 
bases  
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not 
enlarged by palpation. No abdominial bruits.  
EXTREMITIES: No c/c/e. No femoral bruits.  
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.  
PULSES:  
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+  
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+  

 

###RESPONSE: GENERAL {General examination of patient}, NAD {No abnormality detected}, Oriented x3 {Oriented to person, time and place}, Mood {Level of mood - normal}, affect {Mood finding}, HEENT {Physical examination procedure}, NC {Normal head}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva {Conjunctival structure}, pallor {Pallor of skin of face}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthalesma {Xanthelasma}, Carotid Bruits {Carotid bruit}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, intercostal space {Structure of intercostal space}, midclavicular 
line {Midclavicular line}, RR {Finding of rate of respiration}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, No m/r/g {Heart sounds normal}, thrills {Thrill}, lifts {Does lift}, No S3 {Third heart sound, S>3<, inaudible}, LUNGS {Examination of respiratory system}, chest wall deformities {Deformity of chest wall}, scoliosis {Scoliosis deformity of spine}, kyphosis {Kyphosis deformity of spine}, Resp {Examination of respiratory system}, accessory muscle {Accessory skeletal muscle}, crackles {Respiratory crackles}, bases {Structure of base of lung}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, Abd {Examination of abdomen}, enlarged {Enlargement}, palpation {Palpation}, abdominial bruits {Abdominal bruit}, EXTREMITIES {Examination of limb}, femoral bruits {Femoral bruit}, SKIN {Examination of skin}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, Right {Right coronary artery structure}, Carotid {Carotid artery structure}, Femoral {Structure of femoral artery}, DP {Structure of dorsalis pedis artery}, Left {Structure of left carotid artery}, Carotid {Carotid artery structure}, Femoral {Structure of femoral artery}, DP {Structure of dorsalis pedis artery}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, WDWN {Well nourished}, NAD {Distress}, Oriented x3 {Oriented to person, time and place}, Mood {Level of mood - normal}, affect {Mood finding}, NCAT {Normal head}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva {Conjunctival structure}, pallor {Pallor of skin of face}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthalesma {Xanthelasma}, Carotid Bruits {Carotid bruit}, Supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, intercostal space {Structure of intercostal space}, midclavicular 
line {Midclavicular line}, RR {Finding of rate of respiration}, normal S1, S2 {Heart sounds normal}, No m/r/g {Heart sounds normal}, thrills {Thrill}, lifts {Does lift}, No S3 {Third heart sound, S>3<, inaudible}, chest wall deformities {Deformity of chest wall}, scoliosis {Scoliosis deformity of spine}, kyphosis {Kyphosis deformity of spine}, Resp 
were unlabored {Breathing easily}, accessory muscle {Accessory skeletal muscle}, crackles {Respiratory crackles}, bases {Structure of base of lung}, Soft {Abdomen soft}, NTND {Abdominal tenderness}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, Abd aorta {Abdominal aorta structure}, enlarged {Enlargement}, palpation {Palpation}, abdominial bruits {Abdominal bruit}, femoral bruits {Femoral bruit}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, Right {Right coronary artery structure}, Carotid {Carotid artery structure}, Femoral {Structure of femoral artery}, DP {Structure of dorsalis pedis artery}, Left {Structure of left carotid artery}, Carotid {Carotid artery structure}, Femoral {Structure of femoral artery}, DP {Structure of dorsalis pedis artery}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 11:45AM BLOOD WBC-6.1 RBC-3.45* Hgb-10.8* Hct-31.8* 
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.7 Plt ___
___ 11:45AM BLOOD Neuts-60.5 ___ Monos-6.3 Eos-1.8 
Baso-0.7
___ 11:45AM BLOOD ___ PTT-20.5* ___
___ 11:45AM BLOOD Glucose-277* UreaN-18 Creat-1.2* Na-140 
K-4.5 Cl-104 HCO3-26 AnGap-15
___ 08:45PM BLOOD CK(CPK)-48
___ 11:45AM BLOOD cTropnT-<0.01
___ 08:45PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:13AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0
UA negative

___ CXR: No acute cardiopulmonary process

Discharge labs:

___ 06:13AM BLOOD WBC-6.0 RBC-3.30* Hgb-10.3* Hct-30.7* 
MCV-93 MCH-31.3 MCHC-33.7 RDW-13.8 Plt ___
___ 06:13AM BLOOD ___ PTT-69.1* ___
___ 06:13AM BLOOD Plt ___
___ 06:13AM BLOOD Glucose-156* UreaN-15 Creat-1.1 Na-141 
K-4.2 Cl-108 HCO___ AnGap-___ year old female with CAD, HTN, Type II DM, CKD and a history 
of bradycardia with ___ rhythm, CVA, s/p DVT with 
indwelling IVC filter w/o coumadin, presenting with ___ left 
sided jaw, neck, chest, torso pain lasting for ___ hours.  

# Atypical chest pain: Has long history of chest pain with 
previous cath in ___ showing normal arteries and stress echo in 
___ showing evidence of old infarct with no inducible 
ischemia. CE negative x2. No acute changes on EKG. Has long 
history of similar pain. Given history, ACS is possible and she 
was ruled out with enzymes and seriel EKGs. Other possibilities 
included anxiety/psychosomatic component which has been 
documented in past. She has cervical stenosis which may have had 
component. ___ have had musculoskeletal sprain/strain/pull.  PE 
was unlikely given no tachycardia, no pleuritic component, no 
s/s DVT, s/p IVC filter. Pna unlikely given no infiltrate on 
CXR, no cough, no F/C/S.
--On the floor she was weaned off nitro gtt with no return of 
her pain, and stopped heparin. No events noted on telemetry.  
ticlopidine was continued as pt allergic to asa.  Simvastatin 
was continued - patient had a documented allergy as ""elevated 
CPK"" however pt has been on this medication at home for some 
time without documented CPK elevations. No issues while in 
house.  Acetaminophen was used PRN for pain, further analgesic 
options were limited given extensive allergy list.  No beta 
blocker was started as patient has documented allergy to 
propanolol.  Patient had a negative UA and UTI was unlikely 
cause.
  
#nausea: was controlled with home prn compazine.  

# Normocytic anemia: stable  during admission
 
# Hypertension: patient not currently treated, has been on ACE-I 
in past but blood pressures were controlled while in house.
 
# Diabetes Mellitus Type II- stable on sliding scale insulin in 
house
# CKD - At baseline. Cr remained stable.  
# H/o cerebrovascular accident - stable. continued ticlopidine.  

# GERD - stable. continued home omeprazole.  
.  
FEN: Cardiac Heart Healthy  
.  
ACCESS: PIV's  while in house
.  
PROPHYLAXIS:  
-DVT ppx with heparin gtt followed by sub cutaneous heparin.  
-Pain management with tylenol  
-Bowel regimen with senna/colace  
.  
CODE: full  

Transitional issues:
-Atypical chest pain:  Felt very unlikely to be cardiac.  
Definitive diagnosis was difficult.  She does have previously 
diagnosed CAD, but does not tolerate beta blockers or aspirin.
-Social work/psych:  ___ benefit from seeing a therapist 
regarding anxiety. This has been broached with her in the past 
and may be worth speaking to her about again.
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, UA {Urinalysis}, CXR {Plain chest X-ray}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, AnGap {Anion gap measurement}, CAD {Coronary arteriosclerosis}, HTN {Hypertensive disorder, systemic arterial}, Type II DM {Diabetes mellitus type 2}, CKD {Chronic kidney disease}, bradycardia {Bradycardia}, rhythm {Irregular heart beat}, CVA {Cerebrovascular accident}, DVT {Deep venous thrombosis}, IVC filter {Inferior vena cava filter in situ}, coumadin {Anticoagulant therapy}, jaw {Pain radiating to jaw}, neck {Neck pain}, chest {Chest pain}, torso {Trunk structure}, pain {Pain}, Atypical chest pain {Atypical chest pain}, chest pain {Chest pain}, cath {Cardiac catheterization}, arteries {Arterial structure}, stress echo {Stress echocardiography}, old infarct {Healed infarct}, ischemia {Ischemia}, EKG {Electrocardiographic procedure}, pain {Chest pain}, ACS {Acute coronary syndrome}, EKGs {Electrocardiographic procedure}, anxiety {Anxiety}, cervical stenosis {Spinal stenosis in cervical region}, musculoskeletal sprain/strain/pull {Muscle strain}, PE {Pulmonary embolism}, tachycardia {Tachycardia}, pleuritic {Pleuritic pain}, DVT {Deep venous thrombosis}, IVC filter {Inferior vena cava filter in situ}, Pna {Pneumonia}, infiltrate {Infiltration}, CXR {Plain chest X-ray}, cough {Cough}, F/C {Fever with chills}, pain {Chest pain}, heparin {Heparin therapy}, telemetry {Cardiac telemetry}, allergy {Allergic disposition}, ""elevated 
CPK"" {Serum creatine kinase MB isoenzyme measurement}, pain {Pain}, allergy {Allergic disposition}, allergy to 
propanolol {Allergy to propranolol}, UA {Urinalysis}, UTI {Urinary tract infectious disease}, nausea {Nausea}, Normocytic anemia {Normocytic anemia}, stable {Patient's condition stable}, Hypertension {Hypertensive disorder, systemic arterial}, blood pressures {Blood pressure monitoring}, Diabetes Mellitus Type II {Diabetes mellitus type 2}, sliding scale insulin {Sliding scale insulin regime}, CKD {Chronic kidney disease}, baseline {Baseline state}, stable {Patient's condition stable}, cerebrovascular accident {Cerebrovascular accident}, stable {Patient's condition stable}, GERD {Gastroesophageal reflux disease}, stable {Patient's condition stable}, Cardiac {Heart structure}, Heart {Heart structure}, PROPHYLAXIS {Preventive procedure}, DVT {Deep venous thrombosis}, ppx {Preventive procedure}, heparin {Heparin therapy}, cutaneous {Skin structure}, heparin {Heparin therapy}, Pain management {Pain management}, Bowel {Normal bowel habits}, regimen {Therapeutic regimen}, Atypical chest pain {Atypical chest pain}, cardiac {Heart disease}, CAD {Coronary arteriosclerosis}, anxiety {Anxiety}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at 
bedtime).  
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a 

day (in the morning)).  
3. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO three times a 

day as needed for dizziness.  
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO once a day.  
5. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO 
every six (6) hours as needed for nausea.  
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.  
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 
___ MLs PO QID (4 times a day) as needed for heartburn.  
8. ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times 

a day).  
9. Lantus 100 unit/mL Solution Sig: Fifteen (15) units 
Subcutaneous at bedtime.

 
Discharge Medications:
1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at 
bedtime). Capsule(s) 
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a 
day (in the morning)).  
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
4. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO 
Q6H (every 6 hours) as needed for Nausea.  
5. ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times 
a day).  
6. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO three times a 
day as needed for nausea.  
7. Lantus 100 unit/mL Solution Sig: Fifteen (15) Units 
Subcutaneous At bedtime.  
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Atypical chest pain with normal cardiac enzymes and no 
electrocardiogram changes.

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: Home With Service {Home health aide service management}, Atypical chest pain {Atypical chest pain}, cardiac enzymes {Finding of cardiac enzyme levels}, electrocardiogram {Electrocardiographic procedure}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - requires assistance or aid {Finding of walking aid use}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you in the hospital.  You were 
admitted for chest pain.  The major concern was that this was 
related to your heart.  All the testing done, including lab work 
and EKGs were very reassuring and it was unlikely this was 
related to a problem with your heart.  It may have been related 
to your cervical stenosis or it may have been a muscle pull, 
strain, or sprain.  You should keep taking all of your 
medications exactly as prescribed.

 

###RESPONSE: chest pain {Chest pain}, heart {Heart structure}, EKGs {Electrocardiographic procedure}, problem {Problem}, heart {Heart structure}, cervical stenosis {Spinal stenosis in cervical region}, strain {Muscle strain}, sprain {Sprain}, medications {Medication education}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___             Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Bactrim / Claritin / Sulfa (Sulfonamide Antibiotics)
 
Attending: ___.
 
Chief Complaint:
chest pain
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, Claritin {Allergy to histamine H1 receptor antagonist}, Sulfa {Allergy to sulfonamide antibiotic}, Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, chest pain {Chest pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ CAD with NSTEMI in ___ s/p DES to LAD s/p in ___ DES 
to LCX presenting with onset of rightsided cp (typical of his 
angina equivilant). Pain started at rest around 1pm. resolved 
s/p nitroX2. No CP since then. Pt denies SOB, n,v, diaphoresis, 
dizziness, lightheaded. Of note, had a URI type illness ___ 
weeks ago that has resolved, but now has sporadic non-productive 
cough. 

In the ED, initial vitals were:  98.1 64 162/76 96RA  
- Labs were significant for WBC 17. Initial trop<.01, MN trop 
.02, and 02AM trop .03. 
- Imaging revealed  CXR with patchy R base opacity, most likely 
atelectasis, but could be consistent with PNA in the right 
clinical setting.
- The patient was given Asp 325,g, levofloxacin 750mg, 
atorvastatin 80mg. Was started on heparin gtt.  
Vitals prior to transfer were: 56 105/55 18 94% RA  

Upon arrival to the floor, pt CP free. No SOB, dizziness, 
lightheadedness. 
 

###RESPONSE: CAD {Coronary arteriosclerosis}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, DES {Endovascular insertion of drug eluting stent}, LAD {Structure of anterior descending branch of left coronary artery}, DES {Endovascular insertion of drug eluting stent}, LCX {Structure of circumflex branch of left coronary artery}, angina {Angina}, Pain {Pain}, at rest {Chest pain at rest}, resolved {Problem resolved}, SOB {Dyspnea}, n,v {Nausea and vomiting}, diaphoresis {Excessive sweating}, dizziness {Dizziness}, lightheaded {Lightheadedness}, URI {Upper respiratory infection}, resolved {Problem resolved}, non-productive 
cough {Dry cough}, vitals {Vital signs finding}, RA {Breathing room air}, Labs {Laboratory test}, WBC {White blood cell count}, trop {Troponin measurement}, trop {Troponin measurement}, trop {Troponin measurement}, Imaging {Imaging}, CXR {Plain chest X-ray}, R base {Structure of base of right lung}, opacity {Abnormally opaque structure}, atelectasis {Atelectasis}, PNA {Pneumonia}, levofloxacin {Antibiotic therapy}, started {New medication added}, heparin {Heparin therapy}, Vitals {Vital signs finding}, RA {Breathing room air}, CP {Chest pain}, SOB {Dyspnea}, dizziness {Dizziness}, lightheadedness {Lightheadedness}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- Hypertension  
- CAD with NSTEMI in ___ s/p DES to LAD s/p in ___ DES to 
LCX 
- COPD not on oxygen  
- Chronic lymphocytic leukemia  
- Prostate cancer  
- DVT and PE in ___  
- GERD  
- Raynaud's syndrome  
- Osteoarthritis of left knee  
- Osteoporosis  
- Spinal stenosis  
- Attention deficit disorder  
- Anxiety and depression
 

###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, CAD {Coronary arteriosclerosis}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, DES {Endovascular insertion of drug eluting stent}, LAD {Structure of anterior descending branch of left coronary artery}, DES {Endovascular insertion of drug eluting stent}, LCX {Structure of circumflex branch of left coronary artery}, COPD {Chronic obstructive lung disease}, oxygen {Oxygen therapy}, Chronic lymphocytic leukemia {Chronic lymphoid leukemia, disease}, Prostate cancer {Carcinoma of prostate}, DVT {Deep venous thrombosis}, GERD {Gastroesophageal reflux disease}, Raynaud's syndrome {Raynaud's disease}, Osteoarthritis of left knee {Osteoarthritis of left knee joint}, Osteoporosis {Osteoporosis}, Spinal stenosis {Spinal stenosis}, Attention deficit disorder {Attention deficit hyperactivity disorder, predominantly inattentive type}, Anxiety {Anxiety}, depression {Depressive disorder}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
- Sister has a brain tumor.
- No family history of early MI, arrhythmia, cardiomyopathies, 
or 
sudden cardiac death; father had colon cancer
 

###RESPONSE: brain tumor {Neoplasm of brain}, MI {Myocardial infarction}, arrhythmia {Cardiac arrhythmia}, cardiomyopathies {Cardiomyopathy}, sudden cardiac death {Sudden cardiac death}, colon cancer {Malignant neoplasm of colon}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION
Vitals:  98.1 131/73 58 18 94/1L Wt 86.5kg
General: Alert, oriented, no acute distress  
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL  
Neck: Supple, JVP not elevated, no LAD  
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, 
gallops  
Lungs: Clear to auscultation bilaterally, no wheezes, rales, 
rhonchi  
Abdomen: Soft, non-tender, non-distended, bowel sounds present, 
no organomegaly, no rebound or guarding  
GU: No foley  
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
Neuro: CNII-XII intact, ___ strength upper/lower extremities, 
grossly normal sensation, 2+ reflexes bilaterally  

DISCHARGE
Vitals:  t 98 BP 140/70 HR 58 RR 18 94/1L 
General: Alert, oriented, no acute distress  
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL  
Neck: Supple, JVP not elevated, no LAD  
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, 
gallops  
Lungs: right base with rhonchi, no rales or wheezing. left lung 
CTA.   
Abdomen: Soft, non-tender, non-distended, bowel sounds present, 
no organomegaly, no rebound or guarding  
GU: No foley  
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema 
 

###RESPONSE: Vitals {Vital signs finding}, 1L {Oxygen therapy}, Wt {Weight finding}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, GU {Examination of genitourinary system}, foley {Urinary catheter in situ}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, CNII-XII intact {Normal central nervous system}, upper {Upper limb structure}, lower extremities {Lower limb structure}, normal sensation {Normal sensation}, 2+ reflexes {Normal reflex}, Vitals {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, 1L {Oxygen therapy}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Lungs {Examination of respiratory system}, right base {Structure of base of right lung}, rhonchi {Wheeze - rhonchi}, rales {Respiratory crackles}, wheezing {Wheezing}, left lung {Left lung structure}, CTA {Normal breath sounds}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, GU {Examination of genitourinary system}, foley {Urinary catheter in situ}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulse present}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
=======================================================
LABS

ADMISSION
___ 06:10PM BLOOD WBC-17.0* RBC-5.11 Hgb-13.8 Hct-42.8 
MCV-84 MCH-27.0 MCHC-32.2 RDW-18.4* RDWSD-53.7* Plt ___
___ 06:10PM BLOOD ___ PTT-30.3 ___
___ 06:10PM BLOOD Glucose-95 UreaN-32* Creat-1.2 Na-137 
K-4.8 Cl-101 HCO3-24 AnGap-17

CARDIAC BIOMARKERS
___ 06:10PM BLOOD cTropnT-<0.01
___ 12:00AM BLOOD cTropnT-0.02*
___ 01:50AM BLOOD cTropnT-0.03*
___ 09:00AM BLOOD cTropnT-0.03*
___ 03:40PM BLOOD cTropnT-0.03*
___ 10:04PM BLOOD cTropnT-0.02*
___ 10:00AM BLOOD cTropnT-0.01

DISCHARGE
___ 10:00AM BLOOD WBC-15.8* RBC-5.37 Hgb-14.4 Hct-45.5 
MCV-85 MCH-26.8 MCHC-31.6* RDW-19.1* RDWSD-55.3* Plt ___
___ 10:00AM BLOOD Glucose-145* UreaN-28* Creat-1.3* Na-139 
K-4.2 Cl-101 HCO3-26 AnGap-16

=======================================================
MICRO

___ CULTUREBlood Culture, 
Routine-PENDINGINPATIENT

___ CULTUREBlood Culture, 
Routine-PENDINGINPATIENT

___ CULTURE-FINALINPATIENT
No growth

=======================================================
IMAGING/STUDIES

___
Signnificant baseline artifact. Sinus rhythm. Diffuse 
non-specific ST segment straightening throughout. Compared to 
tracing #1 non-specific repolarization abnormalities are new and 
suggest an ongoing pharmacologic metabolic process. Clinical 
correlation is suggested. TRACING #2
Read ___
 Intervals  Axes
RatePRQRSQTQTc (___)  ___
___
 
   
___ (PA & LAT)
Patchy right base opacity most likely due to atelectasis, 
although infectious process is difficult to exclude in the 
appropriate clinical setting.  

___
Sinus rhythm. Tracing is within normal limits. Compared to the 
previous
tracing of ___ the rate is minimally faster and no longer 
technically
bradycardic. TRACING #1
Read ___
 Intervals  Axes
RatePRQRSQTQTc (___)  ___
___

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Plt {Platelet count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, CARDIAC {Heart structure}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Plt {Platelet count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, Culture {Blood culture}, CULTURE {Microbial culture}, No growth {No organism isolated by microbiologic culture}, IMAGING {Imaging}, STUDIES {Evaluation procedure}, baseline {Baseline state}, artifact {Artifact}, Sinus rhythm {Sinus rhythm}, non-specific ST segment straightening {Nonspecific ST-T abnormality on electrocardiogram}, abnormalities {Imaging result abnormal}, Intervals {Finding of electrocardiogram waveform}, (PA & LAT) {Diagnostic radiography of chest, combined posteroanterior and lateral}, right base {Structure of base of right lung}, opacity {Abnormally opaque structure}, atelectasis {Atelectasis}, infectious process {Infectious disease}, Sinus rhythm {Sinus rhythm}, normal {Electrocardiogram normal}, rate {Finding of heart rate}, bradycardic {Bradycardia}, Intervals {Finding of electrocardiogram waveform}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Mr. ___ is an ___ yo man with a history of NSTEMI s/p s/p 
DES to LAD (___), LCX (___) who presented with right sided 
light chest pressure at rest which was similar to his previous 
NSTEMIs. Of note, he described holding his aspirin and 
clopidogrel for a Dermatology procedure.

ACTIVE PROBLEMS
# NSTEMI
# Community acquired pneumonia

He was noted to have an NSTEMI with troponins peaking at 0.03. 
His EKG was unremarkable for ischemic change, normal sinus 
rhythm, TWI in V1, no STE, unchanged from prior. He was placed 
on a heparin gtt with a plan for cardiac catheterization. 
However, patient declined cardiac catheterization given his 
desire for no invasive procedures. He also declines reversal of 
code status from DNR/DNI for procedures. He is on Plavix, 
aspirin, carvidilol, atorvastatin 80, and lisinopril-HCTZ at 
home, and these were continued. Also, we counseled the patient 
yesterday that he could NOT,
under any circumstances, discontinue his DAPT without a 
cardiologist's permission.

In addition, he was noted to have a retrocardiac opacity, 
leukocytosis, and a history of cough x2-3 weeks. He was started 
on levofloxacin 750 mg x5 days with planned course from 
___.

Unfortunately, before our team could prepare his discharge 
paperwork, he walked to the nursing station dressed and shouted 
that we had ""no regard for patient care."" I asked him to stay 
for just a few minutes so that we could prepare the ___ and 
homemaker services he had requested earlier, but he declined, 
saying that we were just trying to ""CYA."" He did not leave with 
his prescription for levofloxacin, or his ___ services 
arranged. We forwarded this information to PCP and ___ 
in hopes they can assist with his follow-up care. 

TRANSITIONAL ISSUES
- NSTEMI likely precipitated by holding DAPT - iterate in the 
outpatient setting that he cannot discontinue these medications
- Levofloxacin 750 mg daily (___) for community acquired 
PNA was prescribed but NOT completed, and he should be queried 
specifically for PNA symptoms at next outpatient f/u
- Patient planned for cardiology appointment in ___ with 
Dr. ___ would recommend follow up in the next month 
with cardiology. Patient vocalized that he would make an 
appointment within the next month to see cardiology. 
 

###RESPONSE: NSTEMI {Acute non-ST segment elevation myocardial infarction}, DES {Endovascular insertion of drug eluting stent}, LAD {Structure of anterior descending branch of left coronary artery}, LCX {Structure of circumflex branch of left coronary artery}, right sided {Right thorax structure}, at rest {Chest pain at rest}, NSTEMIs {Acute non-ST segment elevation myocardial infarction}, aspirin {Administration of aspirin}, PROBLEMS {Problem}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, Community acquired pneumonia {Community acquired pneumonia}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, troponins {Troponin measurement}, EKG {Electrocardiographic procedure}, unremarkable {No abnormality detected}, ischemic change {Ischemia}, normal sinus 
rhythm {Electrocardiogram: normal sinus rhythm}, TWI {Inverted T wave}, V1 {Lead site V1}, STE {ST segment elevation}, unchanged {Patient condition unchanged}, heparin {Heparin therapy}, cardiac catheterization {Cardiac catheterization}, cardiac catheterization {Cardiac catheterization}, procedures {Procedure}, DNR {Not for resuscitation}, procedures {Surgical procedure}, Plavix {Administration of prophylactic clopidogrel}, aspirin {Administration of aspirin}, could NOT,
under any circumstances, discontinue {Recommendation to continue with drug treatment}, opacity {Abnormally opaque structure}, leukocytosis {Leukocytosis}, cough {Cough}, started {New medication added}, levofloxacin {Antibiotic therapy}, walked {Does walk}, leave {Left against medical advice}, prescription {Prescription}, levofloxacin {Antibiotic therapy}, PCP {Primary care management}, follow-up care {Postoperative procedure education}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, cannot discontinue these medications {Recommendation to continue with drug treatment}, Levofloxacin {Antibiotic therapy}, community acquired 
PNA {Community acquired pneumonia}, PNA {Pneumonia}, cardiology appointment {Cardiac care management}, follow up {Follow-up arranged}, cardiology {Cardiology service}, make an 
appointment {Follow-up arranged}, cardiology {Cardiology service}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY 
2. Aspirin 81 mg PO DAILY 
3. BuPROPion (Sustained Release) 300 mg PO QAM 
4. Clopidogrel 75 mg PO DAILY 
5. DiphenhydrAMINE 25 mg PO QHS insomnia 
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN 
7. Lorazepam 1.5 mg PO QHS insomnia 
8. Multivitamins 1 TAB PO DAILY 
9. Omeprazole 20 mg PO DAILY 
10. AndroGel (testosterone) 1.25 gram/ actuation (1 %) 
transdermal 5 pumps daily 
11. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY 
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 
13. Atorvastatin 80 mg PO QPM 
14. Carvedilol 6.25 mg PO BID 
15. Amphetamine-Dextroamphetamine 10 mg PO TID 
16. glucosamine-chondroitin unknown strength oral 2 tablets PO 
daily 
17. Ascorbic Acid ___ mg PO DAILY 
18. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram 
oral with meals 
19. azelastine 137 mcg (0.1 %) nasal 2 sprays NU BID as needed 

 
Discharge Medications:
1. Amlodipine 10 mg PO DAILY 
2. Amphetamine-Dextroamphetamine 10 mg PO TID 
3. Aspirin 81 mg PO DAILY 
4. Atorvastatin 80 mg PO QPM 
5. BuPROPion (Sustained Release) 300 mg PO QAM 
6. Clopidogrel 75 mg PO DAILY 
7. DiphenhydrAMINE 25 mg PO QHS insomnia 
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN 
9. Lorazepam 1.5 mg PO QHS insomnia 
10. Multivitamins 1 TAB PO DAILY 
11. Omeprazole 20 mg PO DAILY 
12. Carvedilol 6.25 mg PO BID 
13. Levofloxacin 750 mg PO DAILY 
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*2 
Tablet Refills:*0
14. AndroGel (testosterone) 1.25 gram/ actuation (1 %) 
transdermal 5 pumps daily 
15. Ascorbic Acid ___ mg PO DAILY 
16. azelastine 137 mcg (0.1 %) nasal 2 sprays NU BID as needed 
17. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram 
oral with meals 
18. glucosamine-chondroitin 0 strength ORAL 2 TABLETS PO DAILY 
19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 
20. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY 

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary:
NSTEMI
community acquired PNA

Secondary:
CAD w/ NSTEMI s/p DES to LAD ___ DES to LCX (___)
COPD
HTN

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: NSTEMI {Acute non-ST segment elevation myocardial infarction}, community acquired PNA {Community acquired pneumonia}, CAD {Coronary arteriosclerosis}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, DES {Endovascular insertion of drug eluting stent}, LAD {Structure of anterior descending branch of left coronary artery}, DES {Endovascular insertion of drug eluting stent}, LCX {Structure of circumflex branch of left coronary artery}, COPD {Chronic obstructive lung disease}, HTN {Hypertensive disorder, systemic arterial}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___, 

You were seen at ___ for the light chest 
pressure you felt in your chest that was the same as you 
experienced before with your heart attacks. You did have 
elevation of troponins, which indicates a lack of blood flow to 
your heart. This is concerning for ischemia, or the beginning of 
a heart attack. We placed you on a medication called heparin to 
prevent ischemia. Your troponins trended down, and your EKG was 
normal. You were seen by our cardiology team, who felt that you 
should have a cardiac catheterization to evaluate your heart 
vessels and stents. You declined this procedure as it is not 
within your goals of care. 

In addition, you were noted to have a pneumonia, and we are 
treating you with antibiotics. Please continue these until 
___.

We are keeping you on your home medications. Please follow up 
with your appointments that we have arranged. Please follow up 
with your cardiologist Dr. ___ the next month as we 
discussed.

It was a pleasure taking care of you.

Your ___ team
 

###RESPONSE: chest 
pressure {Tight chest}, chest {Thoracic structure}, heart attacks {Myocardial infarction}, elevation {Measurement finding above reference range}, troponins {Troponin measurement}, lack of blood flow {Decreased vascular flow}, heart {Heart structure}, ischemia {Ischemia}, heart attack {Myocardial infarction}, medication {Administration of drug or medicament}, heparin {Heparin therapy}, prevent {Preventive procedure}, ischemia {Ischemia}, troponins {Troponin measurement}, EKG {Electrocardiographic procedure}, normal {Electrocardiogram normal}, cardiology {Cardiology service}, cardiac catheterization {Cardiac catheterization}, evaluate {Evaluation procedure}, heart 
vessels {Coronary artery structure}, stents {Coronary stent patent}, procedure {Procedure}, pneumonia {Pneumonia}, antibiotics {Antibiotic therapy}, keeping {Recommendation to continue with drug treatment}, medications {Administration of drug or medicament}, follow up {Follow-up arranged}, follow up {Follow-up arranged}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
none
 
Major Surgical or Invasive Procedure:
None.

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ ___ speaking, with h/o dementia living in senior 
apartment who presented with reported suicidal ideation. History 
is gathered mainly from reports as pt poor historian. Per EMS a 
family member at the scene stated that the pt was upset about 
breaking up with her boyfriend and has had increased depression. 
Tried to jump out of a window and family had to restrain her. 
EMS found her calm, cooperative, and smiling.  
.  
In the ED, initial VS: 98.1 64 160/75 20 99%. She was noted to 
only be oriented to person and needed a sitter for wandering 
off, but was pleasant and cooperative. Through interpreter in 
the ED, the only positive ROS was pain with urination. The ED 
housestaff spoke to the son who stated he's having a hard time 
taking care of her. Case management contacted in the ED -- 
because of her dementia she needs to have a guardian or HCP 
assigned before she can placed and requires admission in the 
meantime.  
.  
Psych saw the pt who noted her to be disoriented at baseline, 
unable to provide any history or details of what happened, no SI 
or HI; they note severe memory deficits and baseline is 
wandering and getting lost, unable to recall family, unable to 
feed or bathe self but can feed herself.  

 

###RESPONSE: dementia {Dementia}, suicidal ideation {Suicidal thoughts}, poor historian {Poor historian}, upset {Feeling upset}, depression {Depressive disorder}, calm {Feeling calm}, cooperative {Cooperative mental state}, smiling {Smiling}, VS {Vital signs finding}, oriented to person {Oriented to person}, wandering {Wandering}, cooperative {Cooperative mental state}, ROS {Review of systems}, pain with urination {Dysuria}, dementia {Dementia}, memory deficits {Memory impairment}, wandering {Wandering}, getting lost {Getting lost}, bathe self {Unable to bath self}, can feed herself {Able to feed self}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- Dementia -> per husband patient has had this diagnosis for ___ 
 
years. She apparently does not remember family members names  
intermittently, she gets lost, has a history of falls, per notes 
with neuropsychologist Dr. ___ also has been having a long 
history of word finding-difficulty. According to her husband, 
her cognitive baseline is that she is alert & oriented to person 
only. She cannot dress or bathe herself but she can eat 
independently. She usually is talkative and understands commands 
and conversations.  
- Diabetes (Type 2)  
- Psoriasis  
- Hypertension  
- Depression  
- cholecystectomy  
- hysterectomy  
- Breast cancer status post lumpectomy, radiation, and CMF  
chemotherapy. This was stage I invasive mucinous carcinoma of  
the right breast diagnosed in ___.  

 

 

###RESPONSE: Dementia {Dementia}, gets lost {Getting lost}, word finding-difficulty {Word finding difficulty}, alert {Mentally alert}, oriented to person {Oriented to person}, cannot dress {Unable to dress}, bathe {Unable to bath self}, can eat 
independently {Able to feed self}, Diabetes (Type 2) {Diabetes mellitus type 2}, Psoriasis {Psoriasis}, Hypertension {Hypertensive disorder, systemic arterial}, Depression {Depressive disorder}, cholecystectomy {Cholecystectomy}, hysterectomy {Hysterectomy}, Breast cancer {Malignant neoplasm of breast}, status post {Postoperative state}, lumpectomy {Excision of mass}, radiation {Radiation oncology AND/OR radiotherapy}, chemotherapy {Chemotherapy}, mucinous carcinoma {Mucinous adenocarcinoma}, right breast {Right breast structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Unknown
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION EXAM:
98.2 134/82 72 20 98%RA  
Overweight elderly F, sleeping soundly but easily awoken, 
appears well, comfortable  
EOMI, no scleral icterus  
CTAB no w/c/r/r  
RRR without m/g  
Obese NT ND, benign  
No BLE edema, cyanasis, mottling,  
CN ___ grossly intact, speech normal, moving all extremities  

DISCHARGE EXAM:
97.2 121/51 79 16 99%
Overweight elderly F, sleeping soundly but easily awoken, 
appears well, comfortable  
EOMI, no scleral icterus  
CTAB no w/c/r/r  
RRR without m/g  
Obese NT ND, benign  
No BLE edema, cyanasis, mottling,  
CN ___ grossly intact, speech normal, moving all extremities 
 

###RESPONSE: RA {Breathing room air}, Overweight {Overweight}, sleeping {Asleep}, comfortable {Comfortable appearance}, EOMI {Normal ocular motility}, scleral icterus {Scleral icterus}, CTAB {Normal breath sounds}, w {Wheezing}, c {Respiratory crackles}, RRR {Normal heart rate}, m {Heart murmur}, g {Gallop rhythm}, Obese {Obese}, NT {Abdominal tenderness}, ND {Swollen abdomen}, BLE {Edema of bilateral lower legs}, edema {Edema}, cyanasis {Cyanosis}, mottling {Mottling}, CN {Cranial nerve structure}, grossly intact {Normal nervous system function}, speech {Speech finding}, normal {No abnormality detected}, all extremities {All extremities}, Overweight {Overweight}, sleeping {Asleep}, comfortable {Comfortable appearance}, EOMI {Normal ocular motility}, scleral icterus {Scleral icterus}, CTAB {Normal breath sounds}, w {Wheezing}, c {Respiratory crackles}, RRR {Normal heart rate}, m {Heart murmur}, g {Gallop rhythm}, Obese {Obese}, BLE {Edema of bilateral lower legs}, edema {Edema}, cyanasis {Cyanosis}, mottling {Mottling}, CN {Cranial nerve structure}, grossly intact {Normal nervous system function}, speech {Speech finding}, normal {No abnormality detected}, moving all extremities {Does move all four limbs}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 09:48PM   WBC-8.7 RBC-3.95* HGB-11.4* HCT-33.9* MCV-86 
MCH-28.9 MCHC-33.6 RDW-14.5
___ 09:48PM   NEUTS-68.2 ___ MONOS-5.3 EOS-4.6* 
BASOS-1.2
___ 09:48PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG 
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:48PM   GLUCOSE-100 UREA N-26* CREAT-1.0 SODIUM-132* 
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-24 ANION GAP-15
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
PATIENT: ___ yo F history of dementia, HTN, DM2 who presents with 
failure to thrive, admitted for ~1 months awaiting guardianship 
papers and nursing home placement.
.
ACUTE ISSUES:
# Failure to thrive - Initially brought to the ED for question 
of suicidal ideation. Family members reported she tried to jump 
out the window. Further evaluation by psychiatry revealed 
worsening dementia and a lack of caregivers in the home. 
Patient's husband had recently moved back to ___, and 
she was unable to care for herself at home. Patient's son 
___ was contacted and agree to guardianship. Paperwork was 
filed with the courts and with approval of guardianship she was 
discharged to nursing home.
.
CHRONIC ISSUES:
# Dementia - continued on home memantine in the hospital. 
Consistently alert but not oriented. Spent most of her time 
walking around the unit. Easily re-directable. Not agitated. 
There was a question of whether she was taking exelon at home, 
this was not given during her hospitalization. 
.
# Diabetes type II - It was confirmed through her pharmacy that 
she was taking metformin 1000mg BID. This was held during her 
hospital stay and instead she was maintained on an insulin 
sliding scale. At discharge, her metformin will be restarted. 
.
# Hypertension - We continued on home regimen of amlopidine, 
HTCZ, and lisinopril. Atenolol was held given good BP control.

 

###RESPONSE: dementia {Dementia}, HTN {Hypertensive disorder, systemic arterial}, DM2 {Diabetes mellitus type 2}, failure to thrive {Failure to thrive}, Failure to thrive {Failure to thrive}, suicidal ideation {Suicidal thoughts}, worsening {Patient's condition worsened}, dementia {Dementia}, Dementia {Dementia}, alert {Mentally alert}, agitated {Feeling agitated}, .
# Diabetes type II {Diabetes mellitus type 2}, insulin 
sliding scale {Sliding scale insulin regime}, Hypertension {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Confirmed with her pharmacy: 
ferrous sulfate 325 daily
multivit
namenda 10 mg BID
HCTZ 25 mg daily
lisinopril 20 mg daily
lipitor 20 mg daily
metformin 1 gm BID
amlodipine 5 mg daily
atenolol 50 daily

 
Discharge Medications:
1. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).  
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
3. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO 
DAILY (Daily).  
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
6. metformin 500 mg Tablet Sig: Two (2) Tablet PO twice a day.  
7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.  
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.  
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a 
day as needed for constipation.  
10. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as 
needed for constipation.  
11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) 
Tablet PO once a day.  
12. Tylenol ___ mg Tablet Sig: ___ Tablets PO four times a day 
as needed for pain.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Dementia

SECONDARY DIAGNOSES:
- Diabetes (Type 2)  
- Psoriasis  
- Hypertension  
- Depression  
- Cholecystectomy  
- Hysterectomy  
- Breast cancer status post lumpectomy, radiation, and CMF  
chemotherapy. This was stage I invasive mucinous carcinoma of  
the right breast diagnosed in ___.  

 
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Dementia {Dementia}, Diabetes (Type 2) {Diabetes mellitus type 2}, Psoriasis {Psoriasis}, Hypertension {Hypertensive disorder, systemic arterial}, Depression {Depressive disorder}, Cholecystectomy {Cholecystectomy}, Hysterectomy {Hysterectomy}, Breast cancer {Malignant neoplasm of breast}, status post {Postoperative state}, lumpectomy {Excision of mass}, radiation {Radiation oncology AND/OR radiotherapy}, chemotherapy {Chemotherapy}, mucinous carcinoma {Mucinous adenocarcinoma}, right breast {Right breast structure}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - 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:
It was a pleasure to participate in Ms. ___ care while she 
was in the hospital.  She was admitted to the hospital after her 
family had some concerns about her behavior.  According to her 
family, she had been trying to jump out of a window.  Our 
psychiatry team evaluated Ms. ___ upon her presentation and 
determined that she was not suicidal.  It was thought that her 
concerning behavior represented confusion due to her dementia.  
Ms. ___ primary caretaker was her boyfriend, but he recently 
moved back to ___.  Ms. ___ is unable to care for 
herself without the assistance of others.  Prior to this 
hospitalization, she did not have a guardian. Her son ___ 
agreed to be her guardian and paperwork for guardianship was 
processed.

 

###RESPONSE: suicidal {Suicidal}, confusion {Clouded consciousness}, dementia {Dementia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                      Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
chest pain
 
Major Surgical or Invasive Procedure:
None.

 

###RESPONSE: chest pain {Chest pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ with PMH of NIDDM, smoking,
CAD s/p MI (___), PCI in ___ at ___ who presents as transfer
from ___ with NSTEMI. 
  
 Pain started on ___ morning while at work as a ___ 
___.
Per pt, pain similar to chest pain from previous MI. Episodic
pain lasting ~15 mins. Per pt, not currently on sublingual
nitroglycerin. Pain epigastric, shartp, ___, and radiates
episodically to R or L chest. No diaphoresis, nausea, vomiting,
or chest pressure.
  
 Went to ___ where he had trop elevated to 0.131. He AMA'd after
not feeling staff were addressing his needs.  

At ___: s/p 4x ASA 81, 4,000U IV heparin @ ___ 140-160s systolic
Cr 1.4
Trop I 0.10

 During initial eval, had brief episode of CP lasting a few
seconds that resolved. CP free currently. Denies headache,
dizziness, fever, chills, SOB, abdominal pain, nausea vomiting,
or dysuria.  
 
In the ED initial vitals were: 98 82 184/99 14 100% RA  
 ED Exam:  
 Gen: NAD  
 HEENT: PERRLA, EOMI, MMM, oropharynx clear  
 Lungs: bibasilar crackles, otherwise CTAB  
 CV: RRR, no murmurs  
 Abd: soft NTND  
 Ext: WWP, no edema  
 
EKG (___)- J point elevation in T2& V3 without reciprocal
changes.  

 Labs notable for:  
 1) CBC 10.4, Hb 16.5, plt 189  
 2) BNP 16  
 3) Trop-T <0.01 x2  
 4) BMP: Na 143, K 4.1, Cl 103, HCO3 21, BUN 17, Cr 1.3, AG 19  
 5) Coags: INR 1.2, PTT 150  
 6) U/A: negative bacteria/nitr, 2 WBC, 0 RBC  
 
Patient was given:  
 ___ 17:13 IV Heparin 900 units/hr  
 ___ 19:14 IV Heparin Stopped As Directed  
 ___ 20:20 IV Heparin Restarted 500 units/hr  
 
Vitals on transfer: ___ pain 97.6 72 173/94 23 98% RA  
 
On the floor: 

He reports he presented initially to ___, and from there went to
___.
He reports his chest pain started after he had gone to see his
sister. He reports he was sitting in his car, and all of a 
sudden
he felt like his heart was beating fast with some pressure. He
reports this pain radiated upward. 
He reports that he did nothing for the pain at that time, and
drove to ___. He reports the pain came and went a few more 
times.

He reports he was given some medications. 
He reports that this pain lasts about 20 minutes and then goes
away.

He reports that he is not currently having any pain or pressure
for at least a few hours. 

Denies dizziness, lightheadedness. Denies pain elsewhere except
for some pain in the back of his neck with extension which is
new. Denies blurry or double vision. Denies SOB. 
Denies f/c, nausea, vomiting, diarrhea, constipation. 
Denies recent infections. Denies DOE. Denies syncope. 

He reports remote history of MI (___) and catheterization with
stent placement at ___. 

REVIEW OF SYSTEMS:  
 Positive per HPI.  

 

###RESPONSE: NIDDM {Diabetes mellitus type 2}, smoking {Smoker}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, PCI {Percutaneous coronary intervention}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, Pain {Pain}, pain {Pain}, chest pain {Chest pain}, MI {Myocardial infarction}, Episodic
pain {Intermittent pain}, Pain epigastric {Epigastric pain}, radiates
episodically to R or L chest {Radiating chest pain}, diaphoresis {Excessive sweating}, nausea, vomiting {Nausea and vomiting}, chest pressure {Tight chest}, trop elevated {Troponin I above reference range}, AMA'd {Patient self-discharge against medical advice}, IV {Intravenous therapy}, heparin {Heparin therapy}, 140-160s systolic {Increased systolic arterial pressure}, Trop {Troponin measurement}, CP {Chest pain}, resolved {Problem resolved}, CP {Chest pain}, headache {Headache}, dizziness {Dizziness}, fever {Fever}, chills {Chill}, SOB {Dyspnea}, abdominal pain {Abdominal pain}, nausea vomiting {Nausea and vomiting}, dysuria {Dysuria}, vitals {Vital signs finding}, RA {Breathing room air}, Exam {Physical examination procedure}, Gen {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, oropharynx {Oropharyngeal structure}, Lungs {Examination of respiratory system}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, CTAB {Normal breath sounds}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, murmurs {Murmur}, Abd {Examination of abdomen}, soft {Abdomen soft}, NTND {Abdominal tenderness}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, edema {Edema}, EKG {Electrocardiographic procedure}, elevation in T2& V3 {Electrocardiogram abnormal}, CBC {Complete blood count}, BNP {Brain natriuretic peptide measurement}, Trop {Troponin measurement}, BMP {Serum metabolic panel}, BUN {Blood urea nitrogen measurement}, INR {Calculation of international normalized ratio}, U/A {Urinalysis}, negative {No abnormality detected}, bacteria {Bacteriuria}, WBC {White blood cell count}, RBC {Red blood cell count}, IV {Intravenous therapy}, Heparin {Heparin therapy}, IV {Intravenous therapy}, Heparin {Heparin therapy}, IV {Intravenous therapy}, Heparin {Heparin therapy}, Restarted {Restart of medication}, Vitals {Vital signs finding}, pain {Pain}, RA {Breathing room air}, chest pain {Chest pain}, sitting {Sitting position}, heart was beating fast {Tachycardia}, pressure {Tight chest}, pain radiated {Radiating pain}, pain {Pain}, pain came and went a few more 
times {Intermittent pain}, medications {Administration of drug or medicament}, pain {Pain}, pain {Pain}, pressure {Tight chest}, dizziness {Dizziness}, lightheadedness {Lightheadedness}, pain {Pain}, pain {Pain}, back of his neck {Cervical region back structure}, blurry {Blurring of visual image}, double vision {Diplopia}, SOB {Dyspnea}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, infections {Infectious disease}, DOE {Dyspnea on exertion}, syncope {Syncope}, MI {Myocardial infarction}, catheterization {Cardiac catheterization}, stent placement {Placement of stent in coronary artery}, REVIEW OF SYSTEMS {Review of systems}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
 1. CARDIAC RISK FACTORS  
- NIDDM
-Tobacco use

 2. CARDIAC HISTORY  
- CAD s/p MI (___)
- PCI in ___ at ___
 
 3. OTHER PAST MEDICAL HISTORY  
-None
 
Past surgical history: 
cyst removal (unknown date)
 

###RESPONSE: CARDIAC RISK FACTORS {Assessment for risk of cardiovascular disease}, NIDDM {Diabetes mellitus type 2}, Tobacco use {Tobacco user}, CARDIAC {Heart disease}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, PCI {Percutaneous coronary intervention}, cyst {Cyst}, removal {Aneurysmectomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.  
 

###RESPONSE: MI {Myocardial infarction}, arrhythmia {Cardiac arrhythmia}, cardiomyopathies {Cardiomyopathy}, sudden cardiac death {Sudden cardiac death}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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

Vital Signs:  2345 98.2 PO 150 / 84 L Sitting 95 18 94 Ra 
General: Patient is well appearing in no acute distress,
cooperative with exam.  Laying flat in bed without difficulty.
Eyes: no conjunctival injection or scleral icterus.
Head, ears, nose, and throat: Normocephalic.  Atraumatic. 
Ears grossly normal bilaterally. Nose grossly normal. MMM
Neck: Supple with full ROM.  Does experience pain with
hyperextension of neck, however full range of motion with no
stiffness.  Some muscular tenderness in bilateral cervical 
spine.
No bony deformities.  JVP not elevated.
Respiratory/chest: No respiratory distress, speaks in full
sentences.  Crackles noted in lung bases bilaterally, no wheezes
noted.
Cardiovascular: RRR no m/r/g, normal S1/S2
Gastrointestinal: Abdomen is soft.  No distension.  + bowel
sounds.  No tenderness. No rebound.
Back: No tenderness. No CVAT
Musculoskeletal: Normal muscle tone, moving all extremities.  No
calf tenderness.  No lower extremity edema.
Skin: Warm and well perfused.  No obvious rash.  No obvious
erythema/ecchymosis.
Neurologic: Alert and oriented x 3, no focal deficits.

Discharge

Vital Signs:  97.4 PO 148 / 83 83 20 99 Ra 
General: comfortable, lying in bed, flat, without difficulty
breathing

Neck: Supple w/ JVP not elevated.
Respiratory/chest: CTAB
Cardiovascular: RRR no m/r/g, normal S1/S2
Gastrointestinal: Abdomen is soft.  NTND, +BS
Extremities: no ___, WWP 
Neurologic: Alert and oriented x 3, moving all extremities with
purpose
 

###RESPONSE: Physical Exam {Physical examination procedure}, Vital Signs {Vital signs finding}, Sitting {Sitting position}, 4 Ra {Breathing room air}, General {General examination of patient}, well appearing {Well cared for appearance}, no acute {No abnormality detected}, distress {Distress}, cooperative {Cooperative mental state}, exam {Physical examination procedure}, Laying flat in bed {Lying in bed}, Eyes {Ophthalmic examination and evaluation}, conjunctival injection {Conjunctival hyperemia}, scleral icterus {Scleral icterus}, Head {Head structure}, ears {Ear structure}, nose {Nasal structure}, throat {Structure of anterior portion of neck}, Normocephalic {Normal head}, Atraumatic {No injuries apparent}, Ears grossly normal bilaterally {Ear normal}, Nose grossly normal {Nose normal}, MMM {Moist oral mucosa}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, full ROM {Normal range of cervical spine movement}, pain {Pain}, hyperextension {Hyperextension}, neck {Neck structure}, stiffness {Stiff neck}, tenderness {Tenderness}, bony deformities {Deformity of bone}, JVP not elevated {Normal jugular venous pressure}, Respiratory {Examination of respiratory system}, chest {Examination of respiratory system}, distress {Distress}, speaks {Does speak}, Crackles {Respiratory crackles}, bases {Structure of base of lung}, wheezes {Wheezing}, Cardiovascular {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, Gastrointestinal {Examination of digestive system}, soft {Abdomen soft}, distension {Swollen abdomen}, + bowel
sounds {Normal bowel sounds}, tenderness {Tenderness}, rebound {Rebound tenderness}, Back {Structure of back of trunk}, tenderness {Tenderness}, CV {Cardiovascular physical examination}, Musculoskeletal {Musculoskeletal system physical examination}, Normal muscle tone {Normal tone in skeletal muscle}, all extremities {All extremities}, tenderness {Tenderness}, edema {Edema}, Skin {Examination of skin}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, rash {Eruption of skin}, erythema {Erythema}, ecchymosis {Ecchymosis}, Neurologic {Neurological examination}, Alert {Mentally alert}, oriented {Orientated}, no focal deficits {Normal nervous system function}, Vital Signs {Vital signs finding}, Ra {Breathing room air}, General {General examination of patient}, comfortable {Comfortable appearance}, lying in bed {Lying in bed}, difficulty
breathing {Difficulty breathing}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, Respiratory {Examination of respiratory system}, chest {Examination of respiratory system}, CTAB {Normal breath sounds}, Cardiovascular {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, Gastrointestinal {Examination of digestive system}, soft {Abdomen soft}, ND {Swollen abdomen}, +BS {Normal bowel sounds}, Extremities {Examination of limb}, WWP {Normal tissue perfusion}, Neurologic {Neurological examination}, Alert {Mentally alert}, oriented {Orientated}, all extremities {All extremities}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Studies

Stress test ___

% MAX HRT RATE ACHIEVED:  89

IMPRESSION: Poor exercise tolerance with the test being 
terminated 
secondary to an exaggerated systolic blood pressure response 
with 
exercise. No anginal symptoms or ischemic ST segment changes. 
Echo 
report sent separately. 

TTE ___

The patient exercised for 4 minutes and 30 seconds according to 
a Modified ___ treadmill protocol ___ METS) reaching a peak 
heart rate of 142 bpm and a peak blood pressure of 256/80 mmHg. 
The test was stopped because of a hypertensive response. This 
level of exercise represents a poor exercise tolerance for age 
and gender. In response to stress, the ECG showed no ST-T wave 
changes (see exercise report for details). with an abnormal 
increase in blood pressure/hypertensive response and a normal 
heart rate response to stress. 
 .
 Resting images were acquired at a heart rate of 63 bpm and a 
blood pressure of 170/96 mmHg. These demonstrated normal 
regional and global left ventricular systolic function. Right 
ventricular free wall motion is normal. There is no pericardial 
effusion. Doppler demonstrated no aortic stenosis, aortic 
regurgitation or significant mitral regurgitation or resting 
LVOT gradient. .

 Echo images were acquired within 46 seconds after peak stress 
at heart rates of 131 - 108 bpm. These demonstrated appropriate 
augmentation of all left ventricular segments with slight 
decrease in cavity size. There was augmentation of right 
ventricular free wall motion. 

 IMPRESSION: Test stopped because of hypertension. No ECG or 2D 
echocardiographic evidence of inducible ischemia to achieved 
workload. Marked hypertensive response to exercise.

Admission labs

___ 04:47PM BLOOD WBC-10.4* RBC-5.76 Hgb-16.5 Hct-49.5 
MCV-86 MCH-28.6 MCHC-33.3 RDW-15.4 RDWSD-47.5* Plt ___
___ 04:47PM BLOOD Neuts-37 Bands-0 ___ Monos-8 Eos-1 
Baso-0 Atyps-3* ___ Myelos-0 AbsNeut-3.85 AbsLymp-5.62* 
AbsMono-0.83* AbsEos-0.10 AbsBaso-0.00*
___ 05:06PM BLOOD ___ PTT-150* ___
___ 04:47PM BLOOD Glucose-154* UreaN-17 Creat-1.3* Na-143 
K-4.1 Cl-103 HCO3-21* AnGap-19*
___ 05:57AM BLOOD ALT-20 AST-22 LD(LDH)-216 AlkPhos-77 
TotBili-0.5
___ 04:47PM BLOOD cTropnT-<0.01 proBNP-16
___ 05:06PM BLOOD proBNP-16
___ 05:06PM BLOOD cTropnT-<0.01
___ 12:10AM BLOOD cTropnT-<0.01 proBNP-19
___ 04:47PM BLOOD Calcium-9.3 Phos-2.9 Mg-2.2

Discharge

___ 06:40AM BLOOD ___ PTT-35.1 ___
___ 06:40AM BLOOD Glucose-129* UreaN-20 Creat-1.2 Na-143 
K-4.3 Cl-103 HCO3-23 AnGap-17
___ 06:40AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.___ with PMH of NIDDM, smoking, CAD s/p MI (___), PCI in ___ 
who presents as transfer from ___ with NSTEMI. 

ACUTE ISSUES: 
============= 
#NSTEMI
#CAD s/p PCI in ___
The patien's presentation in the setting of his significant 
coronary artery disease, status post PCI, and similarity of 
chest pain to prior episodes when he was diagnosed with MI, was 
consistent with an ischemic process underlying his chest pain. 
Elevated troponin at OSH prior to arrival was consistent with 
NSTEMI. Troponins at ___ were negative and EKGs after transfer 
negative for changes suggesting active ischemia. Given these 
negative findings, IV heparin was discontinued and the patient 
underwent a stress test for further risk stratification which 
was negative for anginal symptoms or ischemic ST segment changes 
in the setting of appropiate heart rate response to exercise. 
Given the stress test results, the decision was made to defer 
cardiac catheterization at this point. Aspirin and high dose 
atorvastatin were continued. In addition, the patient was 
started on metoprolol to optimize anti-anginal treatment and 
lisinopril for blood pressure management.

___
Cr 1.3 on admission, baseline unknown; improved to 1.2 in ED. 
Creatinine on discharge stable at 1.2. Potassium stable at 4.3. 
Please obtain BMP on follow up with one to two weeks to monitor 
renal function and potassium

CHRONIC ISSUES: 
=============== 
#Hypertension
The patient had been on lisinopril as an outpatient in the past 
(but wasn't taking any his medications for several months prior 
to admission). No anti-hypertensives were given on admission in 
setting of initial ___ and potential catheterization. Systolic 
blood pressures were subsequently between 150-160 and the 
patient was started on Lisinopril 10mg dialy.
- Follow-up as an outpatient with uptitration of 
anti-hypertensives as tolerated is recommended. 

#Non-insulin dependent diabetes
A1c 6.7% on labs ___ at ___. Patient does not report any
medications to treat this issue at this time. Not started on 
Metformin as he was newly started on Lisinopril with possible 
worsening of his renal function 
- Metformin should be started as an outpatient if his renal 
function allows

TRANSITIONAL ISSUES
===================
[] Discharge Creatinine 1.2; potassium on discharge 4.3 (both 
stable) [] Please repeat BMP within two weeks of discharge to 
ensure resolution ___ and to monitor potassium (newly started 
on Lisinopril)
[] Newly started on Lisinopril 20mg daily - follow-up blood 
pressure, consider uptitration of lisinopril as tolerated by 
renal function and electrolytes
[] Patient also started on Metoprolol succinate 25mg, aspirin 
81mg daily and atorvastatin 80mg daily during this admission; 
please continue this medications in the outpatient setting
[] Follow-up on blood sugar and HBA1c, consider initiating 
metformin going forward pending renal function

#CODE STATUS: FULL, confirmed 
#CONTACT: Silnola (sister) ___ 
 

###RESPONSE: Stress test {Electrocardiogram with exercise test}, HRT RATE {Finding of heart rate}, Poor exercise tolerance {Impaired exercise tolerance}, exaggerated systolic blood pressure {Increased systolic arterial pressure}, exercise {Exercises}, anginal symptoms {Angina}, ischemic {Ischemia}, ST segment changes {Electrocardiographic ST segment changes}, Echo {Echocardiography}, TTE {Transthoracic echocardiography}, exercised {Exercises}, heart rate {Finding of heart rate}, peak blood pressure {Increased systolic arterial pressure}, hypertensive {Increased systolic arterial pressure}, exercise {Exercises}, poor exercise tolerance {Impaired exercise tolerance}, stress {Electrocardiogram with exercise test}, ECG {Electrocardiographic procedure}, no ST-T wave 
changes {Electrocardiogram normal}, exercise {Electrocardiogram with exercise test}, increase in blood pressure {Increased systolic arterial pressure}, hypertensive {Increased systolic arterial pressure}, normal 
heart rate {Normal heart rate}, stress {Electrocardiogram with exercise test}, heart rate {Finding of heart rate}, blood pressure {Blood pressure finding}, normal 
regional and global left ventricular systolic function {Echocardiogram shows normal left ventricular function}, Right 
ventricular {Right cardiac ventricular structure}, free wall motion is normal {Normal ventricular wall motion}, pericardial 
effusion {Pericardial effusion}, Doppler {Doppler ultrasound}, aortic stenosis {Aortic valve stenosis}, aortic 
regurgitation {Aortic valve regurgitation}, mitral regurgitation {Mitral valve regurgitation}, Echo {Echocardiography}, stress {Physical stress}, heart rates {Finding of heart rate}, left ventricular segments {Structure of segment of left cardiac ventricle}, decrease {Decreased size}, cavity {Structure of cavity of left cardiac ventricle}, right 
ventricular {Right cardiac ventricular structure}, free wall motion {Normal ventricular wall motion}, hypertension {Hypertensive disorder, systemic arterial}, ECG {Electrocardiographic procedure}, echocardiographic {Echocardiography}, ischemia {Ischemia}, hypertensive {Hypertensive disorder, systemic arterial}, exercise {Exercises}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Serum total lactate dehydrogenase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, cTropnT {Troponin T cardiac measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, 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}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, NIDDM {Diabetes mellitus type 2}, smoking {Smoker}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, PCI {Percutaneous coronary intervention}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, CAD {Coronary arteriosclerosis}, PCI {Percutaneous coronary intervention}, disease {Disease}, status post {Postoperative state}, PCI {Percutaneous coronary intervention}, chest pain {Chest pain}, MI {Myocardial infarction}, ischemic {Ischemia}, chest pain {Chest pain}, Elevated troponin {Troponin I above reference range}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, Troponins {Troponin measurement}, negative {No abnormality detected}, EKGs {Electrocardiographic procedure}, negative {No abnormality detected}, ischemia {Ischemia}, negative {No abnormality detected}, IV {Intravenous therapy}, heparin {Heparin therapy}, discontinued {Recommendation to stop drug treatment}, stress test {Electrocardiogram with exercise test}, negative {No abnormality detected}, anginal symptoms {Angina}, ST segment changes {Finding of electrocardiogram ST segment}, heart rate {Finding of heart rate}, exercise {Electrocardiogram with exercise test}, stress test {Electrocardiogram with exercise test}, cardiac catheterization {Cardiac catheterization}, Aspirin {Administration of aspirin}, anginal {Angina}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, blood pressure management {Angiotensin converting enzyme inhibitor therapy}, Cr {Creatinine measurement}, baseline {Baseline state}, improved {Patient's condition improved}, Creatinine {Creatinine measurement}, stable {Patient's condition stable}, Potassium {Potassium measurement}, stable {Patient's condition stable}, BMP {Serum metabolic panel}, monitor 
renal function {Renal function monitoring}, potassium {Potassium measurement}, Hypertension {Hypertensive disorder, systemic arterial}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, wasn't taking any his medications {Does not take medication}, anti-hypertensives {On treatment for hypertension}, catheterization {Cardiac catheterization}, Systolic 
blood pressures were subsequently between 150-160 {Increased systolic arterial pressure}, Lisinopril {Angiotensin converting enzyme inhibitor therapy}, uptitration {Increasing dosage of medication}, anti-hypertensives {On treatment for hypertension}, Non-insulin dependent diabetes {Diabetes mellitus type 2}, does not report any
medications to treat {Does not take medication}, Lisinopril {Angiotensin converting enzyme inhibitor therapy}, worsening of his renal function {Decreased renal function}, if his renal 
function allows {Renal function monitoring}, Creatinine {Creatinine measurement}, potassium {Potassium measurement}, stable {Patient's condition stable}, BMP {Serum metabolic panel}, Lisinopril {Angiotensin converting enzyme inhibitor therapy}, Lisinopril {Angiotensin converting enzyme inhibitor therapy}, blood 
pressure {Blood pressure monitoring}, r uptitration {Increasing dosage of medication}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, renal function {Renal function monitoring}, electrolytes {Electrolyte monitoring}, aspirin {Administration of aspirin}, continue this medications {Recommendation to continue with drug treatment}, blood sugar {Blood sugar management}, pending renal function {Renal function monitoring}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
None
 
Discharge Medications:
1.  Aspirin 81 mg PO DAILY 
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth 
daily Disp #*30 Tablet Refills:*0 
2.  Atorvastatin 80 mg PO QPM 
RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet 
Refills:*0 
3.  Lisinopril 20 mg PO DAILY 
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet 
Refills:*0 
4.  Metoprolol Succinate XL 25 mg PO DAILY 
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp 
#*30 Tablet Refills:*0 

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary diagnoses:
#Unstable angina
#CAD s/p PCI in ___
___

Secondary diagnoses:
#Hypertension
#Non-insulin dependent diabetes mellitus

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Unstable angina {Preinfarction syndrome}, CAD {Coronary arteriosclerosis}, PCI {Percutaneous coronary intervention}, Hypertension {Hypertensive disorder, systemic arterial}, Non-insulin dependent diabetes mellitus {Diabetes mellitus type 2}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr ___,

It was a pleasure taking care of you at ___!

Why was I admitted to the hospital?
- you had two episodes of chest pain that were similar in 
character to the pain you had in the past when you had a heart 
attack
- the current episodes were likely caused by a minor heart 
attack. You underwent a test that showed you were able to 
exercise appropriately. Therefore, you did not require any 
intervention at this point.
- You were started on medications to help prevent future 
episodes of chest pain

What should I do after discharge?
- Please take all the medications as prescribed (your were newly 
started on aspirin, metoprolol, lisinopril, and atorvastatin)
- Please follow up with your new PCP as below for further 
management of your blood pressure
- Please see an MD or go to the emergency department in case of 
recurrent or new symptoms

All the best,

Your ___ care team
 

###RESPONSE: chest pain {Chest pain}, pain {Pain}, heart 
attack {Myocardial infarction}, heart 
attack {Myocardial infarction}, exercise {Exercises}, medications {Administration of drug or medicament}, chest pain {Chest pain}, medications {Patient medication education}, aspirin {Administration of aspirin}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, PCP {Primary care management}, management of your blood pressure {Blood pressure monitoring}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
Metastatic Renal Cell Cancer
 
Major Surgical or Invasive Procedure:
Central Line placmeent and removal

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Metastatic Renal Cell Cancer {Metastatic renal cell carcinoma}, Central Line placmeent {Insertion of peripherally inserted central catheter}, removal {Removal of central venous line}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 ___ year old man with a history of T2 renal cell
carcinoma, s/p left nephrectomy on ___, who was recently
found to have pulmonary metastases.

In ___, he noted left back pain, which he thought was
activity-related after working out.  A CT scan showed a 7 cm 
left
kidney mass. Additional imaging showed no evidence of metastatic
disease at the time and a nephrectomy was done on ___ which
revealed clear cell renal cell carcinoma.  A follow-up CT scan
done in ___ showed right-sided pulmonary nodules, the largest 
of
which was 1 cm in size.  Repeat CT scan down ___ revealed 5
masses in the right lung, the largest of which was > 3 cm in
size. A PET scan done ___ showed these pulmonary masses as
well as a mass in the right tonsillar tissue measuring 1.8 cm in
size with an SVU of 6.2 and nonspecific uptake in the left
parotid.  He was seen by ENT on ___, who recommended
observation and follow-up in 1 month. A CT-guided biopsy of the
right lung mass was obtained on ___ and showed metastatic
renal cell carcinoma. He passed all screenign tests and is here 
to begin cycle 1 week 1 of HD Il-2. He feels excellent and ROS 
negative. 
 

###RESPONSE: renal cell
carcinoma {Renal cell carcinoma}, left nephrectomy {Excision of left kidney}, pulmonary metastases {Metastatic malignant neoplasm to lung}, back pain {Backache}, CT scan {Computed tomography}, left {Left kidney structure}, kidney mass {Renal mass}, imaging {Imaging}, no evidence {No abnormality detected}, metastatic
disease {Metastatic malignant neoplasm}, nephrectomy {Total excision of left kidney}, clear cell renal cell carcinoma {Clear cell renal cell carcinoma}, CT scan {Computed tomography}, right-sided {Right lung structure}, pulmonary nodules {Nodule of lung}, CT scan {Computed tomography}, masses {Lung mass}, right lung {Right lung structure}, PET scan {Positron emission tomography}, pulmonary masses {Nodule of lung}, mass {Mass of body structure}, right tonsillar tissue {Right faucial tonsil structure}, left
parotid {Structure of left parotid gland}, CT-guided biopsy {Computed tomography guided biopsy}, right {Right lung structure}, metastatic
renal cell carcinoma {Metastatic renal cell carcinoma}, HD {Hemodialysis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
alcohol abuse, in AA
anxiety and depression
 

###RESPONSE: alcohol abuse {Alcohol abuse}, anxiety {Anxiety}, depression {Depressive disorder}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
He reports a mother with pancreatic cancer.  His father had
diabetes and hypertension.  He has 1 brother and 1 sister who 
are
healthy.

 

###RESPONSE: pancreatic cancer {Malignant tumor of pancreas}, diabetes {Diabetes mellitus}, hypertension {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
GEN: Well appearing gentleman in no acute distress. 
Ht: 67 inches             Wt: 168.3 lbs
VS: ___   O2 sat 99%RA
HEENT: clear, atraumatic, anicteric.
CV: RRR without MGR
RESP: CTA, no wheezes or rhonchi
ABD: Soft, nontender BS positive
M/S: ROM intact
Lymph: No lympadenopathy in the bilateral axillary, 
supraclavicular, ingunal, cervical nodes. 
Neuro: No focal deficit on exam
 

###RESPONSE: GEN {General examination of patient}, Well appearing {Well cared for appearance}, distress {Distress}, VS {Vital signs finding}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, HEENT {Physical examination procedure}, clear {Normal breath sounds}, atraumatic {No injuries apparent}, anicteric {White sclera}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, RESP {Examination of respiratory system}, CTA {Normal breath sounds}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABD {Examination of abdomen}, Soft {Abdomen soft}, nontender {Abdominal tenderness}, BS {Normal bowel sounds}, ROM {Range of motion activity}, intact {Normal sensation}, Lymph {Lymphatic system physical examination}, lympadenopathy {Lymphadenopathy}, axillary {Axillary lymph node structure}, supraclavicular {Structure of supraclavicular lymph node}, ingunal {Inguinal lymph node structure}, cervical nodes {Cervical lymph node structure}, Neuro {Neurological examination}, No focal deficit {Normal nervous system function}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 11:55AM   GLUCOSE-93 UREA N-12 CREAT-1.1 SODIUM-139 
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-31 ANION GAP-9
___ 11:55AM   estGFR-Using this
___ 11:55AM   ALT(SGPT)-13 AST(SGOT)-16 CK(CPK)-147 TOT 
BILI-0.3
___ 11:55AM   ALBUMIN-4.1 CALCIUM-9.3 PHOSPHATE-3.4 
MAGNESIUM-1.8
___ 11:55AM   WBC-6.4 RBC-4.06* HGB-12.6* HCT-37.8* MCV-93 
MCH-31.0 MCHC-33.3 RDW-12.8
___ 11:55AM   PLT COUNT-206
___ 11:55AM   ___ PTT-29.7 ___
___ 04:00AM BLOOD WBC-4.3 RBC-4.14* Hgb-12.5* Hct-36.8* 
MCV-89 MCH-30.3 MCHC-34.1 RDW-12.7 Plt Ct-98*
___ 04:00AM BLOOD Plt Ct-98*
___ 04:00AM BLOOD Glucose-119* UreaN-15 Creat-1.2 Na-137 
K-4.5 Cl-106 HCO3-19* AnGap-17
___ 04:00AM BLOOD ALT-50* AST-44* CK(CPK)-40* TotBili-1.7*
___ 04:00AM BLOOD Albumin-2.8* Calcium-7.7* Phos-2.7 
Mg-1.5*
___ 04:03AM BLOOD WBC-7.6# RBC-3.88* Hgb-12.0* Hct-34.2* 
MCV-88 MCH-30.9 MCHC-35.0 RDW-12.7 Plt Ct-91*
___ 04:03AM BLOOD Glucose-104* UreaN-16 Creat-1.2 Na-135 
K-4.3 Cl-104 HCO3-24 AnGap-11
___ 12:00PM BLOOD CK(CPK)-38*
___ 04:03AM BLOOD ALT-61* AST-46* CK(CPK)-47 TotBili-1.6*
___ 04:03AM BLOOD Albumin-2.5* Calcium-7.9* Phos-2.6* 
Mg-1.9
 

###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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, TOT 
BILI {Bilirubin, total measurement}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, 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 for HD IL-2 cycle 1 week 1.
Upon arrival to ___, informed consent was obtained for HD 
IL-2. He then underwent central line placement with chest X-ray 
confirmation of placement. 
He received HD IL-2, 45.7 Million Units IV Q8H. He recieved 
total of ___ doses this week. His course was complicated by 
chills, rigors, fever, diarrhea, and pruritus. Of all, chills 
and rigors were difficult to control given he refused all 
controlled medications such as lorazepam and demerol due to his 
past medical history of ETOH ause and being in AA. He also had 
thrombocytopenia of PLT 98k. On day 5,  with increased fatigue, 
malaise, rigors after each dose, he refused fruther doses and 
this was agreed by our team as well. 
His central line was removed on day 6 and was discharged to home 
in stable condition on ___. 
 

###RESPONSE: HD {Hemodialysis}, informed consent {Informed consent for procedure}, HD {Hemodialysis}, central line placement {Insertion of peripherally inserted central catheter}, chest X-ray {Plain chest X-ray}, placement {Implantation procedure}, HD {Hemodialysis}, IV {Administration of drug or medicament via intravenous route}, chills {Chill}, rigors {Rigor}, fever {Fever}, diarrhea {Diarrhea}, pruritus {Itching of skin}, chills {Chill}, rigors {Rigor}, ETOH ause {Alcohol abuse}, thrombocytopenia {Thrombocytopenic disorder}, fatigue {Fatigue}, malaise {Malaise}, rigors {Rigor}, central line was removed {Removal of central venous line}, stable condition {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
fluoxetin 40 mg 2 tabs a day
 
Discharge Medications:
1. diphenhydramine HCl 25 mg Capsule Sig: ___ Capsules PO Q6H 
(every 6 hours) as needed for pruritis.
Disp:*30 Capsule(s)* Refills:*0*
2. cephalexin 500 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day) for 5 days.
Disp:*10 Capsule(s)* Refills:*0*
3. oral wound care products     Gel in Packet Sig: Fifteen (15) 
ML Mucous membrane TID (3 times a day) as needed for mucositis.
Disp:*500 ML(s)* Refills:*0*
4. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, 
Rapid Dissolve PO every eight (8) hours.
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2*
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 
5 days.
Disp:*5 Tablet(s)* Refills:*0*
6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical 
QID (4 times a day) as needed for pruritus.
Disp:*1 bottle* Refills:*3*

 

###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:
Metastatic Renal Cell CA

 
Discharge Condition:
Mental Status: Clear and coherent.

 

###RESPONSE: Metastatic Renal Cell CA {Metastatic renal cell carcinoma}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Please call ___, RN for any issues after discharge.
___
 

###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: 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: 
Lisinopril / alcohol
 
Attending: ___
 
Chief Complaint:
atrial fibrillation with RVR
 
Major Surgical or Invasive Procedure:
none
 

###RESPONSE: Lisinopril {Non-allergic hypersensitivity to lisinopril}, alcohol {Allergy to ethyl alcohol}, atrial fibrillation with RVR {Atrial fibrillation with rapid ventricular response}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ presents with tachycardia. Patient with recent admission for 
atrial fibrillation with RVR at that time underwent 
cardioversion and was started on low-dose 
metoprolol. Now with returned for tachycardia to the 150s. 
Patient was reportedly feeling weak at home and noted to be 
orthostatic. She was additionally noted to have highly variable 
heart rate with irregular heart rhythm. At time of evaluation 
she denies any acute complaints however is noted to be 
tachycardic from the 120s to 150s. Patient states she has been 
taking her metoprolol as prescribed.
 
In the ED, initial vitals were 97.8 74 128/50 16 97% ra. Labs 
significant for unremarkable CBC and CHem7 with the exception of 
BUN 21, glucose 127, phos 2.0, Lactate: 1.9. UA unremarkable. 
Urine and blood cultures sent. CXR showed cardiomegaly and small 
bilateral effusions. No superimposed acute cardiopulmonary 
process. Patient was evaluated by cardiology in the ED and 
admitted for AF with RVR, for rate control with beta blocker 
uptitration. VS prior to transfer include 98.8 113 122/78 20 98% 
RA.

On the floor, patient is comfortable without any recent chest 
pain, palpitations, shortness of breath, lightheadedness with 
walking to the bathroom or peripheral edema. She states she 
cannot feel that her heart rate is fast.
 
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. She denies exertional buttock or calf pain. All of the 
other review of systems were negative.  
 
Cardiac review of systems is notable for absence of chest pain, 
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, 
ankle edema, palpitations, syncope or presyncope.  

 

###RESPONSE: tachycardia {Tachycardia}, atrial fibrillation with RVR {Atrial fibrillation with rapid ventricular response}, cardioversion {Cardioversion}, tachycardia {Tachycardia}, feeling weak {Asthenia}, orthostatic {Orthostatic body position}, variable 
heart rate {Alteration in heart rate}, irregular heart rhythm {Irregular heart beat}, evaluation {Evaluation procedure}, tachycardic {Tachycardia}, vitals {Vital signs finding}, ra {Breathing room air}, unremarkable {No abnormality detected}, CBC {Complete blood count}, BUN {Blood urea nitrogen measurement}, Lactate {Lactic acid measurement}, UA unremarkable {Urinalysis = no abnormality}, Urine {Urine culture}, blood cultures {Blood culture}, CXR {Plain chest X-ray}, cardiomegaly {Cardiomegaly}, small {Symptom mild}, bilateral effusions {Bilateral pleural effusion}, cardiology {Cardiology service}, AF with RVR {Atrial fibrillation with rapid ventricular response}, uptitration {Increasing dosage of medication}, VS {Vital signs finding}, RA {Breathing room air}, chest 
pain {Chest pain}, palpitations {Palpitations}, shortness of breath {Dyspnea}, lightheadedness {Lightheadedness}, walking {Does walk}, peripheral edema {Peripheral edema}, heart rate is fast {Tachycardia}, 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}, buttock {Pain in buttock}, calf pain {Pain in calf}, review of systems {Review of systems}, negative {No abnormality detected}, Cardiac {Cardiovascular physical examination}, review of systems {Review of systems}, chest pain {Chest pain}, dyspnea on exertion {Dyspnea on exertion}, paroxysmal nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, ankle edema {Ankle edema}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1. CARDIAC RISK FACTORS: + Hypertension  
2. CARDIAC HISTORY: afib
3. OTHER PAST MEDICAL HISTORY:                             
CATARACT                                                        
DEGENERATIVE JOINT DISEASE                                       

OSTEOPOROSIS                                                    
PELVIC FRACTURE                                                 
TINNITUS                                                        
RETINAL VASCULAR OCCLUSION                                      
H/O COLLES' FRACTURE                                            
H/O HEMATURIA S/P CYSTOSCOPY                                 
H/O PROLAPSE VAGINAL WALL W/O UTERINE PROLAPSE 
H/O SYNCOPE   

 

###RESPONSE: CARDIAC RISK FACTORS {Assessment for risk of cardiovascular disease}, Hypertension {Hypertensive disorder, systemic arterial}, CARDIAC {Heart structure}, afib {Atrial fibrillation}, CATARACT {Cataract}, DEGENERATIVE JOINT DISEASE {Osteoarthritis}, OSTEOPOROSIS {Osteoporosis}, PELVIC FRACTURE {Fracture of pelvis}, TINNITUS {Tinnitus}, RETINAL VASCULAR OCCLUSION {Retinal vascular occlusion}, COLLES' FRACTURE {Colles' fracture}, HEMATURIA {Blood in urine}, CYSTOSCOPY {Transurethral cystoscopy}, PROLAPSE VAGINAL WALL {Vaginal wall prolapse}, UTERINE PROLAPSE {Uterine prolapse}, SYNCOPE {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: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
non-contributory to this admission
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
On Admission:
VS: 98.1 123/71 120s-140s 16 93%RA wt 38kg (discharged at 
36.4kg) 
GENERAL: awake and alert, in NAD, pleasant
HEENT: AT/NC, + cataracts, anicteric sclera, good dentition  
NECK: JVP not elevated    
CARDIAC: irreg irreg, no Murmurs appreciated  
LUNG: bibasilar crackles  
ABDOMEN: soft, non-tender, non-distended   
EXT: warm and well-perfused, no edema 
NEURO: alert, neuro exam grossly non-focal 

On Discharge:
Vitals: 97.5  104/76(80-123/46-73)  97(68-136)  16  92%RA 
weight: 38.1kg from 38kg at admission (last discharge at 36.4kg)
GENERAL: awake and alert, in NAD  
HEENT: AT/NC, HOH, anicteric sclera, good dentition  
NECK: JVP of 6  
CARDIAC: RRR, no Murmurs appreciated  
LUNG: bibasilar crackles, no wheezing  
ABDOMEN: soft, non-tender, non-distended  
EXT: warm and well-perfused, no edema.  
NEURO: alert, neuro exam grossly non-focal  
 

###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, wt {Weight finding}, GENERAL {General examination of patient}, awake {Awake}, alert {Mentally alert}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, cataracts {Cataract}, anicteric sclera {White sclera}, good dentition {Normal dentition}, NECK {Physical examination procedure}, JVP not elevated {Normal jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, irreg irreg {Pulse irregularly irregular}, Murmurs {Heart murmur}, LUNG {Examination of respiratory system}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, ABDOMEN {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, EXT {Examination of limb}, warm {Warm skin}, well-perfused {Normal tissue perfusion}, edema {Edema}, NEURO {Neurological examination}, alert {Mentally alert}, neuro exam {Neurological examination}, Vitals {Vital signs finding}, RA {Breathing room air}, weight {Weight finding}, GENERAL {General examination of patient}, awake {Awake}, alert {Mentally alert}, NAD {No abnormality detected}, HOH {Hearing loss}, anicteric sclera {White sclera}, good dentition {Normal dentition}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, Murmurs {Heart murmur}, LUNG {Examination of respiratory system}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, wheezing {Wheezing}, ABDOMEN {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, EXT {Examination of limb}, warm {Warm skin}, well-perfused {Normal tissue perfusion}, edema {Edema}, NEURO {Neurological examination}, alert {Mentally alert}, neuro exam {Neurological examination}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
On Admission:
___ 01:49PM URINE  COLOR-Yellow APPEAR-Clear SP ___
___ 01:49PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-30 
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 
LEUK-TR
___ 01:49PM URINE  RBC-30* WBC-4 BACTERIA-NONE YEAST-NONE 
EPI-6
___ 01:49PM URINE  MUCOUS-FEW
___ 01:33PM   LACTATE-1.9
___ 01:15PM   GLUCOSE-127* UREA N-21* CREAT-0.6 SODIUM-138 
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
___ 01:15PM   CALCIUM-8.6 PHOSPHATE-2.0*# MAGNESIUM-2.2
___ 01:15PM   WBC-5.9 RBC-4.02* HGB-11.5* HCT-36.6 MCV-91 
MCH-28.7 MCHC-31.5 RDW-15.7*
___ 01:15PM   NEUTS-64.9 ___ MONOS-10.6 EOS-1.2 
BASOS-1.4
___ 01:15PM   PLT COUNT-324

Other Pertinent Labs:
___ 06:10AM BLOOD ___ PTT-36.7* ___
___ 06:10AM BLOOD ALT-37 AST-20 AlkPhos-72 TotBili-0.4

On Dishcarge:
___ 06:20AM BLOOD WBC-3.9* RBC-3.64* Hgb-10.7* Hct-34.0* 
MCV-93 MCH-29.5 MCHC-31.6 RDW-15.6* Plt ___
___ 06:20AM BLOOD Glucose-79 UreaN-20 Creat-0.6 Na-136 
K-4.7 Cl-103 HCO3-28 AnGap-10
___ 06:20AM BLOOD Mg-2.1

Imaging:
CXR ___:
Cardiomegaly and small bilateral effusions.  No superimposed 
acute cardiopulmonary process. 

EKG:  ___:
afib with RVR, rate 127, normal axis, nonspecific ST changes 
laterally and Q waves w/TWI in III, aVF similar to last 
admission

 

###RESPONSE: URINE {Evaluation of urine specimen}, COLOR {Color finding}, Clear {Urine looks clear}, PROTEIN {Measurement of protein in urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, URINE {Evaluation of urine specimen}, RBC {Red blood cell count}, WBC {White blood cell count}, AST {Aspartate aminotransferase measurement}, URINE {Evaluation of urine specimen}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, CALCIUM {Blood calcium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, PTT {Partial thromboplastin time, activated}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Mg {Blood magnesium measurement}, CXR {Plain chest X-ray}, Cardiomegaly {Cardiomegaly}, bilateral effusions {Bilateral pleural effusion}, afib with RVR {Atrial fibrillation with rapid ventricular response}, normal {No abnormality detected}, axis {Electrocardiographic axis finding}, ST changes {Electrocardiographic ST segment changes}, TWI {Inverted T wave}, III {Lead III}, aVF {Finding present on electrocardiogram}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ with history of hypertension, presented with recurrent 
atrial fibrillation with RVR s/p cardioversion on ___.
 
# Atrial fibrillation with rapid ventricular response: CHADS2=3 
(HTN, CHF, Age). Underwent workup for etiology of new atrial 
fibrillation at last admission. She returned with rapid atrial 
fibrillation but no signs of systolic heart failure 
exacerbation. Rate control strategy was favored given paroxysmal 
nature of her atrial fibrillation despite being euvolemic as 
volume overload was initially felt to be a contributing factor. 
She was rate controlled on increased dose of metoprolol and her 
symptoms of fatigue resolved. She also continued Rivaroxaban for 
stroke prevention. 
   
# Chronic Systolic Congestive Heart Failure Exacerbation: Has 
dilated cardiomyopathy. Appears euvolemic on exam with flat JVP. 
She has crackles but no dyspnea or other signs of volume 
overload on exam. She was discharged on low dose of lasix to 
take outpatient to prevent volume overload as her JVP had 
increased slightly over the course of the hospitalization 
(although remains <10) and her weight was increased from her 
prior discharge weight. She is now lacking her atrial kick to 
aid with forward flow. She was instructed to monitor her weights 
outpatient. 

# Leg Pain: Felt to be from trochanteric bursitis outpatient. No 
acute fracture was seen on imaging. DVT was ruled out with 
ultrasound last admission. Continued Tylenol for pain control 
and physical therapy was consulted.

# Hypertension: Her home olmesartan and Felodipine continued to 
be held from last admission. Metoprolol was given per above. She 
should restart her ___ outpatient as she has systolic heart 
failure if her blood pressure permits. 
  

HOSPITAL ISSUES:   
- Code: Full Code  
- should have BP check at follow up outpatient visit and restart 
___ if BP allows
- CTA last hospitalization showed incidental finding of 
narrowing of the left 
mainstem bronchus with soft tissue fullness posteriorly and 
distal esophageal thickening. This can be further worked up if 
clinically indicated.

 

###RESPONSE: hypertension {Hypertensive disorder, systemic arterial}, recurrent {Recurrent disease}, atrial fibrillation with RVR {Atrial fibrillation with rapid ventricular response}, cardioversion {Cardioversion}, Atrial fibrillation with rapid ventricular response {Atrial fibrillation with rapid ventricular response}, HTN {Hypertensive disorder, systemic arterial}, CHF {Congestive heart failure}, workup {Evaluation procedure}, atrial 
fibrillation {Atrial fibrillation}, rapid atrial 
fibrillation {Rapid atrial fibrillation}, signs {Sign}, systolic heart failure {Systolic heart failure}, atrial fibrillation {Atrial fibrillation}, euvolemic {Normal blood volume}, volume overload {Hypervolemia}, fatigue {Fatigue}, resolved {Problem resolved}, Rivaroxaban {Administration of prophylactic anticoagulant}, stroke prevention {Stroke prevention}, Chronic {Chronic congestive heart failure}, Systolic Congestive Heart Failure {Congestive heart failure due to left ventricular systolic dysfunction}, dilated cardiomyopathy {Congestive cardiomyopathy}, euvolemic {Normal blood volume}, exam {Physical examination procedure}, flat JVP {Normal jugular venous pressure}, crackles {Respiratory crackles}, dyspnea {Dyspnea}, signs {Sign}, volume 
overload {Hypervolemia}, exam {Physical examination procedure}, lasix {Diuretic therapy}, volume overload {Hypervolemia}, JVP had 
increased {Raised jugular venous pressure}, weight was increased {Weight increased}, weight {Weight finding}, atrial {Atrial structure}, monitor her weights {Weight monitoring}, Leg Pain {Pain in lower limb}, trochanteric bursitis {Greater trochanteric pain syndrome}, No 
acute {No abnormality detected}, fracture {Fracture}, imaging {Imaging}, DVT {Deep venous thrombosis}, ultrasound {Ultrasonography}, Tylenol {Administration of analgesic}, pain control {Pain control}, physical therapy {Physical therapy procedure}, Hypertension {Hypertensive disorder, systemic arterial}, restart {Restart of medication}, systolic heart 
failure {Systolic heart failure}, blood pressure {Blood pressure monitoring}, BP check {Blood pressure monitoring}, restart {Restart of medication}, CTA {Computed tomography angiography with contrast}, narrowing {Narrowing}, left {Structure of left bronchus}, bronchus {Bronchial structure}, soft tissue {Structure of soft tissue}, distal esophageal {Structure of lower third of esophagus}, thickening {Increased thickness}, worked up {Evaluation procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1250 mg PO DAILY 
2. Metoprolol Succinate XL 25 mg PO DAILY 
3. Rivaroxaban 15 mg PO DAILY 
4. alendronate 70 mg oral weekly 
5. Estrogens Conjugated 1 gm VG PRN daily 

 
Discharge Medications:
1. Calcium Carbonate 1250 mg PO DAILY 
2. Metoprolol Succinate XL 75 mg PO BID 
RX *metoprolol succinate 25 mg 3 tablet extended release 24 
hr(s) by mouth twice a day Disp #*180 Tablet Refills:*0
3. Rivaroxaban 15 mg PO DAILY 
4. alendronate 70 mg oral weekly 
5. Estrogens Conjugated 1 gm VG PRN daily 
6. Furosemide 10 mg PO DAILY 
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth once a 
day Disp #*20 Tablet Refills:*0

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
atrial fibrillation with rapid ventricular response
chronic systolic heart failure
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 

###RESPONSE: Home {Home health aide service management}, With Service {Home health aide service management}, atrial fibrillation with rapid ventricular response {Atrial fibrillation with rapid ventricular response}, chronic systolic heart failure {Chronic systolic heart failure}, Mental Status {Neurological mental status determination}, Clear {No abnormality detected}, 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:
Dear Ms. ___,

It was a pleasure seeing you again during your recent 
hospitalization at ___. You were admitted to the hospital 
again because your heart rhythm returned into atrial 
fibrillation and was beating very fast. We increased your dose 
of metoprolol and now your heart rate is better controlled. 

Please take your medications as prescribed and go to your clinic 
appointments shown below. Remember to weigh yourself every 
morning and call your doctor if your weight goes up more than 3 
lbs.
 

###RESPONSE: heart rhythm {Finding of heart rhythm}, atrial 
fibrillation {Atrial fibrillation}, beating very fast {Tachycardia}, heart rate {Finding of heart rate}, better controlled {Disease condition determination, well controlled}, take your medications as prescribed {Patient medication education}, clinic {Outpatient care management}, weigh yourself every 
morning {Weight monitoring}, weight goes up {Weight increased}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Penicillins / Ace Inhibitors / Aspirin / Rifaximin / Tramadol / 
Plavix / morphine / Statins-Hmg-Coa Reductase Inhibitors / 
Effexor XR
 
Attending: ___.
 
Chief Complaint:
Chest pain
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Penicillins {Allergy to penicillin}, Ace Inhibitors {Allergy to acetylcholinesterase inhibitor}, Aspirin {Allergy to aspirin}, Tramadol {Allergy to tramadol}, morphine {Allergy to morphine}, Statins-Hmg-Coa Reductase Inhibitors {Allergy to 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor}, Chest pain {Chest pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Patient is a ___ year old female, history of CAD (MI ___ s/p
PCIx2 to ramus intermedius, TTE ___, pAF (on Coumadin),
moderate AS, HTN, anemia, dementia, GERD, and hx breast cancer
(s/p R mastectomy with XRT) who presents with chest pain. 
Patient
reports that symptoms began 2 or 3 days ago. She reports 8 out 
of
10 substernal chest ""pressure."" Mild dyspnea with cough. No
hemoptysis. Denies fever, chills, nausea, vomiting, change in
bowel or bladder function, change in vision or hearing, 
bruising,
adenopathy, new rash or lesion.

She is somewhat difficult to get a clear history from w/r/t her
pain. When it initially started about 48 hours ago, it awoke her
up out of her sleep. She doesn't recall anything that improved 
or
made it worse, but since then it has been rather episodic
throughout the day. She has felt generally ""low energy"" and thus
has not been moving about all that much, but when she has 
exerted
herself she does not think that brought about the pain or made 
it
any worse. She does think that she has felt generally weaker
while exerting herself over the last week or so.

In the ED initial vitals were: 

97.3 56 155/65 16 97% RA 
 
Labs/studies notable for:

___: 35.8  PTT: 43.3  INR: 3.3  

5.1 > 12.1/37.1 < 230 
  
ALT: 36 AP: 85 Tbili: 0.4 Alb: 4.2 
AST: 45 

CK: 295  MB: 8  Trop-T: 0.02 

135  97  29   
-------------< 82 
4.2  23  1.2  

UA negative

Trop 0.02 --> 0.01

 

###RESPONSE: CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, PCI {Percutaneous coronary intervention}, ramus intermedius {Structure of coronary intermediate artery}, TTE {Transthoracic echocardiography}, pAF {Paroxysmal atrial fibrillation}, moderate AS {Moderate stenosis of aortic valve}, HTN {Hypertensive disorder, systemic arterial}, anemia {Anemia}, dementia {Dementia}, GERD {Gastroesophageal reflux disease}, breast cancer {Malignant neoplasm of breast}, R mastectomy {Mastectomy of right breast}, XRT {X-ray beam therapy}, chest pain {Chest pain}, substernal {Structure of substernal region}, chest ""pressure {Tight chest}, dyspnea {Dyspnea}, cough {Cough}, hemoptysis {Hemoptysis}, fever {Fever}, chills {Chill}, nausea {Nausea}, vomiting {Vomiting}, change in
bowel {Altered bowel function}, bladder function {Altered bladder function}, bruising {Contusion}, adenopathy {Lymphadenopathy}, rash {Eruption of skin}, lesion {Lesion}, pain {Pain}, improved {Patient's condition improved}, pain {Pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
HYPONATREMIA  
 ATRIAL FIBRILLATION on Coumadin  
 BREAST CANCER TWICE IN RIGHT BREAST  
 lumpectomy and xrt s/p mastectomy ___  
 CORONARY ARTERY DISEASE  
 s/p ramus stent ___, negative exercise echo ___  
 CORONARY ARTERY DISEASE  
 ___ cath 3-v disease with PCTA ramus of circ  
 DEPRESSION  
 GASTROESOPHAGEAL REFLUX  
 HYPERTENSION  
 OSTEOARTHRITIS  
 OSTEOPOROSIS  
 ANXIETY  
 MDD WITH PSYCHOTIC FEATURES  
 GAD  
 CATARACT  
 AORTIC SCLEROSIS  

 

###RESPONSE: HYPONATREMIA {Hyponatremia}, ATRIAL FIBRILLATION {Atrial fibrillation}, BREAST CANCER {Malignant neoplasm of breast}, RIGHT BREAST {Right breast structure}, lumpectomy {Lumpectomy of breast}, xrt {X-ray beam therapy}, mastectomy {Excision of breast}, CORONARY ARTERY DISEASE {Coronary arteriosclerosis}, stent {Insertion of arterial stent}, exercise echo {Exercise stress echocardiography}, CORONARY ARTERY DISEASE {Coronary arteriosclerosis}, cath {Cardiac catheterization}, 3-v disease {Triple vessel disease of the heart}, PCTA {Percutaneous transluminal coronary angioplasty}, DEPRESSION {Depressive disorder}, GASTROESOPHAGEAL REFLUX {Gastroesophageal reflux disease}, HYPERTENSION {Hypertensive disorder, systemic arterial}, OSTEOARTHRITIS {Osteoarthritis}, OSTEOPOROSIS {Osteoporosis}, ANXIETY {Anxiety}, MDD WITH PSYCHOTIC FEATURES {Major depression with psychotic features}, GAD {Generalized anxiety disorder}, CATARACT {Cataract}, AORTIC SCLEROSIS {Aortic valve sclerosis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
FAMILY PSYCHIATRIC HISTORY: brother with ___ (in ___
Mother died of AD at age ___
Father died of MI age ___. 

 

###RESPONSE: died {Dead}, died {Dead}, MI {Myocardial infarction}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VS:  ___ 0200 Temp: 98.0 PO BP: 150/63 L Lying HR: 58 RR: 
18
O2 sat: 99% O2 delivery: Ra 
GENERAL: Cachectic elderly woman, lying comfortably in bed, NAD
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.  
NECK: No JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. ___, late peaking cresc/decresc
murmur best heart at LUSB, radiating to carotids with delayed
carotid upstroke.   
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.  
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.  
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.  
SKIN: No significant skin lesions or rashes.  
PULSES: Distal pulses palpable and symmetric. 

DISCHARGE PHYSICAL EXAM
=====================================
Temp: 97.7 (Tm 98.8), BP: 159/72 (113-159/53-72), HR: 69
(52-69), RR: 18 (___), O2 sat: 97% (96-98), O2 delivery: Ra,
Wt: 92.15 lb/41.8 kg
GENERAL: Cachectic elderly woman, lying comfortably in bed, NAD
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.  
NECK: No JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. ___, late peaking cresc/decresc
murmur best heart at LUSB, radiating to carotids with delayed
carotid upstroke.   
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.  
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.  
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.  
SKIN: No significant skin lesions or rashes.  
PULSES: Distal pulses palpable and symmetric.

 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, GENERAL {General examination of patient}, Cachectic {Cachexia}, lying comfortably in bed {Lying in bed}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva {Conjunctival structure}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthelasma {Xanthelasma}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, intercostal space {Structure of intercostal space}, midclavicular
line {Midclavicular line}, Regular rate {Normal heart rate}, murmur {Murmur}, LUSB {Structure of upper parasternal region}, carotids {Carotid artery structure}, LUNGS {Examination of respiratory system}, chest wall deformities {Deformity of chest wall}, tenderness {Tenderness}, Respiration {Examination of respiratory system}, unlabored {Breathing easily}, accessory muscle {Accessory skeletal muscle}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, hepatomegaly {Large liver}, splenomegaly {Splenomegaly}, EXTREMITIES {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, SKIN {Examination of skin}, lesions {Lesion}, rashes {Eruption of skin}, pulses palpable {Peripheral pulse palpable}, PHYSICAL EXAM {Physical examination procedure}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, GENERAL {General examination of patient}, Cachectic {Cachexia}, lying comfortably in bed {Lying in bed}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva {Conjunctival structure}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthelasma {Xanthelasma}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, intercostal space {Structure of intercostal space}, midclavicular
line {Midclavicular line}, Regular rate {Normal heart rate}, murmur {Murmur}, LUSB {Structure of upper parasternal region}, carotids {Carotid artery structure}, LUNGS {Examination of respiratory system}, chest wall deformities {Deformity of chest wall}, tenderness {Tenderness}, Respiration {Examination of respiratory system}, unlabored {Breathing easily}, accessory muscle {Accessory skeletal muscle}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, hepatomegaly {Large liver}, splenomegaly {Splenomegaly}, EXTREMITIES {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, SKIN {Examination of skin}, lesions {Lesion}, rashes {Eruption of skin}, pulses palpable {Peripheral pulse palpable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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
=====================
___ 02:10PM   cTropnT-<0.01
___ 12:29PM URINE  HOURS-RANDOM
___ 12:29PM URINE  UHOLD-HOLD
___ 12:29PM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 12:29PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 
LEUK-NEG
___ 08:15AM   GLUCOSE-82 UREA N-29* CREAT-1.2* SODIUM-135 
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-23 ANION GAP-15
___ 08:15AM   estGFR-Using this
___ 08:15AM   ALT(SGPT)-36 AST(SGOT)-45* CK(CPK)-295* ALK 
PHOS-85 TOT BILI-0.4
___ 08:15AM   LIPASE-46
___ 08:15AM   CK-MB-8 cTropnT-0.02*
___ 08:15AM   ALBUMIN-4.2 CALCIUM-9.5 PHOSPHATE-3.0 
MAGNESIUM-2.1
___ 08:15AM   WBC-5.1 RBC-3.90 HGB-12.1 HCT-37.1 MCV-95 
MCH-31.0 MCHC-32.6 RDW-14.0 RDWSD-49.2*
___ 08:15AM   NEUTS-59.3 ___ MONOS-12.4 EOS-1.6 
BASOS-1.2* IM ___ AbsNeut-3.02 AbsLymp-1.29 AbsMono-0.63 
AbsEos-0.08 AbsBaso-0.06
___ 08:15AM   PLT COUNT-230
___ 08:15AM   PLT COUNT-230

PERTINENT STUDIES
========================
CARDIAC PERFUSION PHARM ___
Normal myocardial perfusion exam. The ejection fraction is 70%.

CXR ___
No acute cardiopulmonary abnormality.

TTE ___
Vigorous left ventricular systolic function. Severe aortic 
stenosis with mild aortic regurgitation. Mild mitral and 
tricuspid regurgitation. Borderline pulmonary hypertension.

STRESS TEST ___
Non-anginal type symptoms in the absence of significant ST 
segment changes. Resting systolic hypertension with an 
appropriate 
hemodynamic response to vasodilator stress. Nuclear report sent 
separately. 

DISCHARGE LABS
========================
___ 08:40AM BLOOD WBC-5.1 RBC-3.58* Hgb-11.2 Hct-34.9 
MCV-98 MCH-31.3 MCHC-32.1 RDW-14.2 RDWSD-51.8* Plt ___
___ 07:33PM BLOOD ___ PTT-40.6* ___
___ 08:40AM BLOOD Glucose-75 UreaN-28* Creat-1.1 Na-137 
K-4.3 Cl-101 HCO3-23 AnGap-13
___ 08:40AM BLOOD CK(CPK)-191
___ 08:40AM BLOOD CRP-7.3*
 

###RESPONSE: cTropnT {Troponin T cardiac measurement}, COLOR {Color finding}, PROTEIN {Measurement of protein in urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, TOT BILI {Bilirubin, total measurement}, cTropnT {Troponin T cardiac measurement}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, CXR {Plain chest X-ray}, TTE {Transthoracic echocardiography}, aortic 
stenosis {Aortic valve stenosis}, mild aortic regurgitation {Mild aortic valve regurgitation}, Mild mitral {Mild mitral valve regurgitation}, tricuspid regurgitation {Tricuspid valve regurgitation}, pulmonary hypertension {Pulmonary hypertension}, ST 
segment changes {Electrocardiographic ST segment changes}, systolic hypertension {Systolic hypertension}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
====================
PATIENT SUMMARY:
====================
___ year old female, history of CAD (MI ___ s/p PCIx2 to ramus
intermedius, TTE ___, pAF (on Coumadin), moderate AS, HTN,
anemia, dementia, GERD, and hx breast cancer (s/p R mastectomy
with XRT) who presents with chest pain, possibly anginal vs.
symptomatic severe AS vs. non-cardiac.

CORONARIES: Diffuse 3VD
PUMP: Preserved EF (70%)
RHYTHM: pAF

====================
ACTIVE ISSUES
====================

#Chest pain
#CAD (MI ___ s/p PCIx2 to ramus intermedius, last cath ___
with 3VD, declining intervention)
Suspect that some of her chest pain is anginal in nature, though
not entirely clear from her history. Low concern for ACS given 
very mild trop elevation which was downtrending and no ischemic 
EKG changes. Pmibi was reassuring. Notably long acting nitrates 
have resulted in HA in the past. Beta blocker not uptitrated due 
to resting bradycardia. Also, she recently had two episodic 
visits for diffuse muscle aches and fatigue, with labs showing 
mildly elevated CK; statin was discontinued in this setting. ASA 
was also held on her last admission due to concern for GIB. Her 
symptoms were resolved on the day of discharge.

#pAF: On warfarin. INR on admission 3.3 so Warfarin held on 
admission day but resumed on ___. Patient was in sinus this 
admission. Continued Amiodarone but Carvedilol 3.125 BID held 
due to resting bradycardia. INR on discharge was 2.3.

#Moderate-Severe AS: AS valve area of 1cm, with mean gradient 
36.
This is slightly worsened in the past year with prior area
measured at 1.1cm with mean gradient in the low ___. Aortic 
stenosis will be discussed further at outpatient visit with 
___.

#Diffuse muscle aches: Given vague nature of symptoms, certainly 
possible that her pain was related to neither AS nor ischemic 
heart disease. Interestingly, her CK and AST were both elevated 
on admission likely indicating some skeletal muscle breakdown. 
Statin induced myopathy is certainly possible so continued to 
hold her Atorvastatin, though other myopathies should be 
considered. CRP mildly elevated and ESR pending on discharge. 
TSH also checked which was normal. 

#HTN: Holding carvedilol but continued amlodipine as above.

#Dementia
#Anxiety:
Continued home wellbutrin and mirtazapine.

#CKD: Appeared to be at baseline Cr from most recent checks. Cr 
on discharge was 1.1.

#H/o breast CA s/p R mastectomy with XRT

====================
TRANSITIONAL ISSUES:
====================
- New Meds: None
- Stopped/Held Meds: Carvedilol 3.125mg BID
- Changed Meds: None
- Discharge weight: 41.8 kg (92.15 lb) 
- Discharge creatinine: 1.1

[] Held carvedilol in the setting of resting bradycardia. Please 
consider restarting if heart rates allow.
[] Warfarin held on ___ because patient was supratherapeutic 
but resumed her home dose prior to discharge

# CONTACT: HCP: ___ (Nephew)
Phone number: ___ 
Cell phone: ___ 
 

###RESPONSE: CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, PCI {Electrocardiographic ST segment changes}, ramus
intermedius {Structure of coronary intermediate artery}, TTE {Transthoracic echocardiography}, pAF {Paroxysmal atrial fibrillation}, moderate AS {Moderate stenosis of aortic valve}, HTN {Hypertensive disorder, systemic arterial}, anemia {Anemia}, dementia {Dementia}, GERD {Gastroesophageal reflux disease}, breast cancer {Malignant neoplasm of breast}, R mastectomy {Mastectomy of right breast}, XRT {X-ray beam therapy}, chest pain {Chest pain}, 3VD {Triple vessel disease of the heart}, pAF {Paroxysmal atrial fibrillation}, Chest pain {Chest pain}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, PCI {Electrocardiographic ST segment changes}, ramus intermedius {Structure of coronary intermediate artery}, cath {Cardiac catheterization}, 3VD {Triple vessel disease of the heart}, chest pain {Chest pain}, ACS {Acute coronary syndrome}, ischemic 
EKG changes {Electrocardiographic myocardial ischemia}, HA {Headache}, bradycardia {Bradycardia}, muscle aches {Muscle pain}, fatigue {Fatigue}, elevated CK {Creatine kinase level above reference range}, GIB {Gastrointestinal hemorrhage}, pAF {Paroxysmal atrial fibrillation}, On warfarin {Warfarin therapy}, sinus {Sinus rhythm}, bradycardia {Bradycardia}, AS {Aortic valve stenosis}, AS {Aortic valve stenosis}, Aortic 
stenosis {Aortic valve stenosis}, muscle aches {Muscle pain}, pain {Muscle pain}, AS {Aortic valve stenosis}, ischemic 
heart disease {Ischemic heart disease}, CK {Creatine kinase level above reference range}, AST were both elevated {Aspartate aminotransferase serum level above reference range}, skeletal muscle {Skeletal muscle structure}, myopathy {Disorder of skeletal AND/OR smooth muscle}, myopathies {Disorder of skeletal AND/OR smooth muscle}, CRP mildly elevated {C-reactive protein above reference range}, TSH also checked which was normal {Serum thyroid stimulating hormone level within reference range}, HTN {Hypertensive disorder, systemic arterial}, Dementia {Dementia}, CKD {Chronic kidney disease}, breast CA {Malignant neoplasm of breast}, R mastectomy {Mastectomy of right breast}, XRT {X-ray beam therapy}, bradycardia {Bradycardia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 
2. Amiodarone 100 mg PO DAILY 
3. amLODIPine 2.5 mg PO DAILY 
4. Carvedilol 3.125 mg PO BID 
5. Docusate Sodium 100 mg PO BID 
6. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID 
7. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Second 
Line 
8. Mirtazapine 7.5 mg PO QHS 
9. Polyethylene Glycol 17 g PO DAILY 
10. Senna 17.2 mg PO QHS 
11. Warfarin 2 mg PO 4X/WEEK (___) 
12. Warfarin 1.5 mg PO 3X/WEEK (___) 
13. Azopt (brinzolamide) 1 % ophthalmic (eye) TID 
14. BuPROPion 100 mg PO BID 
15. Chlorpheniramine-Hydrocodone 5 mL PO Q6H:PRN cough 
16. Citracal + D Petites (calcium citrate-vitamin D3) 200 mg 
calcium -250 unit oral BID 
17. Furosemide 20 mg PO DAILY 
18. Mag-Al Plus (alum-mag hydroxide-simeth) 200-200-20 mg/5 mL 
oral TID 
19. melatonin 1 mg oral QHS 
20. Sucralfate 0.5 gm PO TID:PRN stomach upset 
21. trimethobenzamide 300 mg oral Q8H:PRN nausea 
22. Vitamin D 1000 UNIT PO DAILY 
23. Pantoprazole 40 mg PO Q24H 

 
Discharge Medications:
1.  Warfarin 1.5 mg PO DAILY16  
2.  Acetaminophen 650 mg PO Q4H:PRN Pain - Mild  
3.  Amiodarone 100 mg PO DAILY  
4.  amLODIPine 2.5 mg PO DAILY  
5.  Azopt (brinzolamide) 1 % ophthalmic (eye) TID  
6.  BuPROPion 100 mg PO BID  
7.  Chlorpheniramine-Hydrocodone 5 mL PO Q6H:PRN cough  
8.  Citracal + D Petites (calcium citrate-vitamin D3) 200 mg 
calcium -250 unit oral BID  
9.  Docusate Sodium 100 mg PO BID  
10.  Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID  
11.  Furosemide 20 mg PO DAILY  
12.  Mag-Al Plus (alum-mag hydroxide-simeth) 200-200-20 mg/5 mL 
oral TID  
13.  melatonin 1 mg oral QHS  
14.  Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Second 
Line  
15.  Mirtazapine 7.5 mg PO QHS  
16.  Pantoprazole 40 mg PO Q24H  
17.  Polyethylene Glycol 17 g PO DAILY  
18.  Senna 17.2 mg PO QHS  
19.  Sucralfate 0.5 gm PO TID:PRN stomach upset  
20.  trimethobenzamide 300 mg oral Q8H:PRN nausea  
21.  Vitamin D 1000 UNIT PO DAILY  
22.  Warfarin 2 mg PO 4X/WEEK (___)  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
non-coronary chest pain

SECONDARY DIAGNOSIS
====================
coronary artery disease
aortic stenosis

 
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: non-coronary chest pain {Non-cardiac chest pain}, coronary artery disease {Coronary arteriosclerosis}, aortic stenosis {Aortic valve stenosis}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, Alert {Mentally alert}, Ambulatory - requires assistance or aid {Finding of walking aid use}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,  

It was a pleasure taking part in your care here at ___!  

Why was I admitted to the hospital?  
- You were admitted for chest pain and fatigue

What was done for me while I was in the hospital?  
- You underwent a stress test which was normal.
- Your medicines were changed to improve your symptoms. 

What should I do when I leave the hospital?  
- Please continue to take your medicines as prescribed and 
follow up with your outpatient providers.

We wish you the best!

Sincerely,  
Your ___ Care Team  

 

###RESPONSE: chest pain {Chest pain}, fatigue {Fatigue}, stress test {Electrocardiogram with exercise test}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: 
Latex
 
Attending: ___.
 
Chief Complaint:
Chest pain
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Latex {Allergy to Hevea brasiliensis latex protein}, Chest pain {Chest pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ with h/o liver transplant ___ (HBV) on prograf, IDDM, HLD 
with chest pain. Briefly, pt developed severe 
epigastric/substernal pain this morning. Pain was severe and 
woke him up. He describes it as crampy, nonradiating. Pain was 
constant and unremitting, lasting for approximately 3 hours. It 
was associated with 3x episodes of vomiting with some relief of 
pain. It was not affected by position. No 
light-headedness/dizziness. No abdominal pain. Pt notes he had a 
very large meal earlier that night. He has never had this type 
of pain before. He has never had an esopohogram before and 
denies any history of DES. No history of esophageal injury. No 
recent dysphagia/odynophagia. No recent sick contacts/illnesses. 
Mild SOB, which patient attributes to not being able to take a 
deep breath from pain.

In the ambulance, pt received 2x nitro without improvement in 
sx.

On admission to the ED, VS were: 96.4 100 97/62 20 97% 4L. Labs 
significant for Cr 1.4, ALT/AST: ___, AP 86, TBili 0.5, Lipase 
42. Trops negative x2. EKG grossly unchanged from prior. CTA 
negative for PE, and CXR negative for any acute process. Pt was 
given zofran, morphine x2, GI ocktail, donnatal with improvement 
in symptoms. Pt desated to 92% on RA, and he was placed back on 
nasal cannula and admitted for workup of chest pain an hypoxia.

On arrival, VS were: 99.5; 130/85; 80; 16; 97% 2LNC. Pt reported 
feeling much better. He continues to have some mild chest pain 
which is worse with deep breaths.

 

###RESPONSE: liver transplant {Transplanted liver present}, HBV {Viral hepatitis type B}, IDDM {Diabetes mellitus type 1}, HLD {Hyperlipidemia}, chest pain {Chest pain}, severe {Severe pain}, epigastric {Epigastric pain}, substernal {Retrosternal pain}, pain {Pain}, Pain was severe {Severe pain}, crampy {Cramping pain}, Pain {Pain}, constant {Constant pain}, vomiting {Vomiting}, pain {Pain}, light-headedness {Lightheadedness}, dizziness {Dizziness}, abdominal pain {Abdominal pain}, pain {Pain}, DES {Endovascular insertion of drug eluting stent}, esophageal injury {Injury of esophagus}, dysphagia {Dysphagia}, odynophagia {Swallowing painful}, illnesses {Illness}, Mild {Symptom mild}, SOB {Dyspnea}, deep breath {Deep breathing}, pain {Pain}, improvement {Patient's condition improved}, Labs {Laboratory test}, TBili {Bilirubin, total measurement}, Lipase {Serum lipase measurement}, Trops {Troponin measurement}, negative {No pathologic diagnosis}, EKG {Electrocardiographic procedure}, CTA {Computed tomography angiography with contrast}, negative {No pathologic diagnosis}, PE {Pulmonary embolism}, CXR negative {Standard chest X-ray normal}, improvement {Patient's condition improved}, desated {Oxygen saturation below reference range}, placed back on 
nasal cannula {Oxygen administration by nasal cannula}, workup {Evaluation procedure}, chest pain {Chest pain}, hypoxia {Hypoxia}, 2LNC {Oxygen administration by nasal cannula}, mild {Symptom mild}, chest pain {Chest pain}, worse {Increased pain}, deep breaths {Deep breathing}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
HepB cirrhosis s/p OLT in ___
-On Prograf
Hepatitis B on ___ and HepaGam
IDDM
HLD

 

###RESPONSE: HepB cirrhosis {Cirrhosis of liver due to hepatitis B}, OLT {Orthotopic transplantation of whole liver}, Hepatitis B {Viral hepatitis type B}, IDDM {Diabetes mellitus type 1}, HLD {Hyperlipidemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
DM, HTN, HLD
 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
On Admission:
General: Pleasant, well-appearing NAD.
HEENT: NC/AT. MMM. EOMI.
LAD: No LAD appreciated
CV: RRR. No MRG.
Pulmonary: CTAB. No wheezes, rales, rhonchi
Abdomen: +BS. Soft, NTND. Long horizontal incision over 
epigastric region well-healed. No HSM appreciated.
Extremities: WWP. 2+ DP pulese, equal bilaterally. No c/c/e
Neuro: CNII-XII grossly intact

On Discharge:
General: Pleasant, well-appearing NAD.
HEENT: NC/AT. MMM. EOMI.
LAD: No LAD appreciated
CV: RRR. No MRG.
Pulmonary: CTAB. No wheezes, rales, rhonchi
Abdomen: +BS. Soft, NTND. Long horizontal incision over 
epigastric region well-healed. No HSM appreciated.
Extremities: WWP. 2+ DP pulese, equal bilaterally. No c/c/e
Neuro: CNII-XII grossly intact
 

###RESPONSE: General {General examination of patient}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, MMM {Moist oral mucosa}, EOMI {Normal ocular motility}, LAD {Lymphadenopathy}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, No MRG {Heart sounds normal}, Pulm {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, incision {Surgical incision wound}, epigastric region {Epigastric region structure}, well-healed {Wound healed}, HSM {Hepatosplenomegaly}, Extremities {Examination of limb}, WWP {Normal tissue perfusion}, 2+ DP {Dorsalis pulse present}, No c/c/e {No abnormality detected}, Neuro {Neurological examination}, grossly intact {Normal nervous system function}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC/AT {Normal head}, MMM {Moist oral mucosa}, EOMI {Normal ocular motility}, LAD {Examination of lymph nodes}, LAD {Lymphadenopathy}, RRR {Normal heart rate}, No MRG {Heart sounds normal}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Soft {Abdomen soft}, NTND {Abdominal tenderness}, incision {Surgical incision wound}, epigastric region {Epigastric region structure}, well-healed {Wound healed}, HSM {Hepatosplenomegaly}, WWP {Normal tissue perfusion}, 2+ DP {Dorsalis pulse present}, No c/c/e {No abnormality detected}, Neuro {Neurological examination}, CNII-XII grossly intact {Normal nervous system function}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
On Admission:
___ 05:30AM BLOOD WBC-10.5# RBC-4.63 Hgb-14.6 Hct-40.7 
MCV-88 MCH-31.6 MCHC-36.0* RDW-14.8 Plt ___
___ 05:30AM BLOOD ___ PTT-23.1* ___
___ 05:30AM BLOOD Glucose-216* UreaN-22* Creat-1.4* Na-139 
K-4.4 Cl-101 HCO3-27 AnGap-15
___ 05:30AM BLOOD ALT-23 AST-26 AlkPhos-86 TotBili-0.5

Troponins:
___ 05:30AM BLOOD cTropnT-<0.01
___ 11:36AM BLOOD cTropnT-<0.01

On Discharge:
___ 04:35AM BLOOD WBC-8.1 RBC-4.40* Hgb-13.8* Hct-39.1* 
MCV-89 MCH-31.3 MCHC-35.3* RDW-14.3 Plt ___
___ 04:35AM BLOOD ___ PTT-28.4 ___
___ 04:35AM BLOOD Glucose-145* UreaN-23* Creat-1.4* Na-139 
K-4.6 Cl-98 HCO3-30 AnGap-16
___ 04:35AM BLOOD ALT-19 AST-23 AlkPhos-79 TotBili-0.9
___ 04:35AM BLOOD Calcium-9.5 Phos-1.8* Mg-1.9
___ 04:35AM BLOOD tacroFK-3.1*

Microbiology:
None

Imaging:
___ CTA Chest
IMPRESSION:  
1. No pulmonary embolism. 
2. Small pericardial effusion. 
3. Few pulmonary nodules measuring up to 4 mm.  Followup in ___ 
year is 
recommended there is high risk for lung malignancy. 
4. Paraesophageal varices. 

___ CXR:
IMPRESSION:    
1.  Mild vascular congestion. 
2.  Chronic small right pleural effusion versus pleural 
thickening. 
2.  Left lower lobe atelectasis with elevation of left 
hemidiaphragm. 

___ ECG:
Sinus rhythm. Compared to the previous tracing of ___ there 
are no 
significant changes. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, 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}, PTT {Partial thromboplastin time, activated}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, CTA Chest {Computed tomography angiography of chest with contrast}, pulmonary embolism {Pulmonary embolism}, pericardial effusion {Pericardial effusion}, pulmonary nodules {Nodule of lung}, Followup {Follow-up consultation}, lung malignancy {Metastatic malignant neoplasm to lung}, Paraesophageal varices {Esophageal varices}, Mild {Symptom mild}, vascular {Blood vessel structure}, congestion {Congestion}, Chronic {Chronic disease}, right {Right pleura structure}, pleural effusion {Pleural effusion}, pleural 
thickening {Thickening of pleura}, Left lower lobe {Structure of lower lobe of left lung}, atelectasis {Atelectasis}, elevation {Elevated diaphragm}, left 
hemidiaphragm {Structure of left hemidiaphragm}, ECG:
Sinus rhythm {Electrocardiogram: sinus rhythm}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 pmhx of HBV cirrhosis (sp xplant in ___, IDDM, HLD, 
CKD, h/o strongyloides, h/o fasciola who presented with SSCP 
following a large meal. 

#Chest pain: Felt to be esophageal spasm in the setting of GERD. 
EKG unchanged from prior and tropopnins were negative. CTA 
otherwise negative for PE. Pt was started on a PPI, and he had 
only minor recurrence of chest pain after coming to the floor. 
Pt was discharged with a PPT as well as a plan for follow up EGD 
with possible barium swallow.

#Shortness of Breath: Pt's shortness of breath was felt to be 
related to his inability to take a deep breath due to pain. His 
desaturation in the ED may have been related to the pain 
medications he was administered. Pt's oxygen was quickly weanes 
off an admission, and his respiratory status remained stable 
during this admission.

#Hepatitis B: Pt was continued on ___

#Cirrhosis s/p OLT: MELD score 10. Pt was continued on home 
Prograf. Level was 3.1 on morning of discharge.

#Pulmonary nodules: Pt was incidentally found to have pulmonary 
nodules on CTA, and it was recommended that they be followed up 
in ___ year if pt felt to be high risk for malignancy.

Transitional:
[] Please consider up-titration of PPI
[] Pt will be scheduled for follow-up EGD +/- barium swallow - 
manometry may be indicated in the future
[] Consider f/u of pulmonary nodules in ___ year
 

###RESPONSE: HBV cirrhosis {Cirrhosis of liver due to hepatitis B}, xplant {Transplanted liver present}, IDDM {Diabetes mellitus type 1}, HLD {Hyperlipidemia}, CKD {Chronic kidney disease}, strongyloides {Infection caused by Strongyloides}, fasciola {Infection caused by Fasciola}, Chest pain {Chest pain}, esophageal spasm {Diffuse spasm of esophagus}, GERD {Gastroesophageal reflux disease}, EKG {Electrocardiographic procedure}, tropopnins {Troponin measurement}, negative {No pathologic diagnosis}, CTA {Computed tomography angiography of chest with contrast}, negative {No pathologic diagnosis}, PE {Pulmonary embolism}, started {New medication added}, PPI {Proton pump inhibitor therapy}, chest pain {Chest pain}, follow up {Follow-up arranged}, EGD {Esophagogastroduodenoscopy}, barium swallow {Barium swallow}, Shortness of Breath {Dyspnea}, shortness of breath {Dyspnea}, inability to take a deep breath {Unable to take deep breaths}, pain {Pain}, desaturation {Oxygen saturation below reference range}, pain 
medications {Administration of analgesic}, respiratory status {Monitoring of respiration}, stable {Patient's condition stable}, Hepatitis B {Viral hepatitis type B}, Cirrhosis {Cirrhosis of liver}, OLT {Orthotopic transplantation of whole liver}, Prograf. Level {Blood tacrolimus level}, Pulmonary nodules {Nodule of lung}, pulmonary 
nodules {Nodule of lung}, CTA {Computed tomography angiography of chest with contrast}, risk for malignancy {At increased risk of malignancy}, PPI {Proton pump inhibitor therapy}, follow-up {Follow-up arranged}, EGD {Esophagogastroduodenoscopy}, barium swallow {Barium swallow}, manometry {Esophageal manometry}, pulmonary nodules {Nodule of lung}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Pravastatin 40 mg PO QPM 
2. Phosphorus 250 mg PO TID W/MEALS 
3. Amoxicillin ___ mg PO ONE HOUR PRIOR TO DENTAL SURGERY 
4. Tacrolimus 0.5 mg PO Q12H 
5. Multivitamins W/minerals 1 TAB PO DAILY 
6. Entecavir 1 mg PO DAILY 
7. Escitalopram Oxalate 10 mg PO DAILY 
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 
9. GlipiZIDE 7.5 mg PO QAM 
10. GlipiZIDE 10 mg PO QPM 
11. Calcitriol 0.25 mcg PO BID 
12. Glargine 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Hepatitis B Immun Globulin (HepaGam B) 5000 UNIT IV Q4 
MONTHS 

 
Discharge Medications:
1. Calcitriol 0.25 mcg PO BID 
2. Entecavir 1 mg PO DAILY 
3. Escitalopram Oxalate 10 mg PO DAILY 
4. Glargine 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Multivitamins W/minerals 1 TAB PO DAILY 
6. Phosphorus 250 mg PO TID W/MEALS 
7. Pravastatin 40 mg PO QPM 
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 
9. Tacrolimus 0.5 mg PO Q12H 
10. Omeprazole 20 mg PO BID 
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60 
Capsule Refills:*0
11. Amoxicillin ___ mg PO ONE HOUR PRIOR TO DENTAL SURGERY 
___. GlipiZIDE 7.5 mg PO QAM 
13. GlipiZIDE 10 mg PO QPM 
14. Hepatitis B Immun Globulin (HepaGam B) 5000 UNIT IV Q4 
MONTHS 

 

###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: 
Esophageal spasm
Gastroesophageal reflux disease
Chest pain

Secondary:
Diabetes
Chronic kidney disease
Hepatitis B
Hyperlipidemia

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Esophageal spasm {Diffuse spasm of esophagus}, Gastroesophageal reflux disease {Gastroesophageal reflux disease}, Chest pain {Chest pain}, Diabetes {Diabetes mellitus type 1}, Chronic kidney disease {Chronic kidney disease}, Hepatitis B {Viral hepatitis type B}, Hyperlipidemia {Hyperlipidemia}, 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 Dr. ___, 

___ was a pleasure to participate in your care. You were admitted 
for chest pain. You were found to have no evidence of cardiac 
ischemia or pulmonary embolism. Your symptoms improved with a 
proton pump inhibitor. We believe that your symptoms may have 
been due to gastric reflux or esophageal spasm. Please follow up 
with your Gastroenterologist for outpatient endoscopy and barium 
enema. 

Best Regards,
Your ___ Medicine Team
 

###RESPONSE: chest pain {Chest pain}, no evidence {No abnormality detected}, cardiac 
ischemia {Myocardial ischemia}, pulmonary embolism {Pulmonary embolism}, improved {Patient's condition improved}, proton pump inhibitor {Proton pump inhibitor therapy}, gastric reflux {Gastric reflux}, esophageal spasm {Diffuse spasm of esophagus}, follow up {Follow-up arranged}, endoscopy {Endoscopy}, barium 
enema {Barium enema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
Penicillins / Amoxicillin
 
Attending: ___.
 
Chief Complaint:
Back and Left Leg Pain
 
Major Surgical or Invasive Procedure:
PROCEDURES: ___
1. Anterior lumbar interbody fusion, L4-L5, L5-S1.
2. Anterior interbody cage placement L4-L5, L5-S1.

PROCEDURES: ___
1. L5 laminectomy, L4 laminotomy
2. Posterior Spinal Instrumented Fusion L4-S1 

 

###RESPONSE: Penicillins {Allergy to penicillin}, Amoxicillin {Allergy to amoxicillin}, Back {Structure of back of trunk}, Left Leg Pain {Pain in left lower limb}, Anterior lumbar interbody fusion {Interbody fusion of lumbar spine by anterior approach}, L4-L5 {Intervertebral disc structure of fourth lumbar vertebra}, L5-S1 {Structure of intervertebral disc of L5 and S1}, placement {Implantation procedure}, L4-L5 {Intervertebral disc structure of fourth lumbar vertebra}, L5-S1 {Structure of intervertebral disc of L5 and S1}, L5 {Structure of lamina of fifth lumbar vertebra}, laminectomy {Excision of lamina of vertebra}, L4 {Structure of lamina of fourth lumbar vertebra}, laminotomy {Laminotomy}, Posterior Spinal Instrumented {Posterior spinal instrumentation}, Fusion {Fusion procedure}, L4 {Bone structure of L4}, S1 {Structure of first sacral vertebra}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 patient presented with persistent back and left-sided leg 
pain.  This goes down in an L5 distribution. It is approximately 
60% back, 40% leg and it goes down the outside of his leg, 
outside of his calf, top of his foot.  He had
an injury approximately ___ years ago while wrestling and he wore
a back brace for two to three months due to spondylolisthesis. 
He has been followed at ___.  He has been good
for approximately five to ___ years, but the past six months 
have
been significantly bothersome for him.  He had a recent child; 
he
is unable to pick the child up.  He has had no injections
recently.  He discontinued physical therapy secondary to pain. 
It is ___ ___nd ___ with activity.  His mom is with him
today.  He has a history of anxiety and chest pain and he had a
workup for cardiac chest pain, which was negative and with a
diagnosis of stress.  He is on Lamictal and Geodon for bipolar
depression.  He is allergic to amoxicillin.  He smokes
approximately half a pack a day, which is a decrease from the 
two
packs.

His films were reviewed, which show a grade ___ 
spondylolisthesis
at L5-S1 with spondylolysis.  An MRI was reviewed from 
___
from ___ MRI, which shows a bilateral L5 spondylolysis and
L5-S1 spondylolisthesis that is grade 2.  There is severe
foraminal stenosis bilaterally.

On physical examination, he is an alert and oriented male. 
Affect is within normal limits.  He has an antalgic gait.  He 
has
___ strength bilaterally with a ___ ___ and abductors.  His
sensation is grossly intact to light touch.  He has a positive
straight leg raise approximately 70 degrees.  No pain with
internal rotation of hips.  Distal pulses intact.  Calves are
soft.  No signs of atrophy.

This is a patient with a grade ___ spondylolisthesis, who by
report was a grade 1 and followed at ___.  He 
has
severe left back as well as left lower extremity radicular
symptoms.  We talked about possible surgical intervention.  This
would either be an anterior-posterior fusion with interbody 
cages
from ___ versus a strut graft through the sacrum and L5 combined
with a posterolateral fusion.  We discussed this at length as
well as risks and benefits using models as MRI.  All questions
were answered.  I would like to obtain a CT scan and see him 
back
in followup.  I gave him a surgical packet and asked him to look
at the animations and come back with any questions.  Given his
x-rays and MRIs as well as clinical symptoms, I do recommend
surgical intervention.

 

###RESPONSE: back {Structure of back of trunk}, left-sided leg 
pain {Pain in left lower limb}, L5 {Bone structure of L5}, back {Structure of back of trunk}, leg {Structure of left lower leg}, leg {Structure of left lower leg}, calf {Structure of calf of right lower leg}, foot {Structure of right foot}, injury {Traumatic or non-traumatic injury}, wore
a back brace {Application of back brace}, spondylolisthesis {Spondylolisthesis}, unable to pick the child up {Unable to pick up objects}, injections {Injection}, physical therapy {Physical therapy procedure}, pain {Abdominal pain}, anxiety {Anxiety}, chest pain {Chest pain}, cardiac chest pain {Cardiac chest pain}, stress {Stress}, bipolar {Bipolar disorder}, depression {Depressive disorder}, allergic to amoxicillin {Allergy to amoxicillin}, smokes {Smoker}, spondylolisthesis {Spondylolisthesis}, L5 {Bone structure of L5}, S1 {Structure of first sacral vertebra}, spondylolysis {Spondylolysis}, MRI {Magnetic resonance imaging}, MRI {Magnetic resonance imaging}, L5 {Bone structure of L5}, spondylolysis {Spondylolysis}, L5 {Bone structure of L5}, S1 {Structure of first sacral vertebra}, spondylolisthesis that is grade 2 {Spondylolisthesis, grade 2}, foraminal stenosis {Stenosis of lumbar vertebral foramen}, physical examination {Physical examination procedure}, alert {Mentally alert}, oriented {Orientated}, Affect {Mood finding}, antalgic gait {Antalgic gait}, sensation {Normal sensation}, intact to light touch {Light touch sensation present}, straight leg raise {Finding of straight leg raise}, pain {Abdominal pain}, internal rotation of hips {Structure of internal rotator of hip joint}, Calves {Structure of calf of leg}, atrophy {Atrophy}, spondylolisthesis {Spondylolisthesis}, grade 1 {Spondylolisthesis, grade 1}, t back {Structure of back of trunk}, left lower extremity {Structure of left lower limb}, radicular
symptoms {Radicular pain}, surgical intervention {Surgical procedure}, fusion {Fusion procedure}, sacrum {Structure of sacral vertebral column}, L5 {Bone structure of L5}, fusion {Fusion procedure}, MRI {Magnetic resonance imaging}, CT scan {Computed tomography of abdomen}, x-rays {Radiographic imaging procedure}, MRIs {Magnetic resonance imaging}, surgical intervention {Surgical procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
see HPI
 

###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: 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:
see HPI
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
see HPI
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 07:09AM BLOOD ALT-24 AST-18 LD(LDH)-148 AlkPhos-81 
TotBili-1.6*
___ 05:00AM BLOOD Glucose-135* UreaN-10 Creat-0.7 Na-137 
K-4.8 Cl-103 HCO3-28 AnGap-11
___ 05:00AM BLOOD WBC-12.2* RBC-3.43* Hgb-10.7* Hct-30.6* 
MCV-89 MCH-31.2 MCHC-35.1* RDW-12.3 Plt ___
 

###RESPONSE: ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, 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}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Patient was admitted to the ___ Spine Surgery Service and 
taken to the Operating Room for the above procedure.   The two 
portions of the surgery were staged apart by four days.  Refer 
to the dictated operative notes for further details.  The 
surgeries were without complication and the patient was 
transferred to the PACU in a stable condition each time.  
TEDs/pnemoboots were used for postoperative DVT prophylaxis.  
Intravenous antibiotics were continued for 24hrs postop per 
standard protocol. Initial postop pain was controlled with a 
PCA.  Diet was advanced as tolerated.  The patient was 
transitioned to oral pain medication when tolerating PO diet.  
Foley was removed on POD#1.  Physical therapy was consulted for 
mobilization OOB to ambulate.  Hospital course was otherwise 
unremarkable.  On the day of discharge the patient was afebrile 
with stable vital signs, comfortable on oral pain control and 
tolerating a regular diet. 
 

###RESPONSE: procedure {Surgical procedure}, surgery {Surgical procedure}, stable condition {Patient's condition stable}, TEDs {Application of antithromboembolic stockings}, postoperative {Postoperative state}, DVT prophylaxis {Prevention of deep vein thrombosis}, Intravenous antibiotics {Intravenous antibiotic therapy}, pain was controlled {Demonstrates adequate pain control}, PCA {Patient controlled analgesia}, Diet was advanced as tolerated {Advance diet as tolerated}, oral {Administration of drug or medicament via oral route}, pain medication {Administration of analgesic}, diet {Dietary finding}, Foley was removed {Removal of urinary bladder catheter}, mobilization {Mobilization}, ambulate {Ambulation training}, unremarkable {No abnormality detected}, afebrile {Fever}, stable vital signs {Normal vital signs}, oral {Administration of drug or medicament via oral route}, pain control {Pain control}, regular diet {Normal diet}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
2. lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO DAILY 
(Daily).  
3. ziprasidone HCl 20 mg Capsule Sig: One (1) Capsule PO QHS 
(once a day (at bedtime)).  

 
Discharge Medications:
1. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal 
once a day as needed for constipation for 3 doses.  
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
3. lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO DAILY 
(Daily).  
4. ziprasidone HCl 20 mg Capsule Sig: One (1) Capsule PO QHS 
(once a day (at bedtime)).  
5. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO QHS (once a day 
(at bedtime)) as needed for constipation.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
L5-S1 Anterior Spondylolisthesis

 
Discharge Condition:
A+Ox3
Ambulate as tolerated

 

###RESPONSE: 5-S1 {Structure of first sacral vertebra}, Spondylolisthesis {Spondylolisthesis}, Ox3 {Oriented to person, time and place}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You have undergone the following operation: Lumbar Decompression 
With Fusion

Immediately after the operation:

-Activity: You should not lift anything greater than 10 lbs for 
2 weeks. You will be more comfortable if you do not sit or stand 
more than ~45 minutes without getting up and walking around.

-Rehabilitation/ Physical Therapy: 
o2-3 times a day you should go for a walk for ___ minutes as 
part of your recovery.  You can walk as much as you can 
tolerate. 
oLimit any kind of lifting.

-Diet: Eat a normal healthy diet. You may have some 
constipation after surgery.  You have been given medication to 
help with this issue.

-Brace: You may have been given a brace. This brace is to be 
worn when you are walking. You may take it off when sitting in a 
chair or while lying in bed.

-Wound Care: Remove the dressing in 2 days.  If the incision is 
draining cover it with a new sterile dressing.  If it is dry 
then you can leave the incision open to the air.  Once the 
incision is completely dry (usually ___ days after the 
operation) you may take a shower. Do not soak the incision in a 
bath or pool.  If the incision starts draining at anytime after 
surgery, do not get the incision wet. Cover it with a sterile 
dressing.  Call the office. 

-You should resume taking your normal home medications.

-You have also been given Additional Medications to control 
your pain.  Please allow 72 hours for refill of narcotic 
prescriptions, so please plan ahead.  You can either have them 
mailed to your home or pick them up at the clinic located on 
___ 2.  We are not allowed to call in or fax narcotic 
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. 
 In addition, we are only allowed to write for pain medications 
for 90 days from the date of surgery.

 

###RESPONSE: operation {Surgical procedure}, Lumbar Decompression {Decompression of lumbar spine}, Fusion {Lumbar spinal fusion}, operation {Surgical procedure}, Activity {Functional activity education}, Rehabilitation/ Physical Therapy {Physical rehabilitation therapy procedure}, Diet {Dietary finding}, healthy diet {Healthy diet}, constipation {Constipation}, surgery {Surgical procedure}, medication {Administration of drug or medicament}, Brace {Application of back brace}, sitting {Sitting position}, lying in bed {Lying in bed}, Wound Care {Wound treatment education}, dressing {Application of dressing}, incision {Surgical incision wound}, draining {Wound discharge}, sterile dressing {Application of dressing, sterile}, incision {Surgical incision wound}, incision {Surgical incision wound}, operation {Surgical procedure}, soak {Soak}, incision {Surgical incision wound}, incision {Surgical incision wound}, draining {Wound discharge}, surgery {Surgical procedure}, incision {Surgical incision wound}, sterile 
dressing {Application of dressing, sterile}, medications {Administration of drug or medicament}, pain {Pain}, prescriptions {Prescription}, prescriptions {Prescription}, pain medications {Administration of analgesic}, surgery {Surgical 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: 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:
Dyspnea
 
Major Surgical or Invasive Procedure:
NONE
 

###RESPONSE: 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:
___ y/o ___ man with multiple medical problems 
most notable for HTN, COPD, HFpEF, Afib on Coumadin who presents 
with dyspnea. Of note, the patient was discharged on ___ 
following treatment for community acquired pneumonia. The 
patient was found to have RML consolidation, initially treated 
with IV CTX and Azithromycin and transitioned to Levofloxacin x7 
day total course (last day ___.

Patient complained of increasing dyspnea. EMS called, patient 
was not initially hypoxic but hypertensive SBP 210s, patient 
given nitro spray x3 and started on BiPAP. Patient brought to 
___ ED. In the ED, initial vitals:  T 97.5 HR 89 BP 107/67 RR 
19 SpO2 100% cpap. Exam notable for respiratory distress and 
increased work of breathing. No evidence of JVD ___ edema. 
Initial labs notable for lactate 1.3 and VBG pH 7.29 pCO2 66 pO2 
36. The patient was given Albuterol/Ipratropium Nebs and 
Methylpred 125 mg IV x1.

On arrival to the MICU,  ___ y/o ___ man with 
multiple medical problems most notable for HTN, COPD, HFpEF, 
Afib on Coumadin who presents with dyspnea. Of note, the patient 
was discharged on ___ following treatment for community 
acquired pneumonia. The patient was found to have RML 
consolidation, initially treated with IV CTX and Azithromycin 
and transitioned to Levofloxacin x7 day total course (last day 
___.

 

###RESPONSE: problems {Problem}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, HFpEF {Heart failure with normal ejection fraction}, Afib {Atrial fibrillation}, Coumadin {Anticoagulant therapy}, dyspnea {Dyspnea}, community acquired pneumonia {Community acquired pneumonia}, RML {Right middle zone pneumonia}, consolidation {Consolidation}, IV {Administration of drug or medicament via intravenous route}, dyspnea {Dyspnea}, hypoxic {Hypoxia}, hypertensive {Finding of increased blood pressure}, BiPAP {Bilevel positive airway pressure titration}, vitals {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, cpap {Continuous positive airway pressure ventilation treatment}, respiratory distress {Respiratory distress}, No evidence {No abnormality detected}, JVD {Jugular venous engorgement}, edema {Edema}, IV {Administration of drug or medicament via intravenous route}, problems {Problem}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, HFpEF {Heart failure with normal ejection fraction}, Afib {Atrial fibrillation}, Coumadin {Anticoagulant therapy}, dyspnea {Dyspnea}, community 
acquired pneumonia {Community acquired pneumonia}, RML {Right middle zone pneumonia}, consolidation {Consolidation}, IV {Administration of drug or medicament via intravenous route}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
- Hyperlipidemia
- Hypertension   
- COPD  
- CHF  
- Atrial fibrillation (CHADS=3)  
- Gout   
 

###RESPONSE: Hyperlipidemia {Hyperlipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, CHF {Congestive heart failure}, Atrial fibrillation {Atrial fibrillation}, Gout {Inflammatory disorder due to increased blood urate level}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
No cardiac disease, HTN, DM in family.
 

###RESPONSE: cardiac disease {Heart disease}, HTN {Hypertensive disorder, systemic arterial}, DM {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:
ON ADMISSION:
=============
Vitals-  T 97.9 BP138/67 HR78 RR20 SaO2 98RA
GENERAL: Alert, oriented, no acute distress  
HEENT: Sclera anicteric, MMM, oropharynx clear  
NECK: supple, JVP not elevated, no LAD  
LUNGS: Clear to auscultation bilaterally, no wheezes, rales, 
rhonchi  
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, 
gallops  
ABD: soft, non-tender, non-distended, bowel sounds present, no 
rebound tenderness or guarding, no organomegaly  
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema
  
ON DISCHARGE:
=============
Vitals- T 97.7 Tmax98.1 BP 126-148/64-87 HR ___ RR ___ 98% 
RA
General- Alert, oriented, no acute distress, seated in chair at 
bedside  
HEENT- Sclera anicteric, MMM, oropharynx clear  
Neck- supple, JVP not elevated, no LAD  
Lungs- Minimal wheezes diffusely, decreased breath sounds at 
bases
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, 
gallops  
Abdomen- soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding, no organomegaly  
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
Neuro- Moving all 4 limbs without focal neuro deficits
 

###RESPONSE: Vitals {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}, Alert {Mentally alert}, oriented {Orientated}, 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}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, ABD {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, EXT {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, Alert {Mentally alert}, oriented {Oriented to person}, distress {Distress}, seated {Sitting position}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, Neck- supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, wheezes {Wheezing}, decreased breath sounds {Decreased breath sounds}, bases {Structure of base of lung}, Regular rate and rhythm {Normal heart rate}, normal S1 + S2 {Heart sounds normal}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen- soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound tenderness {Rebound tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Moving all 4 limbs {Does move all four limbs}, neuro deficits {Neurological deficit}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ON ADMISSION:
=============
___ 09:24PM BLOOD WBC-9.5 RBC-5.11 Hgb-10.9* Hct-35.7* 
MCV-70* MCH-21.3* MCHC-30.5* RDW-17.9* RDWSD-42.6 Plt ___
___ 09:24PM BLOOD Neuts-55.6 ___ Monos-9.8 Eos-3.5 
Baso-0.7 Im ___ AbsNeut-5.25 AbsLymp-2.85 AbsMono-0.93* 
AbsEos-0.33 AbsBaso-0.07
___ 09:24PM BLOOD ___ PTT-37.6* ___
___ 09:24PM BLOOD Plt ___
___ 09:24PM BLOOD Glucose-138* UreaN-16 Creat-1.3* Na-137 
K-3.9 Cl-96 HCO3-28 AnGap-17
___ 09:24PM BLOOD ALT-14 AST-24 AlkPhos-112 TotBili-0.3
___ 09:24PM BLOOD proBNP-1603*
___ 09:24PM BLOOD cTropnT-<0.01
___ 02:53PM BLOOD CK-MB-3 cTropnT-0.03*
___ 09:24PM BLOOD Albumin-4.1
___ 09:28PM BLOOD ___ pO2-36* pCO2-66* pH-7.29* 
calTCO2-33* Base XS-2
___ 09:28PM BLOOD Lactate-1.3

STUDIES AND IMAGING
___ PORTABLE CXR
Resolved pneumonia.  Limited evaluation of the lung apices.  No 
convincing 
evidence for pneumonia or edema. 

ON DISCHARGE:
=============
___ 06:45AM BLOOD WBC-10.0 RBC-4.89 Hgb-10.4* Hct-33.5* 
MCV-69* MCH-21.3* MCHC-31.0* RDW-18.0* RDWSD-41.5 Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-116* UreaN-23* Creat-1.0 Na-136 
K-3.8 Cl-95* HCO3-33* AnGap-12
___ 06:45AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.7
___ 07:45AM BLOOD Lactate-2.___ old ___ man, ___'s Witness, with dCHF, HTN, 
COPD, AF on coumadin p/w dyspnea, without pain. 

MICU COURSE:
============
# Hypercarbic respiratory failure. Pt admitted after course of 
treatment for CAP with increased dyspnea.  In the the MICU, put 
on BiPAP, PEEP8 FiO2 50% on arrival, breathing comfortably. 
Received ipratropium/albuterol nebs x3, methylprednisolone in 
the ED. Given the findings of the chest X-ray showing 
hyperinflated lungs, there was an initial concern is for COPD 
exacerbation. Patient started on standing duonebs, prn 
albuterol, azithromycin: 500mg x 1, 250mg x 4 days and 
prednisone 40 mg daily for five day course.  However, on ___ 
lactate noted to be uptrending from 3.4 to 5.5 despite fluids 
and IV thiamine.  CXR at this time showed RLL consolidation, 
started Vanc/Cefepime for ___ vs aspiration PNA. Speech/swallow 
eval was ordered but no frank aspiration noted at bedside.  Of 
note, he was going to be called out to the medical floor on 
___ but lactate persistently elevated to 3's. Given no other 
signs of hypoperfusion, ICU team attributed his elevated lactate 
to frequent nebs.  

FLOOR COURSE:
=============
#Acute COPD exacerbation: Continued treatment for ___ and COPD 
exacerbation with 7 day course of Levofloxacin (first day ___, 
last day ___ and 5 days of prednisone (first day ___, last 
day ___. BNP was at his baseline at roughly 1600. Patient was 
on standing duonebs and albuterol PRN.

#Leukocytosis: Initially elevated then improved to 10 on ___. 
Likely secondary to prednisone.

#Acute Renal Failure: Creatinine initially 1.3 and held home 
bumetanide. Creatinine down to 1.0 on ___.

CHRONIC ISSUES  
#dCHF: Creatinine initially 1.3 and held home bumetanide. 
Restarted home bumetanide 3.5mg daily, clinically appears 
euvolemic on exam.

#HTN: Continued carvedilol, valsartan, diltiazem
  
#AF: Rate controlled, continued home diltiazem and carvedilol. 
Warfarin held for INR 3.4 on ___. 

#Gout: Continued allopurinol.

#Anemia:  Microcytic anemia with low iron in ___ gave 1 
dose ferric gluconate here. Can work up further as outpatient if 
within patients goals of care.

***TRANSITIONAL ISSUES:***
- Continue Levofloxacin 750mg PO QDay until last day ___
- Warfarin held for supratherapeutic INR (INR 3.4 on ___, INR 
needs to be monitored and Warfarin restarted accordingly
- Consider anemia work up as outpatient
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, Albumin {Albumin measurement}, pH {pH measurement}, CXR {Plain chest X-ray}, Resolved {Problem resolved}, pneumonia {Pneumonia}, evaluation {Evaluation procedure}, lung apices {Structure of apex of lung}, pneumonia {Pneumonia}, edema {Edema}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, dCHF {Chronic diastolic heart failure}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, AF {Atrial fibrillation}, coumadin {Anticoagulant therapy}, dyspnea {Dyspnea}, without pain {No present pain}, Hypercarbic respiratory failure {Hypercapnic respiratory failure}, CAP {Community acquired pneumonia}, dyspnea {Dyspnea}, BiPAP {Bilevel positive airway pressure titration}, breathing comfortably {Breathing easily}, chest X-ray {Plain chest X-ray}, hyperinflated {Chest over-expanded}, COPD 
exacerbation {Acute exacerbation of chronic obstructive airways disease}, fluids {Administration of fluid therapy}, IV {Administration of drug or medicament via intravenous route}, CXR {Plain chest X-ray}, RLL {Structure of lower lobe of right lung}, consolidation {Consolidation}, aspiration PNA {Aspiration pneumonia}, Speech/swallow 
eval {Evaluation of oral and pharyngeal swallowing function}, aspiration {Pulmonary aspiration}, signs {Sign}, Acute COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD 
exacerbation {Acute exacerbation of chronic obstructive airways disease}, BNP {Brain natriuretic peptide measurement}, baseline {Baseline state}, Leukocytosis {Leukocytosis}, improved {Patient's condition improved}, Acute Renal Failure {Acute kidney injury}, Creatinine {Creatinine measurement}, Creatinine {Creatinine measurement}, CHRONIC ISSUES {Chronic disease}, dCHF {Chronic diastolic heart failure}, Creatinine {Creatinine measurement}, euvolemic {Normal blood volume}, exam {Physical examination procedure}, HTN {Hypertensive disorder, systemic arterial}, AF {Atrial fibrillation}, Gout {Inflammatory disorder due to increased blood urate level}, Anemia {Anemia}, Microcytic anemia {Microcytic anemia}, work up {Evaluation procedure}, anemia {Anemia}, work up {Evaluation procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN pain 
2. albuterol sulfate 2.5 /3 mL (0.083 %) INHALATION BID:PRN 
shortness of breath 
3. Allopurinol ___ mg PO DAILY 
4. Benzonatate 100 mg PO TID 
5. Bumetanide 3.5 mg PO DAILY 
6. Carvedilol 6.25 mg PO BID 
7. Diltiazem Extended-Release 120 mg PO DAILY 
8. Docusate Sodium 200 mg PO BID 
9. Fluticasone Propionate 110mcg 2 PUFF IH BID 
10. Ipratropium Bromide Neb 1 NEB IH BID 
11. Senna 8.6 mg PO BID 
12. Valsartan 40 mg PO BID 
13. Warfarin 4 mg PO DAILY16 

 
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN pain 
2. albuterol sulfate 2.5 /3 mL (0.083 %) INHALATION BID:PRN 
shortness of breath 
3. Allopurinol ___ mg PO DAILY 
4. Benzonatate 100 mg PO TID 
5. Bumetanide 3.5 mg PO DAILY 
6. Carvedilol 6.25 mg PO BID 
7. Diltiazem Extended-Release 120 mg PO DAILY 
8. Docusate Sodium 200 mg PO BID 
9. Fluticasone Propionate 110mcg 2 PUFF IH BID 
10. Senna 8.6 mg PO BID 
11. Valsartan 40 mg PO BID 
12. Ipratropium Bromide Neb 1 NEB IH BID 
13. Levofloxacin 750 mg PO DAILY 
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*2 
Tablet Refills:*0

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary:
Hypercapnia Respiratory Failure
COPD exacerbation
___

Secondary:
___
HTN
Atrial fibrillation
Gout
Anemia

 
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}, Hypercapnia Respiratory Failure {Hypercapnic respiratory failure}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, HTN {Hypertensive disorder, systemic arterial}, Atrial fibrillation {Atrial fibrillation}, Gout {Inflammatory disorder due to increased blood urate level}, Anemia {Anemia}, Mental Status {Neurological mental status determination}, Alert {Mentally alert}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___,

You were admitted to ___ on ___ because you were having 
trouble breathing. We found that you were having a severe 
exacerbation of your COPD as well as pneumonia. We treated you 
with antibiotics and steroids and your breathing improved. You 
were also found to have an acute injury of the kidneys, but we 
gave you fluids and your kidneys recovered.

It was a pleasure taking care of you!
-Your BI___ team
 

###RESPONSE: trouble breathing {Difficulty breathing}, COPD {Chronic obstructive lung disease}, pneumonia {Pneumonia}, antibiotics {Antibiotic therapy}, steroids {Steroid therapy}, improved {Patient's condition improved}, injury {Traumatic or non-traumatic injury}, kidneys {Kidney structure}, fluids {Administration of fluid therapy}, kidneys recovered {Normal renal function}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Right non-healing foot ulcer
 
Major Surgical or Invasive Procedure:
Right lower extremity Angiogram with stent placement to the 
distal SFA/popliteal artery.

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, healing {Structure resulting from tissue repair process}, foot ulcer {Ulcer of foot}, Right lower extremity Angiogram {Angiography of artery of right lower limb}, stent placement {Placement of stent}, SFA {Structure of superficial femoral artery}, popliteal artery {Structure of popliteal artery}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ presents with chronic right
calcaneal ulcer. It has been present for approximately 6 months.
She also reports calf pain on ambulation to suggest 
claudication. Her foot ulcer has been followed by podiatry.  She 
presents for a RLE angiogram for further evaluation and possible 
intervention of RLE peripheral vascular disease.

 

###RESPONSE: chronic right
calcaneal ulcer {Chronic ulcer of right heel}, calf pain {Pain in calf}, ambulation {Pain aggravated by walking}, claudication {Intermittent claudication}, foot ulcer {Ulcer of foot}, RLE angiogram {Angiography of artery of right lower limb}, evaluation {Evaluation procedure}, RLE {Structure of right lower limb}, peripheral vascular disease {Peripheral vascular 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: Past Medical History:
- CAD, s/p stent ___
- Non-healing foot wound
- Diabetes Mellitus , type II 
- Hypertension  
- Hyperlipidemia
- anxiety
 
 

###RESPONSE: CAD {Coronary arteriosclerosis}, stent {Insertion of arterial stent}, Non-healing foot wound {Chronic ulcer of right foot}, Diabetes Mellitus , type II {Diabetes mellitus type 2}, Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, anxiety {Anxiety}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
significant for CAD in father and diabetes mellitis, type II in 
mother

 
Physical ___:
Vital Signs: 98.3  79  150/79  18  98%/RA
General: alert and oriented x 3, lying in bed in NAD
HEENT: atraumatic, skin anicteric, MMM, no lymphadenopathy 
appreciated
CV: RRR
Pulm: breathing unlabored
Abd: Soft, NT, ND
Left groin puncture site: well approximated, soft, no 
ecchymosis, no drainage
Extremities: 
Pulses: (___):
R: P/ /D/faintly palpable L: P/ /D/D
 

###RESPONSE: CAD {Coronary arteriosclerosis}, diabetes mellitis, type II {Diabetes mellitus type 2}, Vital Signs {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, alert {Mentally alert}, oriented x 3 {Oriented to person, time and place}, lying in bed {Lying in bed}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, atraumatic {No injuries apparent}, skin anicteric {Normal color of skin}, MMM {Moist oral mucosa}, lymphadenopathy {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, Pulm {Examination of respiratory system}, unlabored {Breathing easily}, Abd {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, Left groin {Left inguinal region structure}, puncture site {Insertion site}, well approximated {Wound healing well}, soft {Abdomen soft}, ecchymosis {Ecchymosis}, drainage {Wound discharge}, Extremities {Examination of limb}, Pulses {Normal pulse}, palpable {Finding by palpation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:02AM BLOOD Hct-31.9*
___ 06:02AM BLOOD Creat-0.8 K-4.___ with PMH signifcant for CAD, s/p stenting in ___, HTN, DM, 
and HLD who presents with a 6 month history of a non-healing 
right heel ulcer. She was admitted on ___ for a right lower 
extremity angiogram.  As a result of findings, a bare metal 
stent was placed in  distal SFA/popliteal artery and at the end 
of the case, patient had dopplerable ___ signals bilaterally.  
For full details of the surgical procedure please see the 
dictated operative report. Patient tolerated the procedure well. 
 She requested to stay over night which provided opportunity for 
continued monitoring of her groin puncture site. She did have 
some bleeding overnight which was quickly controlled with manual 
pressure.  It continues to do well and on exam has no further 
drainage. Her diet was advanced to a house diet which she 
tolerated well.  She was able to void on her own QS and was able 
to ambulate with her walker in her room.

Paient had a bare metal stent placed in her distal SFA which 
will require a 30 day course of clopidogrel.  Patient reports a 
history of clopidogrel use since placement of coronary stents in 
___ but she reports she no longer requires it.  She was advised 
to follow up with cardiology for further guidance on that.  She 
should continue her daily ASA 81mg.

Patient has a PMH of Diabetes Mellitus which was stable during 
admission.  Her home medication, metformin was held and her 
blood sugars were addressed with SSI.

Patient has a PMH of HTN, which was stable during admission, 
however, the patient had some confusion about which doses and 
medications she should be taking.  The PCP office, Dr. ___, 
as well as the pharmacy, was contacted by this author and 
several discrepancies were found between patient's recollection 
and PCPs recommendations.  ___ services have been arranged to 
follow the patient after discharge and a request was made to 
have the RN complete a medication reconciliation with the 
patient at home.  The current medication list from this 
discharge is complete and accurate per the PCP ___. PCP ___ 
follow up with ___ findings at patient's follow up appt.

Patient will also need to follow up with vascular surgery for a 
RLE duplex and office visit in approximately 1 month. Patient 
should continue to follow up with Podiatry for her right heel 
ulcer and should off-load the heel to assist with healing.

Patient is discharged home with services in an improved and 
stable condition.

 
 

###RESPONSE: Hct {Hematocrit determination}, Creat {Creatinine measurement}, K {Blood potassium measurement}, CAD {Coronary arteriosclerosis}, stenting {Insertion of arterial stent}, HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, HLD {Hyperlipidemia}, non-healing 
right heel ulcer. {Chronic ulcer of right heel}, right lower 
extremity angiogram {Angiography of artery of right lower limb}, stent was placed {Placement of stent}, SFA/popliteal artery {Femoral and popliteal arteries (combined site)}, surgical procedure {Surgical procedure}, procedure {Procedure}, monitoring {Monitoring procedure}, groin {Inguinal region structure}, puncture site {Insertion site}, bleeding {Bleeding}, pressure {Application of dressing, pressure}, drainage {Wound discharge}, diet was advanced {Advance diet as tolerated}, diet {Dietary regime}, able to void {Normal micturition}, able 
to ambulate {Able to walk}, walker {Uses zimmer frame}, stent placed {Placement of stent}, SFA {Structure of superficial femoral artery}, placement of coronary stents {Placement of stent in coronary artery}, follow up with cardiology {Follow-up cardiac assessment}, Diabetes Mellitus {Diabetes mellitus}, stable {Patient's condition stable}, blood sugars {Blood sugar management}, SSI {Sliding scale insulin regime}, HTN {Hypertensive disorder, systemic arterial}, stable {Patient's condition stable}, PCP {Primary care management}, PCP {Primary care management}, medication reconciliation {Medication reconciliation}, PCP {Primary care management}, PCP {Primary care management}, vascular surgery {Vascular surgery procedure}, RLE {Structure of right lower limb}, duplex {Duplex ultrasonography of veins of lower limb}, right heel {Structure of right heel}, heel {Heel structure}, healing {Structure resulting from tissue repair process}, improved {Patient's condition improved}, stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY 
2. amLODIPine 5 mg PO DAILY 
3. Clopidogrel 75 mg PO DAILY 
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 
5. losartan 50 mg oral DAILY 
6. MetFORMIN (Glucophage) 1000 mg PO TAKE 500MG IN AM AND 1000MG 
IN ___ 
7. Omeprazole 20 mg PO DAILY 
8. Pravastatin 10 mg PO QPM 
9. RisperiDONE 1 mg PO DAILY 
10. Collagenase Ointment 1 Appl TP DAILY 

 
Discharge Medications:
1.  Acetaminophen 1000 mg PO Q8H  
2.  Clopidogrel 75 mg PO DAILY 
Take for 30 days only 
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 
Tablet Refills:*0 
3.  amLODIPine 5 mg PO DAILY  
4.  Aspirin 81 mg PO DAILY  
5.  Collagenase Ointment 1 Appl TP DAILY  
6.  Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID  
7.  Losartan Potassium 50 mg PO DAILY  
8.  losartan 50 mg oral DAILY  
9.  MetFORMIN (Glucophage) 1000 mg PO TAKE 500MG IN AM AND 
1000MG IN ___  
10.  Omeprazole 20 mg PO DAILY  
11.  Pravastatin 10 mg PO QPM  
12.  RisperiDONE 1 mg PO DAILY  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary: Peripheral vascular disease with non-healing ulcer

Secondary: Diabetes Mellitus- type II, Hypertension, 
hyperlipidemia

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Home With Service {Home health aide service management}, Peripheral vascular disease {Peripheral vascular disease}, healing ulcer {Healing ulcer}, Diabetes Mellitus- type II {Diabetes mellitus type 2}, Hypertension {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Ms. ___,

It was a pleasure taking care of you at ___ 
___.  You were admitted to the hospital after a 
peripheral angiogram.   To do the test, a small puncture was 
made in one of your arteries.  The puncture site heals on its 
own: there are no stitches to remove.   You tolerated the 
procedure well and are now ready to be discharged from the 
hospital.   Please follow the recommendations below to ensure a 
speedy and uneventful recovery.

Peripheral Angiography
Puncture Site Care
For one week:
•Do not take a tub bath, go swimming or use a Jacuzzi or hot 
tub.
•Use only mild soap and water to gently clean the area around 
the puncture site. 
•Gently pat the puncture site dry after showering. 
•Do not use powders, lotions, or ointments in the area of the 
puncture site. 

You may remove the bandage and shower the day after the 
procedure.  You may leave the bandage off. 
You may have a small bruise around the puncture site.  This is 
normal and will go away one-two weeks. 
Activity 
For the first 48 hours: 
•Do not drive for 48 hours after the procedure
For the first week:
•Do not lift, push , pull or carry anything heavier than 10 
pounds
•Do not do any exercises or activity that causes you to hold 
your breath or bear down with abdominal muscles.   Take care not 
to put strain on your abdominal muscles when coughing, sneezing, 
or moving your bowels.
After one week:
•You may go back to all your regular activities, including 
sexual activity.  We suggest you begin your exercise program at 
half of your usual routine for the first few days.   You may 
then gradually work back to your full routine.
Medications:
Before you leave the hospital, you will be given a list of all 
the medicine you should take at home.  If a medication that you 
normally take is not on the list or a medication that you do not 
take is on the list please discuss it with the team!  

For  Problems or Questions:
Call ___ in an emergency such as:
•Sudden, brisk bleeding or swelling at the groin puncture site 
that does not stop after applying pressure for ___ minutes
•Bleeding that is associated with nausea, weakness, or 
fainting.
Call the vascular surgery office (___) right away if 
you have any of the following. (Please note that someone is 
available 24 hours a day, 7 days a week)
•Swelling, bleeding, drainage, or discomfort at the puncture 
site that is new or increasing since discharge from the hospital
•Any change in sensation or temperature in your legs
•Fever of 101 or greater
•Any questions or concerns about recovery from your angiogram 

 

###RESPONSE: angiogram {Angiography}, puncture {Puncture}, arteries {Arterial structure}, puncture site {Insertion site}, stitches {Removal of suture}, procedure {Procedure}, Peripheral Angiography {Angiography of peripheral vascular system}, Puncture Site {Insertion site}, puncture site {Insertion site}, puncture site {Insertion site}, puncture site {Insertion site}, shower {Functional activity education}, procedure {Procedure}, bruise {Contusion}, puncture site {Insertion site}, normal {No abnormality detected}, Activity {Functional activity education}, Do not drive {Recommendation to avoid activity of daily living}, procedure {Procedure}, lift {Does lift}, push {Does push}, pull {Does pull}, carry {Does carry}, exercises {Exercises}, activity {Functional activity education}, abdominal muscles {Entire skeletal muscle of abdomen}, strain {Muscle strain}, abdominal muscles {Entire skeletal muscle of abdomen}, coughing {Cough}, sneezing {Sneezing}, bowels {Intestinal structure}, activities {Functional activity education}, sexual activity {Finding relating to sexual behavior}, exercise {Exercises}, bleeding {Bleeding}, swelling {Swelling}, groin {Inguinal region structure}, puncture site {Insertion site}, pressure {Application of dressing, pressure}, Bleeding {Bleeding}, nausea {Nausea}, weakness {Asthenia}, fainting {Syncope}, Swelling {Swelling}, bleeding {Bleeding}, drainage {Wound discharge}, discomfort {Discomfort}, puncture 
site {Insertion site}, change in sensation {Altered sensation of skin}, temperature {Body temperature finding}, legs {Lower limb structure}, Fever {Fever}, angiogram {Angiography}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Bactrim / Ampicillin / Sulfa (Sulfonamide Antibiotics) / 
cefuroxime / Gadolinium-Containing Contrast Media / gluten / 
nadolol / Pneumovax 23
 
Attending: ___
 
Chief Complaint:
low grade fevers, abdominal pain  
 
Major Surgical or Invasive Procedure:
___ line placement

 

###RESPONSE: Ampicillin {Allergy to ampicillin}, Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, 
cefuroxime {Allergy to cefuroxime}, Contrast Media {Allergy to contrast media}, gluten {Allergy to gluten}, nadolol {Allergy to nadolol}, low grade fevers {Low grade pyrexia}, abdominal pain {Abdominal pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mrs. ___ is a ___ year-old lady with a history of cirrhosis 
due to PSC complicated by ascites, encephalopathy and varices 
being admitted directly from clinic due to low grade fevers and 
abdominal pain in the setting of recurrent ascending 
cholangitis.  
Mrs. ___ has been having chill and low grade fevers 
(100.0-100.4) with a peak temperature at 100.7 today. She has 
also been having RUQ discomfort, nausea requiring her to take 
her prn ondansetron. She also reports some mild arthralgias and 
fatigue that are typical for her when she has an episode of 
cholangitis.  
In clinic , initial vitals were: 98.5 | 114/53 | 84 | 16 | 99%RA 
 
Labs were notable for:  
*CBC: 5.2 > 10.5/34.0 < 266  
*Na 140 | K 4.3 | Cl 101 | HCO3 29 | BUN 13 | Cr 0.7  
*AST 51 | ALT 46 | AP 292 | TB 1.1 | INR 1.2  
*UA negative  
*1xBCx drawn  
Patient was directly admitted to ___ 10.  
Currently, she complains of mild nausea and abdominal 
discomfort. Does not feel feverish anymore. Denies recent gluten 
exposure although household not gluten-free, uses same pots and 
pans.  
 

###RESPONSE: cirrhosis {Cirrhosis of liver}, PSC {Primary sclerosing cholangitis}, ascites {Ascites}, encephalopathy {Disorder of brain}, varices {Esophageal varices}, low grade fevers {Low grade pyrexia}, abdominal pain {Abdominal pain}, ascending 
cholangitis {Ascending cholangitis}, chill {Chill}, low grade fevers {Low grade pyrexia}, temperature {Body temperature finding}, RUQ {Right upper quadrant pain}, discomfort {Discomfort}, nausea {Nausea}, mild {Symptom mild}, arthralgias {Joint pain}, fatigue {Fatigue}, cholangitis {Cholangitis}, vitals {Vital signs finding}, RA {Breathing room air}, CBC {Complete blood count}, UA {Urinalysis}, negative {No abnormality detected}, mild {Symptom mild}, nausea {Nausea}, abdominal 
discomfort {Abdominal discomfort}, feel feverish {Feeling feverish}, gluten {Allergy to gluten}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
PAST MEDICAL HISTORY:
- Primary sclerosing cholangitis (PSC)
- History of recurrent cholangitis requiring hospitalization and 

IV antibiotics
- ___ Laparoscopic cholecystectomy with liver biopsy 
showing bile ductular proliferation and very focal early, 
incomplete 
nodule formation (stage ___ fibrosis)
- Celiac sprue (diagnosed by biopsy, slightly elevated tTG) 
- Hypertension
- GERD  
- Hypothyroidim  
- OSA previously on CPAP - negative on repeat testing  
- (?) IBD (Crohn disease diagnosed at ___ at the age of ___, but 
questionable diagnosis as no symptoms for over ___
 

###RESPONSE: Primary sclerosing cholangitis {Primary sclerosing cholangitis}, recurrent cholangitis {Recurrent cholangitis}, IV antibiotics {Intravenous antibiotic therapy}, Laparoscopic cholecystectomy {Laparoscopic cholecystectomy}, liver biopsy {Biopsy of liver}, nodule {Nodule}, fibrosis {Fibrosis}, Celiac sprue {Celiac disease}, biopsy {Biopsy}, elevated {Measurement finding above reference range}, tTG {Serum tissue transglutaminase level}, Hypertension {Hypertensive disorder, systemic arterial}, GERD {Gastroesophageal reflux disease}, Hypothyroidim {Hypothyroidism}, OSA {Obstructive sleep apnea syndrome}, on CPAP {Dependence on continuous positive airway pressure ventilation}, negative {No abnormality detected}, IBD {Inflammatory bowel disease}, Crohn disease {Crohn's disease}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Daughter has ___ disease. The patient denies a history of 
premature cardiac disease such as MI, arrhythmia or sudden 
cardiac death. No history of liver disease. Sister with 
endometrial cancer and thyroid condition. Other sister and a 
brother with thyroid condition. Father with CAD, DM. Mother with 
thyroid disease and peritoneal cancer.
 

###RESPONSE: cardiac disease {Heart disease}, MI {Myocardial infarction}, arrhythmia {Cardiac arrhythmia}, sudden 
cardiac death {Sudden cardiac death}, liver disease {Disorder of liver}, endometrial cancer {Endometrial carcinoma}, thyroid condition {Disorder of thyroid gland}, thyroid condition {Disorder of thyroid gland}, CAD {Coronary arteriosclerosis}, DM {Diabetes mellitus}, thyroid disease {Disorder of thyroid gland}, peritoneal cancer {Malignant tumor of peritoneum}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION EXAM: 
===============
VS: 98.7 | 108/60 | 76 | 18 | 98%RA  
General: Well-appearing, alert and oriented, no acute distress  
HEENT: No scleral icterus or conjunctival pallor, MMM  
Neck: No JVD, no LAD  
CV: RRR, no murmurs/rubs/gallops  
Lungs: Clear to auscultation bilaterally  
Abdomen: non-distended, soft, mild tenderness in RUQ, no rebound 
 
GU: no Foley  
Ext: WWP, 1+ bilateral lower extremity edema  
Neuro: AOx3, no asterixis, fluent speech, no focal deficits  
Skin: Tanned skin, no lesions  

DISCHARGE EXAM:
===============
VS: 98.6 tm: 98.8 67 (64-72) 101/51 (95-108/46-58) 18 100RA  
General: Well-appearing, alert and oriented, no acute distress  
HEENT: No scleral icterus or conjunctival pallor, MMM  
Neck: No JVD, no LAD  
CV: RRR, ___ systolic ejection murmur, no rubs/gallops  
Lungs: Clear to auscultation bilaterally  
Abdomen: non-distended, soft, mild tenderness in RUQ, no rebound 
 
GU: no Foley  
Ext: WWP, 1+ bilateral lower extremity edema  
Neuro: AOx3 fluent speech, no focal deficits  
Skin: Tanned skin, no lesions 
 

###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, Well-appearing {Well cared for appearance}, alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, scleral icterus {Scleral icterus}, conjunctival pallor {Pale conjunctiva}, MMM {Moist oral mucosa}, Neck {Physical examination procedure}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, Abdomen {Examination of abdomen}, non-distended {Normal abdominal contour}, soft {Abdomen soft}, mild {Symptom mild}, tenderness {Tenderness}, RUQ {Structure of right upper quadrant of abdomen}, rebound {Rebound tenderness}, GU {Examination of genitourinary system}, Foley {Urinary catheter in situ}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, edema {Edema}, Neuro {Neurological examination}, AOx3 {Oriented to person, time and place}, asterixis {Asterixis}, fluent speech {Finding of fluency of speech}, no focal deficits {Normal nervous system function}, Skin {Examination of skin}, lesions {Lesion}, VS {Vital signs finding}, General {General examination of patient}, Well-appearing {Well cared for appearance}, alert {Mentally alert}, oriented {Oriented to person}, distress {Distress}, scleral icterus {Scleral icterus}, conjunctival pallor {Pale conjunctiva}, MMM {Moist oral mucosa}, Neck {Neck structure}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, systolic ejection murmur {Systolic murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, mild {Symptom mild}, tenderness {Tenderness}, RUQ {Structure of right upper quadrant of abdomen}, rebound {Rebound tenderness}, GU {Examination of genitourinary system}, Foley {Urinary catheter in situ}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, bilateral lower extremity edema {Edema of bilateral lower limbs}, Neuro {Neurological examination}, AOx3 {Oriented to person, time and place}, fluent speech {Finding of fluency of speech}, no focal deficits {Normal nervous system function}, Skin {Examination of skin}, lesions {Skin lesion}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
===============
___ 11:15AM BLOOD WBC-5.2 RBC-3.99 Hgb-10.5* Hct-34.0 
MCV-85 MCH-26.3 MCHC-30.9* RDW-22.2* RDWSD-68.0* Plt ___
___ 11:15AM BLOOD Neuts-67.0 Lymphs-12.8* Monos-15.3* 
Eos-3.9 Baso-0.8 Im ___ AbsNeut-3.45 AbsLymp-0.66* 
AbsMono-0.79 AbsEos-0.20 AbsBaso-0.04
___ 11:15AM BLOOD ___
___ 11:15AM BLOOD UreaN-13 Creat-0.7 Na-140 K-4.3 Cl-101 
HCO3-29 AnGap-14
___ 11:15AM BLOOD ALT-46* AST-51* AlkPhos-292* TotBili-1.1
___ 11:15AM BLOOD Albumin-4.2
___ 11:15AM BLOOD AFP-2.0

MICROBIOLOGY: 
==============
URINE CULTURE (Final ___:    NO GROWTH. 

Blood culture x3: PENDING, NGTD

DISCHARGE LABS:
===============

___ 06:24AM BLOOD WBC-3.4* RBC-3.57* Hgb-9.5* Hct-31.2* 
MCV-87 MCH-26.6 MCHC-30.4* RDW-22.3* RDWSD-71.2* Plt ___
___ 06:24AM BLOOD ___ PTT-39.9* ___
___ 06:24AM BLOOD Glucose-119* UreaN-9 Creat-0.5 Na-141 
K-4.2 Cl-107 HCO3-26 AnGap-12
___ 06:24AM BLOOD ALT-31 AST-30 AlkPhos-257* TotBili-0.6
___ 06:24AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, MICROBIOLOGY {Microbiology}, URINE CULTURE {Urine culture}, Blood culture {Blood culture}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Mrs. ___ is a ___ year-old woman with a history of cirrhosis 
due to PSC complicated by ascites, encephalopathy and varices 
being admitted directly from clinic due to low grade fevers and 
abdominal pain in the setting of history of recurrent ascending 
cholangitis.  

#FEVERS/RUQ tenderness: Low grade fever at home with RUQ 
discomfort and associated nausea. On presentation she was 
afebrile and hemodynamically stable. She was found to have no 
leukocytosis and her LFTS were at baseline, AST: 51, ALT: 46, 
AP: 292, Tb: 1.1.  Lipase was WNL. MRCP was not done given her 
recent unchanged MRCP in ___.  Given her history of recurrent 
ascending cholangitis with resistant organisms, treatment for 
presumed cholangitis was initiated.  Blood cultures were sent, 
with no growth to date. Hepatology was consulted and she was 
initially started on meropenem per their recommendations. She 
was then switched to cefepime/flagyl which she tolerated well. 
Her pain and nausea improved and she continued to be afebrile 
and hemodynamically stable.  A picc line was placed and she 
ultimately was switched to ertapenem on discharge for a total 14 
day course. 

#PSC: There was low concern for new stenotic lesion given recent 
stable MRCP in ___. She was continued on her home ursodiol, 
cholestyramine and hydroxyzine.   

# CIRRHOSIS: Due to PSC. Childs class B. MELD 9. She was 
continued on rifaximin. Her home diuretics were held in the 
setting of infection. They were not resumed on discharge given 
soft blood pressures in the ___ range.
* Transplant status: unclear  
* Hepatic encephalopathy: Cont rifaximin, only takes lactulose 
prn  
* Fluid status: holding diuretics  
* h/o SBP: no hx, protein 0.9
* Variceal status: 2x grade II varices s/p banding  

TRANSITIONAL ISSUES:
=====================
- Lasix and spironolactone were held in the setting of 
infection, blood pressures lower than baseline thoughout 
admission without evidence of volume overload, please 
re-evaluate at follow-up appointment 
- f/u blood cx
- receiving ertapenem 1G daily via ___ line with ___ services, 
will need PICC removed after last day of antibiotics on ___
 

###RESPONSE: cirrhosis {Cirrhosis of liver}, PSC {Primary sclerosing cholangitis}, ascites {Ascites}, encephalopathy {Disorder of brain}, varices {Esophageal varices}, low grade fevers {Low grade pyrexia}, abdominal pain {Abdominal pain}, ascending 
cholangitis {Ascending cholangitis}, FEVERS {Fever}, RUQ tenderness {Tenderness of right upper quadrant of abdomen}, Low grade fever {Low grade pyrexia}, RUQ {Right upper quadrant pain}, discomfort {Discomfort}, nausea {Nausea}, afebrile {Temperature normal}, hemodynamically stable {Hemodynamically stable}, leukocytosis {Leukocytosis}, LFTS {Hepatic function panel}, baseline {Baseline state}, AST {Aspartate aminotransferase measurement}, ALT {Alanine aminotransferase measurement}, AP {Alkaline phosphatase measurement}, Tb {Finding of bilirubin level}, Lipase {Serum lipase measurement}, WNL {No abnormality detected}, MRCP {Magnetic resonance cholangiopancreatography}, MRCP {Magnetic resonance cholangiopancreatography}, ascending cholangitis {Ascending cholangitis}, cholangitis {Cholangitis}, Blood cultures {Blood culture}, pain {Abdominal pain}, nausea {Nausea}, improved {Patient's condition improved}, afebrile {Fever}, hemodynamically stable {Hemodynamically stable}, picc line was placed {Percutaneous transluminal insertion of peripherally inserted central catheter}, PSC {Primary sclerosing cholangitis}, stenotic lesion {Stenosis of bile duct}, MRCP {Magnetic resonance cholangiopancreatography}, CIRRHOSIS {Cirrhosis of liver}, PSC {Primary sclerosing cholangitis}, diuretics {Diuretic therapy}, infection {Infectious disease}, soft blood pressures {Low blood pressure}, Hepatic encephalopathy {Hepatic encephalopathy}, diuretics {Diuretic therapy}, SBP {Primary bacterial peritonitis}, varices {Esophageal varices}, banding {Banding}, infection {Infectious disease}, blood pressures lower than baseline {Low blood pressure}, volume overload {Hypervolemia}, blood cx {Blood culture}, PICC {Peripherally inserted central venous catheter in situ}, removed {Removal of catheter}, antibiotics {Antibiotic therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO BID:PRN nausea 
2. Cholestyramine 4 gm PO DAILY 
3. Escitalopram Oxalate 20 mg PO DAILY 
4. Furosemide 40 mg PO BID 
5. HydrOXYzine 50 mg PO QHS:PRN itching 
6. Lactulose 15 mL PO BID:PRN confusion 
7. Levothyroxine Sodium 75 mcg PO DAILY 
8. Omeprazole 40 mg PO DAILY 
9. Rifaximin 550 mg PO BID 
10. Spironolactone 100 mg PO BID 
11. Temazepam 15 mg PO QHS:PRN insomnia 
12. Ursodiol 300 mg PO TID 
13. Ferrous Sulfate 325 mg PO DAILY 
14. Multivitamins 1 TAB PO DAILY 

 
Discharge Medications:
1. Ertapenem Sodium 1 g IV ONCE cholangitis Duration: 1 Dose 
Continue until last dose on ___.  
RX *ertapenem [Invanz] 1 gram 1 gram IV daily Disp #*12 Vial 
Refills:*0
2. Cholestyramine 4 gm PO DAILY 
3. Escitalopram Oxalate 20 mg PO DAILY 
4. HydrOXYzine 50 mg PO QHS:PRN itching 
5. Lactulose 15 mL PO BID:PRN confusion 
6. Levothyroxine Sodium 75 mcg PO DAILY 
7. Multivitamins 1 TAB PO DAILY 
8. Omeprazole 40 mg PO DAILY 
9. Rifaximin 550 mg PO BID 
10. Temazepam 15 mg PO QHS:PRN insomnia 
11. Ursodiol 300 mg PO TID 
12. Ferrous Sulfate 325 mg PO DAILY 
13. Ondansetron 4 mg PO BID:PRN nausea 

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
CHOLANGITIS
PSC

SECONDARY DIAGNOSIS: 
Cirrhosis ___ PSC
recurrent cholangitis 

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Home With Service {Home health aide service management}, CHOLANGITIS {Cholangitis}, PSC {Primary sclerosing cholangitis}, Cirrhosis {Cirrhosis of liver}, PSC {Primary sclerosing cholangitis}, recurrent cholangitis {Recurrent cholangitis}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___, 

You came into the hospital because you were having low grade 
fevers and abdominal pain. You were treated with antibiotics for 
cholangitis and monitored in the hospital. Your pain improved on 
antibiotics. Your spironolactone and lasix were held because of 
your infection. You were given a PICC line and arranged to have 
antibiotics through the PICC line for a total course of 14 days. 
You were instructed to stop taking your lasix and spironolactone 
on discharge because your blood pressures have been lower than 
usual.  The liver clinic will call you with a follow-up 
appointment with Dr. ___. 

It was a pleasure being involved in your care!

Your ___ Team  
 

###RESPONSE: low grade 
fevers {Low grade pyrexia}, abdominal pain {Abdominal pain}, treated with antibiotics {Antibiotic therapy}, cholangitis {Cholangitis}, pain {Pain}, improved {Patient's condition improved}, antibiotics {Antibiotic therapy}, lasix {Diuretic therapy}, infection {Infectious disease}, PICC line {Percutaneous transluminal insertion of peripherally inserted central catheter}, antibiotics {Antibiotic therapy}, PICC line {Peripherally inserted central venous catheter in situ}, lasix {Diuretic therapy}, blood pressures have been lower {Low blood pressure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Compazine / Tree Nut
 
Attending: ___
 
___ Complaint:
SOB, cough
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: Compazine {Allergy to prochlorperazine}, Tree Nut {Allergy to tree nut}, SOB {Dyspnea}, cough {Cough}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ hx of COPD, s/p trach x2, multiple intubations for resp 
failure who presents with worsening SOB for over a week. Pt had 
been completing prednisone taper however the past several days 
she noted increas in cough and sputum production. Also reports 
chest tightness which began yesterday which she describes as 
pleuritic, non-radiating and non-exertional States she has had 
similar symptoms in past with severe COPD flares. Denies 
abdominal pain or emesis although states she did have decreased 
appetite and nausea yesterday. No dysuria. States she was not 
having known fevers at home although does not appear to have 
been taking temperature. Did take a dose of PO levo today as 
well. Sick contacts include her mother who is currently 
hospitalized with a COPD exacerbation and possible pna. Had been 
using xopenex nebs at home.

On arrival to the ED, VS: 102.0 ___ 28 100% 15L NRB. 
After nebs, VS: HR 160s 220/100. Pt started on nitroglycerin 
gtt. Also received CTX,  azithro and 125 mg methylprednisone. Pt 
required ICU transfer given nonrebreather requirement.
 
On the floor, VS: 98.7, 133/87, HR 119, 96% on 2L NC. Pt states 
her breathing is much improved. She does now have a headache. 
Chest tightness still present although has improved as 
respiratory status improving.
 
Review of systems:  
(+) Per HPI  
(-) Denies recent weight loss or gain.  Denies chest pain, chest 
pressure, palpitations, or weakness. Denies nausea, vomiting, 
diarrhea, constipation, abdominal pain, or changes in bowel 
habits. Denies dysuria, frequency, or urgency. Denies 
arthralgias or myalgias. Denies rashes or skin changes.  

 

###RESPONSE: COPD {Chronic obstructive lung disease}, trach {Exteriorization of trachea}, intubations {Insertion of endotracheal tube}, resp 
failure {Respiratory failure}, worsening {Patient's condition worsened}, SOB {Dyspnea}, prednisone {Steroid therapy}, taper {Medication decreased}, cough {Cough}, sputum production {Sputum finding}, chest tightness {Tight chest}, pleuritic {Pleuritic pain}, radiating {Radiating pain}, exertional {Chest pain on exertion}, severe {Symptom severe}, COPD flares {Acute exacerbation of chronic obstructive airways disease}, abdominal pain {Abdominal pain}, emesis {Vomiting}, decreased 
appetite {Decrease in appetite}, nausea {Nausea}, dysuria {Dysuria}, fevers {Fever}, taking temperature {Temperature taking}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, VS {Vital signs finding}, NRB {Oxygen administration by mask}, VS {Vital signs finding}, HR {Finding of heart rate}, started {New medication added}, ICU transfer {Patient transfer to intensive care unit}, VS {Vital signs finding}, HR {Finding of heart rate}, 2L NC {Oxygen administration by nasal cannula}, breathing {Difficulty breathing}, improved {Patient's condition improved}, headache {Headache}, Chest tightness {Tight chest}, improved {Patient's condition improved}, respiratory {Respiratory function finding}, improving {Patient's condition improved}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, chest pain {Chest pain}, chest 
pressure {Tight chest}, palpitations {Palpitations}, weakness {Asthenia}, nausea, vomiting, 
diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, changes in bowel 
habits {Altered bowel function}, dysuria {Dysuria}, frequency {Increased frequency of urination}, urgency {Urgent desire to urinate}, arthralgias {Joint pain}, myalgias {Muscle pain}, rashes {Eruption of skin}, skin changes {Skin appearance abnormal}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1. COPD, PFTs in ___ with FEV1 0.30 (13%), FVC 1.02 (34%) and  
FVC/FEV1 38% - on Home O2 at 3L NC, on chronic steroids, hx of  
prolonged intubation requiring trach for resp failure in ___,  

___. She was recently taken off the lung transplant list at the 
 
___ due to compression fractures. Has 
previous history of asthma per OMR  
2. Hypertension  
3. Anxiety  
4. Leukocytosis of unknown etiology with negative BMBx.  
5. Osteoporosis with compression fractures  
6. Shoulder pain  
7. History of positive PPD s/p 6mos of isoniazid  
8. Mitral valve prolapse  
9. Obstructive sleep apnea on BiPAP ___ every night)  

 

###RESPONSE: COPD {Chronic obstructive lung disease}, PFTs {Measurement of respiratory function}, FEV {Finding of forced expired volume}, FVC {Finding of forced vital capacity}, Home O2 {Home oxygen therapy}, 3L NC {Oxygen administration by nasal cannula}, steroids {Steroid therapy}, intubation {Insertion of endotracheal tube}, trach {Exteriorization of trachea}, resp failure {Respiratory failure}, lung transplant {Transplant of lung}, compression fractures {Compression fracture}, asthma {Asthma}, Hypertension {Hypertensive disorder, systemic arterial}, Anxiety {Anxiety}, Leukocytosis {Leukocytosis}, negative {No pathologic diagnosis}, BMBx {Bone marrow sampling}, Osteoporosis {Osteoporosis}, compression fractures {Compression fracture}, Shoulder pain {Shoulder pain}, positive PPD {Mantoux: positive}, Mitral valve prolapse {Mitral valve prolapse}, Obstructive sleep apnea {Obstructive sleep apnea syndrome}, BiPAP {Bilevel positive airway pressure titration}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Great uncle had MI in ___, Maternal & Paternal GMs had CVAs in 
___.

 

###RESPONSE: CVAs {Cerebrovascular accident}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:  
Vitals:  98.7, 133/87, HR 119, 96% on 2L NC.
General: Alert, oriented, no acute distress, pursed lips 
breathing, no notable conversational dyspnea  
HEENT: Sclera anicteric, dry MM, oropharynx clear  
Neck: supple, JVP not elevated, no LAD  
Lungs: decreased breath sounds bilaterally, unable to appreciate 
wheezing 
CV: tachy, normal S1 + S2, no murmurs, rubs, gallops  
Abdomen: soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding, no organomegaly  
GU: no foley  
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema 

DISCHARGE PHYSICAL EXAM:
General: Alert, oriented, no acute distress, pursed lips 
breathing, no notable conversational dyspnea  
HEENT: Sclera anicteric, dry MM, oropharynx clear, no dental 
pain, no evidence of swelling/fullness of floor of mouth, no 
dilation of whartons duct
Neck: supple, JVP not elevated, large soft mildly tender left 
cervical mass, unchanged from prior 
Lungs: decreased breath sounds bilaterally, unable to appreciate 
wheezing 
CV: tachy, normal S1 + S2, no murmurs, rubs, gallops  
Abdomen: soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding, no organomegaly  
GU: no foley  
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema

 

 

 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, HR {Finding of heart rate}, NC {Normal head}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, pursed lips 
breathing {Pursed-lip breathing}, dyspnea {Dyspnea}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, dry MM {Mucous membrane dryness}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, decreased breath sounds {Decreased breath sounds}, wheezing {Wheezing}, CV {Cardiovascular physical examination}, tachy {Tachycardia}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, foley {Urinary catheter in situ}, Ext {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, pursed lips 
breathing {Pursed-lip breathing}, dyspnea {Dyspnea}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, dry MM {Mucous membrane dryness}, oropharynx clear {Pharynx normal}, dental 
pain {Toothache}, no evidence {No abnormality detected}, swelling {Swelling of oral cavity structure}, floor of mouth {Floor of mouth structure}, dilation of whartons duct {Dilation of Wharton's duct}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, soft {Mass of soft tissue}, tender {Tenderness of neck}, left {Structure of left half of neck}, cervical mass {Mass of neck}, Lungs {Examination of respiratory system}, decreased breath sounds {Decreased breath sounds}, wheezing {Wheezing}, CV {Cardiovascular physical examination}, tachy {Tachycardia}, normal S1 + S2 {Heart sounds normal}, murmurs {Heart murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound tenderness {Rebound tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, foley {Urinary catheter in situ}, Ext {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 09:59PM   TYPE-ART PO2-289* PCO2-53* PH-7.44 TOTAL 
CO2-37* BASE XS-10 INTUBATED-NOT INTUBA
___ 09:59PM   O2 SAT-99
___ 09:43PM   LACTATE-2.4*
___ 09:35PM   GLUCOSE-138* UREA N-10 CREAT-0.7 SODIUM-136 
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-34* ANION GAP-11
___ 09:35PM   estGFR-Using this
___ 09:35PM   cTropnT-<0.01
___ 09:35PM   CALCIUM-9.3 PHOSPHATE-2.1* MAGNESIUM-1.6
___ 09:35PM   WBC-16.2*# RBC-4.39 HGB-13.2 HCT-39.9 MCV-91 
MCH-30.0 MCHC-33.0 RDW-12.7
___ 09:35PM   NEUTS-86.9* LYMPHS-6.3* MONOS-6.2 EOS-0.4 
BASOS-0.2
___ 09:35PM   PLT COUNT-358
___ 09:35PM   ___ PTT-26.9 ___

MICRO:
BLOOD CX-NEG X2
=======
Final Report 
PORTABLE CHEST:  ___. 
  
HISTORY:  ___ female with respiratory distress.  
Question pneumonia. 
  
COMPARISON:  ___. 
  
FINDINGS:  Streaky linear opacities are again seen, similar to 
prior and may 
be due to atelectasis.  There is no confluent consolidation.  
Costophrenic 
angles are sharp.  The cardiomediastinal silhouette is within 
normal limits.  
Rounded calcific density overlying the anterior left seventh rib 
is compatible 
with calcification at the costochondral junction.  No acute 
osseous 
abnormality is detected. 
  
IMPRESSION:  No focal consolidations to suggest pneumonia. 

=======

Final Report CT NECK W/CONTRAST (EG:PAROTIDS) Study Date of 
___ 1:45 ___
HISTORY:  History of COPD with shortness of breath and 2new 
eft-sided tender 
neck mass.  Rule out infection versus mass. 
  
COMPARISON:  Prior neck soft tissue ultrasound from ___. 
  
TECHNIQUE:  Routine enhanced MDCT study of the neck was 
performed with images 
obtained from the skullbase to the thoracic inlet using 3 mm 
thick sections.  
Coronal and sagittal reformations were performed.  
  
Total exam DLP:  394 mGy-cm. 
  
FINDINGS: 
  
Evaluation of the aerodigestive tract demonstrates no exophytic 
mucosal mass, 
there is no focal mass effect.  There is mild mucosal thickening 
of the 
maxillary sinuses bilaterally and ethmoidal air cells, worse on 
the left.  
Evaluation of the cervical lymph chains demonstrate no 
pathologic 
lymphadenopathy by imaging criteria.  The thyroid gland is 
normal.  The left 
salivary gland appears slightly larger than the left however no 
focal 
abnormality is identified.  Adjacent to the left salivary gland 
however, there 
is a heterogeneous soft tissue lesion similar in appearance to 
the left 
parotid gland, measuring 2 x 2 cm and demonstrating fat density. 
 This lesion 
seems to connect to the parotid gland and could correlate to the 
lesion 
identified on prior ultrasound.  There appears to be surrounding 
fat stranding 
and thickening of the adjacent tissues (5 b: 36, 04:39).  There 
is however no 
definite enhancement to suggest abscess formation.  Neck vessels 
enhance 
bilaterally without significant stenosis.   
  
IMPRESSION: 
  
2 x 2 cm heterogeneous soft tissue lesion adjacent to the left 
salivary gland 
with apparent connection to the parotid gland, similar in 
appearance to 
parotid tissue, demonstrating fatty density and surrounding fat 
stranding 
could represent an extension of normal parotid tissue with 
possible early 
signs of inflammatory changes, given surrounding fat stranding.  
However, no 
definite enhancement is seen to suggest abscess formation. This 
lesion likely 
correlates to lesion seen on prior ultrasound. 
  
The study and the report were reviewed by the staff radiologist. 

  
___. ___ 
___. ___ 
___: SAT ___ 5:10 ___ 

DISCHARGE LABS:

___ 04:59AM BLOOD WBC-11.4* RBC-4.42 Hgb-13.1 Hct-40.3 
MCV-91 MCH-29.7 MCHC-32.6 RDW-12.9 Plt ___
___ 04:59AM BLOOD Glucose-96 UreaN-12 Creat-0.7 Na-135 
K-3.9 Cl-88* HCO3-41* AnGap-10
___ 04:59AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.___ hx of COPD, s/p trach x2, multiple intubations for 
respiratory failure who presents with worsening SOB for over a 
week, now with cough, increased sputum production and fevers for 
2 days. Patient was treated for COPD exacerbation

#COPD exacerbation: Patient with history of debilitating COPD, 
on home oxygen. Patient received nebs, 125 mg methylpred, CTX 
and azithro in ED with improvement of respiratory status. In the 
ICU patient was treated with course of azithromycin and 
Prednisone 60mg daily. Patient with continued improvement in 
respiratory status with standing Albuterol and Tiotroprium nebs. 
Plan for ***Prednisone taper for total 2 weeks (down from 60mg x 
7 days): ___ - ___ => Prednisone 40mg daily; ___ => 
Prednisone 20mg daily; ___ => Prednisone 10mg daily. 
Then STOP ___.

# Acute non-suppurative Parotitis: Patient with tender left neck 
swelling noted on ___, U/S and CT scan with possible early 
inflamation vs. extension of parotid tissue. No evidence of 
abcess or stones on imaging and no purulence on exam. Patient 
received several doses of IV clindamycin and was generally well 
appearing. Low suspicion of MRSA. Discussed with ENT who 
reviewed imaging, and agreed patient could be stepped down to PO 
antibiotics. Discharged on Augmentin 875mg BID x 10 days ending 
___. Continue sialigogues (i.e. lemon wedges, lozenges every 
few hours to promote salivation).

#HTN: Pt hypertensive to SBP 220 in ED after receiving nebs. 
Improved with nitro gtt. Stable (133/87) now on floor. Patient 
restarted on home dose of Verapamil with improvement in 
hypertension. Patient should follow up with outpatient PCP for 
consideration of additional antihypertensive.

#Chest Tightness: Patient reports pleuritic CP which she has had 
in past during COPD exacerbations. Unlikely cardiac: 
non-exertional, non-radiating, troponins negative. Pain resolved 
while inpatient.

#Anxiety: Patient with significant anxiety associated with 
tachycardia to 130s. Significant improvement with Lorazepam 
0.5mg q4 hours. Switched to clonazepam at discharge.

#Depression: Continued on home dose Lexapro while inpatient.

TRANSITIONAL ISSUES
- Patient is MRSA nasal swab positive.
1) COPD: Patient with end stage lung disease. Discharged to ___ 
and will require close outpatient follow up.
2) Hypertension: Patient hypertensive while hospitalized. Please 
consider addition of second antihypertensive as an outpatient.
3) Suspected mild Parotitis: Augmentin 875mg BID x 10 days 
ending ___.
***Broaden to IV antibiotics, add MRSA coverage, and obtain 
urgent ENT evaluation if patient has worsening parotitis 
symptoms including high fevers, purulence, redness tracking down 
the neck, or Trismus***
4) Prednisone taper as above.

 

###RESPONSE: ART {Arterial specimen collection for laboratory test}, PO2 {Oxygen measurement, partial pressure, arterial}, PCO2 {Measurement of arterial partial pressure of carbon dioxide}, PH {pH measurement}, TOTAL 
CO2 {Blood total carbon dioxide (calculated)}, BASE XS {Delta base, blood}, O2 SAT {Oxygen saturation measurement}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, CALCIUM {Blood calcium measurement}, PHOSPHATE {Phosphate, total measurement}, MAGNESIUM {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}, BLOOD CX {Blood culture}, NEG {No abnormality detected}, PORTABLE {Portable X-ray}, CHEST {Plain chest X-ray}, respiratory distress {Respiratory distress}, pneumonia {Pneumonia}, opacities {Abnormally opaque structure}, atelectasis {Atelectasis}, consolidation {Lung consolidation}, Costophrenic 
angles {Structure of costophrenic angle}, cardiomediastinal {Mediastinal structure}, normal {No abnormality detected}, calcific {Pathologic calcification, calcified structure}, density {Abnormally opaque structure}, left {Bone structure of left rib}, seventh rib {Bone structure of seventh rib}, calcification {Pathologic calcification, calcified structure}, costochondral junction {Structure of seventh costochondral junction}, No acute {No abnormality detected}, osseous {Bone structure}, consolidations {Lung consolidation}, pneumonia {Pneumonia}, CT NECK W/CONTRAST {Computed tomography of neck with contrast}, PAROTIDS {Parotid gland structure}, Study {Evaluation procedure}, COPD {Chronic obstructive lung disease}, shortness of breath {Dyspnea}, eft-sided {Structure of left half of neck}, tender {Tenderness of neck}, neck mass {Mass of neck}, Rule out {Evaluation procedure}, infection {Infectious disease}, mass {Mass of body structure}, neck soft tissue ultrasound {Ultrasonography of mass of soft tissue of neck}, CT study of the neck {Computed tomography of neck}, skullbase {Base of skull structure}, thoracic inlet {Structure of thoracic inlet}, Evaluation {Evaluation procedure}, mass {Mass of body structure}, mild {Symptom mild}, mucosal {Mucous membrane structure}, thickening {Increased thickness}, maxillary sinuses {Maxillary sinus structure}, ethmoidal air cells {Ethmoid sinus structure}, worse {Patient's condition worsened}, left {Structure of left half of head}, Evaluation {Evaluation procedure}, cervical lymph chains {Cervical lymph node structure}, no 
pathologic {No pathologic diagnosis}, lymphadenopathy {Cervical lymphadenopathy}, imaging {Imaging}, thyroid gland {Thyroid structure}, normal {No abnormality detected}, left 
salivary gland {Structure of left salivary gland}, larger {Increased size}, no 
focal 
abnormality {No abnormality detected}, left salivary gland {Structure of left salivary gland}, soft tissue lesion {Soft tissue lesion}, left 
parotid gland {Structure of left parotid gland}, fat density {Lesion with fat containing (radiolucent) density}, lesion {Lesion}, parotid gland {Parotid gland structure}, lesion {Lesion}, ultrasound {Ultrasonography}, thickening {Increased thickness}, tissues {Body tissue structure}, abscess {Abscess}, Neck vessels {Vascular structure of neck}, stenosis {Stenosis}, soft tissue lesion {Soft tissue lesion}, left 
salivary gland {Structure of left salivary gland}, parotid gland {Parotid gland structure}, parotid tissue {Structure of interstitial tissue of parotid gland}, fatty density {Lesion with fat containing (radiolucent) density}, extension {Abnormal extension}, normal {No abnormality detected}, parotid tissue {Structure of interstitial tissue of parotid gland}, signs {Sign}, inflammatory {Inflammatory disorder}, abscess {Abscess}, lesion {Lesion}, lesion {Lesion}, ultrasound {Ultrasonography}, study {Evaluation procedure}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, COPD {Chronic obstructive lung disease}, trach {Exteriorization of trachea}, intubations {Insertion of endotracheal tube}, respiratory failure {Respiratory failure}, worsening {Patient's condition worsened}, SOB {Dyspnea}, cough {Cough}, increased {Patient's condition worsened}, sputum production {Sputum finding}, fevers {Fever}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD {Chronic obstructive lung disease}, home oxygen {Home oxygen therapy}, improvement {Patient's condition improved}, respiratory {Respiratory function finding}, ICU {Admission to intensive care unit}, azithromycin {Antibiotic therapy}, Prednisone {Steroid therapy}, improvement {Patient's condition improved}, respiratory {Respiratory function finding}, taper {Medication decreased}, Prednisone {Steroid therapy}, Prednisone {Steroid therapy}, Prednisone {Steroid therapy}, Parotitis {Parotitis}, tender {Tenderness of neck}, left {Structure of left half of neck}, neck 
swelling {Neck swelling}, U/S {Ultrasonography of mass of soft tissue of neck}, CT scan {Computed tomography of neck}, inflamation {Inflammatory disorder}, parotid tissue {Structure of interstitial tissue of parotid gland}, No evidence {No abnormality detected}, abcess {Abscess}, stones {Calculus}, imaging {Imaging}, purulence {Purulent discharge}, exam {Evaluation procedure}, IV clindamycin {Intravenous antibiotic therapy}, well 
appearing {Normal appearance}, MRSA {Methicillin resistant Staphylococcus aureus infection}, imaging {Imaging}, PO 
antibiotics {Oral antibiotic therapy}, Augmentin {Antibiotic therapy}, HTN {Hypertensive disorder, systemic arterial}, hypertensive {Finding of increased blood pressure}, SBP {Increased systolic arterial pressure}, nebs {Nebulizer therapy}, Improved {Patient's condition improved}, Stable {Patient's condition stable}, restarted {Restart of medication}, improvement {Patient's condition improved}, hypertension {Hypertensive disorder, systemic arterial}, PCP {Primary care management}, antihypertensive {Antihypertensive therapy}, Chest Tightness {Tight chest}, pleuritic CP {Pleuritic pain}, COPD exacerbations {Acute exacerbation of chronic obstructive airways disease}, cardiac {Heart disease}, exertional {Chest pain on exertion}, radiating {Radiating pain}, troponins {Troponin measurement}, negative {No abnormality detected}, Pain resolved {No present pain}, Anxiety {Anxiety}, anxiety {Anxiety}, tachycardia {Tachycardia}, improvement {Patient's condition improved}, Switched {Change of medication}, Depression {Depressive disorder}, MRSA {Methicillin resistant Staphylococcus aureus infection}, nasal swab {Taking nasal swab}, COPD {Chronic obstructive lung disease}, lung disease {Disorder of lung}, outpatient follow up {Outpatient care management}, Hypertension {Hypertensive disorder, systemic arterial}, hypertensive {Hypertensive disorder, systemic arterial}, antihypertensive {Antihypertensive therapy}, mild {Symptom mild}, Parotitis {Parotitis}, Augmentin {Antibiotic therapy}, IV antibiotics {Intravenous antibiotic therapy}, MRSA {Methicillin resistant Staphylococcus aureus infection}, ENT {Ear, nose and throat examination}, evaluation {Evaluation procedure}, worsening {Patient's condition worsened}, parotitis {Parotitis}, fevers {Fever}, purulence {Purulent discharge}, redness {Redness of skin over lesion}, neck {Neck structure}, Trismus {Trismus}, Prednisone {Steroid therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list may be inaccurate and requires 
futher investigation.
1. Tiotropium Bromide 1 CAP IH DAILY 
2. Benzonatate 100 mg PO TID 
3. Verapamil SR 240 mg PO QAM 
4. Verapamil SR 120 mg PO QHS 
5. Ipratropium Bromide MDI 2 PUFF IH QID 
6. Furosemide 20 mg PO ONCE 
7. Fluticasone-Salmeterol Diskus (500/50)  1 INH IH BID 
8. Omeprazole 20 mg PO DAILY 
9. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315mg-200 
unit oral 2 tablets Qday 
10. Levalbuterol Neb 0.63 mg/3 mL inhalation q4 hrs 
11. Escitalopram Oxalate 10 mg PO DAILY 
12. TraZODone 150 mg PO HS:PRN insomnia 
13. Vitamin D 1000 UNIT PO DAILY 
14. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea 

 
Discharge Medications:
1. Escitalopram Oxalate 10 mg PO DAILY 
2. Furosemide 20 mg PO DAILY 
3. Levalbuterol Neb 1.26 mg INHALATION Q4H Wheezing, SOB 
4. TraZODone 50 mg PO HS:PRN insomnia 
5. Verapamil SR 240 mg PO QAM 
6. Verapamil SR 120 mg PO QHS 
7. Acetaminophen 650 mg PO Q6H:PRN pain 
8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days 
9. Cepastat (Phenol) Lozenge 1 LOZ PO Q2H:PRN Sore throat 
10. Docusate Sodium 100 mg PO BID 
11. Ipratropium Bromide Neb 1 NEB IH Q6H SOB 
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 
13. Senna 1 TAB PO BID 
14. Benzonatate 100 mg PO TID 
15. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315mg-200 
unit oral 2 tablets Qday 
16. Fluticasone-Salmeterol Diskus (500/50)  1 INH IH BID 
17. Omeprazole 20 mg PO DAILY 
18. Vitamin D 1000 UNIT PO DAILY 
19. PredniSONE 40 mg PO DAILY Duration: 1 Day 
Start: Tomorrow - ___, First Dose: First Routine 
Administration Time 
Total 2 week taper beginning ___ at 60mg 
20. PredniSONE 20 mg PO DAILY Duration: 2 Days 
Start: After 40 mg tapered dose 
Total 2 week taper beginning ___ at 60mg 
21. PredniSONE 10 mg PO DAILY Duration: 2 Days 
Start: After 20 mg tapered dose 
Total 2 week taper beginning ___ at 60mg 
22. Lemon wedges
Q4H to promote salivation while treating Parotid Gland infection
23. ClonazePAM 0.5 mg PO BID:PRN anxiety 
RX *clonazepam 0.5 mg 1 tablet(s) by mouth twice a day as needed 
Disp #*10 Tablet Refills:*0

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
COPD exacerbation
parotidis

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, parotidis {Parotitis}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___, it was a pleasure taking care of you during your 
stay at ___. You were admitted for a COPD exacerbation. 
You were treated with antibiotics, steroids and nebulizers. Your 
breathing improved. While you were here you developed an 
inflammation of your parotid gland. You should continue on 
antibiotics for this inflammation.
 

###RESPONSE: COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, treated with antibiotics {Antibiotic therapy}, steroids {Steroid therapy}, nebulizers {Nebulizer therapy}, breathing {Finding of respiration}, improved {Patient's condition improved}, inflammation {Inflammatory disorder}, parotid gland {Parotid gland structure}, antibiotics {Antibiotic therapy}, inflammation {Inflammatory disorder}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Tetracyclines
 
Attending: ___.
 
Chief Complaint:
Chest pain 
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: Tetracyclines {Allergy to tetracycline}, Chest pain {Chest pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
This is a ___ year-old female with a history of HTN who presents 
with chest pain.  
.  
For a couple weeks, pt has been feeling fatigued, generalized 
weakness, increased frequency of headaches. Her symptoms 
worsened 4 days ago. Her headache has been persistent the last 4 
days despite motrin, tylenol, zanaflex, excedrin, and zonegran. 
She has had these headaches before. She describes a frontal 
headache, throbbing, currently ___. No photophobia, neck 
stiffness. She also noted chills, but have them with her 
hypothyeroidism. She also reports watery diarrhea over the 
weekend. No abdominal pain. She has her worsening nausea. No 
vomiting. No fevers. No sick contacts.  
.  
Over the years, she has had chest pain intermittently, 
associated with stress. The chest pain started 2 weeks ago but 
intensified over the weekend. She describes the pain as a heavy 
substernal pressure radiating down to her left arm. This pain 
started ___ and worsened until today, prompting her go to 
the ED. She feels the pain is worse when she bends over. It does 
not worsen with deep breaths. She was noted to be pale, 
diaphoretic today while at therapy. She has chronic nausea and 
palpitations. No dizziness, SOB. No recent exertion.  
.  
Of note, pt has had chronic nausea for the past ___ years and was 
evaluated by GI over the summer. EGD showed gastritis and grade 
2 esophagitis; gastric emptying study was normal.  
.  
In the ED, initial vitals were T: 97.1 BP: 129/81 HR: 79 RR: 22 
O2Sat: 98RA. EKG showed sinus bradycardia with HR of ___ without 
acute signs of ischemia. She received ASA, toradol x2, and SL 
NTG x2 with improvement of CP from 6->4. 2 sets of CEs neg.  
.  
Currently her CP is at a 6, improved from 10 this AM. She 
believes the NTG helped the most. Her HA has improved with 
Toradol.  
.  
ROS: The patient denies any orthopnea, PND, lower extremity 
oedema, cough, sinus problems, nasal congestion, sore throat, 
urinary frequency, urgency, dysuria, vision changes, focal 
weakness, rash.  
.  

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, chest pain {Chest pain}, fatigued {Fatigue}, weakness {Asthenia}, headaches {Headache}, worsened {Patient's condition worsened}, headache has been persistent {New daily persistent headache}, tylenol {Administration of analgesic}, headaches {Headache}, frontal 
headache {Frontal headache}, throbbing {Throbbing pain}, photophobia {Photophobia}, neck 
stiffness {Stiff neck}, chills {Chill}, hypothyeroidism {Hypothyroidism}, watery {Liquid stool}, diarrhea {Diarrhea}, abdominal pain {Abdominal pain}, worsening {Patient's condition worsened}, nausea {Nausea}, vomiting {Vomiting}, No fevers {Temperature normal}, chest pain {Chest pain}, stress {Stress}, chest pain {Chest pain}, pain {Chest pain}, substernal {Structure of substernal region}, pressure {Tight chest}, radiating down to her left arm {Pain radiating to left arm}, pain {Chest pain}, worsened {Increased pain}, pain {Chest pain}, worse {Increased pain}, worsen {Patient's condition worsened}, deep breaths {Deep breathing}, pale {Pale discoloration of entire skin of body}, diaphoretic {Excessive sweating}, therapy {Therapy}, chronic {Chronic disease}, nausea {Nausea}, palpitations {Palpitations}, dizziness {Dizziness}, SOB {Dyspnea}, chronic {Chronic disease}, nausea {Nausea}, evaluated {Evaluation procedure}, EGD {Esophagogastroduodenoscopy}, gastritis {Gastritis}, esophagitis {Esophagitis}, gastric emptying study {Gastric emptying study}, normal {No abnormality detected}, vitals {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2Sat {Oxygen saturation measurement}, RA {Breathing room air}, EKG {Electrocardiographic procedure}, sinus bradycardia {Sinus bradycardia}, HR {Finding of heart rate}, without 
acute signs of ischemia {Electrocardiogram normal}, ASA {Administration of aspirin}, NTG {Administration of prophylactic glyceryl trinitrate}, improvement {Patient's condition improved}, CP {Chest pain}, CEs neg {Cardiac enzymes within reference range}, CP {Chest pain}, improved {Patient's condition improved}, NTG {Administration of prophylactic glyceryl trinitrate}, HA {Headache}, improved {Patient's condition improved}, ROS {Review of systems}, orthopnea {Orthopnea}, PND {Paroxysmal nocturnal dyspnea}, lower extremity 
oedema {Edema of lower extremity}, cough {Cough}, sinus problems {Disorder of nasal sinus}, nasal congestion {Nasal congestion}, sore throat {Sore throat}, urinary frequency {Increased frequency of urination}, urgency {Urgent desire to urinate}, dysuria {Dysuria}, vision changes {Visual disturbance}, weakness {Asthenia}, rash {Eruption of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
HTN  
Hypothyroidism  
Migraine and tension headaches  
MVP  
Complex partial seizures  
Sleep apnea, not tolerating CPAP at home  
Depression/Generalized anxiety disorder  
ADHD  
Asthma  

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, Hypothyroidism {Hypothyroidism}, Migraine {Migraine}, tension headaches {Tension-type headache}, partial seizures {Focal onset epileptic seizure}, Sleep apnea {Sleep apnea}, CPAP at home {Uses home continuous positive airway pressure ventilation supply}, Depression {Depressive disorder}, Generalized anxiety disorder {Generalized anxiety disorder}, ADHD {Attention deficit hyperactivity disorder}, Asthma {Asthma}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother with colorectal cancer, pancreatitis. No h/o MI.  
Father died of MI at age of ___.  

 

###RESPONSE: colorectal cancer {Malignant neoplasm of colon and/or rectum}, pancreatitis {Pancreatitis}, MI {Myocardial infarction}, died {Dead}, MI {Myocardial infarction}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Vitals: T: 97.8, BP: 138/94, HR: 61, RR: 20, O2Sat: 100RA  
GEN: Well-appearing, obese female no acute distress  
HEENT: EOMI, sclera anicteric, MMM, OP Clear  
NECK: No JVD, no carotid bruits, no cervical lymphadenopathy, no 
meningismus  
COR: RRR, no M/G/R, normal S1 S2  
PULM: Lungs CTAB, no W/R/R  
CHEST: tender to palpation over sternum, L side of chest and L 
arm  
ABD: Obese, soft, mildly tender in LLQ, no rebound, no guarding, 
ND, +BS  
EXT: No C/C/E, 2+ DP pulses  

 

###RESPONSE: Vitals {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2Sat {Oxygen saturation measurement}, RA {Breathing room air}, GEN {General examination of patient}, Well-appearing {Well cared for appearance}, obese {Obese}, no acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, EOMI {Normal ocular motility}, sclera anicteric {White sclera}, MMM {Moist oral mucosa}, OP Clear {Pharynx normal}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, carotid bruits {Carotid bruit}, cervical lymphadenopathy {Cervical lymphadenopathy}, meningismus {Meningeal irritation}, COR {Cardiovascular physical examination}, RRR {Normal heart rate}, no M/G/R {Heart sounds abnormal}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, no W/R/R {Normal breath sounds}, CHEST {Examination of respiratory system}, tender {Abdominal tenderness}, palpation {Palpation}, sternum {Bone structure of sternum}, L side of chest {Structure of left half of chest wall}, L 
arm {Structure of left upper limb}, ABD {Examination of abdomen}, Obese {Obese}, soft {Abdomen soft}, tender {Abdominal tenderness}, LLQ {Structure of left lower quadrant of abdomen}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, ND {Swollen abdomen}, +BS {Normal bowel sounds}, EXT {Examination of limb}, No C/C/E {No abnormality detected}, 2+ DP pulses {Dorsalis pulse present}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
troponins <0.01 x3
 

###RESPONSE: troponins {Troponin measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Assesment: This is a ___ year-old female with a history of HTN, 
hypothyroidism, GAD who presents with chest pain, fatigue, and 
headaches.  
.
Chest pain: Likely MSK given reproducible pain on exam. ___ also 
be from esophagitis and gastritis, ? esophageal spasm as 
improved with NTG. Unlikely pericarditis since no EKG changes. 
Unlikely to be ACS given duration of symptoms without EKG 
changes or increased CEs. Also had normal stress test in ___. 
Patient had serial normal EKGs, CEs negative x3. 
.  
Headache: Pt reports it's consistent with her tension headaches 
except not being relieved. Has improved with Toradol. No 
meningimus, afebrile, no leukocytosis to suggest meninigitis.  
cont. toradol  
.  
# Nausea: Has been thoroughly worked up by GI.  
- start protonix
- Compazine prn  
.  
# HTN: Well controlled.  
- cont. propranolol  
.  
# Hypothyroidism: TSH WNL on admission.  
- cont. levothyroxine.  
.  
# Complex partial seizures:  
- cont. Lamictal.  
.  
# Sleep apnea, not tolerating CPAP at home:  
- CPAP ordered  
.  
# Depression/Generalized anxiety disorder:  
- cont.  
.  
# ADHD  
- cont. Ritalin  
.  
# Asthma: Currently asymptomatic.  
- albuterol prn  

 

###RESPONSE: Assesment {Evaluation procedure}, HTN {Hypertensive disorder, systemic arterial}, hypothyroidism {Hypothyroidism}, GAD {Generalized anxiety disorder}, chest pain {Chest pain}, fatigue {Fatigue}, headaches {Headache}, Chest pain {Chest pain}, MSK {Structure of musculoskeletal system}, pain {Pain}, exam {Physical examination procedure}, esophagitis {Esophagitis}, gastritis {Gastritis}, esophageal spasm {Diffuse spasm of esophagus}, improved {Patient's condition improved}, NTG {Administration of prophylactic glyceryl trinitrate}, pericarditis {Pericarditis}, no EKG changes {Electrocardiogram normal}, ACS {Acute coronary syndrome}, without EKG 
changes {Electrocardiogram normal}, increased CEs {Cardiac enzyme or marker above reference range}, normal {Electrocardiogram normal}, stress test {Cardiovascular stress testing}, normal EKGs {Electrocardiogram normal}, CEs negative {Cardiac enzymes within reference range}, Headache {Headache}, tension headaches {Tension-type headache}, improved {Patient's condition improved}, meningimus {Meningeal irritation}, afebrile {Temperature normal}, leukocytosis {Leukocytosis}, meninigitis {Meningitis}, Nausea {Nausea}, worked up {Evaluation procedure}, HTN {Hypertensive disorder, systemic arterial}, Well controlled {Disease condition determination, well controlled}, Hypothyroidism {Hypothyroidism}, TSH WNL {Serum thyroid stimulating hormone level within reference range}, partial seizures {Focal onset epileptic seizure}, Sleep apnea {Sleep apnea}, CPAP at home {Uses home continuous positive airway pressure ventilation supply}, CPAP {Continuous positive airway pressure ventilation treatment}, Depression {Depressive disorder}, Generalized anxiety disorder {Generalized anxiety disorder}, ADHD {Attention deficit hyperactivity disorder}, Asthma {Asthma}, asymptomatic {Asymptomatic}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2  

puffs by mouth every four (4) to six (6) hours as needed for  
cough/wheezing  
LAMOTRIGINE [LAMICTAL] - (Prescribed by Other Provider: ___ 
 
- 200 mg Tablet - 1 (One) Tablet(s) by mouth twice a day  
LEVOTHYROXINE SODIUM - 175MCG Tablet - ONE BY MOUTH EVERY DAY  
METHYLPHENIDATE [RITALIN LA] - (Prescribed by Other Provider:  
___ - 30 mg Capsule, Multiphasic Rel.50-50 - 2 (Two)  
Capsule(s) by mouth once a day  
PRAMIPEXOLE [MIRAPEX] - 0.125 mg Tablet - 1 (One) Tablet(s) by  
mouth once a day 2 hours before sleep  
PRAZOSIN - (Prescribed by Other Provider: ___ - 1 mg  
Capsule - 1 (One) Capsule(s) by mouth three times a day  
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth  
twice a day  
PROPRANOLOL - (Prescribed by Other Provider: ___ - 80 mg  
Capsule, Sust. Release 24 hr - 1 (One) Capsule(s) by mouth once 
a  
day  
TIZANIDINE [ZANAFLEX] - 4 mg Tablet - 1 Tablet(s) by mouth twice 
 
a day  
TRAZODONE - 100 mg Tablet - 2 Tablet(s) by mouth at bedtime ___  

take additional tablet qhs prn sleeplessness  
ZONISAMIDE [ZONEGRAN] - 100 mg Capsule - 2 Capsule(s) by mouth 
at  
bedtime  

 
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for 
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as 
needed.  
2. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times 
a day).  
3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
4. Methylphenidate 20 mg Tablet Sustained Release Sig: Three (3) 
Tablet Sustained Release PO DAILY (Daily).  
5. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qhs ().  
6. Prazosin 1 mg Capsule Sig: One (1) Capsule PO TID (3 times a 
day).  
7. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO 
twice a day as needed for nausea.  
8. Propranolol 80 mg Capsule,Sustained Action 24 hr Sig: One (1) 
Capsule,Sustained Action 24 hr PO DAILY (Daily).  
9. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a 
day).  
10. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at 
bedtime) as needed.  
11. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO QHS (once 
a day (at bedtime)).  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary:
Atypical Chest pain

Secondary:
HTN
Hypothyroid
GAD

 
Discharge Condition:
stable

 

###RESPONSE: Atypical Chest pain {Atypical chest pain}, HTN {Hypertensive disorder, systemic arterial}, Hypothyroid {Hypothyroidism}, GAD {Generalized anxiety disorder}, stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted to the hospital with chest pain that was 
thought to NOT be of cardiac origin per blood tests and EKGS.

Please take all medications as prescribed

Please call your doctor or return to the hosptial if you have 
more chest pain, shortness of breath or any other concerning 
symptoms
 

###RESPONSE: chest pain {Chest pain}, cardiac {Heart structure}, blood tests {Blood test}, EKGS {Electrocardiographic procedure}, Please take all medications as prescribed {Patient medication education}, call your doctor {Informing doctor}, chest pain {Chest pain}, shortness of breath {Dyspnea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
amlodipine
 
Attending: ___.
 
Chief Complaint:
fever, dyspnea

 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: amlodipine {Allergy to amlodipine}, fever {Fever}, dyspnea {Dyspnea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ h/o severe COPD not on home O2, s/p endobronchial coil 
placement for stage 4 emphysema as part of a study on ___. Dc'd 
home began having fevers, went to ___ local ___, admitted 
___ (discharged yesterday) after treatment for pneumonia, 
continued on PO levoquin. Presents today after speaking w/ study 
coordinator who recommended he present here for further 
evaluation if temp >100.4. Temp at home to 101. Increased 
dyspnea from baseline. Denies CP. No n/v. Soft stool this AM, no 
abd pain.
In the ED initial vitals were: 99.4 102 146/74 18 100% RA. Pt 
spiked to 100.2 and received tylenol.
- Labs were significant for no leukocytosis, normal lactate, INR 
1.4.
- CXR was pending.
- EKG was unchanged.
- Patient was given IV vanc and zosyn, tylenol, duonebs x2, and 
1L NS.
On the floor, patient is resting fairly comfortably with his 
wife at bedside. He reports that his breathing is still bad. He 
confirms the above history and also adds the following: While 
hospitalized at ___ in ___, his inpatient 
MDs were communicating with Dr. ___ for 
recommendations about his pulmonary management. He was started 
on levaquin ___, which he took for one day and then was 
changed to IV vanc/zosyn while in the hospital, but discharged 
again on levaquin after improvement.
He says that initially after the coil embolization ___ he felt 
well for a few days. However, on the ___ following the 
procedure (___), he began feeling unwell. On ___ he 
developed a fever. Of note, his sputum after the procedure was 
initially white with streaks of BRB but then changed to a rust 
color after he got sick. Even with the antibiotics, he continued 
to feel unwell. His sputum changed to a yellow mucous. He went 2 
days without fevers, was discharged, and then had another fever 
that night (last night). Denies flu like symptoms such as body 
aches, HA, n/v/d. Most importantly, he reports that since being 
unwell, his breathing really hasn't improved. He feels like he 
is not moving any air. No CP or leg swelling. No diarrhea or 
dysuria.
Review of Systems:
(+) per HPI. Remainder of 10 point ROS is negative.

 

###RESPONSE: severe COPD {Severe chronic obstructive pulmonary disease}, home O2 {Home oxygen therapy}, endobronchial coil 
placement {Endotracheal tube present}, emphysema {Emphysema}, study {Evaluation procedure}, fevers {Fever}, pneumonia {Pneumonia}, study {Evaluation procedure}, evaluation {Evaluation procedure}, temp {Body temperature finding}, Temp {Body temperature finding}, Increased {Patient's condition worsened}, dyspnea {Dyspnea}, baseline {Baseline state}, Soft stool {Soft stool}, abd pain {Abdominal pain}, vitals {Vital signs finding}, tylenol {Administration of analgesic}, Labs {Laboratory test}, leukocytosis {Leukocytosis}, normal {No abnormality detected}, lactate {Lactic acid measurement}, INR {Calculation of international normalized ratio}, CXR {Plain chest X-ray}, EKG {Electrocardiographic procedure}, unchanged {Patient condition unchanged}, vanc {Antibiotic therapy}, tylenol {Administration of analgesic}, comfortably {Breathing easily}, breathing {Difficulty breathing}, pulmonary {Pulmonary medicine service}, started {New medication added}, changed {Change of medication}, vanc {Antibiotic therapy}, improvement {Patient's condition improved}, embolization {Embolization procedure}, following the 
procedure {Postoperative state}, feeling unwell {Malaise}, fever {Fever}, sputum {Sputum finding}, procedure {Procedure}, changed {Change of medication}, color {Color finding}, antibiotics {Antibiotic therapy}, feel unwell {Malaise}, sputum {Sputum finding}, yellow {Yellow sputum}, fevers {Fever}, fever {Fever}, flu like symptoms {Influenza-like symptoms}, body 
aches {Generalized aches and pains}, n/v/d {Nausea, vomiting and diarrhea}, breathing {Difficulty breathing}, improved {Patient's condition improved}, leg swelling {Leg swelling symptom}, diarrhea {Diarrhea}, dysuria {Dysuria}, ROS {Review of systems}, negative {No pathologic diagnosis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- Severe COPD/emphysema. FEV1 23% in ___, with significant
hyperinflation. Negative for A1AT deficiency. No history of
respiratory failure.
- s/p RUL endobronchial coil placement ___
- CAD s/p MI and PCI x2, in ___
- Hypertension
- Nephrolithiasis, with lithotripsy, stenting, and nephrostomies
in the past.
- Hypothyroidism
- Systolic HF with EF 40% on ___

 

###RESPONSE: Severe COPD {Severe chronic obstructive pulmonary disease}, emphysema {Emphysema}, hyperinflation {Hyperdistention}, Negative {No pathologic diagnosis}, A1AT deficiency {Alpha-1-antitrypsin deficiency}, respiratory failure {Respiratory failure}, endobronchial coil placement {Endotracheal tube present}, CAD {Coronary arteriosclerosis}, PCI {Percutaneous coronary intervention}, Hypertension {Hypertensive disorder, systemic arterial}, Nephrolithiasis {Kidney stone}, lithotripsy {Lithotripsy}, stenting {Insertion of arterial stent}, Hypothyroidism {Hypothyroidism}, Systolic {Systolic heart failure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
His grandfather had emphysema and asbestos exposure.

 

###RESPONSE: emphysema {Emphysema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.3, 122/75, 80, 18, 97% on RA
GENERAL: well nourished middle aged man lying in bed with O2 on 
for comfort, AAOx3, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, 
MMM, good dentition
NECK: no JVD
CARDIAC: very difficult to auscultate, no murmurs, gallops, or 
rubs appreciated
LUNG: mild RUL crackles, overall poor air movement. no wheezing. 
no use of accessory muscles. able to speak in full sentences.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no 
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 
extremities with purpose
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no 
rashes

DISCHARGE PHYSICAL EXAM:
Vitals: Tmax 98.6 Tc 97.8 122-133/78-79 HR ___ RR ___ 99% RA
GEN: Well appearing, speaks in full sentences on room air
Exam otherwise unchanged
 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, well nourished {Well nourished}, middle aged {Middle-age}, lying in bed {Lying in bed}, Ox3 {Oriented to person, time and place}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclera {White sclera}, pink conjunctiva {Conjunctival hyperemia}, MMM {Moist oral mucosa}, good dentition {Normal dentition}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, murmurs {Murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, LUNG {Examination of respiratory system}, mild {Symptom mild}, RUL {Structure of upper lobe of right lung}, crackles {Respiratory crackles}, poor air movement {Decreased breath sounds}, wheezing {Wheezing}, accessory muscles {Accessory skeletal muscle}, able to speak {Able to speak}, full sentences {Able to complete sentence in one breath}, ABDOMEN {Examination of abdomen}, nondistended {Normal abdominal contour}, nontender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, hepatosplenomegaly {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, cyanosis {Cyanosis}, clubbing {Clubbing}, edema {Edema}, moving all 4 
extremities {Does move all four limbs}, NEURO {Neurological examination}, CN II-XII intact {Normal central nervous system}, SKIN {Examination of skin}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Lesion}, rashes {Eruption of skin}, Vitals {Vital signs finding}, RA {Breathing room air}, Well appearing {Well cared for appearance}, speaks {Does speak}, full sentences {Able to complete sentence in one breath}, on room air {Breathing room air}, Exam {Lung finding}, unchanged {Patient condition unchanged}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
LABS:
=======
___ 03:10PM   GLUCOSE-140* UREA N-13 CREAT-1.0 SODIUM-138 
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16
___ 03:10PM   WBC-8.6 RBC-4.21* HGB-12.6* HCT-37.3* MCV-89 
MCH-30.0 MCHC-33.9 RDW-12.8
___ 03:10PM   PLT COUNT-286
___ 03:10PM   ___ PTT-29.6 ___
___ 12:30PM URINE  COLOR-Yellow APPEAR-Clear SP ___
___ 12:30PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-TR 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 
LEUK-NEG
___ 12:30PM URINE  RBC-7* WBC-5 BACTERIA-NONE YEAST-NONE 
EPI-0
___ 12:30AM   ___ COMMENTS-GREEN TOP
___ 12:30AM   LACTATE-1.3 K+-4.1
___ 12:20AM   GLUCOSE-105* UREA N-15 CREAT-1.0 SODIUM-136 
POTASSIUM-5.6* CHLORIDE-100 TOTAL CO2-24 ANION GAP-18
___ 12:20AM   WBC-11.0 RBC-4.42* HGB-13.5* HCT-38.9* MCV-88 
MCH-30.5 MCHC-34.7 RDW-13.1
___:20AM   NEUTS-71.8* LYMPHS-13.6* MONOS-11.7* EOS-2.0 
BASOS-0.8
___ 12:20AM   PLT COUNT-282
___ 12:20AM   ___ PTT-28.4 ___
___ 05:59AM BLOOD WBC-8.8 RBC-4.22* Hgb-12.6* Hct-37.6* 
MCV-89 MCH-30.0 MCHC-33.6 RDW-12.9 Plt ___
___ 05:59AM BLOOD Glucose-90 UreaN-20 Creat-1.1 Na-143 
K-3.7 Cl-105 HCO3-28 AnGap-14
___ 05:59AM BLOOD ALT-30 AST-16 AlkPhos-38* TotBili-0.3

MICRO:
========
___ 11:45 am SPUTUM     Site: EXPECTORATED
      Source: Expectorated. 

   ACID FAST SMEAR (Final ___: 
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. 

   ACID FAST CULTURE (Preliminary): 

___ 8:30 pm SPUTUM      Source: Expectorated. 

   ACID FAST SMEAR (Final ___: 
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. 

   ACID FAST CULTURE (Preliminary): 

   MTB Direct Amplification (Final ___: 
      M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT 
cannot rule
      out TB  or other mycobacterial infection. 
      NAAT results will be followed by confirmatory testing with
      conventional culture and DST methods. This TB NAAT method 
has not
      been approved by FDA for clinical diagnostic purposes. 
However, ___
      ___ Institute (___) has established assay 
performance by
      in-house validation in accordance with ___ standards. 
      TEST PERFORMED BY ___ LAB (___). 

___ 11:36 am SPUTUM      Source: Expectorated. 

   GRAM STAIN (Final ___: 
      >25 PMNs and <10 epithelial cells/100X field. 
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S). 
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI IN 
PAIRS. 

   RESPIRATORY CULTURE (Final ___: 
      SPARSE GROWTH Commensal Respiratory Flora. 
      YEAST.    SPARSE GROWTH. 

   FUNGAL CULTURE (Preliminary): 
      YEAST. 

   ACID FAST SMEAR (Final ___: 
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. 

   ACID FAST CULTURE (Pending): 

___ 12:20 am BLOOD CULTURE

   Blood Culture, Routine (Pending): 

___ 10:54 am BRONCHIAL WASHINGS      RIGHT BRONCHIAL WASH. 

   GRAM STAIN (Final ___: 
      2+   ___ per 1000X FIELD):   POLYMORPHONUCLEAR 
LEUKOCYTES. 
      3+  ___ per 1000X FIELD):   GRAM NEGATIVE ROD(S). 

   RESPIRATORY CULTURE (Final ___: 
      ~4000/ML Commensal Respiratory Flora. 
      PSEUDOMONAS AERUGINOSA.    >100,000 ORGANISMS/ML.. 
         Piperacillin/Tazobactam sensitivity testing performed 
by ___
         ___.  MEROPENEM sensitivity testing performed by 
___. 
      ACHROMOBACTER SPECIES.    10,000-100,000 ORGANISMS/ML.. 
         sensitivity testing performed by Microscan. 
         MEROPENEM <= 1 MCG/ML.  Cefepime >16 MCG/ML. 
      PSEUDOMONAS AERUGINOSA.    10,000-100,000 ORGANISMS/ML.. 
         SECOND MORPHOLOGY. 
         Piperacillin/Tazobactam sensitivity testing performed 
by ___
         ___. 

                              SENSITIVITIES: MIC expressed in 
MCG/ML
                      
_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |          ACHROMOBACTER SPECIES
                             |          |          PSEUDOMONAS 
AERUGINOSA
                             |          |          |   
CEFEPIME--------------    32 R          R        2 S
CEFTAZIDIME-----------  =>64 R     =>32 R        4 S
CEFTRIAXONE-----------               32 I
CIPROFLOXACIN---------     2 I      =>4 R      0.5 S
GENTAMICIN------------   <=1 S        2 S      <=1 S
IMIPENEM--------------              <=1 S
LEVOFLOXACIN----------              <=1 S
MEROPENEM-------------       R          S   <=0.25 S
PIPERACILLIN/TAZO-----       I      <=8 S          S
TOBRAMYCIN------------   <=1 S        2 S      <=1 S
TRIMETHOPRIM/SULFA----              <=2 S

   ACID FAST SMEAR (Final ___: 
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. 

   ACID FAST CULTURE (Preliminary): 
            MYCOBACTERIUM AVIUM COMPLEX. 
         Identified by ___ Laboratory ,REPORT DATE: 
___. 

   FUNGAL CULTURE (Final ___: 
      EXOPHIALA SPECIES.    1 COLONY. 

IMAGING:
=========
___ Imaging CHEST (PA & LAT)      
1. Large right upper lobe consolidation, concerning for 
pneumonia versus 
hemorrhage little change since ___. Concurrent 
peribronchial 
infiltration in the right middle and lower lobes has improved. 
     
___ Cardiovascular ECG 
Sinus tachycardia. Borderline R wave progression. Borderline 
leftward axis. Compared to the previous tracing of ___ the 
rate is faster. The findings are otherwise similar. 
  Intervals Axes 
Rate PR QRS QT/QTc P QRS T 
103 140 88 ___ ___ with h/o severe COPD s/p right sided endobronchial coil 
placement on ___ admitted with fever, RUL infiltrate consistent 
with PNA.

# RUL bacterial pneumonia: Pt developed fever and increased 
sputum production following last admission for endobronchial 
coil placement. He was started on levofloxacin as an outpatient 
and shortly after admitted to OSH where he received 
vanc/piperacillin-tazobactam for several days and was discharged 
home on levofloxacin. He experienced recurrent fever at home and 
was advised to present to ___ where CXR showed RUL 
consolidation infiltrate, most likely postobstructive PNA in 
area of coiling procedure given fevers, change in sputum 
production and temporary clinical improvement while on broad 
spectrum abx at OSH. He was initially treated with 
vanc/piperacillin-tazobactam /levofloxacin. Notably, BAL from 
___ on last admission grew resistant pseudomonas. Patient at 
risk for developing further antibiotic resistance given 
interrupted courses of levofloxacin and vanc/zosyn in the week 
prior to presentation. However, given clinical improvement, 
antibiotics were narrowed to piperacillin-tazobactam in 
consultation with ID with plan for 14 day total course with 
close outpatient follow up. Sputum culture this admission grew 
commensal respiratory flora and sparse yeast, which may 
represent exophiala species felt to represent colonization on 
prior BAL. Endobronchial coil removal was discussed with IP and 
ID, but deferred given clinical improvement on antibiotics. 

# COPD: Severe with FEV1 23% and reduced DLCO s/p endobronchial 
coiling as above. Normally on prednisone 10mg daily, recently on 
prednisone taper following coiling procedure. Increased to 60mg 
on admission in case COPD symptoms were contributing to SOB. 
Treated with prednisone 60mg daily x 5 day burst (d1 = ___. 
Continued home advair, spiriva, zyrtec, montelukast.

# ___: AFB cx from ___ BAL returned positive on ___. Patient 
had history of partially treated ___ in ___ per Parters 
records. Ruled out for active pulm TB with negative sputum AFB x 
3. AFB cx from ___ sent to state lab and identified as ___. 

# Emergency Contact: ___ ___ (wife)

TRANSITIONAL ISSUES:
====================
# RUL Pseudomonal PNA: Discharged on piperacillin-tazobactam for 
14 day total course (last day ___. If worsens clinically, 
may require tobramycin given intermediate sensitivity of 
pseudomonas from BAL ___ to pip-tazo. Has ID followup on 
___. Will need labs to include CBC with differential, 
Creatinine, LFTs in 5 days of discharge ___ or ___ 
given upcoming ___) faxed to Dr. ___ 
new ID provider ___ ___.
# ___: Consider reattempting outpatient treatment, would require 
prolonged course. ___ have positive AFB culture on future BALs 
given known ___ infection.

 

###RESPONSE: GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}, URINE {Evaluation of urine specimen}, COLOR {Color finding}, PROTEIN {Measurement of protein in urine}, GLUCOSE-NEG {Urine glucose not detected}, KETONE-NEG {Urine ketones not detected}, BILIRUBIN {Bilirubin measurement, urine}, NEG {No abnormality detected}, UROBILNGN {Urobilinogen measurement, urine}, NEG {No abnormality detected}, PH {pH measurement}, LEUK-NEG {Urine leukocytes not detected}, URINE {Urinalysis}, RBC {Red blood cell count}, WBC {White blood cell count}, AST {Aspartate aminotransferase measurement}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, SPUTUM {Microbial culture of sputum}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, CULTURE {Microbial culture}, SPUTUM {Microbial culture of sputum}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, CULTURE {Microbial culture}, TUBERCULOSIS {Tuberculosis}, negative {No pathologic diagnosis}, infection {Infectious disease}, culture {Microbial culture}, SPUTUM {Microbial culture of sputum}, GRAM STAIN {Gram stain method}, epithelial cells {Epithelial cells present}, NEGATIVE {No pathologic diagnosis}, RESPIRATORY CULTURE {Respiratory microbial culture}, YEAST {Yeast culture}, FUNGAL {Mycology culture}, CULTURE {Microbial culture}, YEAST {Yeast culture}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, CULTURE {Microbial culture}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, BRONCHIAL WASHINGS {Lavage of bronchus}, RIGHT {Right lung structure}, BRONCHIAL {Bronchial structure}, WASH {Bronchoscopic lavage}, GRAM STAIN {Gram stain method}, POLYMORPHONUCLEAR 
LEUKOCYTES {Polymorphonuclear leukocyte count}, NEGATIVE {No pathologic diagnosis}, RESPIRATORY CULTURE {Respiratory microbial culture}, sensitivity {Antimicrobial susceptibility test}, sensitivity {Antimicrobial susceptibility test}, sensitivity {Antimicrobial susceptibility test}, sensitivity {Antimicrobial susceptibility test}, SENSITIVITIES {Antimicrobial susceptibility test}, CIPROFLOXACIN {Antibiotic therapy}, LEVOFLOXACIN {Antibiotic therapy}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, ACID FAST {Acid fast bacilli culture}, CULTURE {Microbial culture}, Laboratory {Laboratory test}, FUNGAL {Mycology culture}, CULTURE {Mycology culture}, Imaging CHEST (PA & LAT {Diagnostic radiography of chest, combined posteroanterior and lateral}, right upper lobe {Structure of bronchus of right upper lobe}, consolidation {Lung consolidation}, pneumonia {Pneumonia}, hemorrhage {Hemorrhage}, infiltration {Infiltration}, right {Right lung structure}, middle {Structure of middle lobe of right lung}, lower lobes {Structure of lower lobe of right lung}, improved {Patient's condition improved}, ECG {Electrocardiographic procedure}, Sinus tachycardia {Sinus tachycardia}, R wave progression {Electrocardiographic R wave abnormal}, axis {Electrocardiographic axis finding}, rate {Finding of heart rate}, Rate {Finding of heart rate}, QRS {Finding of electrocardiogram QRS complex}, QRS {Finding of electrocardiogram QRS complex}, severe COPD {Severe chronic obstructive pulmonary disease}, right sided {Right lung structure}, endobronchial coil 
placement {Endotracheal tube present}, fever {Fever}, RUL {Structure of upper lobe of right lung}, infiltrate {Infiltration}, PNA {Pneumonia}, RUL {Structure of upper lobe of right lung}, bacterial pneumonia {Bacterial pneumonia}, fever {Fever}, increased {Patient's condition worsened}, sputum production {Productive cough}, placement {Implantation procedure}, started {New medication added}, levofloxacin {Antibiotic therapy}, vanc {Antibiotic therapy}, levofloxacin {Antibiotic therapy}, recurrent {Recurrent disease}, fever {Fever}, CXR {Plain chest X-ray}, RUL {Structure of upper lobe of right lung}, consolidation {Lung consolidation}, infiltrate {Infiltration}, PNA {Pneumonia}, procedure {Procedure}, fevers {Fever}, sputum 
production {Sputum finding}, improvement {Patient's condition improved}, vanc {Antibiotic therapy}, levofloxacin {Antibiotic therapy}, BAL {Bronchoscopy and bronchoalveolar lavage}, antibiotic {Antibiotic therapy}, levofloxacin {Antibiotic therapy}, vanc {Antibiotic therapy}, improvement {Patient's condition improved}, antibiotics {Antibiotic therapy}, consultation {Consultation}, outpatient follow up {Outpatient care management}, Sputum culture {Microbial culture of sputum}, yeast {Yeast detected}, BAL {Bronchoscopy and bronchoalveolar lavage}, Endobronchial coil removal {Removal of endotracheal tube}, improvement {Patient's condition improved}, antibiotics {Antibiotic therapy}, COPD: Severe {Severe chronic obstructive pulmonary disease}, prednisone {Steroid therapy}, prednisone {Steroid therapy}, taper {Medication decreased}, procedure {Procedure}, Increased {Medication increased}, COPD {Chronic obstructive lung disease}, SOB {Dyspnea}, prednisone {Steroid therapy}, BAL {Bronchoscopy and bronchoalveolar lavage}, r active pulm TB {Active tuberculosis}, negative {No pathologic diagnosis}, sputum {Microbial culture of sputum}, RUL {Structure of upper lobe of right lung}, Pseudomonal PNA {Pneumonia caused by Pseudomonas}, worsens {Patient's condition worsened}, sensitivity {Antimicrobial susceptibility test}, BAL {Bronchoscopy and bronchoalveolar lavage}, labs {Laboratory test}, CBC {Complete blood count}, differential {Differential white cell count within reference range}, Creatinine {Creatinine measurement}, LFTs {Hepatic function panel}, AFB culture {Acid fast bacilli culture}, infection {Infectious disease}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze 
2. Cetirizine 10 mg PO DAILY 
3. Fluticasone-Salmeterol Diskus (500/50)  1 INH IH BID 
4. Guaifenesin ER 600 mg PO Q12H 
5. Levothyroxine Sodium 150 mcg PO DAILY 
6. Lorazepam 1 mg PO BID 
7. Montelukast 10 mg PO DAILY 
8. Losartan Potassium 25 mg PO DAILY 
9. Tiotropium Bromide 1 CAP IH DAILY 
10. Aspirin 81 mg PO DAILY 
11. Multivitamins 1 TAB PO DAILY 
12. Vitamin D 1000 UNIT PO DAILY 
13. PredniSONE 10 mg PO DAILY 
Start: After 20 mg tapered dose 
14. Levofloxacin 500 mg PO Q24H 

 
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze 
2. Aspirin 81 mg PO DAILY 
3. Cetirizine 10 mg PO DAILY 
4. Fluticasone-Salmeterol Diskus (500/50)  1 INH IH BID 
5. Guaifenesin ER 600 mg PO Q12H 
6. Levothyroxine Sodium 150 mcg PO DAILY 
7. Lorazepam 1 mg PO BID 
8. Losartan Potassium 25 mg PO DAILY 
9. Montelukast 10 mg PO DAILY 
10. Multivitamins 1 TAB PO DAILY 
11. Tiotropium Bromide 1 CAP IH DAILY 
12. Vitamin D 1000 UNIT PO DAILY 
13. Piperacillin-Tazobactam 4.5 g IV Q6H 
RX *piperacillin-tazobactam 4.5 gram 4.5 gram IV Every 6 hours 
Disp #*44 Vial Refills:*0
14. PredniSONE 60 mg PO DAILY Duration: 1 Dose 
Take on ___ and return to regular 10mg dosing after that. 
RX *prednisone 20 mg 3 tablet(s) by mouth Once Disp #*3 Tablet 
Refills:*0

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary:
Bacterial Pneumonia

Secondary: 
COPD
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 

###RESPONSE: Home With Service {Home health aide service management}, Bacterial Pneumonia {Bacterial pneumonia}, COPD {Chronic obstructive lung disease}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___, 

It was a pleasure participating in your care at ___. You were 
admitted to the hospital for shortness of breath due to a 
pneumonia. You were treated with IV antibiotics and should 
continue to take them through your new ___ line for a total of 
14 days (last day ___. You are scheduled to see Dr. ___ in 
the ___ Diseases clinic to discuss whether you will need 
additional antibiotics after that. Please follow up with the 
interventional pulmonary doctors as ___. 

We gave you high dose prednisone (60mg) in the hospital which 
you should also take tomorrow to complete 5 days. On ___, you 
may resume your normal dose of 10mg daily.
 

###RESPONSE: shortness of breath {Dyspnea}, pneumonia {Pneumonia}, IV antibiotics {Intravenous antibiotic therapy}, antibiotics {Antibiotic therapy}, follow up {Follow-up arranged}, pulmonary {Pulmonary medicine service}, prednisone {Steroid therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Penicillins / Latex
 
Attending: ___.
 
Chief Complaint:
Shortness of Breath
 
Major Surgical or Invasive Procedure:
Thoracentesis (x2)
Chest Tube
Bronchoscopy

 

###RESPONSE: Penicillins {Allergy to penicillin}, Latex {Allergy to Hevea brasiliensis latex protein}, Shortness of Breath {Dyspnea}, Thoracentesis {Thoracentesis}, Chest Tube {Insertion of pleural tube drain}, Bronchoscopy {Bronchoscopy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ with newly diagnosed Stage IV NSCLC, rapidly progrsesive, 
presenting to clinic today with SOB. She was diagnosed on ___ 
after a ___ week history of cough following which the patient 
palpated a R supraclavicular node. One week ago the pt was seen 
by medical oncology and is now s/p a right supraclavicular node 
biopsy that revealed NSCLC. She presented for follow up PET/CT 
and subsequently to clinic today. and found be hypoxic (O2 sat 
___ on RA). The patient was recently started on prednisone 80 mg 
daily by her PCP for the last 2 days without significant 
improvement.  
.  
Upon further ROS: The pt denies fevers, chills, headache, chest 
pain, nausea, vomitting, diarrhea, dysuria. The patient notes 
mild constipation when taking Vicoden.  

 

###RESPONSE: Stage IV NSCLC {Non-small cell carcinoma of lung, TNM stage 4}, progrsesive {Patient's condition worsened}, clinic {Outpatient care management}, SOB {Dyspnea}, cough {Cough}, palpated {Palpation}, R supraclavicular node {Structure of right supraclavicular lymph node}, supraclavicular node 
biopsy {Supraclavicular lymph node biopsy}, NSCLC {Non-small cell lung cancer}, PET/CT {Positron emission tomography}, clinic {Outpatient care management}, hypoxic {Hypoxia}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, PCP {Primary care management}, improvement {Patient's condition improved}, fevers {Fever}, chills {Chill}, headache {Headache}, chest 
pain {Chest pain}, nausea {Nausea}, vomitting {Vomiting}, diarrhea {Diarrhea}, dysuria {Dysuria}, mild {Symptom mild}, constipation {Constipation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Past Oncology History:  
- Initial symptoms: cough, supraclavicular lymph node, nodular 
mass lower abdomen  
- CXR demonstrated R hilar mass. CT on ___ showed 3.5 X 3.7 
cm R hilar mass with marked narrowing of the right upper lobe 
bronchus and apparent obstruction of the posterior bronchus to 
the right upper lobe. Bulky bilateral mediastinal 
lymphadenopathy was noted. The  
dominant lymph node mass in the right paratracheal region 
measured 2.9 x 2.7 cm, with a dominant conglomerate nodal mass 
in the precarinal lesion measuring 3.3 x 2.8 cm. Multiple lymph 
nodes were identified throughout the mediastinum including the 
prevascular space bilaterally, the posterior subcarinal space, 
and the right hilum. There was a moderate dependent right 
pleural effusion and a small left pleural effusion as well as a 
small pericardial effusion. Also noted was a 2.8 x 1.9 cm nodule 
within the periphery of the right upper lobe. Heterogeneous 
enhancement of the left adrenal gland was seen, measuring 1.9 x 
1.8 cm. In addition, an enlarged left supraclavicular lymph node 
measured 1.4 x 1 cm. Several lucent vertebral body lesions were 
identified in the lower thoracic spine.  
- Excisional biopsy of the right supraclavicular lymph node on 
___.  
- Pathology: poorly differentiated neuroendocrine carcinoma of 
pulmonary origin, probably best characterized as large cell 
type, although there is considerable variation in cell size. No 
e/o lymphoproliferative disorder.  
.  

###RESPONSE: cough {Cough}, supraclavicular lymph node {Structure of supraclavicular lymph node}, nodular 
mass {Nodule}, lower abdomen {Lower abdomen structure}, CXR {Plain chest X-ray}, hilar mass {Mass of hilum}, CT {Computed tomography of abdomen}, hilar mass {Mass of hilum}, narrowing {Narrowing}, right upper lobe 
bronchus {Structure of bronchus of right upper lobe}, obstruction {Obstruction}, posterior bronchus to 
the right upper lobe {Structure of right upper lobe posterior segmental bronchus}, mediastinal 
lymphadenopathy {Mediastinal lymphadenopathy}, lymph node {Structure of lymph node}, mass {Mass}, right paratracheal {Structure of right paratracheal lymph node}, mass {Mass}, precarinal {Structure of pretracheal lymph node}, lesion {Lesion}, lymph 
nodes {Structure of lymph node}, mediastinum {Mediastinal lymph node structure}, prevascular {Structure of prevascular and/or retrotracheal lymph node}, subcarinal {Structure of subcarinal lymph node}, right hilum {Structure of hilum of right lung}, right {Right sphenoid sinus structure}, pleural effusion {Pleural effusion}, pleural effusion {Pleural effusion}, pericardial effusion {Pericardial effusion}, nodule {Nodule of lung}, right upper lobe {Structure of upper lobe of right lung}, enhancement {Adrenal hyperplasia}, left adrenal gland {Structure of left adrenal gland}, enlarged {Localized enlarged lymph nodes}, left supraclavicular lymph node {Structure of left supraclavicular lymph node}, vertebral body {Structure of body of vertebra}, lesions {Lesion}, thoracic spine {Structure of thoracic vertebral column}, Excisional biopsy {Excisional biopsy}, right supraclavicular lymph node {Structure of right supraclavicular lymph node}, Pathology {Abnormal histology findings}, poorly differentiated neuroendocrine carcinoma {Malignant poorly differentiated neuroendocrine carcinoma}, pulmonary {Examination of respiratory system}, large cell {Large cell carcinoma of lung}, variation in cell size {Cell size alteration}, lymphoproliferative disorder {Lymphoproliferative disorder}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:  
1. L4/L5 spondylolisthesis with synovial cyst resected in  
___.  
2. Left piriformis syndrome.  
3. Hypertension.  
4. Status post hysterectomy in ___ for leiomyomata with foci of 
 
atypical hyperplasia of the endometrium, focally involving an  
endometrial polyp.  

 

###RESPONSE: L4 {Bone structure of L4}, L5 {Bone structure of L5}, spondylolisthesis {Spondylolisthesis of lumbar vertebra}, synovial cyst resected {Excision of synovial cyst}, Left {Structure of left piriformis muscle}, piriformis syndrome {Piriformis syndrome}, Hypertension {Hypertensive disorder, systemic arterial}, Status post {Postoperative state}, hysterectomy {Hysterectomy}, leiomyomata {Leiomyoma}, atypical hyperplasia of the endometrium {Endometrioid intraepithelial neoplasia}, endometrial polyp {Polyp of endometrium}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
The patient's mother died at age ___ from squamous cell carcinoma 
of the oral cavity. Her father died of congestive heart failure 
at age ___. She has no siblings. Her  paternal aunt was diagnosed 
with breast cancer in her ___.  
.  

 

###RESPONSE: died {Dead}, squamous cell carcinoma {Squamous cell carcinoma}, oral cavity {Oral cavity structure}, died {Dead}, congestive heart failure {Congestive heart failure}, breast cancer {Malignant neoplasm of breast}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Tc 97.3 BP 125/79 HR 95 RR 28 93% 3L NC  
Gen: Mild Distress, Sitting upright, AOx3  
HEENT: PEERLA, EOMI, OP without exudates or erythema  
Neck: Supple  
Resp: Healing R supraclavicular bx site with palpable node, 
bilateral diffuse expiratory wheezes, no accessory muscle use, 
decreased BS at bases, coarse BS throughout.  
Card: Regular, S1S2 No MRG  
Abd: Palpable non-tender mobile 2cm nodule in LLQ, soft, 
slightly protuberant, non-tender, non-distended, BS+  
Extr: Trace edema bilaterally, Bilateral mild ulnar deviation of 
the phalanges  
Neuro: AOx3, CNII-XII tested and intact. ___ strength and 
sensation in upper and lower extremities, normal finger to nose 
bilaterally.  
Psych: Patient visibly anxious but appropriate conversation.  

 

###RESPONSE: BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, NC {Normal head}, Gen {General examination of patient}, Mild {Symptom mild}, Distress {Distress}, Sitting upright {Sitting upright}, AOx3 {Oriented to person, time and place}, HEENT {Physical examination procedure}, PEERLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, OP {Oropharyngeal structure}, exudates {Exudate}, erythema {Erythema}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Resp {Examination of respiratory system}, Healing {Structure resulting from tissue repair process}, R supraclavicular bx site with palpable node {Supraclavicular lymph node biopsy}, wheezes {Wheezing}, accessory muscle {Accessory skeletal muscle}, decreased BS {Decreased breath sounds}, bases {Structure of base of lung}, BS {Normal bowel sounds}, Card {Cardiovascular physical examination}, Regular {Normal heart rate}, S2 {Normal second heart sound, S>2<}, No MRG {Heart sounds normal}, Abd {Examination of abdomen}, Palpable {Finding by palpation}, non-tender {Abdominal tenderness}, nodule {Nodule}, LLQ {Structure of left lower quadrant of abdomen}, soft {Abdomen soft}, protuberant {Swollen abdomen}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, BS+ {Normal bowel sounds}, Extr {Examination of limb}, edema {Edema}, mild {Symptom mild}, ulnar deviation of 
the phalanges {Ulnar deviation of fingers}, Neuro {Neurological examination}, AOx3 {Oriented to person, time and place}, XII {Hypoglossal nerve structure}, intact {Normal sensation}, sensation {Normal sensation}, upper {Upper limb structure}, lower extremities {Lower limb structure}, normal {No abnormality detected}, nose {Nasal structure}, Psych {Psychological assessment}, anxious {Anxiety}, appropriate conversation {Conversation content appropriate}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Admission Labs:
___ 04:40PM   WBC-25.2*# RBC-4.08* HGB-12.0 HCT-35.7* 
MCV-88 MCH-29.5 MCHC-33.7 RDW-13.2
___ 04:40PM   NEUTS-86.9* LYMPHS-5.3* MONOS-5.6 EOS-2.0 
BASOS-0.3
___ 04:40PM   PLT COUNT-570*
___ 04:40PM   ___ PTT-35.1* ___
___ 04:40PM   CALCIUM-9.7 PHOSPHATE-3.3 MAGNESIUM-2.5 URIC 
ACID-4.5
___ 04:40PM   CK-MB-5 cTropnT-<0.01 proBNP-2531*
___ 04:40PM   LIPASE-23
___ 04:40PM   ALT(SGPT)-26 AST(SGOT)-35 LD(LDH)-370* ALK 
PHOS-148* AMYLASE-59 TOT BILI-0.2
___ 04:40PM   GLUCOSE-69* UREA N-19 CREAT-0.7 SODIUM-130* 
POTASSIUM-4.2 CHLORIDE-85* TOTAL CO2-26 ANION GAP-23*
.
CT Head ___
IMPRESSION: There is no evidence of abnormal enhancement or 
evidence of focal
or diffuse lesions. There is no evidence of intracranial 
hemorrhage, mass, or
mass effect. No metastasic lesions are visulized, however CT 
with contrast
is not able to provide the same anatomical detail comparable to 
MRI with and
without contrast.
.
PET CT: ___
MPRESSION: 1. Widespread metastatic disease. 2. Malignant soft 
tissue nodule
in the deep right breast is most likely a metastasis from lung 
cancer (given
second subcutaneous deposit in the anterior abdominal wall), but 
the possibility
of a second breast primary remains a remote consideration. 3. 
Suspicious
focus in the pancreas is also likely a metastasis, but again, a 
primary
malignancy would be difficult to entirely exclude.
.
ECHO: ___
The left atrium is normal in size. Left ventricular wall 
thicknesses are normal. The left ventricular cavity size is 
normal. Overall left ventricular systolic function is normal 
(LVEF 60-70%). Right ventricular chamber size and free wall 
motion are normal. There are focal calcifications in the aortic 
arch. The aortic valve leaflets (3) are mildly thickened but 
aortic stenosis is not present. Trace aortic regurgitation is 
seen. The mitral valve leaflets are mildly thickened. There is 
no mitral valve prolapse. Trivial mitral regurgitation is seen. 
There is mild pulmonary artery systolic hypertension. The main 
pulmonary artery is dilated.
.
There is a small to moderate sized pericardial effusion. The 
effusion appears circumferential. There is brief right atrial as 
well as right ventricular free wall diastolic invagination. 
However, there is no major respirophasic variation of right or 
left ventriculart inflow. These findings suggest that increased 
pericardial pressure is present, without major impairment of 
ventricular filling or frank cardiac tamponade. Serial clinical 
and echocardiographic followup is recommended. 
.
ECHO ___:
Overall left ventricular systolic function is normal (LVEF>55%). 
Right ventricular chamber size and free wall motion are normal. 
The aortic valve leaflets (3) are mildly thickened. The mitral 
valve leaflets are mildly thickened. There is a small to 
moderate sized pericardial effusion. The effusion appears 
circumferential. There are no echocardiographic signs of 
tamponade. There is brief right atrial diastolic collapse. 
.
Compared with the prior study (images reviewed) of ___, no 
right ventricular diastolic invagination is appreciated. The 
pericardial effusion appears slightly smaller.
.
___:
IMPRESSION:
1. No evidence of aortic dissection or pulmonary embolism to the 
subsegmental
level.
2. Increased dense nonenhancing right lower lobe consolidation 
consistent
with pneumonia, with additional increased predominantly 
ground-glass
consolidation / post obstructive changes (due to right hilar 
mass /
adenopathy) within the posterior portion of the left upper lobe 
and adjacent
to the right pleural effusion, which are also presumably 
infectious in
etiology. Please note reexpansion edema involving a portion of 
the right lower
lobe may also have a similar appearance.
3. Increased enhancing atelectasis involving the left lower lobe 
with left
pleural fluid noted to insinuate around regions of ""drowned"" 
lung.
4. No significant interval change in the degree of previously 
described
adenopathy and a dominant right hilar mass, with stable mass 
effect on right
upper lobe and bronchus intermedius bronchi. Stable mass effect 
on the right
upper lobe pulmonary artery, which remains patent.
5. Unchanged soft tissue density within the deep right breast, 
which was
noted to be FDG-avid.
6. Unchanged background emphysema and interstitial septal 
thickening, which
is worrisome for lymphangitic carcinomatosis.
7. Stable lytic metastatic lesions and thickening of the left 
adrenal gland.
.
___:
Cytology ReportPLEURAL FLUIDProcedure Date of ___
  
REPORT APPROVED ___
SPECIMEN ___    ___    PLEURAL FLUID
 
SPECIMEN DESCRIPTION: Received 1,300 ml of bloody fluid.
  Prepared 1 ThinPrep slide.
 
CLINICAL DATA: 73 with metastatic NSCLA with R pleural 
effusion.
PREVIOUS BIOPSIES:
___ PLEURAL FLUID
___ PERITONEAL WASHINGS
REPORT ___. ___
 
___: Pleural fluid:
  
  ATYPICAL.
  
  Clusters of atypical epithelioid cells on cell block
  (___) only. The cells are negative for ___ 31,
  B72.3, TTF-1 and CEA and cannot be further classified.
  
DIAGNOSED BY:
___, CT(___)
___, M.D.
 
(___)
.
___: TTE
Overall left ventricular systolic function is normal (LVEF>55%). 
Right ventricular chamber size and free wall motion are normal. 
The aortic valve leaflets are mildly thickened. The mitral valve 
leaflets are mildly thickened. There is a small to moderate 
sized pericardial effusion. The effusion appears 
circumferential. No right ventricular diastolic collapse is 
seen. There is brief right atrial diastolic collapse. There is 
significant, accentuated respiratory variation in 
mitral/tricuspid valve inflows, consistent with impaired 
ventricular filling. 

Compared with the prior study (images reviewed) of ___, 
the resting heart rate is faster and respiratory variation in 
mitral valve inflow is present (this may be secondary to other 
entities than impending tamponade such as volume depletion or 
lung disease). Left ventricular function is more vigorous. 
.
___: CXR
FINDINGS: As compared to the previous examination, there is 
increasing
consolidation and volume loss in the right upper lobe. The 
perihilar right
lung areas, notably neighboring a hilar mass, are denser than on 
the previous
examination. A pre-existing right-sided pleural effusion is 
unchanged, and
the expansion of the right lower lobe is slightly improved as 
compared to the
previous exam. No pathologic changes in the left lung.
.
Discharge Labs:
___ 06:40AM BLOOD WBC-4.6 RBC-3.37* Hgb-10.0* Hct-29.9* 
MCV-89 MCH-29.7 MCHC-33.5 RDW-13.0 Plt ___
___ 06:40AM BLOOD Plt ___
___ 07:10AM BLOOD ___ PTT-33.6 ___
___ 06:40AM BLOOD Glucose-97 UreaN-23* Creat-0.7 Na-136 
K-3.8 Cl-100 HCO3-29 AnGap-11
___ 07:10AM BLOOD ALT-12 AST-15 LD(LDH)-168 AlkPhos-91 
TotBili-0.6
___ 06:40AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.___ with newly diagnosed metastatic NSCLC here with dyspnea and 
new 02 requirement.
.
# Dyspnea, Hypoxia: The patients initial differential included 
worsening atelectasis, bronchospasms, worsening effusions, 
post-obstructive PNA, anxiety, anemia. The patient was admitted 
on Prednsione 80mg PO Daily which was tapered down during her 
hospital course in addition to receiving nebs PRN. CXR revealed 
a large R sided effusion and the  pt underwent thoracentesis on 
___ during which 2.1L were removed. That evening the pt had an 
episode of desaturation requiring up to 10L with CXR evidence of 
re-expansion pulmonary edema, this improved somewhat with 
diuresis, but CT chest ___ showed marked worsening of effusions 
& dense consolodate of RLL with ground glass opacities 
surrounding. A second thoarcenetsis was then performed which was 
complcated by a PTX after which a chest tube was placed for 24 
hrs without complication. The patient was placed on Levo/Flagyl 
for a questionable post-obstructive PNA. The chest tube was 
removed and ___ 48hrs the patient an the patients 02 requirement 
resolved. The patient was discharged on room air with home 02 
PRN.
.
# Metastatic NSCLC: PET-CT revealed wide-spread metastatic 
disease. Pathology ""poorly differentiated neuroendocrine 
carcinoma of pulmonary origin, probably best characterized as 
large cell type"". Potentially the etiology of the patients SOB. 
The patient was initiated on her first cycle of 
Cabroplatin/Etoposide on ___ for 3 days. The patient tolerated 
the treatment during her hospital course without complications.
.
# Pericardial effusion: A pericardial effusion was noted on CT 
prior to admittion. TTE (details above) revealed early signs of 
tamponade on ___, this was improved on ___ echo. Care was 
taken during diureses not to drop the patients BP. (The patient 
tolerated doses of 20IV lasix, although 40IV lasix caused 
asymptomatic drops to the mid ___ systolically). The patient 
required no interventions and the patients TTE was repeated on 
___ prior to d/c (details above).
.
# Anxiety: Continued anxiety over the past ___ weeks. Has been 
taking Ativan and Valium while at home.The patient was continued 
on Ativan 0.5-1mg as needed.
.
# HTN: BP controlled.The patients BP was exchanged (Toprol XL 
50mg for Metoprolol 25mg PO BID) while in house.
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, PTT {Partial thromboplastin time, activated}, CALCIUM {Blood calcium measurement}, cTropnT {Troponin T cardiac measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, LIPASE {Triacylglycerol lipase measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Lactate dehydrogenase measurement}, TOT BILI {Bilirubin, total measurement}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, no evidence {No abnormality detected}, enhancement {Refractive surgery enhancement}, lesions {Lesion}, no evidence {No abnormality detected}, intracranial 
hemorrhage {Intracranial hemorrhage}, mass {Mass}, mass {Mass}, metastasic {Metastatic malignant neoplasm}, lesions {Lesion}, MRI with {Magnetic resonance imaging of head with contrast}, without contrast {Magnetic resonance imaging without contrast}, disease {Disease}, Malignant soft 
tissue {Malignant neoplasm of soft tissue}, nodule {Nodule}, right breast {Metastatic malignant neoplasm to right breast}, metastasis from lung 
cancer {Primary malignant neoplasm of lung}, subcutaneous {Subcutaneous tissue structure of anterior abdominal wall}, deposit {Deposition}, anterior abdominal wall {Anterior abdominal wall structure}, breast primary {Primary malignant neoplasm of breast}, pancreas is also likely a metastasis {Metastatic malignant neoplasm to pancreas}, primary
malignancy {Primary malignant neoplasm of pancreas}, ECHO {Echocardiography}, left atrium {Left atrial structure}, normal in size {Normal size}, Left ventricular wall {Left cardiac ventricular structure}, thicknesses are normal {Normal thickness}, left ventricular cavity {Structure of cavity of left cardiac ventricle}, size is 
normal {Normal size}, left ventricular systolic function {Normal left ventricular systolic function and wall motion}, normal {No abnormality detected}, Right ventricular chamber {Right cardiac ventricular structure}, wall 
motion are normal {Normal ventricular wall motion}, focal calcifications {Focal calcium deposition, calcified structure}, aortic 
arch {Aortic arch structure}, aortic valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve leaflets are mildly thickened {Thickened mitral leaflet}, mitral valve prolapse {Mitral valve prolapse}, Trivial mitral regurgitation {Mild mitral valve regurgitation}, mild {Mild mitral valve regurgitation}, pulmonary artery systolic hypertension {Pulmonary hypertensive arterial disease}, pulmonary artery is dilated {Dilatation of pulmonary artery}, pericardial effusion {Pericardial effusion}, effusion {Pericardial effusion}, right atrial {Right atrial structure}, right ventricular {Right cardiac ventricular structure}, wall {Cardiac wall structure}, invagination {Invagination}, right {Right cardiac ventricular structure}, left ventriculart {Left cardiac ventricular structure}, inflow {Abnormal cardiac flow}, pericardial {Pericardial structure}, pressure {Pressure}, impairment {Impairment}, ventricular {Cardiac ventricular structure}, filling {Abnormal cardiac flow}, cardiac tamponade {Cardiac tamponade}, echocardiographic {Echocardiography}, followup {Follow-up consultation}, left ventricular systolic function {Normal left ventricular systolic function and wall motion}, normal {No abnormality detected}, Right ventricular chamber {Right cardiac ventricular structure}, wall motion are normal {Normal ventricular wall motion}, aortic valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, mitral 
valve leaflets are mildly thickened {Thickened mitral leaflet}, pericardial effusion {Pericardial effusion}, effusion {Pericardial effusion}, echocardiographic {Echocardiography}, signs {Sign}, tamponade {Cardiac tamponade}, right atrial {Right atrial structure}, collapse {Collapse}, study {Evaluation procedure}, right ventricular {Right cardiac ventricular structure}, invagination {Invagination}, pericardial effusion {Pericardial effusion}, No evidence {No abnormality detected}, aortic dissection {Dissection of aorta}, pulmonary embolism {Pulmonary embolism}, right lower lobe {Structure of lower lobe of right lung}, consolidation {Lung consolidation}, pneumonia {Pneumonia}, ground-glass {Ground glass lung opacity}, consolidation {Lung consolidation}, obstructive {Obstruction}, hilar 
mass {Mass of hilum}, adenopathy {Lymphadenopathy}, left upper lobe {Structure of upper lobe of left lung}, right {Right sphenoid sinus structure}, pleural effusion {Pleural effusion}, infectious {Infectious disease}, edema {Edema}, right lower
lobe {Structure of lower lobe of right lung}, atelectasis {Atelectasis}, left lower lobe {Structure of lower lobe of left lung}, pleural fluid {Pleural effusion}, lung {Lung structure}, adenopathy {Lymphadenopathy}, hilar mass {Mass of hilum}, stable {Symptom not changed}, mass {Nodule of lung}, right
upper lobe {Structure of upper lobe of right lung}, bronchus {Structure of right bronchus}, Stable {Symptom not changed}, mass {Nodule of lung}, right
upper lobe pulmonary {Structure of upper lobe of right lung}, soft tissue {Structure of soft tissue}, density {Abnormally opaque structure}, right breast {Right breast structure}, FDG {Positron emission tomography with computed tomography using fluorodeoxyglucose (18-F)}, emphysema {Emphysema}, septal {Cardiac septum structure}, thickening {Increased thickness}, lymphangitic carcinomatosis {Lymphangitis carcinomatosa}, Stable {Patient's condition stable}, lytic {Lysis}, metastatic {Metastatic malignant neoplasm}, lesions {Lesion}, thickening {Increased thickness}, left 
adrenal gland {Structure of left adrenal gland}, Cytology {Cytology examination - general}, PLEURAL FLUID {Pleural effusion}, SPECIMEN DESCRIPTION {Specimen description}, bloody fluid {Pleural fluid bloodstained}, metastatic {Metastatic malignant neoplasm}, NSCLA {Non-small cell lung cancer}, pleural 
effusion {Pleural effusion}, BIOPSIES {Biopsy}, PLEURAL FLUID {Pleural effusion}, Pleural fluid {Pleural effusion}, cells {Cell structure}, cell {Cell structure}, block {Obstruction}, cells {Cell structure}, negative {No abnormality detected}, TTE {Transthoracic echocardiography}, left ventricular systolic function {Normal left ventricular systolic function and wall motion}, normal {No abnormality detected}, Right ventricular chamber {Right cardiac ventricular structure}, wall motion are normal {Normal ventricular wall motion}, aortic valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, mitral valve 
leaflets are mildly thickened {Thickened mitral leaflet}, pericardial effusion {Pericardial effusion}, effusion {Pericardial effusion}, right ventricular {Right cardiac ventricular structure}, collapse {Collapse}, right atrial {Right atrial structure}, collapse {Collapse}, respiratory {Examination of respiratory system}, mitral {Mitral valve regurgitation}, tricuspid valve {Tricuspid valve structure}, inflows {Abnormal cardiac flow}, impaired {Impairment}, ventricular {Cardiac ventricular structure}, filling {Abnormal cardiac flow}, study {Evaluation procedure}, heart rate is faster {Tachycardia}, respiratory {Examination of respiratory system}, mitral valve {Mitral valve structure}, inflow {Abnormal cardiac flow}, tamponade {Cardiac tamponade}, volume depletion {Decreased blood volume}, lung disease {Disorder of lung}, Left ventricular {Left cardiac ventricular structure}, CXR {Plain chest X-ray}, consolidation {Consolidation}, volume loss {Decreased size}, right upper lobe {Structure of upper lobe of right lung}, perihilar right
lung areas {Structure of perihilar region of right lung}, hilar mass {Mass of hilum}, right-sided {Right breast structure}, pleural effusion {Pleural effusion}, right lower lobe {Structure of lower lobe of right lung}, improved {Patient's condition improved}, exam {Examination of respiratory system}, left lung {Left lung structure}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, metastatic {Metastatic malignant neoplasm}, NSCLC {Non-small cell lung cancer}, dyspnea {Dyspnea}, Dyspnea {Dyspnea}, Hypoxia {Hypoxia}, worsening {Patient's condition worsened}, atelectasis {Atelectasis}, bronchospasms {Bronchospasm}, worsening {Patient's condition worsened}, effusions {Effusion}, post-obstructive PNA {Postobstructive pneumonia}, anxiety {Anxiety}, anemia {Anemia}, CXR {Plain chest X-ray}, R sided {Right pleura structure}, effusion {Pleural effusion}, thoracentesis {Thoracentesis}, removed {Drainage of pleural cavity}, desaturation {Oxygen saturation below reference range}, 10L {Oxygen therapy}, CXR {Plain chest X-ray}, pulmonary edema {Pulmonary edema}, improved {Patient's condition improved}, diuresis {Diuretic therapy}, CT chest {Computed tomography of chest}, worsening {Patient's condition worsened}, effusions {Pleural effusion}, RLL {Structure of lower lobe of right lung}, ground glass opacities {Ground glass lung opacity}, thoarcenetsis {Thoracentesis}, PTX {Pneumothorax}, chest tube was placed {Insertion of pleural tube drain}, on Levo/Flagyl {Antibiotic therapy}, post-obstructive PNA {Postobstructive pneumonia}, chest tube was 
removed {Intercostal drain removal}, resolved {Problem resolved}, on room air {Breathing room air}, 02 {Oxygen therapy}, Metastatic {Metastatic malignant neoplasm}, NSCLC {Non-small cell lung cancer}, PET-CT {Positron emission tomography}, wide-spread metastatic 
disease {Widespread metastatic malignant neoplastic disease}, Pathology {Abnormal histology findings}, poorly differentiated neuroendocrine 
carcinoma {Malignant poorly differentiated neuroendocrine carcinoma}, pulmonary {Primary malignant neoplasm of lung}, large cell {Large cell carcinoma of lung}, SOB {Dyspnea}, Cabroplatin/Etoposide {Chemotherapy}, Pericardial effusion {Pericardial effusion}, pericardial effusion {Pericardial effusion}, TTE {Transthoracic echocardiography}, signs {Sign}, tamponade {Cardiac tamponade}, improved {Patient's condition improved}, echo {Echocardiography}, diureses {Diuretic therapy}, drop the patients BP {Finding of decreased blood pressure}, lasix {Diuretic therapy}, lasix {Diuretic therapy}, asymptomatic {Asymptomatic}, drops {Finding of decreased blood pressure}, TTE {Transthoracic echocardiography}, Anxiety {Anxiety}, anxiety {Anxiety}, HTN {Hypertensive disorder, systemic arterial}, BP {Blood pressure finding}, BP {Blood pressure finding}, exchanged {Change of medication}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - ___ Tablet(s) 
by  
mouth every six (6) hours as needed for pain  
LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet -  
Tablet(s) by mouth  
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg  
Tablet Sustained Release 24 hr - 1 (One) Tablet(s) by mouth qd  
- OTC  
ACETAMINOPHEN [TYLENOL ARTHRITIS] - (___) - 650 mg Tablet  
Sustained Release - Tablet(s) by mouth as needed for pain  
ASPIRIN [BABY ASPIRIN] - (OTC) - 81 mg Tablet, Chewable - 1  
Tablet(s) by mouth once a day  
DOCUSATE SODIUM [DOCUSIL] - 100 mg Capsule - 1 Capsule(s) by  
mouth twice a day as needed for while on pain med HOLD if having 
 
diarrhea  
IBUPROFEN [MOTRIN] - (___) - 600 mg Tablet - 1 Tablet(s) by  
mouth twice a day as needed for pain  

 
Discharge Medications:
1. Home O2 therapy ___
Patient requires home O2 for hypoxia with malignant pleural 
effusion
2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) 
for 4 days: to complete taper.
Disp:*4 Tablet(s)* Refills:*0*
3. Percocet ___ mg Tablet Sig: ___ Tablets PO every six (6) 
hours as needed for pain: do not drive or drink alcohol with 
this medication.  
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 
hours) as needed for anxiety: do not drink or drink alcohol with 
this medication.  
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr 
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.  
6. Tylenol ___ mg Tablet Sig: ___ Tablets PO every six (6) hours 
as needed for pain.  
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.  

 

###RESPONSE: mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary Diagnosis:
Community acquired pneumonia
Pleural Effusion
Pericardial effusion
.
Secondary Diagnosis:
Non small cell lung cancer
Anxiety

 
Discharge Condition:
Good, on RA. Desats to the high ___ when climbing stairs. At her 
mental baseline.

 

###RESPONSE: With Service {Home health aide service management}, Community acquired pneumonia {Community acquired pneumonia}, Pleural Effusion {Pleural effusion}, Pericardial effusion {Pericardial effusion}, Non small cell lung cancer {Non-small cell lung cancer}, Anxiety {Anxiety}, Good {Patient's condition satisfactory}, RA {Breathing room air}, climbing stairs {Difficulty walking up stairs}, mental {Mental state finding}, baseline {Baseline state}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted with shortness of breath.  You were found to 
have both a pneumonia and fluid in your lung (pleural effusion). 
 You underwent a thoracentesis with removal of fluid in your 
lung.  Your chest x rays have been stable since then, as well as 
your echocardiogram.
.
Please continue your home medications as before.  You have 
completed a course of antibiotics for presumed pneumonia.  
Additionally, we are tapering your steroids starting by your 
primary physician.  Please continue Prednisone 10mg daily for an 
additional 4 days and then stop.
.
Please follow up with Dr. ___ on ___ as scheduled, and 
follow up with Dr. ___ in 2 weeks to reassess your pericardial 
effusion
.
Please return to the hospital if you experience worsening 
shortness of breath, chest pain, high fever, or low blood 
pressure
 

###RESPONSE: shortness of breath {Dyspnea}, pneumonia {Pneumonia}, fluid in your lung {Pleural effusion}, pleural effusion {Pleural effusion}, thoracentesis {Thoracentesis}, removal {Removal}, fluid in your 
lung {Pleural effusion}, chest x rays {Plain chest X-ray}, stable {Patient's condition stable}, echocardiogram {Echocardiography}, medications {Administration of drug or medicament}, antibiotics {Antibiotic therapy}, pneumonia {Pneumonia}, steroids {Steroid therapy}, primary physician {Primary care management}, follow up {Follow-up arranged}, pericardial 
effusion {Pericardial effusion}, worsening {Patient's condition worsened}, shortness of breath {Dyspnea}, chest pain {Chest pain}, fever {Fever}, low blood 
pressure {Low blood pressure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                      Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Penicillins / Citalopram
 
Attending: ___.
 
Chief Complaint:
Shortness of breath
 
Major Surgical or Invasive Procedure:
None 

 

###RESPONSE: Penicillins {Allergy to penicillin}, Shortness of breath {Dyspnea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ woman with history of moderate COPD/asthma (FEV1 40% 
pred. in ___, CAD, diastolic CHF, and aortic aneurysm who 
presented to the emergency room overnight with several weeks of 
SOB and cough productive of yellow sputum. Pt reports that 
symptoms have been intermittent for several weeks; recently 
symptoms have become worse. She was seen by her PCP ___ who 
recommended that she keep her appointment with her pulmonologist 
___ for consideration of initiation of daily low dose 
prednisone. Of note, in the past pt has had issues with 
noncompliance with meds. Pt reports that she has been using her 
nebs more frequently recently given her SOB.  
.  
Her initial vitals in the ED were 100.4, 86, 136/89, 16, and 
94%. Labs notable for no white count, normal electrolytes and 
normal lactate (1.3). Chest x-ray notable for stable left 
lingular nodule and linear opacities in the right mid lung. 
There was no acute process. Nevertheless, the patient was 
treated for CAP in the ED with ceftriaxone and azithromycin. She 
was also treated with methylprednisolone and Combivent nebs for 
presumptive COPD exacerbation. Blood cultures were drawn prior 
to antibiotic administration. The patient was then admitted for 
further treatment. Vitals at time of admit: 97.9, 77, 157/83, 
18, 100% RA.  
.  
Review of Systems:  
(+) Pt reports feeling nightsweats yesterday, nausea two days 
ago, intermittent headaches (recently changed from amitriptyline 
prn to daily), chronic constipation  
(-) Denies rhinorrhea, sore throat, chest pain, palpitations, 
abdominal pain  

 

###RESPONSE: COPD {Chronic obstructive lung disease}, asthma {Asthma}, CAD {Coronary arteriosclerosis}, diastolic CHF {Heart failure with normal ejection fraction}, aortic aneurysm {Aortic aneurysm}, emergency {Emergency treatment management}, SOB {Dyspnea}, cough productive of yellow sputum {Productive cough-yellow sputum}, worse {Patient's condition worsened}, PCP {Primary care management}, prednisone {Steroid therapy}, noncompliance with meds {Non-compliance of drug therapy}, nebs {Nebulizer therapy}, SOB {Dyspnea}, vitals {Vital signs finding}, Labs {Laboratory test}, white count {White blood cell count outside reference range}, normal electrolytes {Electrolytes within reference range}, normal {No abnormality detected}, lactate {Lactic acid measurement}, Chest x-ray {Plain chest X-ray}, stable {Symptom not changed}, left {Left pleura structure}, lingular {Structure of lingular bronchus}, nodule {Nodule of lung}, opacities {Abnormally opaque structure}, right mid lung {Structure of middle lobe of right lung}, no acute {No abnormality detected}, CAP {Community acquired pneumonia}, azithromycin {Antibiotic therapy}, nebs {Nebulizer therapy}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, Blood cultures {Blood culture}, antibiotic {Antibiotic therapy}, Vitals {Vital signs finding}, Review of Systems {Review of systems}, nightsweats {Night sweats}, nausea {Nausea}, intermittent headaches {Intermittent headache}, changed {Change of medication}, chronic constipation {Chronic constipation}, rhinorrhea {Nasal discharge}, sore throat {Sore throat}, chest pain {Chest pain}, palpitations {Palpitations}, abdominal pain {Abdominal pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- Chronic obstructive pulmonary disease  
- Asthma  
- Hypertension  
- Headaches  
- Duodenal and stomach ulcers, s/p partial gastrectomy  
- Aortic aneurysm  
- Cataracts  
- History of pulmonary nodule  
- Diastolic CHF  

 

###RESPONSE: Chronic obstructive pulmonary disease {Chronic obstructive lung disease}, Asthma {Asthma}, Hypertension {Hypertensive disorder, systemic arterial}, Headaches {Headache}, Duodenal {Ulcer of duodenum}, stomach ulcers {Gastric ulcer}, partial gastrectomy {Subtotal gastrectomy}, Aortic aneurysm {Aortic aneurysm}, Cataracts {Cataract}, pulmonary nodule {Nodule of lung}, Diastolic CHF {Heart failure with normal ejection fraction}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Non-contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
On admission:
VS: 98.1  140/80  72  24  100%4L 
Gen: NAD. Alert and oriented x3. Mood and affect appropriate. 
Pleasant and cooperative. Resting in bed.
HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP clear.
Neck: Supple. JVP not elevated.  
CV: RRR.  Normal S1, S2.  No murmur, rubs, or gallops.
Chest: Faint diffuse wheezes, decreased breath sounds diffusely, 
bibasilar crackles  
Abd: BS present. Soft, NT, ND. No HSM detected.
Ext: WWP, no cyanosis or clubbing. Trace ___ edema. Digital cap 
refill <2 sec.  Distal pulses DP 2+, ___ 2+.
Neuro/Psych: CNs II-XII intact. ___ strength in U/L extremities
 

###RESPONSE: VS {Vital signs finding}, Gen {General examination of patient}, NAD {No abnormality detected}, Alert {Mentally alert}, oriented {Orientated}, Mood {Level of mood - normal}, affect {Mood finding}, cooperative {Cooperative mental state}, Resting in bed {Lying in bed}, HEENT {Physical examination procedure}, NC {Normal head}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, anicteric sclera {White sclera}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmur {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Chest {Examination of respiratory system}, wheezes {Wheezing}, decreased breath sounds {Decreased breath sounds}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, Abd {Examination of abdomen}, BS present {Normal bowel sounds}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, cyanosis {Cyanosis}, clubbing {Clubbing}, edema {Edema}, pulses {Pulse finding}, DP 2 {Dorsalis pulse present}, Neuro {Neurological examination}, CNs II-XII {Cranial nerve structure}, intact {No abnormality detected}, extremities {All extremities}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS
--------------
___ 01:00AM BLOOD WBC-4.1 RBC-4.26 Hgb-12.3 Hct-37.7 MCV-89 
MCH-28.9 MCHC-32.6 RDW-14.0 Plt ___
___ 01:00AM BLOOD Glucose-148* UreaN-14 Creat-0.8 Na-141 
K-5.1 Cl-102 HCO3-31 AnGap-13
___ 01:19AM BLOOD Lactate-1.3
___ 1:00 am Blood Culture, Routine (Preliminary): 
      STAPHYLOCOCCUS, COAGULASE NEGATIVE. 
.
DISCHARGE LABS
--------------
___ 07:20AM BLOOD WBC-5.3 RBC-4.20 Hgb-12.4 Hct-38.0 MCV-90 
MCH-29.5 MCHC-32.6 RDW-14.7 Plt ___
___ 07:20AM BLOOD Glucose-112* UreaN-26* Creat-0.8 Na-144 
K-3.5 Cl-105 HCO3-26 AnGap-17
___ 07:20AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.0
.
IMAGING
-------
Chest (PA & LAT) ___:
FRONTAL AND LATERAL VIEWS OF THE CHEST: Linear opacities in the 
right lung are again seen, unchanged since the prior study and 
likely relate to 
scarring/nonspecific fibrosis. The left lingular nodular opacity 
is not as discretely seen on this study but appears stable in 
size. There is no new pleural effusion or pneumothorax. Mild 
cardiomegaly is unchanged. The aorta remains tortuous. 
  
IMPRESSION: No acute intrathoracic process. Stable appearance of 
scarring/fibrosis over the right mid lung and lingular nodular 
density. 
.
MICROBIOLOGY
------------
___ 1:00 am BLOOD CULTURE

   Blood Culture, Routine (Preliminary): 
      STAPHYLOCOCCUS, COAGULASE NEGATIVE. 
         Isolated from only one set in the previous five days. 
         SENSITIVITIES PERFORMED ON REQUEST.. 

   Aerobic Bottle Gram Stain (Final ___: 
      Reported to and read back by ___ @ 5:54A 
___. 
      GRAM POSITIVE COCCI. 
      IN PAIRS AND CLUSTERS.
.
Blood culture ___: pending, no growth to date

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Lactate {Lactic acid measurement}, Blood Culture {Blood culture}, NEGATIVE {No pathologic diagnosis}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, IMAGING {Imaging}, CHEST {Plain chest X-ray}, opacities {Abnormally opaque structure}, right lung {Right lung structure}, unchanged {Patient condition unchanged}, study {Evaluation procedure}, scarring {Scar}, fibrosis {Fibrosis}, left {Left pleura structure}, lingular {Structure of lingular bronchus}, nodular {Nodule of lung}, opacity {Abnormally opaque structure}, study {Evaluation procedure}, stable {Symptom not changed}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, cardiomegaly {Cardiomegaly}, unchanged {Patient condition unchanged}, aorta {Aortic structure}, tortuous {Tortuosity}, No acute intrathoracic process {No abnormality detected}, scarring {Scar}, fibrosis {Fibrosis}, right mid lung {Structure of middle lobe of right lung}, lingular {Structure of lingular bronchus}, nodular {Nodule of lung}, density {Abnormally opaque structure}, MICROBIOLOGY {Microbiology}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, NEGATIVE {No pathologic diagnosis}, SENSITIVITIES {Antimicrobial susceptibility test}, Gram Stain {Gram stain method}, Blood culture {Blood culture}, no growth {No organism isolated by microbiologic culture}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ woman with history of moderate obstructive lung 
disease presents with two weeks of shortness of breath and a 
couple days of sputum production, with low-grade fevers in the 
emergency room.  
.  
ACTIVE ISSUES
-------------
# Shortness of breath, productive cough, low-grade fever: 
dyspnea likely secondary to COPD flare, possibly exacerbated by 
viral bronchitis given cough and low grade temperature.  Chest 
X-ray did not show pneumonia.  Patient was given standing 
nebulizers and prednisone 60mg x 7 days without a taper.  She 
was also treated with azithromycin x 5 days.  She was kept on 
her home oxygen of 4 liters with maintenance of oxygen 
saturations.
.  
INACTIVE ISSUES
---------------
# Diastolic CHF: Last TTE on ___ showed preserved ejection 
fraction, and no significant valvular disease.  She appeared 
euvolemic on exam.  Chest X-ray was without any large effusions. 
 Patient was continued on her home dose of furosemide during 
hospitalization. 
.  
# Aortic aneurysm: CTA performed on ___ showing slightly 
enlarged aortic aneurysm measuring approximately 4.5 cm AP x 4.9 
cm transversely (previously 4.2 cm in AP x 4.2 cm transverse).  
She should follow-up with her PCP as an outpatient further 
regarding this problem.
. 
# Hypertension: patient was continued on her home dose of lasix 
and lisinopril. 
.  
# Headaches: patient was continued on her home dose of 
amitryptiline.  
.
# Gastroesophageal reflux disease: patient was continued on home 
proton pump inhibitor. 
.
TRANSITION OF CARE
------------------
# Follow-up: patient has pending blood cultures that should be 
followed up upon discharge.  She will be scheduled by her 
primary care provider for ___ follow-up 
appointment.  She will also be seen by Pulmonary soon after 
discharge for an initial assessment.
.
# Code status: patient is confirmed full code
.
# Communication:
- Al (son): ___.  
- ___ (son): ___. 
 

###RESPONSE: moderate obstructive lung 
disease {Moderate chronic obstructive pulmonary disease}, shortness of breath {Dyspnea}, sputum production {Productive cough}, low-grade fevers {Low grade pyrexia}, emergency {Emergency treatment management}, Shortness of breath {Dyspnea}, productive cough {Productive cough}, low-grade fever {Low grade pyrexia}, dyspnea {Dyspnea}, COPD flare {Acute exacerbation of chronic obstructive airways disease}, viral bronchitis {Viral bronchitis}, cough {Cough}, temperature {Body temperature above reference range}, Chest 
X-ray {Plain chest X-ray}, pneumonia {Pneumonia}, nebulizers {Nebulizer therapy}, prednisone {Steroid therapy}, taper {Medication decreased}, azithromycin {Antibiotic therapy}, home oxygen {Home oxygen therapy}, oxygen 
saturations {Finding of oxygen saturation}, Diastolic CHF {Heart failure with normal ejection fraction}, TTE {Transthoracic echocardiography}, valvular disease {Heart valve disorder}, euvolemic {Normal blood volume}, exam {Evaluation procedure}, Chest X-ray {Plain chest X-ray}, effusions {Pleural effusion}, Aortic aneurysm {Aortic aneurysm}, CTA {Computed tomography angiography with contrast}, enlarged {Enlargement}, aortic aneurysm {Aortic aneurysm}, PCP {Primary care management}, problem {Problem}, Hypertension {Hypertensive disorder, systemic arterial}, lasix {Diuretic therapy}, Headaches {Headache}, Gastroesophageal reflux disease {Gastroesophageal reflux disease}, proton pump inhibitor {Proton pump inhibitor therapy}, TRANSITION OF CARE {Transition of care}, blood cultures {Blood culture}, primary care {Primary care management}, Pulmonary {Pulmonary medicine service}, assessment {Evaluation procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
- albuterol 90 mcg HFA 2 puffs q6h prn  
- amitryptiline 50 mg once daily at night  
- budesonide 0.5 mg/2 mL solution for nebulizer bid  
- furosemide 40 mg every morning  
- ibuprofen 600 mg tid to qid prn  
- ipratropium-albuterol nebs up to three times daily  
- lactulose hs prn for constipation  
- lisinopril 40 mg qday  
- omeprazole 20 mg qday  
- oxygen 4L at night  
- acetaminophen prn  
- multivitamin 
 
Discharge Medications:
1. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at 
bedtime).  
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY 
(Daily) as needed for constipation.  
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 
 
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
6. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
7. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY 
(Daily) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
8. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 
24 hours) for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
9. acetaminophen  Oral
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 
Two (2) puffs Inhalation every six (6) hours as needed for 
shortness of breath or wheezing.  
11. budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One 
(1)  Inhalation twice a day.  
12. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution 
for Nebulization Sig: One (1)  Inhalation three times a day as 
needed for shortness of breath or wheezing.  
13. ibuprofen  Oral

 

###RESPONSE: mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary diagnosis:

Chronic obstructive pulmonary disease flare
Bacteremia

Secondary diagnosis: 

Diastolic congestive heart failure
Hypertension
Aortic aneurysm
Gastroesophageal reflux disease

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Chronic obstructive pulmonary disease flare {Acute exacerbation of chronic obstructive airways disease}, Bacteremia {Bacteremia}, Diastolic congestive heart failure {Heart failure with normal ejection fraction}, Hypertension {Hypertensive disorder, systemic arterial}, Aortic aneurysm {Aortic aneurysm}, Gastroesophageal reflux disease {Gastroesophageal reflux disease}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,

It was a pleasure taking care of you at the ___.  You came for 
further evaluation of shortness of breath.  Further evaluation 
suggested that you had a flare-up of your chronic obstructive 
pulmonary disease.  It is very important that you continue to 
take your medications as prescribed and follow up with your 
primary care provider after discharge.

The following changes have been made to your medications:
1) Prednisone 60mg was started, which you should continue for 
three more days, starting tomorrow
2) Azithromycin 250mg was started, which you should continue for 
one more day, starting tomorrow

 

###RESPONSE: evaluation {Evaluation procedure}, shortness of breath {Dyspnea}, evaluation {Evaluation procedure}, flare-up of your chronic obstructive 
pulmonary disease {Acute exacerbation of chronic obstructive airways disease}, continue to 
take your medications as prescribed {Recommendation to continue with drug treatment}, primary care {Primary care management}, Prednisone {Steroid therapy}, started {New medication added}, Azithromycin {Antibiotic therapy}, started {New medication added}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Sulfa (Sulfonamide Antibiotics)
 
Attending: ___.
 
Chief Complaint:
Shortness of Breath 
 
Major Surgical or Invasive Procedure:
None 

 

###RESPONSE: Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, Shortness of Breath {Dyspnea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Patient is an ___ year old female with PMH of moderate-to-severe 
COPD (on home 2L O2, no intubations/ICU stays) who presents from 
home with shortness of breath for 4 days. Patient was last in 
her usual state of health until 3 days prior to presentation 
when she developed insidious onset shortness of breath with 
cough. She had no fevers or chills and noted increased chest 
congestion but is unable to expectorate. She presented to her 
PCP's office 2 days PTA when she was prescribed prednisone and a 
z-pak. Then on the day prior to this admission she presented to 
the ___ ED for persistant SOB nad weakness. She was unable to 
eat large quantities because of the shortness of breath. In the 
ED she was treated with albuterol nebs and was discharged after 
performing well on a walk test around the ED. Then, on the day 
of presentation, patient's shortness of breath again became 
suddenly worse. She was speaking in short sentences and 
activities such as walking across the room or going to the 
bathroom caused her severe dyspnea. She called the ambulance and 
was taken back to the ED.
.  
In the ED, initial vital signs were T95.6, HR98, BP175/96, RR28, 
O2sat99% 2L nasal prongs. Exam was significant for initially 
speaking in 2 word sentences, and poor air entry b/l with no 
wheezes/crackles. This improved with nebulizers and she was able 
to speak in full sentences. ECG showed sinus tachycardia with no 
acute ST-t wave changes. Troponin was <0.01. WBC count was 
normal, and patient received prednisone 60mg, ipratropium and 
albuterol nebs, and azithromycin 250mg. She had an episode of 
desaturation to 86% on nebs and was placed on NIPPV (FiO2: 100 
PEEP: 5 PS: 10) with improvement of sats up to 96%. Unable to 
tolerate further bipap she was placed on 5LNC with O2sats 96%. 
She received 1mg of IV ativan for anxiety. Vital signs prior to 
transfer were T97.9 HR103 BP177/87 RR28 O2sat95% 5LNC.  
. 
On arrival to the MICU, intial VS were T98.1, HR99, BP152/90, 
RR29, O2sat94% 5LNC. She reports improvement in her SOB. She 
reports being hungry. She endorses a slight headache. She 
reports having some loose stool that corresponds to when she 
started azithromycin as an outpatient.  
 

###RESPONSE: COPD {Chronic obstructive lung disease}, intubations {Intubation}, shortness of breath {Dyspnea}, cough {Cough}, fevers {Fever}, chills {Chill}, unable to expectorate {Unable to expectorate}, SOB {Dyspnea}, weakness {Asthenia}, unable to 
eat {Unable to eat}, shortness of breath {Dyspnea}, shortness of breath {Dyspnea}, dyspnea {Dyspnea}, wheezes {Wheezing}, crackles {Respiratory crackles}, improved {Patient's condition improved}, nebulizers {Nebulizer therapy}, able 
to speak {Able to speak}, ECG {Electrocardiographic procedure}, sinus tachycardia {Sinus tachycardia}, t wave changes {Electrocardiographic T wave abnormal}, Troponin {Troponin measurement}, WBC count was 
normal {White blood cell count within reference range}, bipap {Bilevel positive airway pressure titration}, anxiety {Anxiety}, SOB {Dyspnea}, hungry {Hungry}, headache {Headache}, loose stool {Loose stool}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- Asthma
- COPD
- GERD
- Anxiety
- Osteopenia 
- S/p cataract surgery
- White coat HTN (BPs at home 120s-130s/70s-80s) 
 

###RESPONSE: Asthma {Asthma}, COPD {Chronic obstructive lung disease}, GERD {Gastroesophageal reflux disease}, Anxiety {Anxiety}, Osteopenia {Osteopenia}, cataract surgery {Cataract surgery}, White coat HTN {Labile hypertension due to being in a clinical environment}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother had angina. No other CAD, no cancers. Brother has 
___.  

 

###RESPONSE: angina {Angina}, CAD {Coronary arteriosclerosis}, cancers {Malignant neoplasm}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION EXAM: 
Vitals: T 98.1, HR 99, BP 152/90, RR 29, O2sat 94% 5LNC  
General: Alert, oriented, no acute distress  
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL  
Neck: Supple, JVP not elevated, no LAD  
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, 
gallops  
Lungs: Poor air movement bilaterally, diffuse rhonchi  
Abdomen: Soft, non-tender, non-distended, bowel sounds present, 
no organomegaly  
GU: No foley  
Ext: Warm, well perfused, no edema or cyanosis  
Neuro: CNII-XII intact, ___ strength upper/lower extremities, 
grossly normal sensation, gait deferred  
.
DISCHARGE EXAM: 
VS: Tm 98.5, BP 164/82, P 70, R 18, 97-99% on 1L NC    
GENERAL: NAD, comfortable, speaking in full sentences  
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear  
NECK: Supple, no thyromegaly, no JVD
HEART: RRR, nl S1-S2, no MRG
LUNGS: Ronchorus BS throughout with diffuse expiratory wheezing 
though improved 
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)  

SKIN: Scattered ecchymoses
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, strength and 
sensation grossly intact 
 

###RESPONSE: Vitals {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, NC {Normal head}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Lungs {Examination of respiratory system}, rhonchi {Wheeze - rhonchi}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, foley {Urinary catheter in situ}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, edema {Edema}, cyanosis {Cyanosis}, Neuro {Neurological examination}, CNII {Optic nerve structure}, XII intact {Intact hypoglossal nerve}, upper {Upper limb structure}, lower extremities {Lower limb structure}, normal sensation {Normal sensation}, gait deferred {Abnormal gait}, VS {Vital signs finding}, BP {Blood pressure finding}, NC {Normal head}, GENERAL {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, sclerae anicteric {White sclera}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, thyromegaly {Goiter}, JVD {Jugular venous engorgement}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, no MRG {Heart sounds normal}, LUNGS {Examination of respiratory system}, Ronchorus {Wheeze - rhonchi}, wheezing {Wheezing}, improved {Patient's condition improved}, ABDOMEN {Examination of abdomen}, NABS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, 2+ peripheral pulses {Peripheral pulses normal}, radials {Normal radial pulse}, SKIN {Examination of skin}, ecchymoses {Ecchymosis}, NEURO {Neurological examination}, Awake {Awake}, A {Mentally alert}, Ox3 {Oriented to person, time and place}, CNs II {Optic nerve structure}, XII {Hypoglossal nerve structure}, grossly intact {Normal nervous system function}, sensation grossly intact {Normal sensation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 06:12PM BLOOD WBC-8.8 RBC-4.78 Hgb-14.1 Hct-42.5 MCV-89 
MCH-29.6 MCHC-33.3 RDW-12.8 Plt ___
___ 06:12PM BLOOD Neuts-91.7* Lymphs-6.7* Monos-1.4* Eos-0 
Baso-0.2
___ 06:12PM BLOOD Glucose-169* UreaN-18 Creat-0.9 Na-136 
K-4.5 Cl-101 HCO3-23 AnGap-17
___ 04:06AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.3
___ 09:55AM BLOOD cTropnT-<0.01
___ 04:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:00PM URINE Blood-TR Nitrite-NEG Protein-TR 
Glucose-150 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 04:00PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-1
.
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-11.9* RBC-4.66 Hgb-13.8 Hct-42.4 
MCV-91 MCH-29.7 MCHC-32.6 RDW-12.6 Plt ___
___ 08:00AM BLOOD Glucose-130* UreaN-27* Creat-0.9 Na-142 
K-4.0 Cl-99 HCO3-34* AnGap-13
___ 08:00AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.0
.
MICRO:
___ Blood cultures: no growth to date
___ Urine culture: pending  
.
IMAGING:
___ PA/LAT/OBLIQUE CXR: The heart is normal in size. The 
mediastinal and hilar contours appear unchanged. The aortic arch 
is calcified. Central pulmonary arteries are again prominent. 
The chest is hyperinflated. Bronchovascular markings are 
attenuated and irregular, particularly in the upper lungs, 
suggesting obstructive pulmonary disease. A hiatal hernia is 
probably small-to-moderate in size. No focal opacity is 
identified. There is no pleural effusion or pneumothorax. Mild 
degenerative changes are similar along the lower thoracic spine.
IMPRESSION: Findings suggesting chronic obstructive pulmonary 
disease. No evidence of pneumonia. Small-to-moderate hiatal 
hernia. 
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, cTropnT {Troponin T cardiac measurement}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, RBC {Red blood cell count}, WBC {White blood cell count}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Blood cultures {Blood culture}, Urine culture {Urine culture}, PA {Plain x-ray of chest posteroanterior view}, LAT {Diagnostic radiography of chest, lateral}, CXR {Plain chest X-ray}, heart {Heart structure}, normal in size {Normal size}, mediastinal {Mediastinal structure}, hilar {Hilar lymphadenopathy}, aortic arch {Aortic arch structure}, calcified {Pathologic calcification, calcified structure}, Central pulmonary arteries {Structure of central pulmonary artery}, chest is hyperinflated {Chest over-expanded}, upper lungs {Structure of upper zone of lung}, pulmonary disease {Disorder of lung}, hiatal hernia {Hiatal hernia}, opacity {Abnormally opaque structure}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, thoracic spine {Structure of thoracic vertebral column}, chronic obstructive pulmonary 
disease {Chronic obstructive lung disease}, pneumonia {Pneumonia}, hiatal 
hernia {Hiatal hernia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ year old female with PMH of moderate-to-severe COPD (FEV1 37% 
of predicted ___ on home O2 for exertion, who presented with 
SOB secondary to a COPD exacerbation. 
. 
ACTIVE ISSUES: 
# COPD exacerbation: Patient has moderate-severe COPD on 2LNC 
home oxygen only with exertion, otherwise on room air. She 
presented with 3 days of increasing shortness of breath 
improving with bronchodilators and at one point requiring NIPPV 
in the ED. She had a significant component of anxiety while in 
the ED, exacerbating the tachypnea in addition to her COPD 
flare, which has been the case in prior exacerbations as well 
per discussion with her PCP. Overnight in the ICU she was easily 
weaned to 91% oxygen on room air and was able to be transferred 
to the medical floor. Although there was no evidence of 
pneumonia on her CXR, she was continued on the azithromycin 
which had been started by her PCP and completed ___ 5-day course. 
She was also started on prednisone 60mg daily with plan for a 
slow taper. Her Advair, Spiriva, and albuterol were continued 
and she was treated with lorazepam prn for anxiety with good 
effect. Upon discharge she was breathing comfortably with O2 
sats in the mid-90s on 1L NC and was ambulating. She is 
currently on prednisone 50mg daily with plan to taper as 
follows: 40mg (___), 30mg (___), 20mg (___), 
10mg (___), and then stop. She will have outpatient 
pulmonary rehab and has f/u appointments scheduled with her PCP 
and pulmonologist.   
.
# Hypertension: Patient's blood pressure was persistent elevated 
in the 150s-160s with several readings in the 170s. She denies a 
history of HTN and after discussing this with her PCP ___. 
___ may be a component of white coat hypertension 
and anxiety. We elected not to treat it at this time. She has a 
f/u appointment with Dr. ___ at which time he will recheck 
her BP and decide whether to start an antihypertensive agent.  
.
# UTI: Patient developed a mild leukocytosis (WBC 11.9) on the 
day of discharge. She has been afebrile but UA revealed a UTI. 
She states that she has a history of recurrent UTIs and has a 
prescription for ciprofloxacin 250mg at home which is not 
expired. She wishes to take her own medication at home and 
states that she will take 1 pill BID for the next 3 days. She 
understands warning signs that should prompt her to seek medical 
attention such as worsening abdominal pain, flank pain, or 
fevers. The urine culture is pending at the time of discharge. I 
will follow this up and contact the patient and her PCP should 
the organism return resistant to ciprofloxacin.   
.
INACTIVE ISSUES: 
# Osteopenia: Continued Vitamin D supplementation.
.
TRANSITIONAL ISSUES: 
# Opacity on CXR: Patient had a small opacity in the 
costophrenic recess on the lateral view CXR. Unclear etiology 
but stable since ___. Radiology recommends non-emergent CT scan 
to evaluate. The patient is aware of this. 
 

###RESPONSE: COPD {Chronic obstructive lung disease}, SOB {Dyspnea}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD {Chronic obstructive lung disease}, on room air {Breathing room air}, shortness of breath {Dyspnea}, anxiety {Anxiety}, tachypnea {Tachypnea}, COPD {Chronic obstructive lung disease}, on room air {Breathing room air}, pneumonia {Pneumonia}, CXR {Plain chest X-ray}, anxiety {Anxiety}, ambulating {Fully mobile}, Hypertension {Hypertensive disorder, systemic arterial}, blood pressure was persistent elevated {Finding of increased blood pressure}, HTN {Hypertensive disorder, systemic arterial}, white coat hypertension {Labile hypertension due to being in a clinical environment}, anxiety {Anxiety}, UTI {Urinary tract infectious disease}, leukocytosis {Leukocytosis}, afebrile {Fever}, UA {Urinalysis}, UTI {Urinary tract infectious disease}, recurrent UTIs {Recurrent urinary tract infection}, abdominal pain {Abdominal pain}, flank pain {Flank pain}, fevers {Fever}, urine culture {Urine culture}, Osteopenia {Osteopenia}, Opacity {Abnormally opaque structure}, CXR {Plain chest X-ray}, opacity {Abnormally opaque structure}, costophrenic recess {Structure of phrenicocostal sinus}, lateral view CXR {Diagnostic radiography of chest, lateral}, CT scan {Computed tomography}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
1. Aspirin 81 mg PO 4X/WEEK (___) 
Pt states she only takes it 4x/wk because of increased bruising 
with daily dosing 
2. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH BID 
3. Tiotropium Bromide 1 CAP IH DAILY 
4. Vitamin D 800 UNIT PO DAILY 
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 
6. PredniSONE 40 mg PO DAILY Duration: 10 Days 
started ___ by PCP 
7. Azithromycin 250 mg PO Q24H Duration: 4 Days 
Day 1 of z-pack was ___ from PCP 

 
___:
1. Aspirin 81 mg PO 4X/WEEK (___) 
Pt states she only takes it 4x/wk because of increased bruising 
with daily dosing 
2. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH BID 
3. Tiotropium Bromide 1 CAP IH DAILY 
4. Vitamin D 800 UNIT PO DAILY 
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 
6. Pulmonary rehab
Patient requires outpatient pulmonary rehab.
7. PredniSONE 40 mg PO daily Duration: 2 Days Start: In am 
RX *prednisone 10 mg see below tablet(s) by mouth daily Disp 
#*20 Tablet Refills:*0
8. PredniSONE 30 mg PO daily Duration: 2 Days Start: After 40 mg 
tapered dose. 
9. PredniSONE 20 mg PO daily Duration: 2  Days Start: After 30 
mg tapered dose. 
10. PredniSONE 10 mg PO daily Duration: 2  Days Start: After 20 
mg tapered dose. 
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
COPD 
UTI 

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: COPD {Chronic obstructive lung disease}, UTI {Urinary tract infectious disease}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Ms. ___,
.
It was a pleasure caring for you at ___ 
___. You were admitted with shortness of breath due 
to an exacerbation of your COPD. We treated you with 
azithromycin and prednisone and your breathing improved. You 
should continue to use the oxygen at home while your breathing 
continues to get better. We have arranged for you to attend 
outpatient pulmonary rehab. 
.
You were found to have a urinary tract infection on the day of 
discharge. You have a history of frequent UTIs and have 
ciprofloxacin 250mg at home which you would prefer to take. When 
you get home please take this medication twice daily for the 
next 3 days as we discussed.  
 

###RESPONSE: shortness of breath {Dyspnea}, exacerbation of your COPD {Acute exacerbation of chronic obstructive airways disease}, improved {Patient's condition improved}, urinary tract infection {Urinary tract infectious disease}, frequent UTIs {Recurrent urinary tract infection}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
codeine
 
Attending: ___
 
Chief Complaint:
Right hip pain
 
Major Surgical or Invasive Procedure:
Right total hip arthroplasty on ___

 

###RESPONSE: codeine {Allergy to codeine}, Right hip {Right hip region structure}, pain {Hip pain}, Right total hip arthroplasty {Total replacement of right hip joint}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ has been having right knee and hip pain for several 
months.  The pain has progressively worsened.  She has had 
cortisone injections, which did not provide significant relief 
in her knee.  She has groin pain, thigh pain and buttock pain as 
well as knee pain.  She does not use an assistive device.  She 
has taken anti-inflammatory medications and had physical 
therapy.

 

###RESPONSE: right knee {Structure of right knee region}, hip pain {Hip pain}, pain {Pain}, worsened {Increased pain}, cortisone injections {Injection of cortisone}, knee {Knee region structure}, groin pain {Inguinal pain}, thigh pain {Thigh pain}, buttock pain {Pain in buttock}, knee pain {Pain of knee region}, physical 
therapy {Physical therapy procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1. adjustment disorder
2. atrial fibrillation (cardiologist - Dr. ___, 
___
3. anxiety and depression
4. vitamin B12 deficiency
5. breast cancer (T1N0M0 invasive lobular adenocarcinoma
s/p RTX/implant/tamoxifen for ___ years)
6. colonic polyps (___)
7. constipation
8. hypertension
9. osteopenia
10. seasonal affective disorder
11. gastric bypass 01
12. SBO s/p exploratory laparotomy and small bowel resection 
(___)

 

###RESPONSE: adjustment disorder {Adjustment disorder}, atrial fibrillation {Atrial fibrillation}, anxiety {Anxiety}, depression {Depressive disorder}, vitamin B12 deficiency {Cobalamin deficiency}, breast cancer {Malignant neoplasm of breast}, lobular adenocarcinoma {Lobular carcinoma}, colonic polyps {Polyp of colon}, constipation {Constipation}, hypertension {Hypertensive disorder, systemic arterial}, osteopenia {Osteopenia}, seasonal affective disorder {Seasonal affective disorder}, gastric bypass {Bypass of stomach}, SBO {Small bowel obstruction}, exploratory laparotomy {Exploratory laparotomy}, small bowel resection {Small intestine excision}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother deceased from recurrent non-Hodgkin's lymphoma. Multiple 
family members with ovarian and breast ca at early ages (mother 
with ovarian ca in her ___, 2 aunts with breast ca)
 

###RESPONSE: deceased {Dead}, recurrent {Recurrent disease}, non-Hodgkin's lymphoma {Non-Hodgkin's lymphoma}, ovarian {Malignant tumor of ovary}, breast ca {Malignant neoplasm of breast}, ovarian ca {Malignant tumor of ovary}, breast ca {Malignant neoplasm of breast}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Well appearing in no acute distress  
Afebrile with stable vital signs  
Pain well-controlled  
Respiratory: CTAB  
Cardiovascular: RRR  
Gastrointestinal: NT/ND  
Genitourinary: Voiding independently  
Neurologic: Intact with no focal deficits  
Psychiatric: Pleasant, A&O x3  
Musculoskeletal Lower Extremity:  
* Incision healing well with staples  
* Scant serosanguinous drainage  
* Thigh full but soft  
* No calf tenderness  
* ___ strength  
* SILT, NVI distally  
* Toes warm

 

###RESPONSE: Well appearing {Well cared for appearance}, distress {Distress}, Afebrile {Temperature normal}, stable vital signs {Normal vital signs}, Pain well-controlled {Demonstrates adequate pain control}, Respiratory {Examination of respiratory system}, CTAB {Normal breath sounds}, Cardiovascular {Cardiovascular physical examination}, RRR {Normal heart rate}, Gastrointestinal {Examination of digestive system}, NT {Abdominal tenderness}, ND {Swollen abdomen}, Gen {General examination of patient}, Voiding independently {Normal micturition}, Neurologic {Neurological examination}, Intact {Normal sensation}, no focal deficits {Normal nervous system function}, O x3 {Oriented to person, time and place}, Musculoskeletal {Musculoskeletal system physical examination}, Lower Extremity {Lower limb structure}, Incision {Surgical incision wound}, healing well {Wound healing well}, staples {Closure by staple}, serosanguinous drainage {Serosanguineous discharge from wound}, Thigh {Thigh structure}, soft {Abdomen soft}, tenderness {Tenderness}, SILT {Light touch sensation present}, NVI distally {Normal peripheral neurovascular function}, Toes {Structure of all toes}, warm {Warm skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 05:58AM BLOOD WBC-12.0* RBC-2.48* Hgb-8.0* Hct-25.3* 
MCV-102* MCH-32.3* MCHC-31.6* RDW-13.1 RDWSD-49.3* Plt ___
___ 06:35AM BLOOD WBC-10.9* RBC-2.46* Hgb-7.9* Hct-25.1* 
MCV-102* MCH-32.1* MCHC-31.5* RDW-13.2 RDWSD-49.2* Plt ___
___ 05:48AM BLOOD WBC-9.8 RBC-2.68* Hgb-8.6* Hct-27.8* 
MCV-104* MCH-32.1* MCHC-30.9* RDW-13.2 RDWSD-49.9* Plt ___
___ 06:25AM BLOOD WBC-7.4 RBC-2.46* Hgb-8.0* Hct-25.5* 
MCV-104* MCH-32.5* MCHC-31.4* RDW-13.2 RDWSD-49.7* Plt ___
___ 05:48AM BLOOD WBC-7.7 RBC-2.94* Hgb-9.5* Hct-30.7* 
MCV-104* MCH-32.3* MCHC-30.9* RDW-13.0 RDWSD-49.6* Plt ___
___ 05:58AM BLOOD Plt ___
___ 06:35AM BLOOD Plt ___
___ 05:48AM BLOOD Plt ___
___ 06:25AM BLOOD Plt ___
___ 05:48AM BLOOD Plt ___
___ 05:58AM BLOOD Glucose-90 UreaN-21* Creat-0.7 Na-138 
K-3.7 Cl-101 HCO3-24 AnGap-17
___ 06:35AM BLOOD Glucose-92 UreaN-22* Creat-0.7 Na-138 
K-4.3 Cl-101 HCO3-26 AnGap-15
___ 09:15AM BLOOD Glucose-111* UreaN-22* Creat-0.7 Na-135 
K-4.4 Cl-99 HCO3-26 AnGap-14
___ 06:25AM BLOOD Glucose-94 UreaN-23* Creat-0.9 Na-139 
K-4.9 Cl-103 HCO3-26 AnGap-15
___ 05:48AM BLOOD Glucose-107* UreaN-26* Creat-0.9 Na-134 
K-5.0 Cl-99 HCO3-28 AnGap-12
___ 09:15AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:58AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.7
___ 06:35AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.8
___ 09:15AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.0
___ 06:25AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.2
___ 05:48AM BLOOD Calcium-8.3* Phos-4.5 Mg-1.7
___ 06:35AM BLOOD TSH-0.57

___ 10:20AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:20AM URINE Blood-TR Nitrite-NEG Protein-30 
Glucose-NEG Ketone-10 Bilirub-SM  Urobiln->12 pH-6.5 Leuks-SM 
___ 10:20AM URINE RBC-3* WBC-9* Bacteri-FEW Yeast-NONE 
Epi-12 TransE-<1
___ 10:20AM URINE AmorphX-OCC
___ 10:20AM URINE Mucous-RARE
___ 10:20AM URINE
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, TSH {Thyroid stimulating hormone measurement}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, RBC {Red blood cell count}, WBC {White blood cell count}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
The patient was admitted to the orthopedic surgery service and 
was taken to the operating room for above described procedure. 
Please see separately dictated operative report for details. The 
surgery was uncomplicated and the patient tolerated the 
procedure well. Patient received perioperative IV antibiotics.

Postoperative course was remarkable for the following:
Overnight on POD#0, the patient was given a 500 mL bolus for low 
urine output.  She was unable to void and had to be straight 
cath'ed x1.  After that, she was able to void independently 
thereafter. On POD 3, patient became acutely delirious. EKG 
demonstrated Afib with Rvr. Rate was controlled with metoprolol. 
Medicine was consulted who recommended continuing the metoprolol 
for rate control. CXR and KUB were obtained. U/A were obtained. 
Imaging did not demonstrate acute findings other than 
atelectasis. Troponins negative. On POD#4 she became agitated 
and the patient's family was contacted to assist. On POD#5 
patient was noted to have leukocytosis with WBC 12.0 and urinary 
frequency with discomfort, u/a was consistent with infection, 
she was started on Ciprofloxacin for 7 days. Upon discharge her 
mental status was clear, alert, oriented, and cooperative. 

Otherwise, pain was controlled with a combination of IV and oral 
pain medications.  The patient received lovenox for DVT 
prophylaxis starting on the morning of POD#1.  The surgical 
dressing was changed and the Silverlon dressing was removed on 
POD#2. The surgical incision was found to be clean and intact 
without erythema or abnormal drainage. The patient was seen 
daily by physical therapy. Labs were checked throughout the 
hospital course and repleted accordingly. At the time of 
discharge the patient was tolerating a regular diet and feeling 
well.  The patient was afebrile with stable vital signs.  The 
patient's hematocrit was acceptable and pain was adequately 
controlled on an oral regimen. The operative extremity was 
neurovascularly intact and the wound was benign.

The patient's weight-bearing status is weight bearing as 
tolerated on the operative extremity with posterior precautions. 
Walker or two crutches at all times for 6 weeks.
 
Ms. ___ discharged to rehab in stable condition.
 

###RESPONSE: procedure {Procedure}, surgery {Surgical procedure}, IV antibiotics {Intravenous antibiotic therapy}, low 
urine output {Decreased urine output}, unable to void {Retention of urine}, cath {Catheterization of urinary bladder}, able to void {Normal micturition}, delirious {Delirious}, EKG {Electrocardiographic procedure}, Afib with Rvr {Atrial fibrillation with rapid ventricular response}, CXR {Plain chest X-ray}, KUB {Radiography of kidney-ureter-bladder}, Imaging {Imaging}, atelectasis {Atelectasis}, Troponins {Troponin measurement}, negative {No abnormality detected}, agitated {Feeling agitated}, leukocytosis {Leukocytosis}, urinary 
frequency {Increased frequency of urination}, discomfort {Discomfort}, infection {Infectious disease}, mental status {Neurological mental status determination}, clear {Normal state of mind}, alert {Mentally alert}, oriented {Orientated}, cooperative {Cooperative mental state}, pain was controlled {Pain control}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, DVT 
prophylaxis {Prevention of deep vein thrombosis}, surgical 
dressing was changed {Change of dressing}, dressing was removed {Removal of dressing}, surgical incision {Surgical incision wound}, clean and intact {Wound healing well}, erythema {Erythema}, drainage {Wound discharge}, physical therapy {Physical therapy assessment}, Labs {Laboratory test}, feeling 
well {Well in self}, afebrile {Fever}, stable vital signs {Normal vital signs}, hematocrit was acceptable {Stable hematocrit}, pain was adequately 
controlled {Demonstrates adequate pain control}, operative {Operative site}, extremity {Limb structure}, neurovascularly intact {Normal peripheral neurovascular function}, weight bearing {Weight-bearing}, operative {Operative site}, extremity {Limb structure}, precautions {Safety precautions}, Walker {Uses zimmer frame}, two crutches {Uses two crutches for walking}, stable condition {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
1. ALPRAZolam 0.5 mg PO BID:PRN anxiety 
2. Anastrozole 1 mg PO DAILY 
3. Citalopram 20 mg PO DAILY 
4. Lisinopril 2.5 mg PO DAILY 
5. Omeprazole 20 mg PO BID 
6. Mirtazapine 15 mg PO QHS:PRN insomnia 

 
Discharge Medications:
1.  Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days  
2.  Docusate Sodium 100 mg PO BID 
3.  Enoxaparin Sodium 40 mg SC QD 
4.  Metoprolol Tartrate 25 mg PO Q6H 
Please increase dosage to 37.5mg q6H if HR > 110 consistently  
5.  OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain 
- Moderate  
6.  Senna 8.6 mg PO BID  
7.  ALPRAZolam 0.5 mg PO BID:PRN anxiety  
8.  Anastrozole 1 mg PO DAILY  
9.  Citalopram 20 mg PO DAILY  
10.  Mirtazapine 15 mg PO QHS:PRN insomnia  
11.  Omeprazole 20 mg PO BID  
12. HELD- Lisinopril 2.5 mg PO DAILY  This medication was held. 
Do not restart Lisinopril until SBP > 140
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
___ Diagnosis:
Right total hip arthroplasty 

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: Right total hip arthroplasty {Total replacement of right hip joint}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, walker {Uses zimmer frame}, cane {Uses single walking stick}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
1. Please return to the emergency department or notify your 
physician if you experience any of the following: severe pain 
not relieved by medication, increased swelling, decreased 
sensation, difficulty with movement, fevers greater than 101.5, 
shaking chills, increasing redness or drainage from the incision 
site, chest pain, shortness of breath or any other concerns.
 
2. Please follow up with your primary physician regarding this 
admission and any new medications and refills. 
 
3. Resume your home medications unless otherwise instructed.
 
4. You have been given medications for pain control. Please do 
not drive, operate heavy machinery, or drink alcohol while 
taking these medications. As your pain decreases, take fewer 
tablets and increase the time between doses. This medication can 
cause constipation, so you should drink plenty of water daily 
and take a stool softener (such as Colace) as needed to prevent 
this side effect.  Call your surgeons office 3 days before you 
are out of medication so that it can be refilled.  These 
medications cannot be called into your pharmacy and must be 
picked up in the clinic or mailed to your house.  Please allow 
an extra 2 days if you would like your medication mailed to your 
home.
 
5. You may not drive a car until cleared to do so by your 
surgeon.
 
6. Please call your surgeon's office to schedule or confirm your 
follow-up appointment.
 
7. SWELLING: Ice the operative joint 20 minutes at a time, 
especially after activity or physical therapy. Do not place ice 
directly on the skin. Please DO NOT take any non-steroidal 
anti-inflammatory medications (NSAIDs such as Celebrex, 
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by 
your physician.
 
8. ANTICOAGULATION: Please continue your Lovenox for four (4) 
weeks to help prevent deep vein thrombosis (blood clots).  If 
you were taking Aspirin prior to your surgery, please hold this 
medication until you have completed your one-month course of 
anticoagulation medication or unless cleared by your physician.  

 
9. WOUND CARE: Please keep your incision clean and dry. It is 
okay to shower five days after surgery but no tub baths, 
swimming, or submerging your incision until after your four (4) 
week checkup. Please place a dry sterile dressing on the wound 
each day if there is drainage, otherwise leave it open to air. 
Check wound regularly for signs of infection such as redness or 
thick yellow drainage. Staples will be removed by the visiting 
nurse or rehab facility in two (2) weeks. 
 
10. ___ (once at home): Home ___, dressing changes as 
instructed,  wound checks, and staple removal at two weeks after 
surgery. 
 
11. ACTIVITY: Weight bearing as tolerated with walker or 2 
crutches at all times for six weeks.  Posterior precautions. No 
strenuous exercise or heavy lifting until follow up appointment. 
 Mobilize frequently. 

Physical Therapy:
WBAT RLE
Posterior hip precautions x 3 months post-operatively
Assistive device x 6 weeks post-op (i.e., 2 crutches, walker)
Mobilize frequently

Treatments Frequency:
daily dressing changes as needed for drainage
wound checks daily
ice
staple removal and replace with steri-strips on POD ___ by 
___
 

###RESPONSE: severe pain {Severe pain}, medication, increased {Medication increased}, swelling {Swelling}, decreased 
sensation {Abnormal sensation}, difficulty with movement {Difficulty moving}, fevers {Fever}, shaking {Tremor}, chills {Chill}, redness {Redness of skin over lesion}, drainage {Wound discharge}, incision 
site {Surgical incision wound}, chest pain {Chest pain}, shortness of breath {Dyspnea}, primary physician {Primary care management}, pain control {Pain control}, pain decreases {Sensation of pain reduced}, constipation {Constipation}, drink plenty of water {Fluid intake encouragement}, take a stool softener {Administration of laxative}, prevent 
this side effect {Prevention of constipation}, medication so that it can be refilled {Medication prefill education}, SWELLING {Swelling}, operative joint {Operative site}, physical therapy {Physical therapy procedure}, skin {Skin structure}, ANTICOAGULATION {Anticoagulant therapy}, prevent deep vein thrombosis {Prevention of deep vein thrombosis}, blood clots {Blood clot}, anticoagulation {Anticoagulant therapy}, WOUND CARE {Wound care}, place a dry sterile dressing {Application of dressing}, wound {Wound}, drainage {Wound discharge}, Check wound {Wound assessment}, signs of infection {Monitoring for signs and symptoms of infection}, redness {Redness of skin over lesion}, drainage {Wound discharge}, Staples will be removed {Removal of staples}, dressing changes {Change of dressing}, wound checks {Wound assessment}, staple removal {Removal of staples}, Weight bearing {Weight-bearing}, walker {Uses zimmer frame}, 2 
crutches {Uses two crutches for walking}, precautions {Safety precautions}, WBAT {Weight-bearing gait training}, RLE {Structure of right lower limb}, precautions {Safety precautions}, 2 crutches {Uses two crutches for walking}, walker {Uses zimmer frame}, dressing changes {Change of dressing}, drainage {Wound discharge}, wound checks {Wound assessment}, staple removal {Removal of staples}, steri-strips {Application of adhesive skin closure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
s/p Fall from bicycle, major blunt chest trauma
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: Fall {Falls}, blunt chest trauma {Blunt injury of thorax}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ male helmeted bicyclist s/p fall from bicycle, flipping and 
hitting back on pole. He was transported to ___ for further 
care. 

 

###RESPONSE: fall {Falls}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Asthma
Pneumonia
 

###RESPONSE: Asthma {Asthma}, Pneumonia {Pneumonia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Noncontributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 11:59AM   GLUCOSE-148* UREA N-14 CREAT-1.0 SODIUM-141 
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
___ 11:59AM   estGFR-Using this
___ 11:59AM   WBC-7.3 RBC-5.57 HGB-14.5 HCT-43.3 MCV-78* 
MCH-26.1* MCHC-33.6 RDW-13.3
___ 11:59AM   NEUTS-60.3 ___ MONOS-3.5 EOS-2.3 
BASOS-0.8
___ 11:59AM   PLT COUNT-247

CT Chest ___
IMPRESSION: 
  
1. Numerous right-sided rib fractures, with fractures involving 
multiple 
sites within the ribs, placing the patient at risk for flail 
chest. Associated moderate right hemothorax with pulmonary 
contusion and small right pneumothorax with locules of air in 
the right epicardial fat. 
  
2. Comminuted right scapular fracture. 

Chest xray ___

IMPRESSION: Newly apparent tiny right apical pneumothorax. 
Blunting of the 
right costophrenic sulcus consistent with a small effusion. 
Increased density in the lower right chest consistent with 
contusion probably unchanged. 
Subsegmental atelectasis left base. Multiple rib fractures and 
possible 
fracture right scapula. 

 

###RESPONSE: GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, right-sided {Bone structure of right rib}, rib fractures {Fracture of rib}, fractures involving 
multiple 
sites within the ribs {Fracture of multiple ribs}, flail 
chest {Flail chest}, right {Right lung structure}, hemothorax {Hemothorax}, pulmonary 
contusion {Contusion of lung}, pneumothorax {Pneumothorax}, right {Right lung structure}, Comminuted {Fracture, comminuted}, scapular fracture. {Fracture of scapula}, Chest xray {Plain chest X-ray}, right apical {Structure of apex of right lung}, pneumothorax {Pneumothorax}, right {Right lung structure}, costophrenic sulcus {Structure of costophrenic angle}, effusion {Pleural effusion}, Increased density {Density above reference range}, right chest {Right thorax structure}, contusion {Contusion}, atelectasis {Atelectasis}, left base {Structure of base of left lung}, Multiple rib fractures {Fracture of multiple ribs}, fracture right scapula {Fracture of scapula}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
He was admitted to the Trauma service for pain control and 
pulmonary management related to his rib fractures. He was 
initially placed on PCA and later changed over to oral 
narcotics. Epidural analgesia was discussed with him for which 
he declined. His oxygen saturations on room air were in the high 
90's and he had little to no oxygen requirements.

His right scapula fracture was managed non operatively and he 
will follow up in Orthopedics clinic in 2 weeks.

Adjunct pain therapy treatments were also implemented; around 
the clock Tylenol, prn NSAID's and a Lidoderm patch were all 
started. This regimen appeared to be effective as he was better 
able to ambulate, use the incentive spirometer, cough and deep 
breathe. A bowel regimen was also initiated.

He was discharged to home with his wife on hospital day 4 with 
instructions for follow up.
 

###RESPONSE: pain control {Pain control}, rib fractures {Fracture of multiple ribs}, PCA {Patient controlled analgesia}, oral 
narcotics {Administration of drug or medicament via oral route}, Epidural analgesia {Epidural anesthesia}, oxygen saturations {Finding of oxygen saturation}, on room air {Breathing room air}, scapula fracture {Fracture of scapula}, follow up {Follow-up arranged}, pain {Pain}, therapy {Therapy}, able to ambulate {Able to walk}, cough and deep 
breathe {Deep breathing and coughing exercises}, bowel {Intestinal structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Albuterol
 
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day) as needed for pain.  
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours).  
3. Hydromorphone 4 mg Tablet Sig: ___ - 2 Tablet PO Q3H (every 
3 hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 
hours): take with food.
Disp:*120 Tablet(s)* Refills:*1*
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: 
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply 
to right chest wall region. Remove old patch first.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1*
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as 
needed for constipation.  
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) 
ML PO Q6H (every 6 hours) as needed for constipation.  
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 
Two (2) Puffs Inhalation every six (6) hours as needed for 
shortness of breath or wheezing.
Disp:*1 * Refills:*1*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
s/p Fall from bicycle
Right communicated scapula fracture
Multiple right rib fractures (posterior & lateral)
Right hemothorax
Small right apical pneumothorax
 
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain 
adequately controlled.
 

###RESPONSE: Fall {Falls}, Right {Bone structure of right scapula}, communicated {Fracture, comminuted}, Multiple right rib fractures {Fracture of multiple ribs}, Right {Right lung structure}, hemothorax {Hemothorax}, right apical {Structure of apex of right lung}, pneumothorax {Pneumothorax}, Hemodynamically stable {Hemodynamically stable}, tolerating {Tolerating diet}, regular diet {Normal diet}, pain 
adequately controlled {Demonstrates adequate pain control}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Return to the Emergency room if you develop any fevers, chills, 
headaches, productive cough, shortness of breath, increased rib 
pain not relieved with the medication prescribed, nausea, 
vomiting, diarrhea and/or any other symptoms that are concerning 
to you.

It is important that you cough, deep breathe and use the 
incentive spirometer every hour that you are awake in order to 
minmize developing pneumonia which is commonly associated with 
rib fractures.

Take the pain medication as prescribed and continue the bowel 
regimen while you are on narcotics in order to prevent 
constipation.
 

###RESPONSE: fevers {Fever}, chills {Chill}, headaches {Headache}, productive cough {Productive cough}, shortness of breath {Dyspnea}, rib 
pain {Rib pain}, nausea, 
vomiting, diarrhea {Nausea, vomiting and diarrhea}, cough {Cough}, awake {Awake}, pneumonia {Pneumonia}, rib fractures {Fracture of multiple ribs}, pain medication {Administration of analgesic}, bowel {Intestinal structure}, narcotics {Narcotherapy}, constipation {Constipation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Chest pain, headache.
 
Major Surgical or Invasive Procedure:
Stress MIBI.

 

###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, Chest pain {Chest pain}, headache {Headache}, Stress {Electrocardiogram with exercise test}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
This is a ___ yof with hx of Stroke, DM II diet controlled, HTN, 
Hypercholesterolemia, Cervical Radiculopathy who presents from 
home chest pain. Patient reports she had an episdode of ___ 
""chest pressure"" today while she was reading a magazine. The 
episode lasted for about 45 minutes and was not relieved with 
NTG given by EMS. +nausea but no vomiting. She denies SOB, 
palpitations or radiating pain with this episode. She has had 2 
similar episodes in the last two weeks. She has history of GERD 
in the past and stopped her Protonix because she was feeling 
better. She started the Protonix because she had similar 
episodes of chest pain a few years ago. The only difference is 
the her current episodes are more severe. She denies any recent 
chest burning, nightime cough but she does have an occasional 
sour taste in her mouth. She also reports an episode of 'shaking 
chills' today along with a ___ frontal headache. Headache was 
associated with some body weakness and patient was worred she 
was having another stroke. EMS was called and she came to ___ ED. 
She denies any recent fevers, sweats, cough, abdominal pain, 
diarrhea, dysuria, urinary frequency or hematuria. While in the 
ED, the patient was noted to have gait difficulty. No vision 
complaints. Neurology was consulted and symptoms resolved on 
their examination. CT Head was performed and was similar to 
prior dated ___. The patient and her daughter report that she 
gets right sided weakness occasionally as a result of her prior 
CVA. Currently, she denies any weakness or numbness.  
In the ED: Temp 98.3, BP 132/63, HR 102, RR 20, 100% NRB. She 
was given ASA 325mg x 1 and NS 1 Liter bolus. Neurology was 
consulted as above for transient right sided weakness. She was 
admitted for ___.
 

###RESPONSE: Stroke {Cerebrovascular accident}, DM II diet controlled {Type 2 diabetes mellitus controlled by diet}, HTN {Hypertensive disorder, systemic arterial}, Hypercholesterolemia {Hypercholesterolemia}, Cervical Radiculopathy {Cervical radiculopathy}, chest pain {Chest pain}, chest pressure {Tight chest}, nausea {Nausea}, vomiting {Vomiting}, SOB {Dyspnea}, palpitations {Palpitations}, radiating pain {Radiating pain}, GERD {Gastroesophageal reflux disease}, feeling 
better {Patient's condition improved}, chest pain {Chest pain}, chest burning {Burning chest pain}, cough {Cough}, sour taste {Unpleasant taste in mouth}, mouth {Mouth region structure}, shaking {Tremor}, chills {Chill}, frontal headache {Frontal headache}, Headache {Headache}, weakness {Asthenia}, stroke {Cerebrovascular accident}, fevers {Fever}, sweats {Sweating}, cough {Cough}, abdominal pain {Abdominal pain}, diarrhea {Diarrhea}, dysuria {Dysuria}, urinary frequency {Increased frequency of urination}, hematuria {Blood in urine}, gait difficulty {Abnormal gait}, No vision 
complaints {Normal vision}, Neurology was consulted {Seen by neurologist}, resolved {Problem resolved}, CT Head {Computed tomography of head}, right sided weakness {Right hemiparesis}, CVA {Cerebrovascular accident}, weakness {Asthenia}, numbness {Numbness}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, NRB {Oxygen administration by mask}, Neurology was 
consulted {Seen by neurologist}, right sided weakness {Right hemiparesis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
CVA x 4 with residual mild right sided weakness  
Diabetes Mellitus Type II, diet controlled  
Hypertension  
Hypercholesterolemia  
Gastroesophageal Reflux Disease  
Cervical radiculopathy  
Diverticulitis
 

###RESPONSE: CVA {Cerebrovascular accident}, right sided weakness {Right hemiparesis}, Diabetes Mellitus Type II, diet controlled {Type 2 diabetes mellitus controlled by diet}, Hypertension {Hypertensive disorder, systemic arterial}, Hypercholesterolemia {Hypercholesterolemia}, Gastroesophageal Reflux Disease {Gastroesophageal reflux disease}, Cervical radiculopathy {Cervical radiculopathy}, Diverticulitis {Diverticulitis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
1. brother - died late ___ w/ CVA
2. brother - died lung ca (smoker)
No hx of MI in first degree relative
Mother with HTN
 

###RESPONSE: died {Dead}, CVA {Cerebrovascular accident}, died {Dead}, lung ca {Malignant tumor of lung}, smoker {Smoker}, MI {Myocardial infarction}, HTN {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VS: Temp 97.3, BP 108/61, HR 76, RR 20, 97% RA  
GEN: Elderly in NAD, awake, alert  
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP 
moist and without lesion  
NECK: Supple, no JVD  
CV: Reg rate, normal S1, S2. No m/r/g.  
CHEST: Resp were unlabored, no accessory muscle use. CTAB, no 
crackles, wheezes or rhonchi.  
ABD: Soft, NT, ND  
EXT: No c/c/e  
SKIN: No rash  
Neuro: CN II-XII intact, ___ strenght right arm extension, ___ 
strenght right leg extension, ___ strenght remaining 
extremities, sensation intact, +brisk patellar reflex, other 
reflexes normal, Gait unstable on right side on walking, no 
pronator drift, no intention tremor, no ataxia  

 

###RESPONSE: VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, GEN {General examination of patient}, NAD {No abnormality detected}, awake {Awake}, alert {Mentally alert}, HEENT {Physical examination procedure}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, sclera anicteric {White sclera}, conjunctivae clear {Conjunctiva normal}, OP 
moist {Moist oral mucosa}, lesion {Lesion}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, JVD {Jugular venous engorgement}, CV {Cardiovascular physical examination}, Reg rate {Pulse regular}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, No m/r/g {Heart sounds normal}, CHEST {Thoracic structure}, Resp {Examination of respiratory system}, accessory muscle {Accessory skeletal muscle}, CTAB {Normal breath sounds}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABD {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, No c/c/e  {No abnormality detected}, SKIN {Examination of skin}, rash {Eruption of skin}, Neuro {Neurological examination}, CN II-XII {Normal central nervous system}, intact {Normal central nervous system}, strenght {Finding of power of skeletal muscle}, right arm {Structure of right upper limb}, extension {Abnormal extension}, strenght {Finding of power of skeletal muscle}, right leg {Structure of right lower limb}, extension {Abnormal extension}, strenght {Finding of power of skeletal muscle}, extremities {All extremities}, sensation intact {Normal sensation}, brisk patellar reflex {Knee reflex brisk}, reflexes normal {Normal reflex}, Gait unstable {Unsteady when walking}, right side {Structure of right half of body}, walking {Does walk}, pronator drift {Downward drift of outstretched supinated arm}, intention tremor {Intention tremor}, ataxia {Ataxia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
On Admission:
___ 03:20PM   WBC-11.6* RBC-4.47 HGB-12.6 HCT-37.4 MCV-84 
MCH-28.3 MCHC-33.8 RDW-14.6
___ 03:20PM   NEUTS-91.7* LYMPHS-6.5* MONOS-0.7* EOS-0.8 
BASOS-0.2
___ 03:20PM   PLT COUNT-279
___ 03:20PM   GLUCOSE-116* UREA N-16 CREAT-1.2* SODIUM-140 
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
___ 03:20PM   CK(CPK)-81
___:20PM   CK-MB-NotDone
___ 03:20PM   cTropnT-0.02*
___ 03:20PM   ___ PTT-25.2 ___
___ 08:40PM URINE  ___ BACTERIA-MOD YEAST-NONE 
___ 08:40PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
___ 08:40PM URINE  COLOR-Yellow APPEAR-Clear SP ___
.
CT head ___:
No intracranial hemorrhage or evidence of acute major vascular 
territorial infarct. Chronic microvascular ischemic changes 
reidentified in the periventricular white matter.
.
Stress MIBIL:
Limited exercise tolerance. No anginal type symptoms or ischemic 
ECG changes seen at workload achieved. Nuclear report sent 
separately.
1. Normal myocardial perfusion. 2. Calculated LVEF is 63%. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, PTT {Partial thromboplastin time, activated}, URINE {Urine culture}, AST {Aspartate aminotransferase measurement}, PROTEIN {Measurement of protein in urine}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, URINE {Evaluation of urine specimen}, COLOR {Color finding}, intracranial hemorrhage {Intracranial hemorrhage}, vascular {Blood vessel structure}, infarct {Infarct}, Chronic {Chronic disease}, ischemic {Ischemia}, periventricular white matter {Structure of periventricular white matter}, Limited exercise tolerance {Impaired exercise tolerance}, anginal {Angina}, ischemic {Ischemia}, ECG changes {Finding present on electrocardiogram}, Normal myocardial perfusion {Myocardial perfusion normal}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ yof with hx of Stroke, DM II diet controlled, HTN, 
Hypercholesterolemia, Cervical Radiculopathy who presents from 
home with chest pain associated with shaking chills and 
headache.  
.  
# Chest Pain: Chest pain was concerning for ACS as she felt 
""chest pressure"" along with nausea and it lasted for 45 minutes. 
Patient had negative cardiac enzymes x3 and serial ECG without 
any changes. Patient was continued on her PPI for history of 
GERD. Due to the concern with multiple risk factors and history, 
patient had a stress MIBI that showed good HR of 137 (93% of 
max) with product of ___, which does not suggest active 
ischemia. However, her prognostic value was poor with 6:30 on a 
Gervino protocol with ___ MTS. Patient did not have any 
abnormalities on telemetry and is on tripple anti-platelet 
therapy with aggrenox and plavix for her stroke that will 
decrease her cardiovascular risk as well. Patient was continued 
in her outpatient statin and ___. Will recommend starting 
beta-blocker as outaptient; it was not started in house to 
assess her neurologic status in the question of acute stroke and 
severe headache.
.  
# Right Sided Weakness: Patient with prior history of CVA. 
Patient had transient weakness today and was evaluated by Neuro 
in the ED. CT Head was negative and symptoms have now resolved. 
Patient and daughter report occasional right sided fatigue s/p 
her prior CVA. She uses a can at baseline for ambulation. Due to 
her prior strokes patient is in an atypical regimen with 
aggrenox and plavix suggested by neurology. 
.  
# Headache: Patient had episode of Headache today along with her 
chest pain and weakness. She has history of headaches similar to 
this. Most likely etiology is her cervical spine disease. 
Conservative measurements with ice-packs, soft collar and 
tylenol were done.
.  
# Shaking chills: Patient with episode of shaking chills. 
Afebrile since arrival but she does have a slightly elevated WBC 
at 11.6. No signs of infection by history or exam. UA with Mod 
bacteria but without pyuria. She was treated with a 3-day course 
of ciprofloxacin to complete at home.
.  
# HTN: cont home Diovan; meeting ___-7 criteria while in 
hospital. 
.  
# DM II: diet controlled. Patient was put in ISS with minimal 
requirements and blood sugars 100-200 range.
.  
# Depression: cont home sertraline.  
.  
# FEN: Cardiac, diabetic diet.
.  
# Access: PIV.
.  
# PPx: heparin SC, bowel regimen.
.  
# Code: FULL CODE.
.  
# Dispo: Home with PCP follow up.  
.  
# Comm: With patient.

 

###RESPONSE: Stroke {Cerebrovascular accident}, DM II diet controlled {Type 2 diabetes mellitus controlled by diet}, HTN {Hypertensive disorder, systemic arterial}, Hypercholesterolemia {Hypercholesterolemia}, Cervical Radiculopathy {Cervical radiculopathy}, chest pain {Chest pain}, shaking {Tremor}, chills {Chill}, headache {Headache}, Chest Pain {Chest pain}, Chest pain {Chest pain}, ACS {Acute coronary syndrome}, chest pressure {Tight chest}, nausea {Nausea}, negative cardiac enzymes {Cardiac enzymes within reference range}, ECG {Electrocardiographic procedure}, GERD {Gastroesophageal reflux disease}, stress {Electrocardiogram with exercise test}, HR {Finding of heart rate}, ischemia {Ischemia}, did not have any 
abnormalities {No abnormality detected}, telemetry {Cardiac telemetry}, anti-platelet 
therapy {Anticoagulant therapy}, stroke {Cerebrovascular accident}, decrease {Finding of decreased risk level}, cardiovascular {Cerebrovascular accident}, statin {Administration of prophylactic statin}, outaptient {Outpatient care management}, assess her neurologic status {Neurological examination}, stroke {Cerebrovascular accident}, headache {Headache}, Right Sided Weakness {Right hemiparesis}, CVA {Cerebrovascular accident}, weakness {Asthenia}, evaluated {Evaluation procedure}, Neuro {Neurology service}, CT Head {Computed tomography of head}, resolved {Problem resolved}, right sided {Structure of right half of body}, fatigue {Fatigue}, CVA {Cerebrovascular accident}, uses a can {Dependence on walking stick}, baseline {Baseline state}, strokes {Cerebrovascular accident}, regimen {Therapeutic regimen}, Headache {Headache}, Headache {Headache}, chest pain {Chest pain}, weakness {Asthenia}, headaches {Headache}, cervical spine disease {Disorder of cervical spine}, Conservative measurements {Conservative therapy}, ice {Application of ice}, collar {Application of cervical collar}, tylenol {Administration of analgesic}, Shaking {Tremor}, chills {Chill}, shaking {Tremor}, chills {Chill}, elevated WBC {White blood cell count outside reference range}, signs of infection {Monitoring for signs and symptoms of infection}, exam {Physical examination procedure}, UA {Urinalysis}, bacteria {Bacteriuria}, pyuria {Pyuria}, ciprofloxacin {Antibiotic therapy}, HTN {Hypertensive disorder, systemic arterial}, DM II {Diabetes mellitus type 2}, diet controlled {Type 2 diabetes mellitus controlled by diet}, ISS {Sliding scale insulin regime}, blood sugars {Glucose measurement, blood}, Depression {Depressive disorder}, FEN {Nutrition management}, Cardiac {Heart disease}, diabetic diet {Diabetic diet}, PIV {Peripheral intravenous catheter care}, PPx {Preventive procedure}, heparin SC {Subcutaneous injection of heparin}, bowel {Normal bowel habits}, regimen {Therapeutic regimen}, Dispo {Patient disposition}, PCP {Primary care management}, follow up {Follow-up arranged}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Plavix 75mg daily  
Aggrenox 25mg-200mg cap BID  
Folic Acid  
Crestor 40mg qHS  
Sertraline 25mg daily  
Diovan 80mg BID  
Calcium/Vit D  
Protonix 40mg daily  
Vit B12  
Colace  
Fish Oil
 
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
2. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr 
Sig: One (1) Cap PO BID (2 times a day).  
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

4. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).  
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) 
Tablet, Chewable PO QID (4 times a day) as needed.  
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Four (4) 
Tablet PO DAILY (Daily).  
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) 
Tablet, Delayed Release (E.C.) PO once a day.  
10. Cyanocobalamin 500 mcg Tablet Sig: 0.5 Tablet PO DAILY 
(Daily).  
11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H 
(every 12 hours) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
12. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.  
13. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a 
day.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis:
Stable Coronary Artery Disease
Cervicalgia
.
Secondary Diagnsis:
CVA x 4 with residual mild right sided weakness  
Diabetes Mellitus Type II, diet controlled  
Hypertension  
Hypercholesterolemia  
Gastroesophageal Reflux Disease  

 
Discharge Condition:
Stable, pain free, walking, tolerating diet.

 

###RESPONSE: Stable {Patient's condition stable}, Coronary Artery Disease {Coronary arteriosclerosis}, Cervicalgia {Neck pain}, CVA {Cerebrovascular accident}, mild {Symptom mild}, right sided weakness {Right hemiparesis}, Diabetes Mellitus Type II, diet controlled  {Type 2 diabetes mellitus controlled by diet}, Hypertension {Hypertensive disorder, systemic arterial}, Hypercholesterolemia {Hypercholesterolemia}, Gastroesophageal Reflux Disease {Gastroesophageal reflux disease}, Stable {Patient's condition stable}, pain {Pain}, walking {Does walk}, tolerating diet {Tolerating diet}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were seen at ___ for chest pain. We were concern about 
your heart and did some blood test, serial ECGs, heart monitor 
(telemetry) and stress test that were all negative. This rules 
you out as having an acute heart attack and puts you at low risk 
from having one soon. We are sending you home with follow up 
with your PCP.
.
You also have a headache and because of that you were seen by 
the neurology stroke service who did not think you were having a 
stroke. You had a CT scan that did not show any bleeding. Your 
signs and symptoms are compatible with your cervical lessions 
and we recommend conservative management with cold and pain 
medication (Tylenol) as well as PCP follow up.
.
You were found to have a urinary tract infection and will need 
to complete 3 days of antibiotics (ciprofloxacin). See attached 
prescription.
.
Your medications were left unchanged.
.
If you notice any worsening in your weakness, new problems while 
talking, facial droop, worsening of your chest pain or that it 
last more than 15 minutes associated with sweating, bleeding or 
anything else that concerns you please come back to the ER ASAP.
.
Please follow up as below.
 

###RESPONSE: chest pain {Chest pain}, heart {Heart structure}, blood test {Blood test}, ECG {Electrocardiographic procedure}, heart monitor {Cardiac monitoring}, telemetry {Cardiac telemetry}, stress test {Electrocardiogram with exercise test}, negative {No abnormality detected}, acute heart attack {Acute myocardial infarction}, follow up {Follow-up arranged}, PCP {Primary care management}, headache {Headache}, seen by 
the neurology stroke service {Seen by stroke service}, stroke {Cerebrovascular accident}, CT scan {Computed tomography}, bleeding {Bleeding}, signs {Sign}, cervical {Bone structure of cervical vertebra}, lessions {Lesion}, conservative management {Conservative therapy}, cold {Cryoanalgesia}, pain 
medication {Administration of analgesic}, PCP {Primary care management}, follow up {Follow-up arranged}, urinary tract infection {Urinary tract infectious disease}, antibiotics {Antibiotic therapy}, prescription {Prescription}, medications {Prescription of drug}, weakness {Asthenia}, problems {Problem}, talking {Speech problem}, facial {Face structure}, chest pain {Chest pain}, sweating {Sweating}, bleeding {Bleeding}, ER {Emergency treatment management}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
s/p Multiple gunshot wounds
 
Major Surgical or Invasive Procedure:
___ EXPLORATORY LAPAROTOMY 

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, gunshot wounds {Gunshot wound}, EXPLORATORY LAPAROTOMY {Exploratory laparotomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ year old male who is s/p multiple gunshot wounds to abdomen 
and left hand. He was transported from ___ 
for further managemnt of his injuries.
 

###RESPONSE: gunshot wounds {Gunshot wound}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, left hand {Structure of left hand}, injuries {Traumatic injury}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
 Asthma, ?depression/ anxiety, ETOH use per family, h/o assault 
 

###RESPONSE: Asthma {Asthma}, depression {Depressive disorder}, anxiety {Anxiety}, ETOH {Finding relating to alcohol drinking behavior}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Noncontributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Upon presentation to ___:
HR: 70 BP: 100/p Resp: bagged O(2)Sat: 100 Normal
 
Constitutional: intubated, sedated
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
ETT in place
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry, GSW to L chest, LLQ x2, R flank, L hip,
R back, L thigh x 2, L thumb
Neuro: intubated, sedated
Psych: intubated, sedated
___: No petechiae

 

###RESPONSE: HR {Finding of heart rate}, BP {Blood pressure finding}, Resp {Examination of respiratory system}, bagged {Respiratory assist, manual}, intubated {Insertion of endotracheal tube}, sedated {Sedated}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, Pupils equal, round and
reactive to light {Pupils equal and reacting to light}, ETT in place {Endotracheal tube present}, Chest {Examination of respiratory system}, Clear to auscultation {Normal breath sounds}, Cardiovascular {Cardiovascular physical examination}, Regular Rate and Rhythm {Normal heart rate}, Normal first and
second heart sounds {Heart sounds normal}, Abd {Examination of abdomen}, Soft {Abdomen soft}, distended {Swollen abdomen}, GU {Examination of genitourinary system}, Flank {Flank structure}, tenderness {Tenderness}, Extr {Examination of limb}, Back {Structure of back of trunk}, cyanosis {Cyanosis}, clubbing {Clubbing}, edema {Edema}, Skin {Examination of skin}, Warm {Warm skin}, dry {Xeroderma}, GSW {Gunshot wound}, L chest {Structure of left half of chest wall}, LLQ {Structure of left lower quadrant of abdomen}, flank {Flank structure}, hip {Left hip region structure}, back {Structure of back of trunk}, L thigh {Structure of left thigh}, L thumb {Structure of left thumb}, Neuro {Neurological examination}, intubated {Insertion of endotracheal tube}, sedated {Sedated}, Psych {Neurological mental status determination}, intubated {Insertion of endotracheal tube}, sedated {Sedated}, petechiae {Petechia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 09:20AM   GLUCOSE-111* UREA N-7 CREAT-0.7 SODIUM-143 
POTASSIUM-3.0* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18
___ 09:20AM   CALCIUM-7.8* PHOSPHATE-3.3 MAGNESIUM-1.5*
___ 09:20AM   WBC-6.2 RBC-3.94* HGB-12.3* HCT-34.3* MCV-87 
MCH-31.2 MCHC-35.9* RDW-13.5
___ 09:20AM   ___ PTT-25.3 ___
___ 09:20AM   PLT COUNT-130*
___ 07:13AM   GLUCOSE-88 LACTATE-3.2* K+-2.9* CL--109*

IMAGING:  
___: Femur AP: Known lucency in the left iliac bone. No 
evidence of bullet fragments. The left femur shows normal 
cortical borders, no evidence of cortical disruption suggesting 
fracture. No soft tissue abnormalities.  
___: CXR: no evidence of larger parenchymal abnormalities and  
no pneumothorax. The abnormalities seen on the outside CT torso 
from ___, 4:48 a.m., are not depicted on the chest 
radiograph. Only the dorsal right 11th rib fracture is visible 
on the edge-enhanced image.  
___: AP chest and pelvis: A focal lucency within the left iliac 
bone corresponds to a traumatic injury seen on the reference CT 
torso examination from 4:48 a.m. No bullet fragments are 
detected. A Foley catheter resides within the bladder, which is 
opacified with contrast.  
___: Hand: comminuted fracture at the head of the first 
proximal phalanx is seen, with extension to the IP joint.  

 

###RESPONSE: GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, CALCIUM {Blood calcium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, GLUCOSE {Glucose measurement, blood}, CL {Chloride measurement, blood}, IMAGING {Imaging}, Femur {Bone structure of femur}, AP {Diagnostic radiography, anteroposterior}, left iliac bone {Bone structure of left ilium}, No 
evidence {No abnormality detected}, left femur {Structure of left femur}, no evidence {No abnormality detected}, disruption {Disruption}, fracture {Fracture}, soft tissue {Structure of soft tissue of thigh}, abnormalities {No abnormality detected}, CXR {Plain chest X-ray}, no evidence {No abnormality detected}, abnormalities {No abnormality detected}, pneumothorax {Pneumothorax}, abnormalities {Imaging result abnormal}, torso {Trunk structure}, chest 
radiograph {Plain chest X-ray}, right {Bone structure of right rib}, rib fracture {Fracture of rib}, AP chest {Plain x-ray of chest anteroposterior view}, pelvis {Plain X-ray of pelvis, anteroposterior view}, left iliac 
bone {Bone structure of left ilium}, traumatic injury {Traumatic injury}, torso {Trunk structure}, Foley catheter {Urinary catheter in situ}, bladder {Urinary bladder structure}, Hand {Hand structure}, comminuted fracture {Fracture, comminuted}, head {Structure of head of phalanx}, proximal phalanx {Bone structure of proximal phalanx of hand}, IP joint {Interphalangeal joint structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
He was admitted to the Acute Care Surgery team was taken from 
the ED to the OR for exploratory laparotomy. He was transferred 
to the Trauma SICU postoperatively  for close monitoring. He 
remained hemodynamically stable and continued to have palpable 
lower extremity pulses. He was extubated without difficulty and  
was alert and responsive. Hand surgery was consulted for the 
left open thumb fracture for which he was fitted with a spica 
cast. Ultimately he will follow up as an outpatient with Hand 
Surgery to discuss operative repair. His pain was controlled 
with IV narcotics initially. On the ___ postoperative day his 
diet was advanced. His wounds were closely monitored for signs 
of infection and they remained clean. His vital signs were 
stable and his urine output was adequate; he was then 
transferred out of the ICU to the floor on POD 1. 

Once transferred to the floor he progressed slowly primarily 
limited by pain. His narcotics required several adjustments. 
Toradol was added to his regimen which was helpful. At time of 
discharge his pain is well controlled with Oxycodone and 
Baclofen both prn.

He was seen by Social work due to the nature of his trauma and 
also due to +blood alcohol level. He was provided with 
information pertaining to reactions to trauma.
 

###RESPONSE: exploratory laparotomy {Exploratory laparotomy}, transferred 
to the Trauma SICU {Patient transfer to intensive care unit}, postoperatively {Postoperative state}, monitoring {Monitoring response to treatment}, hemodynamically stable {Hemodynamically stable}, lower extremity pulses {Lower limb pulse present}, extubated {Removal of endotracheal tube}, alert {Mentally alert}, Hand surgery was consulted {Referral to hand surgery service}, left {Structure of left thumb}, thumb {Structure of left thumb}, fracture {Open fracture of hand}, fitted with a spica 
cast {Application of thumb spica plaster cast}, Hand 
Surgery {Referral to hand surgery service}, operative {Surgical procedure}, repair {Repair of finger}, pain was controlled {Pain control}, IV {Administration of drug or medicament via intravenous route}, narcotics {Narcotherapy}, postoperative {Postoperative state}, diet was advanced {Advance diet as tolerated}, wounds {Wound}, signs 
of infection {Monitoring for signs and symptoms of infection}, remained clean {Wound healing well}, vital signs were 
stable {Normal vital signs}, urine output {Finding of measures of urine output}, transferred out of the ICU {Discharge from intensive care service}, pain {Pain}, narcotics {Narcotherapy}, adjustments {Procedure related to management of drug administration}, regimen {Therapeutic regimen}, pain is well controlled {Demonstrates adequate pain control}, seen by Social work {Seen by social worker}, trauma {Traumatic injury}, blood alcohol level {Blood ethanol measurement}, trauma {Traumatic injury}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Denies
 
Discharge Medications:
1. Acetaminophen 1000 mg PO TID 
2. Baclofen 10 mg PO TID 
RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp 
#*21 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID 
4. OxycoDONE (Immediate Release)  ___ mg PO Q3H:PRN pain 
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours as 
needed Disp #*60 Tablet Refills:*0
5. Senna 1 TAB PO BID:PRN constipation 

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
s/p Multiple Gunshot wounds to abdomen & left hand
Injuires:
Comminuted fracture of the left thumb proximal phalanx

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Gunshot wounds {Gunshot wound}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, left hand
Injuires {Injury of left hand}, Comminuted fracture {Fracture, comminuted}, left thumb {Structure of left thumb}, proximal phalanx {Bone structure of proximal phalanx of hand}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted to the hopstial after sustaining multiple 
gunshot wounds to your adbominal region and your left hand. You 
underwent an operation to explore your abomen for internal organ 
injuries and none were identified. You did sustain an open 
fracture of your left thumb and was placed in a special cast. 
You will need to follow up with the Orthopedic hand surgeon in 
the next couple of weeks to discuss possible surgery. You have 
staples along the incision in your abdomen and these will be 
reomoved inthe next ___ days when you return for your 
appointment in the Acute Care Surgery clinic. 

You are being discharged on medications to treat the pain from 
your operation. These medications will make you drowsy and 
impair your ability to drive a motor vehicle or operate 
machinery safely. You MUST  refrain from such activities while 
taking these medications. 

 

 

Please call your doctor or return to the emergency room if you 
have any of the following:
 

 * You experience new chest pain, pressure, squeezing or 
 tightness.
 
* New or worsening cough or wheezing.
 
* If you are vomiting and cannot keep in fluids or your 
 medications.
 
* You are getting dehydrated due to continued vomiting, 
 diarrhea or other reasons. Signs of dehydration include dry 
 mouth, rapid heartbeat or feeling dizzy or faint when standing.
 
* You see blood or dark/black material when you vomit or have a 
 bowel movement.
 

* You have shaking chills, or a fever greater than 101.5 (F) 
 degrees or 38(C) degrees.
 
* Any serious change in your symptoms, or any new symptoms that 
 concern you. 
 
* Please resume all regular home medications and take any new 
meds 
 as ordered.  

Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may 
resume moderate
exercise at your discretion, no abdominal exercises.

Wound Care:
You may shower, no tub baths or swimming. 

If there is clear drainage from your incisions, cover with 
clean, dry gauze. 
Please call the doctor if you have increased pain, swelling, 
redness, or drainage from the incision sites.

 

###RESPONSE: gunshot wounds {Gunshot wound}, adbominal {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, left hand {Structure of left hand}, operation {Surgical procedure}, explore your abomen {Exploratory laparotomy}, internal organ 
injuries {Internal injury of abdominal organ}, open 
fracture {Open fracture of hand}, left thumb {Structure of left thumb}, cast {Application of thumb spica plaster cast}, Orthopedic hand surgeon {Seen by orthopedic surgeon}, surgery {Surgical procedure}, incision {Abdomen incision}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, medications {Prescription of drug}, pain {Pain}, operation {Surgical procedure}, medications {Administration of analgesic}, drowsy {Drowsy}, impair your ability to drive a motor vehicle or operate 
machinery safely {Patient should not drive or operate machinery}, activities {Functional activity education}, while 
taking these medications {Patient medication education}, call your doctor {Informing doctor}, return to the emergency {Emergency treatment education}, chest pain {Chest pain}, pressure {Tight chest}, squeezing {Squeezing chest pain}, tightness {Tight chest}, cough {Cough}, wheezing {Wheezing}, vomiting {Vomiting}, cannot keep in fluids or your 
 medications {Nausea and vomiting}, dehydrated {Dehydration}, vomiting {Vomiting}, diarrhea {Diarrhea}, Signs {Sign}, dehydration {Dehydration}, dry 
 mouth {Xerostomia}, rapid heartbeat {Tachycardia}, dizzy {Dizziness}, faint {Feeling faint}, standing {Orthostatic body position}, blood or dark/black material when you vomit {Vomit contains blood}, bowel movement {Hematochezia}, shaking {Tremor}, chills {Chill}, fever {Fever}, resume all regular home medications {Patient medication education}, lifting {Does lift}, moderate
exercise {Physical activity target moderate exercise}, abdominal exercises {Abdominal exercises}, may shower {Wound treatment education}, drainage {Wound discharge}, incisions {Surgical incision wound}, cover with 
clean, dry gauze {Application of dressing}, increased pain {Increased pain}, swelling {Swelling}, redness {Redness of skin over lesion}, drainage {Wound discharge}, incision sites {Surgical incision wound}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Iodine; Iodine Containing / Penicillins
 
Attending: ___.
 
Chief Complaint:
Abdominal pain and RLE claudication
 
Major Surgical or Invasive Procedure:
Angiogram x 2, celiac and SMA angioplasty

 

###RESPONSE: Iodine; Iodine {Allergy to iodine compound}, Penicillins {Allergy to penicillin}, Abdominal pain {Abdominal pain}, RLE {Structure of right lower limb}, claudication {Intermittent claudication}, Angiogram {Angiography}, celiac {Angioplasty of celiac artery}, SMA angioplasty {Angioplasty of superior mesenteric artery}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ with bilateral PVD presents with ___ abdominal pain
which has become unbearable and worsening RLE claudication which
has been controlled on oral pain medications.  He underwent an
arteriogram in ___ that showed occluded SFA with runoff via
the peroneal and ___, the AT was occluded.  Plans were made to
bring him back for a Left Fem to AK-pop bypass, but he failed to
keep his follow up appointments.  He now presents with worsening
claudication in his right leg.  He can only walk a few steps now
and then he gets pain in his calf and thigh.  Resting and
percocet alleviate the pain.  This is much worse than it was a
few months ago.  He does get pain in his left leg too, but his
right leg is more severe.  He does not have rest pain.  He 
denies
fevers, chills, nausea, emesis, paresthesias in his feet, and
weakness.  He has no lesions on his feet.  He quit smoking ___
years ago but does have ___ cigs to calm his nerves.  His feet
have never been cold or turned blue.

 

###RESPONSE: PVD {Peripheral vascular disease}, abdominal pain {Abdominal pain}, RLE {Structure of right lower limb}, claudication {Intermittent claudication}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, arteriogram {Angiography of artery}, SFA {Structure of superficial femoral artery}, peroneal {Structure of peroneal artery}, AT {Structure of anterior tibial artery}, Fem to AK-pop bypass {Femoral-popliteal artery bypass graft}, claudication {Intermittent claudication}, right leg {Structure of right lower leg}, walk {Does walk}, pain {Pain}, calf {Structure of calf of leg}, thigh {Structure of left thigh}, pain {Pain}, pain {Pain}, left leg {Structure of left lower limb}, right leg {Structure of right lower leg}, rest pain {Pain provoked by rest}, fevers {Fever}, chills {Chill}, nausea {Nausea}, emesis {Vomiting}, paresthesias {Paresthesia}, feet {Foot structure}, weakness {Weakness of foot}, lesions {Skin lesion}, feet {Foot structure}, quit smoking {Ex-smoker}, calm {Feeling calm}, feet {Foot structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1. HTN
2. CAD, s/p CABG ___
3. Hyperlipidemia
4. Carotid artery disease, s/p L CEA approximately ___
5. Taxus drug-eluting stent and a 2.0mm MiniVision stent
6. PTCA & stenting Cypher ___ 3, LMA into ostial LAD, ___
7. S/p CVA x 2 in ___, R-sided weakness & expressive aphasia, 
(now
improved)
8. s/p Fall / foot trauma ___, no surgery, wheelchair bound 6 
months
9. GERD
10. Depression
11. DJD
12. Chronic kidney disease 
 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, Hyperlipidemia {Hyperlipidemia}, Carotid artery disease {Disorder of carotid artery}, L {Structure of left carotid artery}, CEA {Carotid endarterectomy}, drug-eluting stent {Endovascular insertion of drug eluting stent}, stent {Placement of stent}, PTCA {Percutaneous transluminal coronary angioplasty}, stenting {Insertion of arterial stent}, LMA {Structure of left coronary artery main stem}, LAD {Structure of anterior descending branch of left coronary artery}, CVA {Cerebrovascular accident}, R-sided weakness {Right hemiparesis}, expressive aphasia {Expressive dysphasia}, improved {Patient's condition improved}, Fall {Falls}, foot {Foot structure}, trauma {Traumatic injury}, surgery {Surgical procedure}, wheelchair bound {Does mobilize using wheelchair}, GERD {Gastroesophageal reflux disease}, Depression {Depressive disorder}, DJD {Osteoarthritis}, Chronic kidney disease {Chronic kidney disease}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father died at age ___ of unknown cause. Mother died in her ___ 
of Influenza. 
 

###RESPONSE: died {Dead}, died {Dead}, Influenza {Influenza}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
At time of discharge:

AVSS
A&O X 3, NAD
PERRL, EOMI
RRR
CTAB
Abdomen soft, nondistended, mild generalized tenderness, no 
rebound or guarding
___ warm
Pulses: b/l fem 2+, pop, DP and ___ all dopplerable
 

###RESPONSE: AVSS {Vital signs finding}, A {Mentally alert}, O X 3 {Oriented to person, time and place}, NAD {No abnormality detected}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, RRR {Normal heart rate}, CTAB {Normal breath sounds}, soft {Abdomen soft}, nondistended {Normal abdominal contour}, mild {Symptom mild}, tenderness {Tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, warm {Warm skin}, Pulses {Pulse finding}, fem 2+ {Normal femoral pulse}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 07:10AM BLOOD WBC-10.0# RBC-3.39* Hgb-9.8* Hct-29.8* 
MCV-88 MCH-28.8 MCHC-32.8 RDW-18.2* Plt ___
___ 06:50AM BLOOD Hct-32.6*
___ 06:50AM BLOOD UreaN-27* Creat-2.2* K-3.4
___ 07:10AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.8
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Hct {Hematocrit determination}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, K {Blood potassium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Mr. ___ was admitted on ___ under the care of Dr. 
___. He underwent ___ angiogram on ___ that showed occlusion 
of the superficial femoral artery with
reconstitution in the above-knee popliteal artery and 2-vessel 
runoff to the foot.  Given these findings, the operation was 
terminated at that point with a plan for surgical bypass at a 
later point. The following day he underwent a mesenteric 
angiogram via brachial approcah. He underwent balloon 
angioplasty of iliac artery stenosis and balloon angioplasty of 
SMA stenosis. Post-operatively he recovered well. He continued 
to have generalized abdominal pain and a GI consult was 
obtained. Since he had evidence of gastritis and duodenal ulcers 
in ___ on EGD, and since he
is unsure if he took PPI since then, the gastroenterologists 
felt that remaining ulcers may also be contributing to the 
abdominal pain. They recommended increasing PPI to 40 mg PO BID 
for 2 weeks, avoiding NSAIDs and will consider repeat EGD as 
outpatient if no improvement. He was discharged home on ___ 
tolerating a regular diet but with similar abdominal complaints 
as prior.
 

###RESPONSE: angiogram {Angiography}, occlusion {Complete obstruction}, superficial femoral artery {Structure of superficial femoral artery}, above-knee popliteal artery {Structure of supragenicular popliteal artery}, vessel {Blood vessel structure}, foot {Foot structure}, operation {Surgical procedure}, surgical bypass {Construction of shunt}, mesenteric 
angiogram {Angiography of mesenteric artery}, balloon 
angioplasty {Angioplasty of artery}, iliac artery stenosis {Iliac artery stenosis}, balloon angioplasty of 
SMA {Percutaneous balloon angioplasty of superior mesenteric artery}, stenosis {Stenosis}, Post-operatively {Postoperative state}, generalized abdominal pain {Generalized abdominal pain}, gastritis {Gastritis}, duodenal ulcers {Ulcer of duodenum}, EGD {Esophagogastroduodenoscopy}, ulcers {Ulcer}, abdominal pain {Abdominal pain}, EGD {Esophagogastroduodenoscopy}, tolerating {Tolerating diet}, regular diet {Normal diet}, abdominal {Abdominal pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
amlodipine 10mg daily, clonidine 0.1mg bid, isosorbide 
mononitrate 180mg daily, metoprolol XL 50mg daily, omeprazole 
40mg daily, papaverine 150mg bid, simvastatin 40mg daily, 
aspirin 325mg daily, plavix 75mg daily, niacin 1000mg daily, 
benicar 40mg daily, clonazepam 0.5mg tid, zolpidem 5mg daily, 
MVI  
 
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).  

2. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).  
3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr 
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).  

4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr 
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).  
5. Papaverine 150 mg Capsule, Sustained Release Sig: One (1) 
Capsule, Sustained Release PO Q12H (every 12 hours).  
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
7. Niacin 500 mg Capsule, Sustained Release Sig: Two (2) 
Capsule, Sustained Release PO DAILY (Daily).  
8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times 
a day).  
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 
 
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) 
Capsule, Delayed Release(E.C.) PO BID (2 times a day).  
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
14. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours 
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
RLE ischemia 
Abdominal pain

 
Discharge Condition:
Good

 

###RESPONSE: RLE {Structure of right lower limb}, Abdominal pain {Abdominal pain}, Good {Patient's condition satisfactory}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Call your doctor or go to the ER if you experience any of the 
following: fever > 101.5, severe pain, bleeding from groin, or 
any other concerning symptoms
 

###RESPONSE: Call your doctor {Informing doctor}, fever {Fever}, severe pain {Severe pain}, bleeding {Bleeding}, groin {Inguinal region structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Penicillins / Prednisone
 
Attending: ___.
 
Chief Complaint:
Palpitations, diaphoresis
 
Major Surgical or Invasive Procedure:
___: Biopsy of retroperitoneal mass by ___ under 
fluoroscopic guidance  

 

###RESPONSE: Penicillins {Allergy to penicillin}, Prednisone {Allergy to prednisone}, Palpitations {Palpitations}, diaphoresis {Excessive sweating}, Biopsy of retroperitoneal mass by ___ under 
fluoroscopic guidance {Biopsy of retroperitoneum using fluoroscopic guidance}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness: This is a ___ YO M CAD, chronic, 
likely diastolic CHF who is representing to the ED after 
presenting with diaphoresis, nausea, presyncope at rehab.  After 
being recently discharged from ___, while at rehab, he was 
sitting in his wheelchair when he developed diaphoresis at rest. 
 He did have a bowel movement about half hour prior to event.  
Diaphoresis was associated with nausea and feeling of confusion. 
 Experienced chest palpitations.  Unclear if Mr ___ lost 
consciousness; denies any loss of stool or urine.  Discomfort 
lasted about 10 minutes and then resolved; has not recurred. 
Most recently he was admitted to the hospital on ___ 
after being pushed down the stairs; he also had fevers and 
chills at that point and was found to be hypotensive and in 
renal failure.  He was transferred to the MICU briefly for 
management; his hypotension was fluid responsive, his renal 
failure responded to fluids.  He was started on vancomycin and 
levoquin for pneumonia and was ruled out for influenza.  
.
In the ED one set of cardiac enzymes were obtained.  UA was done 
which was positive and urine cultures were sent.  Aspirin was 
given.  Chest X-ray was obtained which showed improving 
bibasilar infiltrate compared to prior images.  EKG showed new 
afib, rate controlled, with old T wave inversions (I, aVL, V5, 
V6).  Lower extremity dopplers obtained which were negative.  
His vitals in the ED were 84 112/75, 16, 96% RA.
 

###RESPONSE: CAD {Coronary arteriosclerosis}, chronic {Chronic disease}, diastolic CHF {Heart failure with normal ejection fraction}, diaphoresis {Excessive sweating}, nausea {Nausea}, presyncope {Near syncope}, sitting {Sitting position}, diaphoresis {Excessive sweating}, bowel movement {Does defecate}, Diaphoresis {Excessive sweating}, nausea {Nausea}, confusion {Clouded consciousness}, chest {Thoracic structure}, palpitations {Palpitations}, lost 
consciousness {Loss of consciousness}, loss of stool {Incontinence of feces}, urine {Urinary incontinence}, Discomfort {Discomfort}, resolved {Problem resolved}, fevers {Fever}, chills {Chill}, hypotensive {Low blood pressure}, renal failure {Renal failure syndrome}, transferred to the MICU {Patient transfer to intensive care unit}, hypotension {Low blood pressure}, fluid {Administration of fluid therapy}, renal 
failure {Renal failure syndrome}, fluids {Administration of fluid therapy}, vancomycin {Antibiotic therapy}, pneumonia {Pneumonia}, influenza {Influenza}, cardiac enzymes {Cardiac enzymes/isoenzymes measurement}, UA {Urinalysis}, urine cultures {Urine culture}, Aspirin {Administration of aspirin}, Chest X-ray {Plain chest X-ray}, bibasilar {Structure of base of lung}, infiltrate {Infiltration}, EKG {Electrocardiographic procedure}, afib {Atrial fibrillation}, rate {Finding of heart rate}, T wave inversions {Inverted T wave}, I {Lead site V1}, aVL {aVL}, V5 {Lead site V5}, V6 {Lead site V6}, Lower extremity dopplers {Doppler ultrasonography of vascular structure of lower limb}, negative {No abnormality detected}, vitals {Vital signs finding}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1) HTN  
2) DM - diet controlled, with neuropathy  
3) CAD s/p MI ___ s/p CABG in ___ with multiple CHF  
hospitalizations since then.  
4) CHF  
5) etoh abuse  
6) Gout  
7) CRI, baseline Cr 1.2; per patient ___ longterm NSAID use  

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, DM - diet controlled {Type 2 diabetes mellitus controlled by diet}, neuropathy {Neuropathy}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, CABG {Coronary artery bypass grafting}, CHF {Congestive heart failure}, CHF {Congestive heart failure}, etoh abuse {Alcohol abuse}, Gout {Inflammatory disorder due to increased blood urate level}, CRI {Chronic renal insufficiency}, baseline {Baseline state}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Significant for grandmother with CHF. 
 

###RESPONSE: CHF {Congestive heart failure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:

###RESPONSE: Physical Exam {Physical examination procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:  98.9, 121/77, 74, 29, 96% RA
Gen: Sitting up in bed in NAD
Card: Irregular rhythm, no extrasystolic HS
Resp: lungs CTAB
Abd: soft NT ND
Ext: no ___ edema
Neuro: no focal deficits
 

###RESPONSE: Physical Exam {Physical examination procedure}, RA {Breathing room air}, Gen {General examination of patient}, Sitting up in bed {Fowler's position}, NAD {No abnormality detected}, Card {Cardiovascular physical examination}, Irregular rhythm {Irregular heart beat}, Resp {Examination of respiratory system}, CTAB {Normal breath sounds}, Abd {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, edema {Edema}, Neuro {Neurological examination}, no focal deficits {Normal nervous system function}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Electrolytes:
GLUCOSE-117* UREA N-18 CREAT-1.4* SODIUM-141 POTASSIUM-3.8 
CHLORIDE-103 TOTAL CO2-25 ANION GAP-17
.
Urine analysis:
URINE  BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR 
BILIRUBIN-SM UROBILNGN-8* PH-7.0 LEUK-TR
___ BACTERIA-RARE YEAST-NONE EPI-0
.
CARDIAC ENZYMES:
CK-MB-2 cTropnT-<0.01
cTropnT-<0.01
cTropnT < 0.01
.
CEA: < 1
PSA 0.9
___: pending
.
EKG: Atrial fibrillation. Left axis deviation may be due to left 
anterior 
fascicular block, although it is non-diagnostic. Anterior 
myocardial  
infarction of indeterminate age but it may be old. Anterolateral 
lead 
ST-T wave abnormalities are non-specific but cannot exclude 
ischemia. 
Clinical correlation is suggested. Since the previous tracing of 
___ 
right precordial lead T wave changes appear less prominent but 
there may be no significant change. 
.
Abd/pelvis CT:
IMPRESSION: 
1. Large conglomerate retroperitoneal lymphadenopathy along with 
bilateral 
common and external iliac lymphadenopathy with mediastinal 
lymphadenopathy and right hilar lymphadenopathy raise concern 
for the lymphoma. 
2. Bilateral ground-glass opacity, increased interstitial 
markings in the 
right lung and micronodular lesions bilaterally, also concerning 
for 
lymphangitic spread. 
3. 4.7 cm lesion in the interpolar region of the right kidney 
likely also 
represents lymphoma. (please note that the pattern of lymph 
adenopathy is 
unusual for metastases from renal cell carcinoma) 
4. Spleen is elongated, measuring 16.9 cm. 
.
ECHO: The left atrium is dilated. Left ventricular wall 
thickness, cavity size and regional/global systolic function are 
normal (LVEF >55%). There is no ventricular septal defect. Right 
ventricular chamber size and free wall motion are normal. The 
ascending aorta is mildly dilated. The aortic valve leaflets (3) 
are mildly thickened but aortic stenosis is not present. No 
aortic regurgitation is seen. The mitral valve appears 
structurally normal with trivial mitral regurgitation. There is 
no mitral valve prolapse. The estimated pulmonary artery 
systolic pressure is normal. There is no pericardial effusion. 

IMPRESSION: Normal regional and global biventricular systolic 
function. No pathologic valvular abnormality seen.  
.

 

###RESPONSE: Electrolytes {Electrolytes measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, Urine analysis {Urinalysis}, URINE  BLOOD {Urine blood test}, PROTEIN {Measurement of protein in urine}, GLUCOSE {Glucose measurement, blood}, KETONE {Urinalysis, acetone or ketone bodies measurement}, PH {pH measurement}, cTropnT {Troponin T cardiac measurement}, EKG {Electrocardiographic procedure}, Atrial fibrillation {Atrial fibrillation}, Left axis deviation {Left axis deviation}, left 
anterior 
fascicular block {Left anterior fascicular block}, myocardial  
infarction {Myocardial infarction}, T wave abnormalities {Electrocardiographic T wave abnormal}, ischemia {Ischemia}, right {Structure of right side of heart}, T wave changes {Electrocardiographic T wave abnormal}, retroperitoneal lymphadenopathy {Retroperitoneal lymphadenopathy}, common {Iliac lymphadenopathy}, external iliac lymphadenopathy {External iliac lymphadenopathy}, mediastinal 
lymphadenopathy {Mediastinal lymphadenopathy}, hilar lymphadenopathy {Hilar lymphadenopathy}, lymphoma {Malignant lymphoma}, ground-glass opacity {Ground glass lung opacity}, increased {Increased size}, right lung {Right lung structure}, lesions {Lesion}, lymphangitic spread {Lymphangitis carcinomatosa}, lesion {Lesion}, right kidney {Right kidney structure}, lymphoma {Malignant lymphoma}, lymph 
adenopathy {Lymphadenopathy}, metastases {Metastatic malignant neoplasm to lung}, renal cell carcinoma {Renal cell carcinoma}, Spleen {Splenic structure}, ECHO {Echocardiography}, left atrium {Left atrial structure}, dilated {Dilatation}, Left ventricular wall {Left cardiac ventricular structure}, thickness {Normal thickness}, cavity {Structure of cavity of left cardiac ventricle}, size {Normal size}, regional/global systolic function are 
normal {Normal left ventricular systolic function and wall motion}, ventricular septal defect {Ventricular septal defect}, Right 
ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Normal ventricular wall motion}, ascending aorta {Ascending aorta structure}, dilated {Dilatation}, aortic valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve appears 
structurally normal {Mitral valve normal}, trivial mitral regurgitation {Mild mitral valve regurgitation}, mitral valve prolapse {Mitral valve prolapse}, pulmonary artery {Pulmonary artery structure}, systolic pressure is normal {Normal systolic arterial pressure}, pericardial effusion {Pericardial effusion}, biventricular {Cardiac ventricular structure}, systolic 
function {Normal left ventricular systolic function and wall motion}, No pathologic {No pathologic diagnosis}, valvular {Cardiac valve structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
1. Fevers/Neoplastic Process: Differential initially broad 
encompassing hospital acquired pneumonia versus neoplastic 
process.  A subacute neoplastic process is more likely given 
several weeks-months of night sweats, malaise, and fevers with 
finding of extensive retroperitoneal and mediastinal adenopathy 
on CT.  Other possibly pertinent symptoms include note of 
intermittent hematuria, intermittent abdominal discomfort.  
Other laboratory findings of note: anemia, microscopic 
hematuria, ESR > 100, CRP > upper limit of assay.  Preliminary 
staining is suggestive of a carcinoma given findings of 
organizing tubular structures seen on microscopy.  The type of 
carcinoma is still under review but some stains are suggestive 
of renal cell carcinoma.  CT suggests there is a renal nodule 
that is less likely to be renal cell. At this point, we have 
told Mr ___ that the culmination of our studies so far suggest 
that he likely has an underlying carcinoma leading to his 
constellation of symptoms, however this is not definitive, and 
if it is a carcinoma, we don't yet have a finalized primary 
source.  According to pathology, it should take an additional 
week or so before the pathology report is finalized.  He was set 
up for a primary care appointment with me on ___, and I emphasized the importance of follow-up.  
.
While he was in the hospital, we also evaluated other sources of 
fever.  A chest x-ray revealed a multifocal pneumonia.  Given 
his recent hospitalization, we treated this as a hospital 
acquired pneumonia with an 8 day course of vancomycin and 
cefepime and covered him with azithromycin for a 7 day course 
for the possibility of atypicals.  His cough slowly improved 
over the course of his hospitalization and his fevers trended 
down.  He did not have any leukocytosis during the course of his 
hospitalization.  At time of discharge, he was afebrile for > 48 
hours and his antibiotics course was complete. 
.
2) Atrial fibrillation: Was found to be in new onset atrial 
fibrillation in ED.  Unclear what precipitant of afib could be; 
could be secondary to recent pneumonia/infection. Also has 
significant mediastinal adenopathy; could represent infiltrative 
or compressive process creating an irritant focus.  Had no RVR; 
rates were 70 - 80.  CHADS score was +3.  Coumadin was started 
with goal INR near 2.  Carvedilol was continued at dose of 12.5 
mg BID.  He was discharged and set up with ___ 
clinic. He was discharged with a ___ mg alternating dose 
coumadin regimen.
.
3) Acute on Chronic renal failure: Creatinine was initially 
elevated on presentation, however her electrolytes were 
consistent with prerenal disease.  Following administration of 
fluids, his creatinine resolved to below her baseline. 
.
4) Coronary artery disease:  Troponin levels were checked on 
admission and were negative.  He was continued on his statin, 
aspirin, beta blocker and Ace inhibitor.  His lisinopril was 
held as this tended to precipitously decrease his blood pressure 
< 80 systolic.  At time of discharge, his lisinopril continued 
to be held.
.
5) Congestive heart failure: There was no evidence for fluid 
overload; there were no rales on lung exam.  His JVP was not 
elevated.  He has unilateral 1+ left lower extremity edema; he 
was continued on lasix 80 mg daily.  
.
6) Left ankle pain: Differential is gout vs trauma from recent 
fall.  Mild inflammatory changes seen along left foot (erythema, 
decreased range of motion, mildly warm).  Started on colchicine 
with improvement in symptoms.  Has crystal proven gout last year 
after left ankle joint was tapped.  Was discharged with a 3 day 
continued supply of colchicine.   
.
7) Dispo:  Was discharged to assisted living facility after 
cleared by physical therapy.  Appointments were set up with 
primary care and is being followed by ___ clinic.  
 

###RESPONSE: Fevers {Fever}, hospital acquired pneumonia {Nosocomial pneumonia}, night sweats {Night sweats}, malaise {Malaise}, fevers {Fever}, retroperitoneal {Retroperitoneal lymphadenopathy}, mediastinal adenopathy {Mediastinal lymphadenopathy}, CT {Computed tomography}, hematuria {Blood in urine}, abdominal discomfort {Abdominal discomfort}, laboratory {Laboratory test}, anemia {Anemia}, microscopic 
hematuria {Microscopic hematuria}, ESR {Erythrocyte sedimentation rate above reference range}, CRP {C-reactive protein measurement}, carcinoma {Carcinoma}, microscopy {Microscopy}, carcinoma {Carcinoma}, renal cell carcinoma {Renal cell carcinoma}, CT {Computed tomography}, renal {Kidney structure}, renal {Kidney structure}, cell {Cell structure}, carcinoma {Carcinoma}, carcinoma {Carcinoma}, fever {Fever}, chest x-ray {Plain chest X-ray}, pneumonia {Pneumonia}, hospital 
acquired pneumonia {Nosocomial pneumonia}, vancomycin {Antibiotic therapy}, atypicals {Atypical pneumonia}, cough {Cough}, improved {Patient's condition improved}, fevers {Fever}, leukocytosis {Leukocytosis}, afebrile {Fever}, antibiotics {Antibiotic therapy}, Atrial fibrillation {Atrial fibrillation}, atrial 
fibrillation {Atrial fibrillation}, afib {Atrial fibrillation}, pneumonia {Pneumonia}, infection {Infectious disease}, mediastinal adenopathy {Mediastinal lymphadenopathy}, infiltrative {Infiltration}, compressive {Compression}, RVR {Atrial fibrillation with rapid ventricular response}, rates {Finding of heart rate}, regimen {Therapeutic regimen}, Acute on Chronic renal failure {Acute-on-chronic renal failure}, Creatinine was initially 
elevated {Serum creatinine above reference range}, electrolytes {Finding of electrolyte levels}, disease {Disease}, administration of 
fluids {Administration of fluid therapy}, creatinine {Creatinine measurement}, resolved {Problem resolved}, baseline {Baseline state}, Coronary artery disease {Coronary arteriosclerosis}, Troponin {Troponin measurement}, checked {Monitoring procedure}, negative {No abnormality detected}, aspirin {Administration of aspirin}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, decrease his blood pressure 
< 80 systolic {Decreased systolic arterial pressure}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, Congestive heart failure {Congestive heart failure}, no evidence {No abnormality detected}, fluid 
overload {Hypervolemia}, rales {Respiratory crackles}, lung exam {Examination of respiratory system}, JVP was not 
elevated {Normal jugular venous pressure}, left lower extremity edema {Edema of left lower limb}, lasix {Diuretic therapy}, Left ankle {Structure of left ankle}, pain {Pain}, gout {Inflammatory disorder due to increased blood urate level}, trauma {Traumatic injury}, fall {Falls}, Mild inflammatory {Mild inflammation}, left foot {Structure of left foot}, erythema {Erythema}, warm {Warm skin}, improvement {Patient's condition improved}, gout {Inflammatory disorder due to increased blood urate level}, left {Left hip region structure}, ankle joint {Ankle joint structure}, tapped {Arthrocentesis}, Dispo {Patient disposition}, physical therapy {Physical therapy assessment}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Aspirin 325 mg PO Daily   
Citalopram 20mg PO daily  
Carvedilol 12.5 mg PO BID   
Omperazole 40mg PO daily  
Simvastatin 80mg PO Daily 
Clonzaepam 1mg PO TID  
Trazodone 100mg PO QHS PRN   
Colchicine 0.6mg PO Daily PRN Gout 
Lisinopril 40mg PO Daily  
Lasix 80mg PO daily 
Ferrous Sulfate 325mg PO daily  
NTG 0.3mg SL PRN  .
MVI 1 Tab PO Daily  .
Thiamine 100mg PO Daily .  
Folate 1mg PO Daily  
Acet 325mg PO Q6 PRN Pain . 
Oxycodone 10 mg q6-8 hrs PRN .
Lidoderm 5% adhesive patch topical 12 hrs on 12 hrs off
 
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times 
a day).  
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a 
day).  
7. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) 
as needed for insomnia.  
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
10. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H 
(every 6 hours) as needed for pain.  
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: 
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).  
13. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day: 
two tablets daily at 4PM or as directed by your physician or 
clinic.
Disp:*60 Tablet(s)* Refills:*2*
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)  
Sublingual PRN as needed for chest pain.  
15. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*3 Tablet(s)* Refills:*0*
16. Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet 
PO every ___ hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
17. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 
___ Puffs Inhalation Q4H (every 4 hours) as needed for shortness 
of breath.
Disp:*1 1* Refills:*0*
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 
(2 times a day).  
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day) as needed for constipation.  
20. Maalox 200-200-20 mg/5 mL Suspension Sig: ___  PO PRN as 
needed for pain.
Disp:*1 1* Refills:*0*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
1. New onset atrial fibrillation
2. Urinary tract infection
3. Coronary disease
4. Congestive heart failure

 
Discharge Condition:
Stable for rehab facility.  Saturating well on room air.

 

###RESPONSE: atrial fibrillation {Atrial fibrillation}, Urinary tract infection {Urinary tract infectious disease}, Coronary disease {Coronary arteriosclerosis}, Congestive heart failure {Congestive heart failure}, Stable {Patient's condition stable}, on room air {Breathing room air}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr ___,

It was a pleasure caring for you while you were at ___ 
___.  As you know, the result of some of our studies are 
concerning for a cancer diagnosis, however we do not yet have 
enough information to suggest what kind of cancer you may have.  
In the coming weeks, these results should become clearer, and 
this will help us to develop a plan.  You are not alone in this 
challenge; there will be several doctors who ___ be 
participating in your care.  The most important things for you 
will be to keep your mind and body as healthy as you can so that 
you can put your best foot forward.  You will be followed by me 
in primary care so that I can coordinate all of your care in the 
coming months.  Following up with all of your appointments is 
one of your most important priorities.
.
I've explained some of the important points of your 
hospitalization at ___ below:
(1) When you came into the hospital, you had symptoms of fevers, 
cough, and night sweats.  A lot of these symptoms could be 
because of the possibility of cancer.  However, when we did a 
chest x-ray, we found that you also had a pneumonia in your 
lungs.  This could explain some of your symptoms.  We started 
you on antibiotics for 8 days which led to improvement in your 
cough and fevers.  
(2) While you were hospitalized we found that your heart was 
beating irregularly in a rhythm that we call atrial 
fibrillation.  This can happen when you have an underlying 
infection like pneumonia.  Sometimes this heart rhythm can lead 
to formations of a clot in your heart which can increase your 
risk of stroke.  To help treat this, we started you on a 
medicine called coumadin, which helps to thin the blood.  This 
medicine will require frequent monitoring of your labs and your 
assisted living facility will help draw these.  It is important 
that you take this medicine daily as directed to ensure that you 
do not develop a clot.
(3) While you were here you also developed pain in your left 
foot that we felt was consistent with gout.  We started you on 
colchicine which helped your pain and also increased your pain 
medicine.  You will have enough colchicine for another three 
days to continue to treat your gout.  
.
We made the following medication changes to your usual meds that 
are summarized below:
(1) You should take coumadin (the blood thinner) 5 mg every 
___ and ___, and 2.5mg on ___, 
___ and ___. This dose may be adjusted after we check 
your blood. The ___ lab will be checking your 
blood at your assisted living facility on ___. 
From then on you will get labs checked every week so that your 
dose can be adjusted appropriately.
(2) You should stop taking lisinopril, a blood pressure medicine 
that was decreasing your blood pressure too much.  You can 
restart this as an outpatient as directed by your outpatient 
team.
(3) You should take colchicine 0.6 mg daily for another 3 days 
after you leave the hospital.
(4) You should take oxycodone 10 mg as needed every six hours 
for pain.  
(5) You can use your albuterol inhaler ___ puffs as needed for 
wheezing and shortness of breath.
(6) You can take maalox as needed for your stomach pain.
.
If you experience worsening fevers, diaphoresis, vomiting, 
worsening cough, worsening blood in your urine, or any other 
concerning symptoms, please let your primary care doctor know or 
return to the emergency department.  
 

###RESPONSE: cancer {Malignant neoplasm}, cancer {Malignant neoplasm}, fevers {Fever}, cough {Cough}, night sweats {Night sweats}, cancer {Malignant neoplasm}, chest x-ray {Plain chest X-ray}, pneumonia {Pneumonia}, lungs {Lung structure}, antibiotics {Antibiotic therapy}, improvement {Patient's condition improved}, cough {Cough}, fevers {Fever}, heart was 
beating irregularly {Irregular heart beat}, rhythm {Irregular heart beat}, atrial 
fibrillation {Atrial fibrillation}, infection {Infectious disease}, pneumonia {Pneumonia}, this heart rhythm {Irregular heart beat}, clot {Blood clot}, heart {Heart structure}, increase your 
risk of stroke {At increased risk of cerebrovascular accident}, coumadin {Administration of prophylactic anticoagulant}, thin the blood {Anticoagulant therapy}, monitoring {Monitoring response to treatment}, clot {Blood clot}, pain {Pain}, left 
foot {Structure of left foot}, gout {Inflammatory disorder due to increased blood urate level}, pain {Pain}, pain 
medicine {Administration of analgesic}, gout {Inflammatory disorder due to increased blood urate level}, medication changes {Change of medication}, blood thinner {Anticoagulant therapy}, check 
your blood {Blood test}, checking your 
blood {Blood test}, stop taking {Recommendation to stop treatment}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, blood pressure medicine {On treatment for hypertension}, decreasing your blood pressure {Finding of decreased blood pressure}, restart {Restart of medication}, pain {Pain}, wheezing {Wheezing}, shortness of breath {Dyspnea}, stomach pain {Stomach ache}, fevers {Fever}, diaphoresis {Excessive sweating}, vomiting {Vomiting}, cough {Cough}, blood in your urine {Blood in urine}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___
 
Chief Complaint:
BRBPR, LLQ pain
 
Major Surgical or Invasive Procedure:
.
 

###RESPONSE: BRBPR {Hematochezia}, LLQ {Structure of left lower quadrant of abdomen}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
This is a ___ yo F with h/o PAF on coumadin who presents with 
BRBPR and LLQ pain X 3 days. Her symptoms began ___ night 
when she began to experience BRBPR with minimal amounts of loose 
stools. This was associated with crampy LLQ > RLQ pain. Denies 
n/v, melena, fevers. + chills. These symptoms continued until 
___ when the blood became less brisk with an increase in the 
amount of loose stools. She attempted to keep well hydrated over 
the weekend but began to feel increasingly lightheaded to the 
point that she felt she may pass out if she stood up too 
quickly. The pt has had BRBPR in the past ___ hemorrhoids but 
reports those past episodes were not nearly as significant and 
not accompanied by abdominal pain. She was recently started on a 
baby ASA 1 week ago and also reports that her lasix dose was 
increased 2 weeks ago. No recent antibiotics. Denies recent 
change in diet, including increased ingestion of leafy, green 
vegetables. She went to see her PCP today who noted her SBP to 
be in the ___ (usual baseline 140s) and referred her to the ED 
for further evaluation.  
.  
In the ED, pt AF, BP 97/49, HR 61. Rectal exam significant only 
for small amounts of dried blood in the vault, NGL was negative. 
Labs were significant for WBC 15.2, Hct 43.5, BUN 31, Cr 2.0, 
lactate 1.4, and INR 17.1. A CT abd/pelvis was significant for 
pancolitis. She was given 2 units FFP, 10 mg IV vitamin K, 
protonix 40 IV X 1, levaquin 750 mg IV X 1, flagyl 500 mg IV X 
1, and a total of 3 L IVFs. Repeat INR 2.6. She remained 
hemodynamically stable and did not have any episodes of BRBPR in 
the ED in spite of having several BMs. She was then admitted to 
the ___ for further management.  
.  
ROS otherwise only positive for stable DOE. She is unable to 
walk up a flight of stairs without becoming signicantly winded. 
ROS otherwise negative.  
.  

 

###RESPONSE: PAF {Paroxysmal atrial fibrillation}, BRBPR {Hematochezia}, LLQ {Structure of left lower quadrant of abdomen}, BRBPR {Hematochezia}, minimal {Symptom mild}, loose 
stools {Loose stool}, crampy {Stomach cramps}, LLQ {Structure of left lower quadrant of abdomen}, RLQ {Structure of right lower quadrant of abdomen}, n/v {Nausea and vomiting}, melena {Melena}, fevers {Fever}, chills {Chill}, loose stools {Loose stool}, lightheaded {Lightheadedness}, BRBPR {Hematochezia}, hemorrhoids {Hemorrhoids}, abdominal pain {Abdominal pain}, ASA {Administration of aspirin}, lasix {Diuretic therapy}, increased {Increasing dosage of medication}, antibiotics {Antibiotic therapy}, baseline {Baseline state}, evaluation {Evaluation procedure}, AF {Atrial fibrillation}, Rectal exam {Rectal examination}, WBC {White blood cell count}, BUN {Blood urea nitrogen measurement}, lactate {Lactic acid measurement}, INR {Calculation of international normalized ratio}, CT abd/pelvis {Computed tomography of abdomen and pelvis}, IVFs {Administration of intravenous fluids}, INR {Calculation of international normalized ratio}, hemodynamically stable {Hemodynamically stable}, BRBPR {Hematochezia}, ROS {Review of systems}, DOE {Dyspnea on exertion}, unable to 
walk up a flight of stairs without becoming signicantly {Deterioration in ability to walk up stairs}, winded {Winded}, ROS {Review of systems}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
PAF on coumadin  
HTN (baseline BP 140/70s)  
h/o CHF (EF 20% in ___, TTE in ___ with nl EF)  
mod MR and TR  
s/p PPM ___ syncope in ___, s/p dual chamber PPM replacement in 
___  
Melanoma s/p resection  
Asthma  
Depression  
Breast cancer ___ years ago, s/p R lumpectomy and XRT, s/p L 
lumpectomy in early ___ ___ yrs ago that was negative  
Pancreatic lesion, reportedly extensively worked up ___ yrs ago 
that was negative, stable lesion on serial CTs  
Post granulomatous infection of liver and spleen  
Seasonal allergies  
Gout  

 

###RESPONSE: PAF {Paroxysmal atrial fibrillation}, HTN {Hypertensive disorder, systemic arterial}, baseline {Baseline state}, BP {Blood pressure finding}, CHF {Congestive heart failure}, TTE {Transthoracic echocardiography}, MR {Mitral valve regurgitation}, PPM {Permanent cardiac pacemaker}, syncope {Syncope}, chamber {Cardiac chamber structure}, PPM replacement {Replacement of permanent transvenous electrodes}, Melanoma {Malignant melanoma of skin}, resection {Excision}, Asthma {Asthma}, Depression {Depressive disorder}, Breast cancer {Malignant neoplasm of breast}, R lumpectomy {Lumpectomy of right breast}, XRT {X-ray beam therapy}, L 
lumpectomy {Lumpectomy of left breast}, negative {No pathologic diagnosis}, Pancreatic {Pancreatic structure}, lesion {Lesion}, negative {No pathologic diagnosis}, stable {Patient's condition stable}, lesion {Lesion}, CTs {Computed tomography}, granulomatous infection {Infective granuloma}, liver {Liver structure}, spleen {Splenic structure}, Seasonal allergies {Seasonal allergy}, Gout {Inflammatory disorder due to increased blood urate level}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
father with colon CA 
 

###RESPONSE: colon CA {Neoplasm of colon}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VS: Temp: 98.9 BP: 145/45 HR: 64 RR: 22 O2sat 100% on 2L NC  
GEN: pleasant, comfortable, NAD  
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions  
NECK: supple, no LAD, jvd flat  
RESP: + bibasilar rales that clear with deeper breaths  
CV: RR, II/VI holosystolic murmur radiating to apex  
ABD: Soft, diffusely TTP especially over LLQ, + guarding, + 
rebound, normoactive BS, no HSM  
EXT: no c/c/e, warm, good pulses  
SKIN: no rashes/no jaundice  
NEURO: AAOx3  
RECTAL: guaiac positive, dried blood in vault  

 

###RESPONSE: VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2sat {Oxygen saturation measurement}, NC {Normal head}, GEN {General examination of patient}, comfortable {Comfortable appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, anicteric {White sclera}, dry MM {Mucous membrane dryness}, op {Oropharyngeal structure}, lesions {Lesion}, NECK {Physical examination procedure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, jvd flat {Normal jugular venous pressure}, RESP {Examination of respiratory system}, bibasilar {Structure of base of lung}, rales {Respiratory crackles}, clear {Normal breath sounds}, CV {Cardiovascular physical examination}, RR {Finding of rate of respiration}, murmur {Murmur}, apex {Structure of apex of heart}, ABD {Examination of abdomen}, Soft {Abdomen soft}, TTP {Tenderness}, LLQ {Structure of left lower quadrant of abdomen}, guarding {Abdominal guarding}, rebound {Rebound tenderness}, normoactive BS {Normal bowel sounds}, HSM {Hepatosplenomegaly}, EXT {Examination of limb}, no c/c/e {No abnormality detected}, warm {Warm skin}, good pulses {Normal pulse}, SKIN {Examination of skin}, rashes {Eruption of skin}, jaundice {Jaundice}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, CTA {Normal breath sounds}, guaiac {Guaiac test for occult blood in feces specimen}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 04:35PM   GLUCOSE-95 UREA N-31* CREAT-2.0* SODIUM-136 
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14
___ 04:35PM   CALCIUM-8.4 PHOSPHATE-3.8 MAGNESIUM-2.4
___ 04:35PM   ALT(SGPT)-21 AST(SGOT)-35 LD(LDH)-370* 
AMYLASE-71 TOT BILI-0.4 LIPASE-88*
.
___ 11:57PM   LACTATE-1.0
___ 07:00PM   LACTATE-1.4
.

 

###RESPONSE: GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, CALCIUM {Blood calcium measurement}, PHOSPHATE {Phosphate, total measurement}, MAGNESIUM {Blood magnesium measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Serum total lactate dehydrogenase measurement}, AMYLASE {Amylase measurement}, TOT BILI {Bilirubin, total measurement}, LIPASE {Triacylglycerol lipase measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
# Bright red blood per rectum- Evidence of pancolitis on initial 
CT, stool studies significant for c diff colitis.  Bleeding 
stopped once INR was corrected.  GI was consulted and suggest a 
colonoscopy in about 4 weeks, after colitis has had time to 
improve.  Follow up scheduled with GI, ___ to check INR and hct 
3 times per week.  
.
# C Difficile colitis: Diarrhea improved on Flagyl, planned 14 
day course.
.
# Supratherapeutic INR: Coumadin restarted prior to discharge 
without GI bleed.  She was discharged on approx ___ the dose of 
coumadin she was on prior to admission.  ___ to check INR 3 
times per week.  Nutritionist saw pt to eduated re: food 
restrictions while on coumadin.
.
# Falls/imbalance- Patient had a fall while in the ___ ICU 
overnight, and hit her head (likely on an open cabinet door 
adjacent to the toilet), requiring 3 stitches for a laceration. 
A CT head was obtained immediately after and showed no acute 
hemorrhage. There had been no significant events on telemetry 
and no indication of pacemaker malfunction. A CT spine was 
obtained and the read showed no fracture, and her C-spine was 
cleared. Approximately 12 hours later, a nurse observed the 
patient to be extremely unsteady on her feet, somewhat 
tremulous, and not as easily conversant as prior. A second CT 
head was obtained and was negative for edema or new subdural. 
The patient was observed overnight on fall precautions and there 
were no further events, and her mental status was at baseline. 
The attending radiologist later re-read the C-spine study and 
notified the team that there was possible cervical cord 
compression.
.
# Cervical Cord compression w/o radiculopathy: Possible C6-C7 
cord compression based on CT cervical spine. No associated 
neurologic deficits. Neurosurgery was consulted and recommended 
myelogram for further assessment. The family and patient chose 
not to have the CT myelogram done.  They stated that they would 
never opt for surgery, and if that was the only recommendation 
to come out of CT myelogram, they felt there was no use for the 
study.  Neurosurgery team confirmed this was in fact the case.  
Family is aware that if symptoms develop, falls increase from 
weakness, or any other concerns for symptomatic cord 
compression, and they should see PCP immediately to discuss CT 
myelogram and possible decompressive surgery.
.
#CKD, stage III: Pt in ARF at admission, resolved to baseline 
creatinine of 1.3
.
#Chronic systolic heart failure: Past EF 20% per family, however 
recent echo in ___ with EF > 60%.  Pt was continued on 
isosorbide, metoprolol, lasix.  Lisinopril was held as pt 
noticed that she had a chronic cough that had resolved during 
the hospitalization while off of Lisinopril.  Plan is to hold 
off on restarting, note any cough symptoms at home, and follow 
up with PCP ___ 2 weeks to discuss whether Lisinopril could in 
fact be cause of cough.  Also will need to discuss whether 
alternative ___ needed.  Digoxin was held at request of family.  
No recent CHF exacerbations, most recent EF >60%, and pacer 
interrogations show atrial fibrillation despite therapuetic 
digoxin levels.  They asked to stop this because they were 
concerned that it may be the cause of the patients chronic 
diarrhea.  They are aware that they will need to follow up with 
cardiologist Dr. ___ need to restart digoxin.
 

###RESPONSE: Bright red blood per rectum {Hematochezia}, CT {Computed tomography}, stool studies {Stool microscopy}, c diff colitis {Clostridium difficile colitis}, Bleeding {Bleeding}, INR {Calculation of international normalized ratio}, colonoscopy {Colonoscopy}, colitis {Colitis}, INR {Calculation of international normalized ratio}, C Difficile colitis {Clostridium difficile colitis}, Diarrhea {Diarrhea}, improved {Patient's condition improved}, INR {Calculation of international normalized ratio}, restarted {Restart of medication}, GI bleed {Gastrointestinal hemorrhage}, INR {Calculation of international normalized ratio}, food 
restrictions {Restricting food intake}, Falls {Falls}, fall {Falls}, head {Head structure}, laceration {Laceration}, CT head {Computed tomography of head}, acute 
hemorrhage {Acute hemorrhage}, telemetry {Electroencephalogram telemetry}, CT spine {Computed tomography of spine}, fracture {Fracture}, C-spine {Structure of cervical vertebral column}, unsteady on her feet {Unsteady when standing}, tremulous {Tremor}, CT 
head {Computed tomography of head}, negative {No pathologic diagnosis}, edema {Edema}, fall {Falls}, precautions {Safety precautions}, baseline {Baseline state}, C-spine {Structure of cervical vertebral column}, cervical cord 
compression {Compression of cervical spinal cord}, Cervical Cord compression {Compression of cervical spinal cord}, radiculopathy {Nerve root disorder}, C6-C7 {Structure of intervertebral foramen of sixth cervical vertebra}, cord compression {Compression of cervical spinal cord}, CT cervical spine {Computed tomography of cervical spine}, neurologic deficits {Neurological deficit}, myelogram {Myelogram}, CT myelogram {Computed tomography myelogram}, surgery {Surgical procedure}, CT myelogram {Computed tomography myelogram}, falls {Falls}, weakness {Asthenia}, cord 
compression {Compression of cervical spinal cord}, CT 
myelogram {Computed tomography myelogram}, surgery {Surgical procedure}, CKD, stage III {Chronic kidney disease stage 3}, ARF {Acute kidney injury}, baseline {Baseline state}, creatinine {Serum creatinine within reference range}, Chronic systolic heart failure {Chronic systolic heart failure}, echo {Echocardiography}, lasix {Diuretic therapy}, chronic cough {Chronic cough}, resolved {Problem resolved}, hold {Recommendation to stop drug treatment}, restarting {Restart of medication}, cough {Cough}, cough {Cough}, held {Recommendation to stop drug treatment}, CHF exacerbations {Exacerbation of congestive heart failure}, atrial fibrillation {Atrial fibrillation}, chronic 
diarrhea {Chronic diarrhea}, restart {Restart of medication}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
ASA 81 mg daily  
Coumadin 4 mg daily  
Zestril 10 mg daily  
Lopressor 25 mg bid  
Digoxin 125 mcg daily  
Isosorbide dinitrate 20 mg bid  
Lasix 40 mg qod, 20 mg qod  
Singulair 10 mg daily  
Prednisone 10 mg prn (for gout flares)  
Allegra 60 mg bid  
Advair 250/50 1 puff bid  
Allopurinol ___ mg daily  
Celexa 20 mg daily  
Omeprazole 20 mg daily  
Caltrate daily  
.  

 
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 
times a day) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
2. Allopurinol ___ mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).  

3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily).  
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once 
Daily at 16).
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID 
(2 times a day).  
6. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO 
twice a day.  
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO every other day.  
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day.  
9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
10. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 
times a day).  
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: 
One (1) Disk with Device Inhalation BID (2 times a day).  
12. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO once a day.  
14. DISCONTINUED MEDICATIONS
STOP TAKING DIGOXIN AND LISINOPRIL UNTIL YOU SEE ___. ___.
15. INR checks
Please check INR and Hct 3 times per week for the next 2 weeks.

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
c difficile colitis
acute renal failure (now resolved)

 
Discharge Condition:
stable

 

###RESPONSE: Home With Service {Home health aide service management}, c difficile colitis {Clostridium difficile colitis}, acute renal failure {Acute kidney injury}, resolved {Problem resolved}, stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Please call your PCP with shortness of breath, weight gain of 
more than 2 pounds in one day, dizziness, blood in stool, or 
other concerning symptoms.
 

###RESPONSE: shortness of breath {Dyspnea}, weight gain {Weight gain}, dizziness {Dizziness}, blood in stool {Hematochezia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Penicillins / Erythromycin Base / Codeine / Ultram / Oxycodone / 
Lipitor / Vicodin / Combivent / Latex / simvastatin
 
Attending: ___.
 
Chief Complaint:
SOB, cough
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: Penicillins {Allergy to penicillin}, Erythromycin {Allergy to erythromycin}, Codeine {Allergy to codeine}, Ultram {Allergy to tramadol}, Lipitor {Allergy to atorvastatin}, Latex {Allergy to Hevea brasiliensis latex protein}, simvastatin {Allergy to simvastatin}, SOB {Dyspnea}, cough {Cough}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ with history of COPD on home O2 at night, Pulmicort, 
albuterol, history of fibromyalgia, hypertension, presenting 
with two-day history of worsening shortness of breath and 
wheezing. Symptoms started on ___ evening. Slight cough. No 
fevers or chills. Does describe some body aches. No nausea or 
vomiting or diarrhea. Went to ___'s office today where an x-ray 
of the chest performed and showed no evidence of pneumonia. 
Given her wheezing, just into the emergency department for 
nebulizer treatments and steroid initiation.
  
In the ED, initial vital signs were 96.3 66 151/77 100% 2L NC. 
Labs were notable for K of 3.1. Otherwise, no leukocytosis. CXR 
was negative for pneumonia. Patient was given 60mg prednisone 
and 750mg levofloxacin in addition to albuterol nebs. She was 
also given 60 meq of potassium chloride. After several neb 
treatments she was still notably tachypneic and wheezing. She 
was admitted to the medicine service for management of COPD 
exacerbation.
 
On the floor, pt complains of 3 days of increased SOB and 
wheezing with feeling of body aches and sore throat. She has a 
___ year old grandson who she takes care of and thinks she may 
have caught a cold from him. Denies increased sputum production. 
Cough is increased but nonproductive. No fevers or chills.
 

###RESPONSE: COPD {Chronic obstructive lung disease}, home O2 {Home oxygen therapy}, fibromyalgia {Fibromyalgia}, hypertension {Hypertensive disorder, systemic arterial}, worsening {Patient's condition worsened}, shortness of breath {Dyspnea}, wheezing {Wheezing}, cough {Cough}, No 
fevers {Temperature normal}, chills {Chill}, body aches {Generalized aches and pains}, nausea {Nausea}, vomiting {Vomiting}, diarrhea {Diarrhea}, x-ray {Radiographic imaging procedure}, chest {Plain chest X-ray}, no evidence {No abnormality detected}, pneumonia {Pneumonia}, wheezing {Wheezing}, emergency {Emergency treatment management}, nebulizer treatments {Nebulizer therapy}, steroid {Steroid therapy}, vital signs {Vital signs finding}, 2L NC {Oxygen administration by nasal cannula}, Labs {Laboratory test}, K {Blood potassium measurement}, leukocytosis {Leukocytosis}, CXR {Plain chest X-ray}, negative {Standard chest X-ray normal}, pneumonia {Pneumonia}, prednisone {Steroid therapy}, levofloxacin {Antibiotic therapy}, nebs {Nebulizer therapy}, neb {Nebulizer therapy}, tachypneic {Tachypnea}, wheezing {Wheezing}, COPD 
exacerbation {Acute exacerbation of chronic obstructive airways disease}, increased {Patient's condition worsened}, SOB {Dyspnea}, wheezing {Wheezing}, body aches {Generalized aches and pains}, sore throat {Sore throat}, cold {Common cold}, increased {Patient's condition worsened}, sputum production {Sputum finding}, Cough {Cough}, increased {Patient's condition worsened}, nonproductive {Dry cough}, No fevers {Temperature normal}, chills {Chill}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
-COPD
- Depression  
- Chronic pain syndrome/fibromyalgia  
- Low back pain  
- s/p tibial plateau fracture  
- Hypertension  
- Hypokalemia  
- GERD  
- Tobacco abuse  
- Hyperlipidemia  
 

###RESPONSE: COPD {Chronic obstructive lung disease}, Depression {Depressive disorder}, Chronic pain syndrome {Chronic pain syndrome}, fibromyalgia {Fibromyalgia}, Low back pain {Low back pain}, tibial plateau fracture {Fracture of tibial plateau}, Hypertension {Hypertensive disorder, systemic arterial}, Hypokalemia {Hypokalemia}, GERD {Gastroesophageal reflux disease}, Tobacco abuse {Tobacco dependence syndrome}, Hyperlipidemia {Hyperlipidemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother died of emphysema, colon cancer. Father died in his ___ 
of heart problems (bypass, valve). Sister with pancreatitic 
cancer, sister with HIV and breast cancer, brother died at ___ of 
tuberculosis, brother with drug abuse and bad kidneys.  
-sister: breast cancer
-sister: pancreatic cancer
-mother: gastric cancer
-grand father: gastric cancer
-Father: lung cancer, CAD
 
 

###RESPONSE: died {Dead}, emphysema {Emphysema}, colon cancer {Malignant neoplasm of colon}, died {Dead}, heart problems {Heart disease}, bypass {Cardiac revascularization with bypass anastomosis}, valve {Cardiac valve structure}, pancreatitic 
cancer {Malignant tumor of pancreas}, HIV {Human immunodeficiency virus infection}, breast cancer {Malignant neoplasm of breast}, died {Dead}, tuberculosis {Tuberculosis}, drug abuse {Drug abuse}, kidneys {Kidney disease}, breast cancer {Malignant neoplasm of breast}, pancreatic cancer {Malignant tumor of pancreas}, gastric cancer {Malignant tumor of stomach}, gastric cancer {Malignant tumor of stomach}, lung cancer {Malignant tumor of lung}, CAD {Coronary arteriosclerosis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Admission exam:
Vitals- 97.9, 147/74, 81, 18, 96% on 2L
General- Pleasant middle aged ___ woman breathing 
comfortably in full sentences. Alert, oriented, no acute 
distress.  
HEENT- Sclera anicteric, MMM, PERRL, EOMI, oropharynx clear  
Neck- supple, JVP not elevated 
Lungs- diffuse posterior wheezing with poor air movement at the 
apices but good air movement at the bases. No crackles or 
rhonchi.
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, 
gallops  
Abdomen- soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding, no organomegaly  
GU- no foley  
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema
Neuro- CNs2-12 intact, motor function grossly normal

Discharge exam:
VS: 98.8, 120/77, 72, 18, 100% on 2L
General- Pleasant middle aged ___ woman breathing 
comfortably in full sentences. Alert, oriented, no acute 
distress.  
HEENT- Sclera anicteric, MMM, PERRL, EOMI, oropharynx clear  
Neck- supple, JVP not elevated 
Lungs- CTAB. No wheezes, crackles, or rhonchi.
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, 
gallops  
Abdomen- soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding, no organomegaly  
GU- no foley  
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema
Neuro- CNs2-12 intact, motor function grossly normal  
 

###RESPONSE: Vitals {Vital signs finding}, 2L {Oxygen therapy}, General {General examination of patient}, middle aged {Middle-age}, breathing 
comfortably {Breathing easily}, full sentences {Able to complete sentence in one breath}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, Lungs {Examination of respiratory system}, wheezing {Wheezing}, apices {Structure of apex of lung}, good air movement {Breath normal}, bases {Structure of base of lung}, crackles {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, foley {Urinary catheter in situ}, Ext {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, CNs2-12 {Cranial nerve structure}, intact {No abnormality detected}, motor function grossly normal {Normal motor response to command}, VS {Vital signs finding}, 2L {Oxygen therapy}, General {General examination of patient}, middle aged {Middle-age}, breathing 
comfortably {Breathing easily}, full sentences {Able to complete sentence in one breath}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, oropharynx clear {Pharynx normal}, Neck- supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, crackles {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 + S2 {Heart sounds normal}, murmurs {Heart murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen- soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound tenderness {Rebound tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, GU {Physical examination procedure}, foley {Urinary catheter in situ}, Ext {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, CNs2-12 {Cranial nerve structure}, intact {No abnormality detected}, motor function grossly normal {Normal motor response to command}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Admission labs:

___ 02:00PM BLOOD WBC-6.0 RBC-3.76* Hgb-11.7* Hct-35.5* 
MCV-94 MCH-31.1 MCHC-33.0 RDW-14.7 Plt ___
___ 02:00PM BLOOD Neuts-76.4* Lymphs-17.0* Monos-2.9 
Eos-3.3 Baso-0.3
___ 02:00PM BLOOD Glucose-147* UreaN-15 Creat-0.7 Na-141 
K-3.1* Cl-102 HCO3-30 AnGap-12
___ 07:00AM BLOOD Calcium-10.2 Phos-3.4 Mg-2.0

Discharge labs:

___ 07:10AM BLOOD WBC-8.9 RBC-3.94* Hgb-11.9* Hct-36.7 
MCV-93 MCH-30.2 MCHC-32.4 RDW-14.4 Plt ___
___ 07:10AM BLOOD Glucose-89 UreaN-18 Creat-0.8 Na-144 
K-3.8 Cl-104 HCO3-28 AnGap-16
___ 07:10AM BLOOD Calcium-9.9 Phos-3.1 Mg-2.2

Pertinent micro:

Blood cultures pending x2

Pertinent imaging:

CXR: In comparison with study of ___, there is little change and 
no
evidence of acute cardiopulmonary disease.  There is a streak of 
fibrosis or
atelectasis again in the left mid zone.  Otherwise, no 
pneumonia, vascular
congestion, or pleural effusion.
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Blood cultures {Blood culture}, CXR {Plain chest X-ray}, study {Evaluation procedure}, no
evidence {No abnormality detected}, disease {Disease}, fibrosis {Fibrosis}, atelectasis {Atelectasis}, left {Left lung structure}, mid zone {Structure of middle zone of lung}, pneumonia {Pneumonia}, vascular {Blood vessel structure}, congestion {Congestion}, pleural effusion {Pleural effusion}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ with history of COPD, HTN, depression, fibromyalgia with 
recent hospitalization for COPD flare who presents with acute 
SOB and wheezing on exam consistent with recurrent COPD flare.

# COPD with acute exacerbation: She appeared euvolemic with no 
suspected CHF, normal TTE in ___. Positive URI symptoms 
likely triggered flare. Of note, pt was supposed to follow up 
with pulmonology for PFTs but had to reschedule. She was started 
on a prednisone taper and a 3 day course of levaquin. Her 
symptoms improved dramatically. She was discharged on flovent 
instead of budesonide. Her home COPD medications were otherwise 
unchanged. 

# Hypokalemia: Etiology likely secondary to diuretic and/or 
frequent administration of albuterol. She normally takes 20meq 
KCl daily at home. HCTZ was held, and K improved. Blood 
pressures remained well controlled. Recommend uptitrating 
lisinopril as needed. 

Chronic issues:
# Anemia: Hct at baseline. History of normal iron studies. 
# HTN: held HCTZ and continued lisinopril as above.
# Fibromyalgia: continued home gabapentin and ibuprofen
# Depression: continued home zoloft. SW consult.
# PACT patient: PACT aware of admission, following.

Transitional issues:
# HCTZ discontinued; can uptitrate lisinopril as needed.
# Budesonide d/c'd and flovent started
 

###RESPONSE: COPD {Chronic obstructive lung disease}, HTN {Hypertensive disorder, systemic arterial}, depression {Depressive disorder}, fibromyalgia {Fibromyalgia}, COPD flare {Acute exacerbation of chronic obstructive airways disease}, SOB {Dyspnea}, wheezing {Wheezing}, exam {Physical examination procedure}, recurrent {Recurrent disease}, COPD flare {Acute exacerbation of chronic obstructive airways disease}, COPD {Chronic obstructive lung disease}, acute exacerbation {Acute exacerbation of chronic obstructive airways disease}, euvolemic {Normal blood volume}, CHF {Congestive heart failure}, normal {No abnormality detected}, TTE {Transthoracic echocardiography}, URI {Upper respiratory infection}, flare {Acute infective exacerbation of chronic obstructive airways disease}, PFTs {Measurement of respiratory function}, prednisone {Steroid therapy}, taper {Medication decreased}, improved {Patient's condition improved}, COPD {Chronic obstructive lung disease}, medications {Administration of drug or medicament}, Hypokalemia {Hypokalemia}, secondary {Medication side effects present}, diuretic {Diuretic therapy}, held {Recommendation to stop drug treatment}, K {Blood potassium measurement}, improved {Patient's condition improved}, Blood 
pressures {Blood pressure monitoring}, well controlled {Disease condition determination, well controlled}, Anemia {Anemia}, Hct {Hematocrit determination}, baseline {Baseline state}, normal iron studies {Serum iron within reference range}, HTN {Hypertensive disorder, systemic arterial}, held {Recommendation to stop drug treatment}, lisinopril {Angiotensin converting enzyme inhibitor therapy}, Fibromyalgia {Fibromyalgia}, Depression {Depressive disorder}, discontinued {Recommendation to stop drug treatment}, started {New medication added}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 
2. Gabapentin 800 mg PO TID 
3. Gabapentin 400 mg PO HS 
4. Hydrochlorothiazide 25 mg PO DAILY 
hold for sbp <100 
5. Ibuprofen 800 mg PO Q8H:PRN pain 
6. Lisinopril 5 mg PO DAILY 
7. Pravastatin 80 mg PO DAILY 
8. Sertraline 200 mg PO DAILY 
9. Montelukast Sodium 10 mg PO DAILY 
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing 
11. Budesonide Nasal Inhaler *NF* 90 mcg Other BID 
12. Tiotropium Bromide 1 CAP IH DAILY 

 
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 
2. Gabapentin 800 mg PO TID 
3. Gabapentin 400 mg PO HS 
4. Ibuprofen 800 mg PO Q8H:PRN pain 
5. Lisinopril 5 mg PO DAILY 
6. Montelukast Sodium 10 mg PO DAILY 
7. Pravastatin 80 mg PO DAILY 
8. Sertraline 200 mg PO DAILY 
9. Tiotropium Bromide 1 CAP IH DAILY 
10. Fluticasone Propionate 110mcg 2 PUFF IH BID 
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing 
12. PredniSONE 60 mg PO  once a day Duration: 1  Days  
13. PredniSONE 40 mg PO  once a day Duration: 3 Days  Start: 
After 60 mg tapered dose. 
14. PredniSONE 30 mg PO once a day Duration: 3 Days  Start: 
After 40 mg tapered dose. 
15. PredniSONE 20 mg PO  once a day Duration: 3 Days  Start: 
After 30 mg tapered dose. 
16. PredniSONE 10 mg PO once a day Duration: 3 Days  Start: 
After 20 mg tapered dose. 
17. Fluconazole 150 mg PO ONCE Duration: 1 Doses  
RX *fluconazole 150 mg 1 tablet(s) by mouth once Disp #*2 Tablet 
Refills:*0

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Chronic obstructive pulmonary disease
Upper respiratory tract infection

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Chronic obstructive pulmonary disease {Chronic obstructive lung disease}, Upper respiratory tract infection {Upper respiratory infection}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear ___,

___ were admitted to ___ for shortness of breath likely 
related to an exacerbation of your COPD. ___ were started on 
antibiotics and a prednisone taper with nebulizers to help ___ 
breathe. Your symptoms improved notably, and we now feel ___ are 
safe to leave the hospital.

We made the following changes to your medications:
START prednisone 10mg 3 tabs x3 days, 3x 3 days, 2 x 3 days , 1 
x 3 days (this is waiting at your pharmacy)
START fluconazole 125mg once if ___ begin having symptoms of 
yeast infection 
START flovent (this is waiting at your pharmacy)
STOP HCTZ
STOP budesonide
 

###RESPONSE: shortness of breath {Dyspnea}, exacerbation of your COPD {Acute exacerbation of chronic obstructive airways disease}, started {New medication added}, antibiotics {Antibiotic therapy}, prednisone {Steroid therapy}, nebulizers {Nebulizer therapy}, improved {Patient's condition improved}, prednisone {Steroid therapy}, yeast {Yeast detected}, infection {Infectious disease}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Hypotension, Fatigue/anemia  
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: Hypotension {Low blood pressure}, Fatigue {Fatigue}, anemia {Anemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 an ___ year old ___ female who presents with one 
month of progressive fatigue/weakness.  She has had significant 
fatigue for the past 6 months, but this has become worse over 
the last month, and she has been feeling dizzy everyday.  Her 
daughter also notes that she looks paler than usual.  The 
patient has mild DOE.  She has a known history of chronic anemia 
with baseline HCT of ___ (in ___ of unclear etiology.  
Per PCP records, she was evaluated at ___ several years ago 
but no formal records of the results of that eval are known, 
although the patient's daughter reports that ""no problem was 
found"".  She presented to her PCP today for evaluation, where 
immediate labs were sent and noted to have a Hct of 23.1 and 
plts of 59 from a baseline of 134.  She was hypotensive in the 
office, documented at 78/60, heart rate 93.  Her PCP called her 
to come into the ___ ED due to the hypotension, as well as to 
work up her anemia.  The patient denies fevers, chills, HA, 
cough, chest pain, abdominal pain, N/V/D, vaginal bleeding, 
dysuria, increased frequency, or rash.  She does note some 
constipation, which has been a chronic issue, and her last bowel 
movement was ___ years ago.  She has not had any episodes of 
hematemesis, bloody or tarry stools.
.  
In the ED, initial VS were: T 100.4 HR 95 BP 119/63 RR 16 O2-sat 
100% RA. The patient was given nothing in the ED.  Vitals on 
transfer were T 99 HR 85 BP 106/60 RR19 O2-sat 98% RA.  
.  
On the floor, feels well but continues to feel fatigued.  
.  
Review of systems:  
(+) Per HPI  
(-) Denies fever, chills, night sweats. Denies headache, sinus 
tenderness, rhinorrhea or congestion. Denied cough, shortness of 
breath. Denied chest pain or tightness, palpitations. Denied 
nausea, vomiting, diarrhea, or abdominal pain. No recent change 
in bowel or bladder habits. No dysuria. Denied arthralgias or 
myalgias.
 

###RESPONSE: progressive {Patient's condition worsened}, fatigue {Fatigue}, weakness {Asthenia}, fatigue {Fatigue}, dizzy {Dizziness}, mild {Symptom mild}, DOE {Dyspnea on exertion}, chronic anemia {Chronic anemia}, baseline {Baseline state}, HCT {Hematocrit determination}, PCP {Primary care management}, evaluated {Evaluation procedure}, eval {Evaluation procedure}, problem {Problem}, PCP {Primary care management}, evaluation {Evaluation procedure}, labs {Laboratory test}, baseline {Baseline state}, hypotensive {Low blood pressure}, heart rate {Finding of heart rate}, PCP {Primary care management}, hypotension {Low blood pressure}, work up {Evaluation procedure}, anemia {Anemia}, fevers {Fever}, chills {Chill}, cough {Cough}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, N/V/D {Nausea, vomiting and diarrhea}, vaginal bleeding {Bleeding from vagina}, dysuria {Dysuria}, increased frequency {Increased frequency of urination}, rash {Eruption of skin}, constipation {Constipation}, chronic issue {Chronic disease}, hematemesis {Hematemesis}, bloody {Hematochezia}, tarry stools {Melena}, O2-sat {Oxygen saturation measurement}, Vitals {Vital signs finding}, O2-sat {Oxygen saturation measurement}, feels well {Well in self}, fatigued {Fatigue}, Review of systems {Review of systems}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, headache {Headache}, sinus 
tenderness {Tenderness over frontal sinus}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, cough {Cough}, shortness of 
breath {Dyspnea}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, abdominal pain {Abdominal pain}, change 
in bowel {Altered bowel function}, bladder habits {Alteration in patterns of urinary elimination}, dysuria {Dysuria}, arthralgias {Joint pain}, myalgias {Muscle pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
# chronic anemia of unclear etiology, previously eval at ___, 
family does not recall any abnormalities  
# chronic constipation  
# stress urinary incontinence  
# osteoporosis  
# osteoarthritis  
# heart murmur  
# mild dementia  
# hematuria  
# macular degeneration  
# depression not on medications  
# hyperlipidemia  
# varicose veins in legs

 

###RESPONSE: chronic anemia {Chronic anemia}, eval {Evaluation procedure}, chronic constipation {Chronic constipation}, stress urinary incontinence {Genuine stress incontinence}, osteoporosis {Osteoporosis}, osteoarthritis {Osteoarthritis}, heart murmur {Heart murmur}, dementia {Dementia}, hematuria {Blood in urine}, macular degeneration {Degenerative disorder of macula}, depression {Depressive disorder}, medications {Administration of drug or medicament}, hyperlipidemia {Hyperlipidemia}, varicose veins {Venous varices}, legs {Lower limb structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
Patient's father died of stomach cancer prior to World War II.
 

###RESPONSE: died {Dead}, stomach cancer {Malignant tumor of stomach}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Vitals: T 98.2, BP 138/82, HR 78, RR 16, O2 97% RA  
General: Alert, oriented, no acute distress, pale  
HEENT: Sclera anicteric, MMM, oropharynx clear, pale conjunctiva 
 
Neck: supple, JVP not elevated, no LAD  
Lungs: Bibasilar crackles, L>R
CV: Regular rate and rhythm, normal S1 + S2, ___ SEM loudest at 
base
Abdomen: soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding, no organomegaly, guaiac 
negative in ED  
Pelvic: Performed in ED, per report, no uterus felt, no vaginal 
bleeding seen  
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
Neuro: CN II-XII intact
 

###RESPONSE: Vitals {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}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, pale {Pale complexion}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, pale conjunctiva {Pale conjunctiva}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, Bibasilar {Structure of base of lung}, 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<}, SEM {Ejection murmur}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, guaiac {Guaiac test for occult blood in feces specimen}, negative {No pathologic diagnosis}, Pelvic {Manual pelvic examination}, uterus {Uterine structure}, vaginal 
bleeding {Bleeding from vagina}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, CN II-XII 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:
___ 09:50PM   GLUCOSE-114* UREA N-26* CREAT-1.3* SODIUM-136 
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13
___ 11:35AM   GLUCOSE-100
___ 11:35AM   UREA N-20 CREAT-1.2* SODIUM-139 POTASSIUM-4.0 
CHLORIDE-100 TOTAL CO2-28 ANION GAP-15
___ 08:08AM BLOOD Glucose-93 UreaN-18 Creat-1.0 Na-136 
K-4.0 Cl-102 HCO3-27 AnGap-11
___ 08:08AM BLOOD Albumin-3.5 Calcium-8.4 Phos-3.5 Mg-2.0
.
Hematology:
.
___ 09:50PM   WBC-3.1* RBC-2.12* HGB-7.2* HCT-20.8* MCV-98 
MCH-34.0* MCHC-34.7 RDW-16.7*
___ 09:50PM   NEUTS-41* BANDS-1 LYMPHS-44* MONOS-12* EOS-0 
BASOS-0 ATYPS-2* ___ MYELOS-0
___ 09:50PM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ 
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-2+
___ 09:50PM   PLT SMR-VERY LOW PLT COUNT-52*
___ 09:50PM   ___ PTT-28.1 ___
___ 09:50PM   RET AUT-0.9*
___ 10:49PM   D-DIMER-321
___ 10:20PM   ___
___ 11:35AM   WBC-4.0 RBC-2.25*# HGB-8.0* HCT-23.1* 
MCV-102*# MCH-35.6*# MCHC-34.8 RDW-16.0*
___ 11:35AM   PLT SMR-VERY LOW PLT COUNT-59*#
___ 08:08AM BLOOD WBC-3.1* RBC-2.62* Hgb-8.7* Hct-24.3* 
MCV-93 MCH-33.1* MCHC-35.7* RDW-17.4* Plt Ct-49*
___ 08:08AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-1+ 
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL 
Ovalocy-OCCASIONAL Tear ___
___ 08:08AM BLOOD Plt Ct-49*
___ 08:08AM BLOOD ___ PTT-28.8 ___
.
LFTs -
.
___ 09:50PM   LD(LDH)-158 CK(CPK)-34 TOT BILI-0.6 DIR 
BILI-0.2 INDIR BIL-0.4
___ 11:35AM   ALT(SGPT)-8 AST(SGOT)-15 ALK PHOS-69
___ 11:35AM   TOT PROT-7.1 CALCIUM-8.9 CHOLEST-185
___ 11:35AM   TRIGLYCER-69 HDL CHOL-76 CHOL/HDL-2.4 
LDL(CALC)-95
___ 08:08AM BLOOD ALT-7 AST-13 LD(LDH)-155 AlkPhos-65 
TotBili-2.8*
.
___ 09:50PM   CK-MB-NotDone cTropnT-<0.01
___ 09:50PM   TOT PROT-6.6 IRON-51
___ 09:50PM   calTIBC-226* VIT ___ FOLATE-11.6 
___ FERRITIN-447* TRF-174*
___ 11:35AM   estGFR-Using this
___ 11:35AM   TSH-1.3
.
ON DISCHARGE: ___ 09:10a   
.
139  102  18     
------------< 97  gap 13
3.9  28  1.0  
.
Ca: 8.8 Mg: 2.1 P: 3.2
.
    10.0           
2.8 >--< 67  mcv 96
    29.0
.
Urinalysis-
.
___ 05:40AM URINE Color-Straw Appear-Clear Sp ___
___ 05:40AM URINE Blood-SM Nitrite-NEG Protein-NEG 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 05:40AM URINE ___ Bacteri-RARE Yeast-NONE 
Epi-<1
___ 05:40AM URINE Eos-NEGATIVE  
___ 05:40AM URINE Hours-RANDOM UreaN-563 Creat-69 Na-72
.
MICROBIOLOGY:
___: Blood Culture, Routine (Pending): x 2 
___: URINE CULTURE - final - MIXED BACTERIAL FLORA ( >= 3 
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL 
CONTAMINATION. 
.
IMAGING:
.
CXR (___): 
Lung volumes are low resulting in vascular crowding. Minimally 
increased interstitial markings, predominantly at the lung bases 
may indicate an underlying interstitial abnormality. There is no 
consolidation or pleural effusion. There is no pneumothorax. The 
heart size is top normal. The aorta is tortuous and calcified. 
There is no hilar or mediastinal enlargement. Pulmonary 
vascularity is normal. Degenerative changes and ossification of 
the anterior longitudinal ligament are noted in the spine. 
IMPRESSIONS: No consolidation. No hilar enlargement. 
.
EKG (___): Normal sinus rhythm, left axis deviation, Right 
bundle branch block with ? left anterior fascicular block. No 
obvious ischemic changes.
 

###RESPONSE: GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, 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}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PLT {Platelet count}, LOW {Platelet count below reference range}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}, D-DIMER {D-dimer assay}, 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}, LOW {Platelet count below reference range}, PLT COUNT {Platelet 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}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NORMAL {Normal size}, NORMAL {Normal size}, PTT {Partial thromboplastin time, activated}, LFTs {Hepatic function panel}, LDH {Lactate dehydrogenase measurement}, CK(CPK {Creatine kinase measurement}, TOT BILI {Bilirubin, total measurement}, BILI {Bilirubin measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, ALK PHOS {Alkaline phosphatase measurement}, CALCIUM {Blood calcium measurement}, CHOLEST {Cholesterol measurement}, HDL {High density lipoprotein measurement}, HDL {High density lipoprotein measurement}, LDL(CALC) {Calculated low density lipoprotein cholesterol level}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Lactate dehydrogenase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, FOLATE {Whole blood folate within reference range}, TSH {Thyroid stimulating hormone measurement}, Urinalysis {Urinalysis}, URINE Color-Straw {Normal urine color}, Appear-Clear {Urine looks clear}, URINE Blood {Urine blood test}, Nitrite-NEG {Nitrite not detected in urine}, Protein-NEG {Urine protein not detected}, Glucose-NEG {Urine glucose not detected}, Ketone-NEG {Urine ketones not detected}, NEG {No abnormality detected}, Urobiln-NEG {Urine urobilinogen not detected}, pH {pH measurement}, Leuks-NEG {Urine leukocytes not detected}, URINE {Evaluation of urine specimen}, Bacteri {Bacteriuria}, Yeast {Urine microscopy for yeasts}, URINE {Evaluation of urine specimen}, NEGATIVE {No pathologic diagnosis}, URINE {Evaluation of urine specimen}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Blood Culture {Blood culture}, URINE CULTURE {Urine culture}, BACTERIAL {Bacterial infectious disease}, SKIN AND/OR GENITAL 
CONTAMINATION. {Sample contaminated}, CXR {Plain chest X-ray}, Lung volumes {Finding of respiratory volume}, vascular crowding {Pulmonary hypertension}, lung bases {Structure of base of lung}, abnormality {Imaging result abnormal}, consolidation {Consolidation}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, heart {Heart structure}, size {Normal size}, normal {Normal size}, aorta {Aortic structure}, tortuous {Tortuosity}, calcified {Pathologic calcification, calcified structure}, hilar {Structure of hilum of lung}, mediastinal {Mediastinal structure}, enlargement {Enlargement}, Pulmonary {Lung structure}, normal {Normal size}, Degenerative changes {Cervical spondylosis}, anterior longitudinal ligament {Anterior longitudinal ligament structure}, spine {Structure of vertebral column}, consolidation {Consolidation}, hilar {Hilar lymphadenopathy}, enlargement {Enlargement}, EKG {Electrocardiographic procedure}, Normal sinus rhythm {Electrocardiogram: normal sinus rhythm}, left axis deviation {Left axis deviation}, Right 
bundle branch block with ? left anterior fascicular block {Right bundle branch block AND left anterior fascicular block}, ischemic changes {Ischemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
This is an ___ year old female with chronic anemia who presents 
with 1 month of fatigue and found to have worsening anemia, 
thrombocytopenia, and ARF.  
.  
# Hypotension:  Pt presented to PCP ___ ___ with BP 78/60, but 
BP has been stable and within normal limits since admission to 
___.  Hypotension was potentially hypovolemic in nature, 
although patient did not require fluids for resolution of low 
BP.  The patient's orthostatics were negative during this 
admission; an outpatient workup for orthostatic hypotension may 
be worth considering, although the patient does not have a 
history of falls and is otherwise asymptomatic.
.
# Anemia - Multiple possible causes, including aplastic anemia, 
myelodysplastic syndrome, anemia of chronic disease, plasma cell 
dyscrasias, blood loss, or hemolytic process.  Symptoms suggest 
a relatively chronic process but HCT dropped from 23->21 in 12 
hours on ___, suggesting a possibly accelerating process. 
Possible slow GI bleed but less likely given guaiac negative and 
constipation.  Hemolysis labs reportedly negative overnight, but 
re-sent because could not find in system.  DIC very unlikely 
given elevated fibrinogen, normal D-dimer, and normal coags.  
Concern for TTP-HUS with anemia, thrombocytopenia, low grade 
fever and ARF but no schistocytes seen on smear and again, no 
evidence of hemolysis (elevated TBili on ___ likely 
post-transfusional).  All cell lines down so possible marrow 
process affecting production, especially with slight lymphocytic 
predominance and atypicals on smear.  Previous Fe studies and 
B12/folate normal.  Previous renal function normal and anemia is 
normocytic, so anemia of chronic disease less likely.  SPEP 
normal in ___, resent to r/o plasma cell dyscrasia.  No 
chemotherapy, radiation exposure, or medications suggestive of 
aplastic anemia.  MDS is ___ strong possibility given her age, 
pancytopenia, low reticulocyte count.
.
Two peripheral IVs (18-gauge) were placed and 2 units PRBCs 
given on ___, with an improvement in Hct to from 
20.8->24.3->29.0 on ___.  Reticulocyte count was found to be 
low at 0.9.  Iron studies did not suggest iron deficiency anemia 
or B12/folate deficiency, although we will continue the 
patient's outpatient iron supplementation regimen.  A peripheral 
smear and SPEP/UPEP were sent and were pending at discharge.  
Hematology-oncology saw the patient, agrees with our 
differential of myelodysplastic syndrome vs. myelofibrosis and 
recommended follow up in clinic for possible consideration of BM 
biopsy which could provide definitive diagnosis, though the 
extent that this would change management in this ___ year old 
woman is unclear.
.  
# Thrombocytopenia: Similar concerns as above.  DIC and TTP were 
thought to be unlikely in the absence of evidence for hemolysis. 
 There is a possible production problem as noted above. Could be 
ITP but that is a diagnosis of exclusion, and less likely given 
the patient's pancytopenia.   
.  
# ARF: Pt had a mild elevation in creatinine to 1.3 (baseline 
1.0) on admission, which resolved with transfusion and 
hydration.  Likely related to anemia and relative hypovolemia. 
BUN/Cr<20, suggestive of mild prerenal process.  Receiving 2 
units of blood which should be a good volume challenge.  
Creatinine improved with transfusion to 1.0 on ___.
.  
# Fever: Low grade temp to 100.4 in triage. No clear localizing 
source. Will hold on abx unless decompensates.  CXR was negative 
for consolidation, exam does show some dry crackles most likely 
due to atalectasis.  Urinalysis was negative in detail, and 
urine and blood cultures remain pending.
.  
# Osteoporosis: Reports not taking her fosamax due to concerns 
about not being able to sit up long enough.  Will hold for now.  

.
 

###RESPONSE: chronic anemia {Chronic anemia}, fatigue {Fatigue}, worsening {Patient's condition worsened}, anemia {Anemia}, thrombocytopenia {Thrombocytopenic disorder}, ARF {Acute kidney injury}, Hypotension {Low blood pressure}, PCP {Primary care management}, stable {Stable blood pressure}, normal {Normal vital signs}, Hypotension {Low blood pressure}, hypovolemic {Hypovolemia}, fluids {Administration of fluid therapy}, resolution {Problem resolved}, low 
BP {Low blood pressure}, orthostatics {Orthostatic hypotension}, negative {No pathologic diagnosis}, workup {Evaluation procedure}, orthostatic hypotension {Orthostatic hypotension}, falls {Falls}, asymptomatic {Asymptomatic}, Anemia {Anemia}, aplastic anemia {Aplastic anemia}, myelodysplastic syndrome {Myelodysplastic syndrome}, anemia of chronic disease {Anemia of chronic disorder}, plasma cell 
dyscrasias {Plasma cell neoplasm}, blood loss {Hemorrhage}, chronic {Chronic disease}, HCT {Hematocrit determination}, GI bleed {Gastrointestinal hemorrhage}, guaiac {Guaiac test for occult blood in feces specimen}, negative {No pathologic diagnosis}, constipation {Constipation}, Hemolysis {Hemolysis}, labs {Laboratory test}, negative {No pathologic diagnosis}, DIC {Blood coagulation panel, disseminated intravascular coagulation}, elevated fibrinogen {Fibrinogen in blood above reference range}, normal coags {Coagulation/bleeding tests normal}, TTP {Thrombotic thrombocytopenic purpura}, HUS {Hemolytic uremic syndrome}, anemia {Anemia}, thrombocytopenia {Thrombocytopenic disorder}, low grade 
fever {Low grade pyrexia}, ARF {Acute kidney injury}, no 
evidence {No abnormality detected}, hemolysis {Hemolysis}, elevated TBili {Total bilirubin above reference range}, cell {Cell structure}, Fe studies {Iron kinetics study}, B12/folate {B12/folate level}, renal function normal {Normal renal function}, anemia is 
normocytic {Normocytic anemia}, anemia of chronic disease {Anemia of chronic disorder}, SPEP 
normal {Serum proteins within reference range}, plasma cell dyscrasia {Plasma cell neoplasm}, chemotherapy {Chemotherapy}, radiation {Radiation oncology AND/OR radiotherapy}, aplastic anemia {Aplastic anemia}, MDS {Myelodysplastic syndrome}, pancytopenia {Pancytopenia}, reticulocyte count {Reticulocyte count}, placed {Implantation procedure}, PRBCs 
given {Transfusion of packed red blood cells}, improvement {Patient's condition improved}, Reticulocyte count {Reticulocyte count outside reference range}, studies {Evaluation procedure}, iron deficiency anemia {Iron deficiency anemia}, B12/folate deficiency {Combined B12 and folate deficiency anemia}, iron supplementation regimen {Iron supplement therapy}, SPEP {Serum protein electrophoresis}, UPEP {Urine protein electrophoresis}, myelodysplastic syndrome {Myelodysplastic syndrome}, myelofibrosis {Myelofibrosis}, BM 
biopsy {Bone marrow sampling}, Thrombocytopenia {Thrombocytopenic disorder}, DIC {Disseminated intravascular coagulation}, TTP {Thrombotic thrombocytopenic purpura}, hemolysis {Hemolysis}, problem {Problem}, ITP {Chronic idiopathic thrombocytopenic purpura}, pancytopenia {Pancytopenia}, ARF {Acute kidney injury}, elevation in creatinine {Serum creatinine above reference range}, baseline {Baseline state}, resolved {Problem resolved}, transfusion {Transfusion}, hydration {Administration of fluid therapy}, anemia {Anemia}, relative hypovolemia {Relative hypovolemia}, BUN/Cr {Blood urea nitrogen/creatinine ratio}, mild {Symptom mild}, Creatinine {Creatinine measurement}, improved {Patient's condition improved}, transfusion {Transfusion}, Fever {Fever}, temp {Body temperature finding}, triage {Triage}, hold {Recommendation to stop drug treatment}, CXR {Plain chest X-ray}, negative {Standard chest X-ray normal}, consolidation {Consolidation}, exam {Evaluation procedure}, crackles {Respiratory crackles}, atalectasis {Atelectasis}, Urinalysis {Urinalysis}, negative {No pathologic diagnosis}, urine {Urine culture}, blood cultures {Blood culture}, Osteoporosis {Osteoporosis}, able to sit up {Able to sit up}, hold {Recommendation to stop drug treatment}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Ferrous Sulfate 352mg PO daily  
Fosamax 70mg PO qwk  
Trospium 20mg PO BID  
Calc/Vit. D 1000U PO daily
 
Discharge Medications:
1. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.  
2. Trospium 20 mg Tablet Sig: One (1) Tablet PO twice a day.  
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) 
Tablet PO once a day.  
4. Cholecalciferol (Vitamin D3) 1,000 unit Capsule Sig: One (1) 
Capsule PO once a day. Capsule(s) 
5. Outpatient Lab Work
Please check a CBC on ___ and have the results faxed to Dr. 
___ (FAX ___

 

###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:
Anemia
Pancytopenia
Acute renal insufficiency
Fever
Hypotension

Secondary:
Osteoporosis
Stress urinary incontinence

 
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent

 

###RESPONSE: Anemia {Anemia}, Pancytopenia {Pancytopenia}, Acute renal insufficiency {Acute renal insufficiency}, Fever {Fever}, Hypotension {Low blood pressure}, Osteoporosis {Osteoporosis}, Stress urinary incontinence {Genuine stress incontinence}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted for weakness and fatigue and were found to 
have a low red blood cell count (anemia).  You were given a 
blood transfusion and your symptoms improved.  You were found to 
have low platelets (thrombocytopenia) and white blood cell count 
(leukopenia).  You were seen by the hematology-oncology team and 
they felt the low cell lines may be due to a process of abnormal 
blood cell proliferation or other cause of hindrance in the bone 
marrow (myelodysplastic syndrome or myelofibrosis).  

No changes were made to your medication regimen.  Please take 
all of your home medications as prescribed.
 

###RESPONSE: weakness {Asthenia}, fatigue {Fatigue}, red blood cell count {Red blood cell count}, anemia {Anemia}, blood transfusion {Transfusion of blood product}, improved {Patient's condition improved}, low platelets {Thrombocytopenic disorder}, thrombocytopenia {Thrombocytopenic disorder}, white blood cell count {White blood cell count}, leukopenia {Leukopenia}, abnormal 
blood cell proliferation {Proliferation of hematopoietic cell type}, bone 
marrow {Bone marrow structure}, myelodysplastic syndrome {Myelodysplastic syndrome}, myelofibrosis {Myelofibrosis}, changes were made to your medication {Change of medication}, regimen {Therapeutic regimen}, medications {Administration of drug or medicament}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: CARDIOTHORACIC
 

###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:
Shortness of breath
 
Major Surgical or Invasive Procedure:
Left Thoracentesis- yield 1300mL

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Shortness of breath {Dyspnea}, Thoracentesis {Thoracentesis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 ___ year old man with a history of carotid 
artery stenosis, chronic renal insufficiency, coronary artery 
disease, hyperlipidemia, and hypertension. He developed upper 
back pain in ___ and presented to an outside hospital. An 
EKG demonstrated nonspecific ST changes. Cardiac catheterization 
demonstrated severe multivessel coronary artery disease. He was
transferred to ___ for surgical revascularization. He 
underwent coronary artery bypass grafting x 5 on ___ with 
Dr. ___. His postoperative course was complicated by acute blood 
loss anemia requiring transfusion of PRBCs. He also had 
intermitted atrial fibrillation and was started on Amiodarone 
and Coumadin. He was discharged to rehab on postoperative day 5. 
He has remained deconditioned at rehab. He has noted shortness 
of breath and serosanguinous sternal drainage. WBC at rehab 
yesterday was 15.8 and he was started on empiric Keflex. He 
presented today for wound evaluation. Prior to his visit he 
underwent a chest x-ray which demonstrated an increase in 
moderate to large left pleural effusion with compressive 
atelectasis. There was also a mildly enlarged cardiomediastinal 
silhouette suspicious for pericardial effusion. Discussed his 
case with Dr. ___ who is covering for Dr. ___. Plan to admit
for observation.

 

###RESPONSE: carotid 
artery stenosis {Carotid artery stenosis}, chronic renal insufficiency {Chronic renal insufficiency}, coronary artery 
disease {Coronary arteriosclerosis}, hyperlipidemia {Hyperlipidemia}, hypertension {Hypertensive disorder, systemic arterial}, upper 
back pain {Thoracic back pain}, EKG {Electrocardiographic procedure}, ST changes {Electrocardiographic ST segment changes}, Cardiac catheterization {Cardiac catheterization}, coronary artery disease {Coronary arteriosclerosis}, surgical {Surgical procedure}, revascularization {Heart revascularization}, coronary artery bypass grafting x 5 {Coronary artery bypass grafts x 5}, postoperative course {Postoperative state}, acute blood 
loss anemia {Acute posthemorrhagic anemia}, transfusion of PRBCs {Transfusion of packed red blood cells}, atrial fibrillation {Atrial fibrillation}, Coumadin {Anticoagulant therapy}, shortness 
of breath {Dyspnea}, serosanguinous sternal drainage {Serosanguineous discharge from wound}, WBC {White blood cell count}, wound evaluation {Evaluation of wound healing progress}, chest x-ray {Plain chest X-ray}, pleural effusion {Pleural effusion}, compressive 
atelectasis {Compression atelectasis}, enlarged {Enlargement}, 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: Past Medical History:
Carotid Artery Stenosis
Chronic Renal Insufficiency (Cre 1.2-1.4)
Coronary Artery Disease
Hyperlipidemia
Hypertension
Macular Degeneration 
Non-ST Elevation Myocardial Infarction, ___ w/RCA stent
Osteoarthritis  

 

###RESPONSE: Carotid Artery Stenosis {Carotid artery stenosis}, Chronic Renal Insufficiency {Chronic renal insufficiency}, Coronary Artery Disease {Coronary arteriosclerosis}, Hyperlipidemia {Hyperlipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, Macular Degeneration {Degenerative disorder of macula}, Non-ST Elevation Myocardial Infarction {Acute non-ST segment elevation myocardial infarction}, RCA {Right coronary artery structure}, stent {Insertion of arterial stent}, Osteoarthritis {Osteoarthritis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
No family history of early MI, arrhythmia, cardiomyopathies, or 
sudden cardiac death; otherwise non-contributory.
 

###RESPONSE: MI {Myocardial infarction}, arrhythmia {Cardiac arrhythmia}, cardiomyopathies {Cardiomyopathy}, sudden cardiac death {Sudden cardiac death}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
HR: 78 SR.  BP: 137/80, right.  RR: 18.  O2 Sat: 97% RA
Height: 66""  Weight: 172 lbs 

General: Pleasant man, WDWN, lying in stretcher 
Skin: Warm, dry, intact
HEENT: PERRLA, EOMI, teeth in good repair 
Neck: Supple, Full ROM 
Chest: Diminished at bilateral bases, no crackles 
Heart: Regular rate and rhythm, no murmur appreciated 
Abdomen: Normal BS, soft, non-tender, non-distended 
Extremities: Warm, well-perfused 
Edema: 1+ edema bilaterally 
Incision: ABD pad removed with scant serosanguinous drainage. 
Wound well approximated without erythema. No click. 

 

###RESPONSE: HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, O2 Sat {Oxygen saturation measurement}, RA {Breathing room air}, Height {Height / growth finding}, Weight {Weight finding}, General {General examination of patient}, WDWN {Well nourished}, lying {Lying in bed}, Skin {Examination of skin}, Warm {Warm skin}, dry {Xeroderma}, intact {Intact skin}, HEENT {Physical examination procedure}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, teeth {Structure of dentition}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Full ROM {Normal range of cervical spine movement}, Chest {Examination of respiratory system}, bases {Structure of base of lung}, crackles {Respiratory crackles}, Heart {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, murmur {Murmur}, Abdomen {Examination of abdomen}, Normal BS {Normal bowel sounds}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, Extremities {Examination of limb}, Warm {Warm skin}, well-perfused {Normal tissue perfusion}, edema {Edema}, Incision {Surgical incision wound}, ABD {Examination of abdomen}, removed {Removal}, serosanguinous drainage {Serosanguineous discharge from wound}, Wound {Wound}, well approximated {Wound healing well}, erythema {Erythema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Transthoracic Echocardiogram (focused) ___
Due to suboptimal technical quality, a focal wall motion 
abnormality cannot be fully excluded. Overall left ventricular 
systolic function is normal (LVEF>55%). Right ventricular 
chamber size and free wall motion are normal. The aortic valve 
leaflets (3) appear structurally normal with good leaflet 
excursion and no aortic stenosis or aortic regurgitation. 
Trivial mitral regurgitation is seen. There is a 
trivial/physiologic pericardial effusion. 

IMPRESSION: Trivial pericardial effusion. Normal global 
biventricular systolic function.  

Chest CT ___
1. Large left pleural effusion with volume loss in the left 
lower lobe, 
lingula. 
2. Mild partially hemorrhagic pericardial effusion. 
.

___ 05:07AM BLOOD WBC-16.8* RBC-3.68* Hgb-10.8* Hct-33.9* 
MCV-92 MCH-29.3 MCHC-31.9* RDW-15.1 RDWSD-50.4* Plt ___
___ 04:25AM BLOOD WBC-21.3* RBC-3.51* Hgb-10.1* Hct-32.3* 
MCV-92 MCH-28.8 MCHC-31.3* RDW-15.3 RDWSD-51.4* Plt ___
___ 05:07AM BLOOD ___ PTT-31.8 ___
___ 04:25AM BLOOD ___
___ 04:35AM BLOOD ___
___ 05:01PM BLOOD ___ PTT-30.4 ___
___ 05:07AM BLOOD Glucose-99 UreaN-30* Creat-1.4* Na-138 
K-4.4 Cl-96 HCO3-27 AnGap-19
___ 04:35AM BLOOD Glucose-95 UreaN-26* Creat-1.3* Na-137 
K-3.9 Cl-98 HCO3-24 AnGap-19
___ 05:07AM BLOOD ALT-82* AST-125* AlkPhos-184* 
Amylase-159* TotBili-3.0*
___ 04:25AM BLOOD ALT-77* AST-113* LD(LDH)-441* 
AlkPhos-182* Amylase-140* TotBili-3.2*
___ 05:07AM BLOOD Phos-4.3 Mg-2.3
___ 04:35AM BLOOD Calcium-7.9* Phos-4.4 Mg-2.6
 

###RESPONSE: Transthoracic Echocardiogram {Transthoracic echocardiography}, focal wall motion 
abnormality {Left ventricular wall motion abnormality}, left ventricular 
systolic function {Normal left ventricular systolic function and wall motion}, Right ventricular 
chamber {Right cardiac ventricular structure}, wall motion are normal {Normal ventricular wall motion}, aortic valve 
leaflets {Structure of cardiac valve leaflet}, structurally normal {Aortic valve normal}, leaflet {Structure of cardiac valve leaflet}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral regurgitation {Mitral valve regurgitation}, pericardial effusion {Pericardial effusion}, pericardial effusion {Pericardial effusion}, biventricular {Cardiac ventricular structure}, systolic function {Normal cardiac function}, pleural effusion {Pleural effusion}, volume loss {Lung volume test abnormal}, left 
lower lobe {Structure of lower lobe of left lung}, lingula {Structure of lingula of left lung}, pericardial effusion {Pericardial effusion}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Serum lactate dehydrogenase level above reference range}, TotBili {Bilirubin, total measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
He was admitted on ___ for further evaluation. A chest CT 
demonstrated a large left pleural effusion. An echocardiogram 
revealed a trivial pericardial effusion.  Warfarin was held for 
procedure.   He underwent left sided thoracentesis on ___ 
for a yield of 1300cc of serosanguinous fluid.  Overall, the 
patient tolerated the procedure well.  Warfarin was resumed for 
post-op afib.  LFTs noted to be elevated- labs will be repeated 
as an outpatient.  He is discharged home after clearing ___ on 
hospital day 3.  He will follow-up as directed.  
 

###RESPONSE: evaluation {Evaluation procedure}, chest CT {Computed tomography of chest}, pleural effusion {Pleural effusion}, echocardiogram {Echocardiography}, pericardial effusion {Pericardial effusion}, procedure {Procedure}, thoracentesis {Thoracentesis}, fluid {Effusion}, procedure {Procedure}, post-op {Postoperative state}, afib {Atrial fibrillation}, LFTs {Hepatic function panel}, elevated {Finding of increased blood pressure}, 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:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY 
2. Atorvastatin 80 mg PO QPM 
3. Amiodarone 400 mg PO BID 
4. Docusate Sodium 100 mg PO BID 
5. Furosemide 40 mg PO DAILY 
___  MD to order daily dose PO DAILY16 afib 
7. Metoprolol Tartrate 50 mg PO TID 
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: 
moderate/severe 
9. Polyethylene Glycol 17 g PO DAILY 
10. Potassium Chloride 20 mEq PO DAILY 
11. Ranitidine 150 mg PO DAILY 

 
Discharge Medications:
1.  Amiodarone 200 mg PO DAILY 
RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30 
Tablet Refills:*1 
2.  Warfarin 2 mg PO DAILY16 afib 
RX *warfarin 2 mg ___ tablet(s) by mouth daily Disp #*60 Tablet 
Refills:*1 
3.  Aspirin 81 mg PO DAILY 
RX *aspirin [Aspir-Low] 81 mg 1 tablet(s) by mouth daily Disp 
#*30 Tablet Refills:*1 
4.  Atorvastatin 80 mg PO QPM 
RX *atorvastatin 80 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet 
Refills:*0 
5.  Docusate Sodium 100 mg PO BID 
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day 
Disp #*60 Capsule Refills:*1 
6.  Furosemide 40 mg PO DAILY Duration: 10 Days 
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*10 Tablet 
Refills:*0 
7.  Metoprolol Tartrate 50 mg PO TID 
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a 
day Disp #*90 Tablet Refills:*1 
8.  OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: 
moderate/severe 
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours 
Disp #*50 Tablet Refills:*0 
9.  Polyethylene Glycol 17 g PO DAILY 
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by 
mouth daily Disp #*10 Packet Refills:*0 
10.  Potassium Chloride 20 mEq PO DAILY Duration: 10 Days 
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp 
#*10 Tablet Refills:*0 
11.  Ranitidine 150 mg PO DAILY 
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth daily Disp #*30 
Tablet Refills:*1 

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Pleural Effusion

Carotid Artery Stenosis
Chronic Renal Insufficiency (Cre 1.2-1.4)
Coronary Artery Disease
Hyperlipidemia
Hypertension
Macular Degeneration 
Non-ST Elevation Myocardial Infarction, ___ w/RCA stent
Osteoarthritis  

 
Discharge Condition:
Alert and oriented x3 non-focal 
Ambulating, deconditioned
Incisional pain managed with oxycodone
Incisions: 
Sternal - healing well, no erythema or drainage 
Leg/left- healing well, no erythema or drainage
Edema: trace bilateral pedal

 

###RESPONSE: Home With Service {Home health aide service management}, Pleural Effusion {Pleural effusion}, Carotid Artery Stenosis {Carotid artery stenosis}, Chronic Renal Insufficiency {Chronic renal insufficiency}, Coronary Artery Disease {Coronary arteriosclerosis}, Hyperlipidemia {Hyperlipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, Macular Degeneration {Degenerative disorder of macula}, Non-ST Elevation Myocardial Infarction {Acute non-ST segment elevation myocardial infarction}, RCA {Right coronary artery structure}, stent {Insertion of arterial stent}, Osteoarthritis {Osteoarthritis}, Alert {Mentally alert}, oriented x3 {Oriented to person, time and place}, Ambulating {Fully mobile}, Incisional {Surgical incision wound}, pain {Pain}, Incisions {Surgical incision wound}, Sternal {Structure of sternal region}, healing well {Wound healing well}, erythema {Erythema}, drainage {Discharge}, Leg/left {Structure of left lower leg}, healing well {Wound healing well}, erythema {Erythema}, drainage {Discharge}, Edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Please shower daily including washing incisions gently with mild 
soap, no baths or swimming until cleared by surgeon. Look at 
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions 
Each morning you should weigh yourself and then in the evening 
take your temperature, these should be written down on the chart 

No driving for one month or while taking narcotics. Driving will 
be discussed at follow up appointment with surgeon-when you will 
be able to drive 
No lifting more than 10 pounds for 10 weeks

**Please call cardiac surgery office with any questions or 
concerns ___. Answering service will contact on call 
person during off hours**
 

###RESPONSE: shower {Able to shower self}, incisions {Surgical incision wound}, incisions {Surgical incision wound}, redness {Redness of skin over lesion}, drainage {Discharge}, incisions {Surgical incision wound}, while taking narcotics {Narcotics education}, No lifting {Functional activity 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: 
all seafood / ibuprofen / bees / acetaminophen
 
Attending: ___.
 
Chief Complaint:
Groin pain
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: seafood {Allergy to seafood}, ibuprofen {Allergy to ibuprofen}, bees {Allergy to bee venom}, acetaminophen {Allergy to paracetamol}, Groin pain {Inguinal pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
The patient is a ___ woman with a past medical history 
significant for HTN, T2DM, seizure disorder, Hepatitis C, and 
schizoaffective disorder who presents with 10 days of R groin 
pain.

At baseline, she uses a walker to ambulate and takes Oxycodone 
for diabetic neuropathy, which she describes a ""burning"" 
sensation in her BLE. She was in her usual state of health until 
2 weeks ago when she slipped on a banana peel and ended up in a 
splits position. 2 days later, she noted R groin pain. On ___, 
she was admitted to ___ with acute urinary retention likely 
___ Oxycodone/Benadryl use and UTI and RLQ abdominal pain. Her 
Benadryl was temporarily D/C'ed, and she was treated with a 
course of Macrobid. In terms of her RLQ abdominal pain, acute 
processes were ruled-out via CT and U/S. She reports that her 
pain, which she clarifies was always R groin and not RLQ, 
slightly improved on D/C, but has gradually worsened since then. 
She describes this pain as non-radiating, pulsating pain that is 
constant; exacerbated with movement; and accompanied by shooting 
pains down her RLE. She endorses fevers (Tm 100.4) and chills, 
but denies N/V, abdominal pain, changes in her bowel habits, or 
urinary symptoms.

In the ED, her initial vitals were T 99.8 HR 96 BP 144/77 RR 18 
SaO2 97% on RA. Her physical examination was notable for R 
inguinal TTP. Her laboratory results were notable for Na 131; 
ALT 51 AST 87 Alk Phos 199 Tbili 1.7 Alb 3.0; and WBC 8.1. She 
underwent RUQ U/S which was unchanged. She received IV Morphine 
17 MG for pain. 

Currently, she continues to report R groin pain and is 
requesting pain medications. Otherwise, she has no additional 
complaints.    

REVIEW OF SYSTEMS: Per HPI, otherwise negative in detail.
 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, T2DM {Diabetes mellitus type 2}, seizure disorder {Seizure disorder}, Hepatitis C {Viral hepatitis type C}, schizoaffective disorder {Schizoaffective disorder}, R groin 
pain {Right inguinal pain}, baseline {Baseline state}, uses a walker to ambulate {Does mobilize using walker}, diabetic neuropathy {Neuropathy due to diabetes mellitus}, burning"" 
sensation {Burning sensation}, BLE {Lower limb structure}, R groin pain {Right inguinal pain}, acute urinary retention {Acute retention of urine}, UTI {Urinary tract infectious disease}, RLQ abdominal pain {Right lower quadrant pain}, RLQ abdominal pain {Right lower quadrant pain}, CT {Computed tomography}, U/S {Ultrasonography of abdomen}, pain {Pain}, R groin {Right inguinal region structure}, RLQ {Structure of right lower quadrant of abdomen}, improved {Patient's condition improved}, D/C {Discharged from hospital}, worsened {Increased pain}, pain {Pain}, radiating {Radiating pain}, pulsating pain {Throbbing pain}, constant {Constant pain}, shooting 
pains {Shooting pain}, RLE {Structure of right lower limb}, fevers {Fever}, chills {Chill}, N/V {Nausea and vomiting}, abdominal pain {Abdominal pain}, changes in her bowel habits {Altered bowel function}, urinary symptoms {Urinary symptom change}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, SaO2 {Finding of oxygen saturation}, RA {Breathing room air}, physical examination {Physical examination procedure}, R 
inguinal {Right inguinal region structure}, TTP {Tenderness}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, WBC {White blood cell count}, RUQ {Structure of right upper quadrant of abdomen}, U/S {Ultrasonography of abdomen}, pain {Pain}, R groin pain {Right inguinal pain}, requesting pain medications {Analgesics requested}, negative {No abnormality detected}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 
Diabetes c/b neuropathy
Seizure disorder
Hepatitis C 
Cirrhosis 
Schizoaffective d/o
Asthma
Migraine headaches
 

###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, Diabetes c/b neuropathy {Neuropathy due to diabetes mellitus}, Seizure disorder {Seizure disorder}, Hepatitis C 
Cirrhosis {Cirrhosis of liver due to chronic hepatitis C}, Schizoaffective {Schizoaffective disorder}, Asthma {Asthma}, Migraine headaches {Migraine}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: HTN, DM, asthma
Father: ___ disorder 
Nephew, niece: ___
 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, asthma {Asthma}, disorder {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: Physical Exam:
On Admission:
Vitals: T 98.9 BP 129/75 HR 90 RR 17 SaO2 100% on RA
General: Well-appearing, obese female lying comfortably in bed
HEENT: Sclera anicteric, PERRLA, MMM, oropharynx clear  
Neck: Supple, no JVD, no LAD
Lungs: CTAB
Heart: RRR, normal s1/2, no m/r/g  
Abdomen: BS+, soft, NT/ND, no organomegaly  
Back: No TTP, no CVA tenderness
Ext: WWP, 2+ pulses, no edema
Neuro: A&Ox3, CN II-XII intact
R hip: TTP along inguinal region and lateral aspect, limited 
passive and active ROM (compared to L), no erythema or warmth, 
no masses

On Discharge:
VS: Tm 99.1 Tc 98.1 BP 125/59 (113-139/59-78) HR 108 (92-108) RR 
18 SaO2 95% on RA
I/O (8hrs) 600(PO)/BRP, (24hrs) 570(PO)/BRP, BM x1
FSBG 107-201 
General: Well-appearing, obese female lying comfortably in bed
HEENT: Sclera anicteric, PERRLA, MMM, oropharynx clear  
Neck: Supple, no JVD, no LAD
Lungs: CTAB
Heart: RRR, normal s1/2, no m/r/g  
Abdomen: BS+, soft, NT/ND, no organomegaly  
Back: No TTP, no CVA tenderness
Ext: WWP, 2+ pulses, no edema
Neuro: A&Ox3, CN II-XII intact
R hip: TTP along inguinal region and lateral aspect, limited 
passive and active ROM (compared to L), no erythema or warmth, 
no masses
 

###RESPONSE: Vitals {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}, Well-appearing {Well cared for appearance}, obese {Obese}, lying comfortably in bed {Lying in bed}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, PERRLA {Pupils equal, react to light and accommodation}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, normal s1 {Normal first heart sound, S>1<}, no m/r/g {Heart sounds normal}, Abdomen {Examination of abdomen}, BS+ {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, organomegaly {Abdominal organomegaly}, TTP {Tenderness}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, WWP {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, edema {Edema}, Neuro {Neurological examination}, A {Mentally alert}, Ox3 {Oriented to person, time and place}, CN II-XII intact {Normal central nervous system}, R hip {Right hip region structure}, TTP {Tenderness}, inguinal region {Right inguinal region structure}, limited 
passive and active ROM {Decreased range of hip movement}, erythema {Erythema}, warm {Warm skin}, masses {Mass}, 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}, BM {Does defecate}, FSBG {Finding of blood glucose level}, General {General examination of patient}, Well-appearing {Well cared for appearance}, obese {Obese}, lying comfortably in bed {Lying in bed}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, PERRLA {Pupils equal, react to light and accommodation}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, normal s1 {Normal first heart sound, S>1<}, no m/r/g {Heart sounds normal}, Abdomen {Examination of abdomen}, BS+ {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, organomegaly {Abdominal organomegaly}, TTP {Tenderness}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, edema {Edema}, Neuro {Neurological examination}, A {Mentally alert}, Ox3 {Oriented to person, time and place}, CN II-XII intact {Normal central nervous system}, R hip {Right hip region structure}, TTP {Tenderness}, inguinal region {Right inguinal region structure}, limited 
passive and active ROM {Decreased range of hip movement}, erythema {Erythema}, warmth {Joint warm}, masses {Mass}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
On Admission:
___ 08:20AM BLOOD WBC-8.1 RBC-3.35* Hgb-10.2* Hct-31.1* 
MCV-93 MCH-30.6 MCHC-33.0 RDW-15.7* Plt ___
___ 08:20AM BLOOD Neuts-73.3* ___ Monos-4.7 Eos-2.1 
Baso-0.2
___ 08:20AM BLOOD Plt ___
___ 08:10AM BLOOD ___
___ 08:20AM BLOOD Glucose-219* UreaN-4* Creat-0.5 Na-131* 
K-3.8 Cl-96 HCO3-31 AnGap-8
___ 08:20AM BLOOD ALT-51* AST-87* AlkPhos-199* TotBili-1.7*
___ 08:20AM BLOOD Albumin-3.0* Calcium-8.2* Phos-2.5* 
Mg-1.5*
___ 08:36AM BLOOD Lactate-2.1*

___ CXR:
IMPRESSION: No acute intrathoracic process.

___ RUQ U/S:
IMPRESSION: 
1. Nodular and coarsened liver compatible with cirrhosis without 
focal lesions. 
2. Splenomegaly. 
3. No evidence of cholecystitis or choledocholithiasis.

___ Hip XR:
FINDINGS: Bony structures and joint spaces are essentially 
within normal limits and symmetric bilaterally. No evidence of 
fracture or dislocation. However, if there is strong clinical 
concern for an occult fracture, cross-sectional imaging should 
be obtained.

___ MR-L spine:
IMPRESSION: 
Multilevel disc disease most notably at the L4-L5 level where 
there is a right paracentral disc bulge with superimposed disc 
extrusion extending superiorly into the right lateral recess.  
This disc causes mass effect on the exiting right L4 nerve root 
and traversing right L5 nerve root.

___ MR-Hip (Prelim):
IMPRESSION: 
MR of the hip demonstrating extensive edema of multiple muscles 
around the pelvic girdle, predominantly involving obturator 
internus, externus, quadratus femoris and gluteus medius. This 
is centered around the superior pubic ramus which demonstrates 
mild bone edema but no fracture. Differentials for this 
appearance include myositis, infection, lymphoma. Recommend 
contrast enhanced MRI to further evaluate.

___ MR-Hip with contrast:
IMPRESSION: 
The area of diffuse muscular and bone marrow edema enhances 
avidly. The lack of any fluid collection or heterogenous 
enhancement makes infection somewhat less likely, however 
differential considerations also include tumor and 
post-traumatic changes.   
  
Additional history was provided confirming recent trauma. Given 
this additional information, post-traumatic change is the most 
likely of the provided differentials. Follow-up with repeat MRI 
in ___ weeks to ensure improvement/resolution is recommended. 
 
On Discharge:
___ 07:00AM BLOOD WBC-6.8 RBC-3.29* Hgb-10.2* Hct-30.5* 
MCV-93 MCH-31.1 MCHC-33.5 RDW-15.7* Plt ___
___ 08:10AM BLOOD ESR-98*
___ 07:00AM BLOOD Glucose-175* UreaN-5* Creat-0.6 Na-130* 
K-3.5 Cl-96 HCO3-29 AnGap-9
___ 08:10AM BLOOD ALT-47* AST-88* LD(LDH)-282* CK(CPK)-155 
AlkPhos-200* TotBili-1.9*
___ 07:00AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.5*
___ 08:10AM BLOOD CRP-50.2*
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, No acute intrathoracic process {No abnormality detected}, liver {Liver structure}, cirrhosis {Cirrhosis of liver}, lesions {Lesion}, Splenomegaly {Splenomegaly}, No evidence {No abnormality detected}, cholecystitis {Cholecystitis}, choledocholithiasis {Common bile duct calculus}, Bony structures {Bone structure of hip joint region}, joint spaces {Structure of articular space}, normal {No abnormality detected}, No evidence {No abnormality detected}, fracture {Fracture}, dislocation {Dislocation}, fracture {Fracture}, imaging {Imaging}, disc disease {Disorder of lumbar disc}, right {Structure of right lumbar region of back}, disc {Intervertebral disc structure of fourth lumbar vertebra}, bulge {Swelling}, d disc 
extrusion {Displacement of lumbar intervertebral disc}, right {Structure of right lumbar region of back}, lateral recess {Structure of transverse process of lumbar vertebra}, disc {Intervertebral disc structure of fourth lumbar vertebra}, L4 nerve root {Structure of spinal nerve root L4}, right {Structure of right lumbar region of back}, L5 nerve root {Structure of spinal nerve root L5}, MR of the hip {Magnetic resonance imaging of hip}, edema {Edema of skeletal muscle}, muscles 
around the pelvic {Skeletal muscle structure of pelvis}, obturator 
internus {Internal obturator muscle structure}, externus {External obturator muscle structure}, quadratus femoris {Structure of quadratus femoris muscle}, gluteus medius {Structure of gluteus medius muscle}, superior pubic ramus {Structure of superior ramus of pubis}, mild {Symptom mild}, bone edema {Edema of bone marrow}, fracture {Fracture}, appearance {Edema of skeletal muscle}, myositis {Myositis}, infection {Infectious disease}, lymphoma {Malignant lymphoma}, contrast enhanced MRI {Magnetic resonance imaging with contrast}, muscular {Edema of skeletal muscle}, bone marrow edema {Edema of bone marrow}, fluid collection {Accumulation of fluid}, infection {Infectious disease}, tumor {Neoplasm}, traumatic {Traumatic injury}, trauma {Traumatic injury}, traumatic {Traumatic injury}, MRI {Magnetic resonance imaging}, ensure {Evaluation procedure}, improvement {Patient's condition improved}, resolution {Problem resolved}, 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}, ESR {Finding of erythrocyte sedimentation rate}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Lactate dehydrogenase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
#R groin pain: The patient presented with R groin pain in the 
setting of a fall. Her pain was likely ___ musculoskeletal 
strain in the setting of trauma. However, given her low-grade 
fevers and elevated inflammatory markers, septic joint was 
considered. Her WBC was WNL, and her Hip-XR were unremarkable. 
Her MR-Hip with and without contrast were consistent with 
post-traumatic changes. Initially, there was concern for 
lymphoma. However, her laboratory values were only notable for a 
slightly elevated LDH (her baseline) and significantly elevated 
ESR and CRP. She was given PO Oxycodone for pain in addition to 
her home Sulindac, and she was discharged on a limited supply of 
PO Oxycodone. ___ evaluated her and felt that she was safe to 
return home with ___. Follow-up with repeat MRI in ___ weeks to 
ensure improvement/resolution is recommended.

#UTI: During her last admission, she was started on Macrobid for 
a complicated UTI. She complicated her course prior to D/C.

#HTN: Her home HCTZ was continued.

#T2DM: Her home Metformin and NPH were continued, and she was 
placed on ISS. Her home Glipizide was held and restarted on D/C. 
For neuropathy, her home Gabapentin was continued.

#Seizure disorder: Her home Phenytoin and Lamotrigine were 
continued.

#Schizoaffective disorder: Her home Abilify and Prazosin were 
continued.

#COPD: Her home Montelukast and nebs were continued.

#Hyponatremia: She was admitted with Na 131, which is her 
baseline and is likely ___ hypervolemia in the setting of liver 
disease.

#Chronic HCV/?Cirrhosis: She presented with ALT 51, AST 87, Alk 
Phos 199, and Tbili 1.7, which is her baseline. Her U/S revealed 
nodular liver and splenomegaly, unchanged from prior. Outpatient 
follow-up with Liver Clinic was scheduled for ___.

#Hypoalbuminemia: She was admitted with Alb 3.0, which is her 
baseline and likely ___ liver disease. Per Nutrition, her Ensure 
TID was continued.

TRANSITIONAL ISSUES:
1. She was treated with PO Oxycodone PRN and discharged on a 
limited supply of PO Oxycodone.
2. ___ evaluated her and felt that she was safe to return home 
with ___.
3. Follow-up with repeat MRI in ___ weeks to ensure 
improvement/resolution is recommended.
4. If her pain persists, please consider an outpatient Ortho 
eval.
5. Her urine and blood cultures will need to be followed-up.
 

###RESPONSE: R groin pain {Right inguinal pain}, R groin pain {Right inguinal pain}, fall {Falls}, pain {Right inguinal pain}, musculoskeletal 
strain {Muscle strain}, trauma {Traumatic injury}, low-grade 
fevers {Low grade pyrexia}, elevated {Elevation}, inflammatory {Inflammatory disorder}, markers {Laboratory test}, septic joint {Bacterial arthritis}, WBC {White blood cell count}, WNL {No abnormality detected}, Hip-XR {Radiography of hip}, unremarkable {No abnormality detected}, MR-Hip with {Magnetic resonance imaging of hip with contrast}, d without contrast {Magnetic resonance imaging without contrast}, traumatic {Traumatic injury}, lymphoma {Malignant lymphoma}, elevated LDH {Serum lactate dehydrogenase level above reference range}, baseline {Baseline state}, elevated 
ESR {Erythrocyte sedimentation rate above reference range}, CRP {C-reactive protein above reference range}, pain {Pain}, Follow-up {Follow-up arranged}, MRI {Magnetic resonance imaging}, ensure {Evaluation procedure}, improvement {Patient's condition improved}, resolution {Problem resolved}, UTI {Urinary tract infectious disease}, UTI {Urinary tract infectious disease}, HTN {Hypertensive disorder, systemic arterial}, T2DM {Diabetes mellitus type 2}, ISS {Sliding scale insulin regime}, restarted {Restart of medication}, neuropathy {Neuropathy}, Seizure disorder {Seizure disorder}, Schizoaffective disorder {Schizoaffective disorder}, COPD {Chronic obstructive lung disease}, Hyponatremia {Hyponatremia}, baseline {Baseline state}, hypervolemia {Hypervolemia}, liver 
disease {Disorder of liver}, Chronic HCV/?Cirrhosis {Cirrhosis of liver due to chronic hepatitis C}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, baseline {Baseline state}, U/S {Ultrasonography of abdomen}, nodular liver {Nodule of liver}, splenomegaly {Splenomegaly}, Outpatient 
follow-up {Follow-up arranged}, Clinic {Outpatient care management}, Hypoalbuminemia {Hypoalbuminemia}, baseline {Baseline state}, liver disease {Disorder of liver}, Nutrition {Under care of dietitian}, Ensure {Administration of nutritional supplement}, Follow-up {Follow-up arranged}, MRI {Magnetic resonance imaging}, ensure {Evaluation procedure}, improvement {Patient's condition improved}, resolution {Problem resolved}, pain {Right inguinal pain}, urine {Urine culture}, blood cultures {Blood culture}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADOL (Ultram) 50 mg PO Q6H 
2. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H 
3. Zolpidem Tartrate 10 mg PO HS 
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 
5. Aripiprazole 30 mg PO DAILY 
6. Gabapentin 800 mg PO TID 
7. Hydrochlorothiazide 25 mg PO DAILY 
8. NPH 25 Units Breakfast
NPH 20 Units Bedtime
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB 
10. Lidocaine Viscous 2% 20 mL PO QID:PRN thrush 
11. Montelukast Sodium 10 mg PO DAILY 
12. Multivitamins 1 TAB PO DAILY 
13. Omeprazole 20 mg PO DAILY 
14. Phenytoin Sodium Extended 200 mg PO BID 
15. Sumatriptan Succinate 50 mg PO ONCE MR1 migraine 
16. Tiotropium Bromide 1 CAP IH DAILY 
17. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 
18. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 
19. GlipiZIDE 5 mg PO BID 
20. MetFORMIN (Glucophage) 1000 mg PO BID 
21. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation 
INHALATION 2 PUFFS BID 
22. Prazosin 2 mg PO QAM 
23. Prazosin 8 mg PO QPM 
24. LaMOTrigine 100 mg PO QAM 
25. LaMOTrigine 200 mg PO QHS 
26. Sulindac 200 mg PO BID
 
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 
3. Aripiprazole 30 mg PO DAILY 
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 
5. Gabapentin 800 mg PO TID 
6. Hydrochlorothiazide 25 mg PO DAILY 
7. NPH 25 Units Breakfast
NPH 20 Units Bedtime
8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB 
9. LaMOTrigine 100 mg PO QAM 
10. LaMOTrigine 200 mg PO QHS 
11. MetFORMIN (Glucophage) 1000 mg PO BID 
12. Montelukast Sodium 10 mg PO DAILY 
13. Multivitamins 1 TAB PO DAILY 
14. Omeprazole 20 mg PO DAILY 
15. Phenytoin Sodium Extended 200 mg PO BID 
16. Prazosin 2 mg PO QAM 
17. Prazosin 8 mg PO QPM 
18. Sulindac 200 mg PO BID 
19. Tiotropium Bromide 1 CAP IH DAILY 
20. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 
21. GlipiZIDE 5 mg PO BID 
22. Lidocaine Viscous 2% 20 mL PO QID:PRN thrush 
23. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation 
INHALATION 2 PUFFS BID 
24. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN pain 
do not drive while taking this medication 
RX *oxycodone 5 mg 1 tablet(s) by mouth four times a day Disp 
#*20 Tablet Refills:*0
25. Docusate Sodium 100 mg PO BID 
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day 
Disp #*20 Capsule Refills:*0
26. Senna 1 TAB PO BID:PRN constipation 
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp 
#*20 Tablet Refills:*0
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Groin pain
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).
 

###RESPONSE: With Service {Home health aide service management}, Groin pain {Inguinal pain}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,

It was a pleasure taking care of you while you were hospitalized 
at ___. You were admitted to the hospital with right groin 
pain. Your pain was likely due to a muscle tear. You were 
treated and discharged with oral pain medications. Physical 
Therapy evaluated you and felt that you were safe to return home 
with physical therapy.

Please take care to follow-up with your Primary Care physician.
 

###RESPONSE: right groin 
pain {Right inguinal pain}, pain {Right inguinal pain}, muscle tear {Rupture of muscle}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, physical therapy {Physical therapy 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:   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: 
Shellfish / Iodine / seasonal allergy / Dilaudid / novocaine
 
Attending: ___.
 
Chief Complaint:
chemo
 
Major Surgical or Invasive Procedure:
port placement

 

###RESPONSE: Shellfish {Allergy to shellfish}, Iodine {Allergy to iodine compound}, seasonal allergy {Seasonal allergy}, chemo {Chemotherapy}, port placement {Insertion of implantable venous access port}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ is a ___ female with a history of
marginal zone lymphoma in ___ with subsequent diagnosis of
aggressive B cell lymphoma in ___.  She is s/p ISRT to her
palate in ___ and surgical resection of left supraclavicular
lymph node in ___ for marginal zone lymphoma.  She was found to
have right leg edema with large mass in ___, and the biopsy
confirmed mantle cell lymphoma, blastic variant.  She is s/p
R-CHOP x 6 cycles in ___ and autologous transplant in ___. 
PET/CT on ___ showed a new enlarged right inguinal lymph 
node
with FDG avidity compatible concerning for relapse.  Core biopsy
of right inguinal lymph node on ___ was consistent with NHL;
intermediate grade non-Hodgkin B-cell lymphoma. She appeared to
have a single site of disease and it was reasonable to attempt
radiation salvage as her systemic options were limited. This was
completed on ___. Restaging in ___ consistent with 
new
PET avid periaortic node; bx consistent with relapsed aggressive
B cell lymphoma. Patient presents for the second cycle of
___.

First cycle complicated by prolonged nausea, constipation and
fatigue. 

 

###RESPONSE: marginal zone lymphoma {Marginal zone lymphoma}, B cell lymphoma {B-cell lymphoma}, p ISRT {Radiation therapy care}, palate {Palatal structure}, surgical {Surgical procedure}, left supraclavicular
lymph node {Structure of left supraclavicular lymph node}, marginal zone lymphoma {Marginal zone lymphoma}, right leg edema {Edema of right lower leg}, mass {Mass}, biopsy {Biopsy}, mantle cell lymphoma {Mantle cell lymphoma}, R-CHOP {Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone chemotherapy regimen}, autologous transplant {Autogenous transplantation}, PET/CT {Positron emission tomography}, enlarged {Localized enlarged lymph nodes}, inguinal lymph 
node {Inguinal lymph node structure}, Core biopsy {Core needle biopsy}, inguinal lymph node {Inguinal lymph node structure}, NHL {Non-Hodgkin's lymphoma}, intermediate grade non-Hodgkin B-cell lymphoma {Intermediate grade B-cell lymphoma}, disease {Disease}, radiation {Radiation oncology AND/OR radiotherapy}, PET {Positron emission tomography}, periaortic node {Structure of aortic lymph node}, bx {Biopsy finding}, B cell lymphoma {B-cell lymphoma}, nausea {Nausea}, constipation {Constipation}, fatigue {Fatigue}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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/SURGICAL HISTORY:  
(1) HTN.  
(2) Hyperlipidemia.  
(3) ___ esophagus  
(4) Partial thyroidectomy for multinodular hyperplasia.  
(5) Colonic hyperplastic polyps.  
(6) Meniere's disease.  
(7) Degenerative disease of the lumbar spine.  
(8) Heterozygous for FXI deficiency by report
(9) Atrial fibrillation, on oral anticoagulation with warfarin.  

(10) Lymphoma, as below 

DETAILED ONCOLOGIC HISTORY: 
History of extranodal marginal zone lymphoma of the palate 
managed with excision and radiation in ___. Nodal recurrence of 
mardinal zone lymphoma ___ that was excised. ___ patient was noted to have right lower extremity edema and 
right inguinal LAD. Excisional biopsy consistent with an 
aggressive B cell lymphoma, blastoid mantle cell.  
R-CHOP x 6 cycles in ___ and autologous transplant in ___.  
PET/CT on ___ showed a new enlarged right inguinal lymph 
node with FDG avidity compatible concerning for relapse.  Core 
biopsy of right inguinal lymph node on ___ was consistent 
with NHL; intermediate grade non-Hodgkin B-cell lymphoma. She 
appeared to have a single site of disease and it was reasonable 
to attempt radiation salvage as her systemic options were 
limited. This was completed on ___. Restaging in ___ 
consistent with new PET avid periaortic node; bx consistent with 
relapsed aggresive B cell lymphoma.
C1 R-BAC ___ 

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, esophagus {Esophageal structure}, thyroidectomy {Thyroidectomy}, multinodular hyperplasia {Multinodular hyperplasia}, Colonic {Colon structure}, hyperplastic polyps {Hyperplastic polyp}, Meniere's disease {Ménière's disease}, Degenerative disease of the lumbar spine.  {Lumbar spondylosis}, FXI deficiency {Factor XI deficiency}, Atrial fibrillation {Atrial fibrillation}, oral {Administration of drug or medicament via oral route}, anticoagulation {Anticoagulant therapy}, Lymphoma {Malignant lymphoma}, marginal zone lymphoma {Marginal zone lymphoma}, palate {Palatal structure}, excision {Excision}, radiation {Radiation oncology AND/OR radiotherapy}, mardinal zone lymphoma {Marginal zone lymphoma}, right lower extremity edema {Edema of right lower limb}, inguinal LAD {Inguinal lymphadenopathy}, Excisional biopsy {Excisional biopsy}, B cell lymphoma {B-cell lymphoma}, cell {Cell structure}, R-CHOP {Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone chemotherapy regimen}, autologous transplant {Autogenous transplantation}, PET/CT {Positron emission tomography}, enlarged {Localized enlarged lymph nodes}, inguinal lymph 
node {Inguinal lymph node structure}, Core 
biopsy {Core needle biopsy}, inguinal lymph node {Inguinal lymph node structure}, NHL {Non-Hodgkin's lymphoma}, intermediate grade non-Hodgkin B-cell lymphoma {Intermediate grade B-cell lymphoma}, radiation {Radiation oncology AND/OR radiotherapy}, PET {Positron emission tomography}, B cell lymphoma {B-cell lymphoma}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Her father apparently had homozygous FXI deficiency, which 
prompted testing in her (performed elsewhere). A niece was  
diagnosed with a ""bad type of lymphoma.""  

 

###RESPONSE: FXI deficiency {Factor XI deficiency}, lymphoma {Malignant lymphoma}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: T 98.8 max, now 98.3 BP 126/70 HR 62 RR 18 O2 100%
Gen: WDWN NAD A&O x4
HEENT: oropharynx moist, no lesions
nodes: no LAD
CV: RRR no m/r/g, not irregular
LS: CTA
Abd: soft NT -HSM +BS, no masses palpated
Extr: no edema
Skin: no rash
Neuro: nonfocal, PERRLA, EOMI, no nystagmus, rapid hand 
movements
and truncal gait appropriate, unsteady at baseline on tandem 
gait
Access: POC with ecchymosis, ozzing resolved

 

###RESPONSE: VS {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 {Oxygen saturation measurement}, Gen {General examination of patient}, WDWN {Well nourished}, NAD {No abnormality detected}, A {Mentally alert}, O {Orientated}, HEENT {Physical examination procedure}, oropharynx {Oropharyngeal structure}, lesions {Lesion}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, irregular {Irregular heart beat}, LS {Examination of respiratory system}, CTA {Normal breath sounds}, Abd {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, HSM {Hepatosplenomegaly}, +BS {Normal bowel sounds}, masses {Mass}, palpated {Palpation}, Extr {Examination of limb}, edema {Edema}, Skin {Examination of skin}, rash {Eruption of skin}, Neuro {Neurological examination}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, nystagmus {Nystagmus}, gait appropriate {Gait normal}, unsteady at baseline on tandem 
gait {Tandem gait test - abnormal}, ecchymosis {Ecchymosis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 12:11AM BLOOD WBC-2.6* RBC-2.26* Hgb-7.5* Hct-21.5* 
MCV-95 MCH-33.3* MCHC-35.0 RDW-19.2* Plt ___
___ 09:05AM BLOOD WBC-4.1 RBC-2.88* Hgb-9.0* Hct-27.3* 
MCV-95 MCH-31.3 MCHC-33.0 RDW-18.2* Plt ___
___ 12:11AM BLOOD Neuts-91.9* Lymphs-1.5* Monos-0.9* 
Eos-5.5* Baso-0.2
___ 09:05AM BLOOD Neuts-84* Bands-0 Lymphs-3* Monos-12* 
Eos-0 Baso-1 ___ Myelos-0 NRBC-1*
___ 12:11AM BLOOD Glucose-95 UreaN-16 Creat-0.7 Na-139 
K-3.0* Cl-104 HCO3-27 AnGap-11
___ 09:05AM BLOOD Glucose-103* UreaN-10 Creat-0.6 Na-140 
K-3.9 Cl-105 HCO3-25 AnGap-14
___ 12:11AM BLOOD Albumin-3.3* Calcium-7.7* Phos-4.7* 
Mg-1.8
___ 09:05AM BLOOD Albumin-4.0 Calcium-9.3 Phos-4.6* Mg-1.7 
UricAcd-5.9*
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, 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}, 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}, 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}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ year old female with multiply relapsed NHL
admitted for cycle 2 of R-bendamustine cytarabine.

# Lymphoma: -Rituxan 700mg IV (375mg/m2) D1
           -Cytarabine 1540 IV (800mg/m2) D2-4
           -Bendamustine 125mg IV (70mg/m2) D2-3
           -Pred drops up until 48hrs after cytarabine completes
          - IVF/antiemetics per protocol
          - Neuro exams assessed prior to each dose of ara-c

#Dyspnea: Resolved. may be combination of reactive airway flare 
vs fluid
overload vs URI. CXR shows some fluid, no signs of active
infection. strict I/Os, diurese prn. resp swab PND.

#Fever: non neutropenic, may be secondary to chemo vs URI. will
send resp swab. b and u culture NTD, (u culture contaminate). 
tylenol prn for relief.
- fever resolved after 1 day

# Nausea: supportive meds with dex, zofran pre chemo. add emend
po D2-4. give script at d/c for zyprexa to prevent delayed n/v
from last cycle. remind her to continue bowel regimen at d/c.

# Prophylaxis: acyclovir. consider bactrim if will not be on
coumadin.

# Osteoarthritis: tramadol prn. tylenol prn for breakthrough.
does not tolerate oxycodone-nausea. ___ evaluate, lifeline at 
home and stable on feet. okay for safe discharge home.

# Paroxysmal a fib: EKG overnight with fever on ___, rate 
stable in
70's, 80's. converted back with HR in 60's prior to discharge. 
continue ___ go home with xarelto per primary 
oncologist.

# HTN: continue amlodipine with parameters

# GERD: omeprazole daily

# Hypothyroidism: continue synthroid daily

# Hypercholestermia: hold during chemotherapy

# DVT prophylaxis: restarted Lovenox after port placement, will 
go home with xarelto
# F/E/N: replace electrolytes prn. IVF as ordered.
# Access: POC
# code status Full
# dispo: home, neulasta in clinic ___

 

###RESPONSE: NHL {Non-Hodgkin's lymphoma}, Lymphoma {Malignant lymphoma}, Neuro exams {Neurological examination}, Dyspnea {Dyspnea}, Resolved {Problem resolved}, reactive airway flare {Reactive airway disease}, fluid
overload {Hypervolemia}, URI {Upper respiratory infection}, CXR {Plain chest X-ray}, fluid {Effusion}, active
infection {Infectious disease}, diurese {Diuresis}, swab {Taking of swab}, Fever {Fever}, neutropenic {Neutropenia}, chemo {Chemotherapy}, URI {Upper respiratory infection}, swab {Taking of swab}, b {Blood culture}, u culture {Urine culture}, (u culture {Urine culture}, fever {Fever}, resolved {Problem resolved}, Nausea {Nausea}, chemo {Chemotherapy}, n/v {Nausea and vomiting}, bowel regimen {Bowel care}, Prophylaxis {Preventive procedure}, Osteoarthritis {Osteoarthritis}, nausea {Nausea}, feet {Foot structure}, Paroxysmal a fib {Paroxysmal atrial fibrillation}, EKG {Electrocardiographic procedure}, fever {Fever}, rate 
stable {Pulse rate stable}, HTN {Hypertensive disorder, systemic arterial}, GERD {Gastroesophageal reflux disease}, Hypothyroidism {Hypothyroidism}, Hypercholestermia {Hypercholesterolemia}, chemotherapy {Chemotherapy}, DVT prophylaxis {Prevention of deep vein thrombosis}, restarted {Restart of medication}, port placement {Insertion of implantable venous access port}, IVF {Administration of intravenous fluids}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Acetaminophen 650 mg PO Q6H:PRN pain 
2. Acyclovir 400 mg PO Q8H 
3. Amlodipine 2.5 mg PO DAILY 
4. Fexofenadine 180 mg PO DAILY 
5. Fluticasone Propionate NASAL ___ SPRY NU DAILY 
6. FoLIC Acid 1 mg PO DAILY 
7. Gabapentin 300 mg PO HS 
8. Levothyroxine Sodium 50 mcg PO DAILY 
9. Omeprazole 20 mg PO DAILY 
10. Prochlorperazine 10 mg PO Q6H:PRN nausea 
11. Sotalol 160 mg PO BID 
12. Warfarin 2.5-5 mg PO ASDIR 
13. Docusate Sodium 100 mg PO BID 
14. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety insomnia nausea 
15. Polyethylene Glycol 17 g PO DAILY:PRN no bm in 24h 
16. PrednisoLONE Acetate 1% Ophth. Susp. 2 DROP BOTH EYES QID 
17. Senna 8.6 mg PO BID 
18. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 
19. Atorvastatin 20 mg PO QPM 
20. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 
mg(1,500mg) -200 unit oral BID 
21. Multivitamins 1 TAB PO DAILY 
22. Vitamin D ___ UNIT PO DAILY 
23. Ondansetron 8 mg PO Q8H:PRN nausea 

 
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain 
2. Acyclovir 400 mg PO Q8H 
3. Docusate Sodium 100 mg PO BID 
4. Fexofenadine 180 mg PO DAILY 
5. Fluticasone Propionate NASAL ___ SPRY NU DAILY 
6. Gabapentin 300 mg PO HS 
7. Levothyroxine Sodium 50 mcg PO DAILY 
8. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety insomnia nausea 
9. Omeprazole 20 mg PO DAILY 
10. Polyethylene Glycol 17 g PO DAILY:PRN no bm in 24h 
11. PrednisoLONE Acetate 1% Ophth. Susp. 2 DROP BOTH EYES QID 
12. Prochlorperazine 10 mg PO Q6H:PRN nausea 
13. Senna 8.6 mg PO BID 
14. Sotalol 160 mg PO BID 
15. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 
16. Vitamin D ___ UNIT PO DAILY 
17. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 
mg(1,500mg) -200 unit oral BID 
18. FoLIC Acid 1 mg PO DAILY 
19. Multivitamins 1 TAB PO DAILY 
20. Ondansetron 8 mg PO Q8H:PRN nausea 
21. Rivaroxaban 20 mg PO DAILY 
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth daily Disp 
#*30 Tablet Refills:*2
22. OLANZapine 5 mg PO HS 
RX *olanzapine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet 
Refills:*0
23. Allopurinol ___ 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:
lymphoma
reactive airway disease

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: lymphoma {Malignant lymphoma}, reactive airway disease {Reactive airway disease}, Mental Status {Neurological mental status determination}, Clear {No abnormality detected}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Ms. ___,

You were admitted to receive chemotherapy. You tolerated this 
well however developed worsening shortness of breath and cough 
overnight on ___. We did a workup which was most consistent 
with your history of asthma flare with an upper respiratory 
infection and fluid overload. Your symptoms improved with 
nebulizer treatment and lasix.

You will follow up tomorrow in clinic to receive your neulasta 
injection and to follow up with your outpatient team. Please do 
not hesitate to call in the meantime with any fevers, chills, 
worsening cough, shortness of breath, or any other concerns.
 

###RESPONSE: chemotherapy {Chemotherapy}, shortness of breath {Dyspnea}, cough {Cough}, workup {Evaluation procedure}, asthma {Asthma}, upper respiratory 
infection {Upper respiratory infection}, fluid overload {Hypervolemia}, improved {Patient's condition improved}, nebulizer treatment {Nebulizer therapy}, lasix {Diuretic therapy}, clinic {Outpatient care management}, injection {Injection}, fevers {Fever}, chills {Chill}, cough {Cough}, shortness of breath {Dyspnea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   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: 
Ketorolac
 
Attending: ___.
 
Chief Complaint:
Chest pain and shortness of breath
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: Chest pain {Chest pain}, shortness of breath {Dyspnea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ year-old woman from nursing facility presents with shortness 
of breath with substernal chest pain since the morning of 
admission.  The patient had no relief from 3 sublingual 
nitroglycerin tablets, but got relief after receiving morphine 
in the emergency department.  The chest pain was non-radiating 
and ___.  She currently only complains of mild discomfort of 
the chest.

She denies fevers or chills, but did have a cough for the last 2 
weeks productive of yellow phlegm.  She is staying at the 
nursing facility because she is very debilitated from lower 
extremity weakness and poor balance.  She can walk short 
distances with a walker.  Denies orthopnea or PND.

She denies headache, neck pain, abdominal pain, nausea, 
vomiting, dysuria.  She does have urinary incontinence, but no 
stool incontinence.  She complains of constipation.  She 
endorses arthritic joint pain everywhere.  She does not have 
confusion.
 

###RESPONSE: shortness 
of breath {Dyspnea}, substernal chest pain {Retrosternal pain}, relief after receiving morphine {Pain relieved by analgesic}, chest pain {Chest pain}, discomfort of 
the chest {Chest discomfort}, fevers {Fever}, chills {Chill}, cough for the last 2 
weeks productive {Productive cough}, lower 
extremity weakness {Paresis of lower extremity}, poor balance {Poor balance}, walk short 
distances with a walker {Does mobilize using walker}, orthopnea {Orthopnea}, headache {Headache}, neck pain {Pain radiating to neck}, abdominal pain {Abdominal pain}, nausea, 
vomiting {Nausea and vomiting}, dysuria {Dysuria}, urinary incontinence {Urinary incontinence}, stool incontinence {Incontinence of feces}, constipation {Constipation}, joint pain {Joint pain}, confusion {Clouded consciousness}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1. CAD status post CABG in ___ with an EF of greater than 55% 
2. Chronic Atrial fibrillation but recently in NSR, on 
amiodarone but not on anti-coagulation
3. Hypertension
4. Diabetes mellitus type 2 
5. Hypercholesterolemia
6. Superficial spreading melanoma 
7. Hip fracture with ORIF in ___
8. Urinary tract infection 
9. Thyroid disease
10. Urinary incontinence
11. Constipation
12. Melanoma, locally metastatic with chemo ___
13. Right humeral head fracture in ___
14. s/p multiple falls 
 

###RESPONSE: CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, Chronic Atrial fibrillation {Chronic atrial fibrillation}, NSR {Normal sinus rhythm}, Hypertension {Hypertensive disorder, systemic arterial}, Diabetes mellitus type 2 {Diabetes mellitus type 2}, Hypercholesterolemia {Hypercholesterolemia}, Superficial spreading melanoma {Superficial spreading melanoma}, Hip fracture {Fracture of proximal end of femur}, ORIF {Open reduction of fracture with internal fixation}, Urinary tract infection {Urinary tract infectious disease}, Thyroid disease {Disorder of thyroid gland}, Urinary incontinence {Urinary incontinence}, Constipation {Constipation}, Melanoma {Malignant melanoma of skin}, metastatic {Metastatic malignant neoplasm}, chemo {Chemotherapy}, Right humeral head fracture {Closed fracture of capitellum of right humerus}, falls {Falls}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Non contributory

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VS: 98.2 123/82 72 19 96% on 2L
GEN: NAD, comfortable in bed, awake and alert
HEENT: PERRL, EOMI, MMM, no oropharyngeal lesions
NECK: Supple, JVP 7-8cm
CHEST: CTAB
CV: RRR, normal s1 and s2
ABD: Soft, nontender, nondistended, bowel sounds present
EXT: No lower extremity edema
SKIN: No rash
NEURO: CN ___ intact x mild decrease in hearing on right ear, 
sensory intact throughout, strength ___ BUE/BLE, did not 
ambulate patient, fluent speech
PSYCH: Pleasant, calm
 

###RESPONSE: VS {Vital signs finding}, GEN {General examination of patient}, NAD {No abnormality detected}, awake {Awake}, alert {Mentally alert}, HEENT {Physical examination procedure}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, lesions {Lesion}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, CHEST {Examination of respiratory system}, CTAB {Normal breath sounds}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, normal s1 {Normal first heart sound, S>1<}, ABD {Examination of abdomen}, Soft {Abdomen soft}, nontender {Abdominal tenderness}, nondistended {Normal abdominal contour}, EXT {Examination of limb}, edema {Edema}, SKIN {Examination of skin}, rash {Eruption of skin}, NEURO {Neurological examination}, decrease in hearing on right ear, {Hearing test right abnormality}, fluent speech {Finding of fluency of speech}, PSYCH {Initial psychiatric assessment}, calm {Feeling calm}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___
WBC-8.9 Hgb-12.7 Hct-38.5 MCV-88 Plt ___
Neuts-72.2* ___ Monos-5.0 Eos-1.8 Baso-0.8

___ PTT-28.4 ___

Glucose-236* UreaN-36* Creat-1.1 Na-142 K-4.1 Cl-99 HCO3-32 
AnGap-15

CK(CPK)-62 cTropnT-0.06* proBNP-2636*

URINE Color-Straw Appear-Clear Sp ___ Blood-NEG 
Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG 
Urobiln-NEG pH-5.0 Leuks-NEG

CXR IMPRESSION: 
Left lower lobe consolidation, possibly atelectasis but 
infection 
is not excluded. Small bilateral pleural effusions. 

 

###RESPONSE: WBC {White blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, cTropnT {Troponin T cardiac measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, URINE Color-Straw {Normal urine color}, Protein {Measurement of protein in urine}, Glucose {Glucose measurement, blood}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, CXR {Plain chest X-ray}, Left lower lobe consolidation {Lung consolidation}, atelectasis {Atelectasis}, infection {Infectious disease}, pleural effusion {Pleural effusion}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ year-old woman admitted with chest pain and shortness of 
breath with evidence of possible PNA on CXR. The patient 
received Vancomycin and Levaquin in the ED for possible 
pneumonia and Lasix 10mg IV for possible congestive heart 
failure. During her hospital course, her presentation was less 
consistent with congestive heart failure, furthermore she does 
not have a history of heart failure. She was ruled out for 
cardiac ischemia or arrythmia. Her symptoms are thought to be 
related to mild pneumonia versus bronchitis. Throughout her stay 
her vital signs were stable and she never required supplemental 
oxygen. We increased her long acting Isosorbide mononitrate to 
60 mg daily for better blood pressure control. She will need to 
finish a 7 day course of Levofloxacin. She was seen by 
cardiology in consultation, who felt that her chest pain may be 
cardiac, but they recommended medical management at present (in 
the absence of elevated cardiac enzymes and EKG changes) with 
potential additional diagnostics (e.g. stress test) to be 
pursued as an outpatient. She will need follow up with 
cardiology, and a new echocardiogram. Both of these should be 
scheduled by the rehab facility, as we could not make these 
appointments over the weekend.  

Her daytime blood sugars were high on multiple occasions. She 
may benefit from oral anti-diabetic regiment, which could be 
considered as outpatient. All her other chronic medical problems 
were stable, and required no change in her treatment plan.  

During this hospitalization she expressed the wish to be 
DNR/DNI.
 

###RESPONSE: chest pain {Chest pain}, shortness of 
breath {Dyspnea}, PNA {Pneumonia}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, congestive heart 
failure {Congestive heart failure}, congestive heart failure {Congestive heart failure}, heart failure {Heart failure}, cardiac ischemia {Myocardial ischemia}, arrythmia {Cardiac arrhythmia}, pneumonia {Pneumonia}, bronchitis {Bronchitis}, vital signs were stable {Normal vital signs}, consultation {Consultation}, chest pain {Chest pain}, cardiac {Heart disease}, elevated cardiac enzymes {Finding of cardiac enzyme levels}, EKG changes {Electrocardiogram abnormal}, stress test {Electrocardiogram with exercise test}, follow up with 
cardiology {Follow-up cardiac assessment}, echocardiogram {Echocardiography}, blood sugars {Glucose measurement, blood}, oral {Administration of drug or medicament via oral route}, regiment {Therapeutic regimen}, problems {Problem}, stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Levothyroxine 50mcg daily
Aspirin 325mg daily
Cyanocobalamin 1000mcg injection qmonth
Senna 8.6mg 2 tabs daily
Plavix 75mg daily
Lisinopril 5mg daily
Digoxin 0.125mg daily
Metoprolol ER 100mg BID
Isosorbide mononitrate 30mg daily
Lidoderm 5% patch to knee 9am, remove at 9pm
Bumetanide 2mg qam, 1mg qpm
Glimepiride 2mg daily
Crestor 10mg daily
Sliding scale insulin
Albuterol/Atrovent nebs prn
 
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for 
Nebulization Sig: One (1) Nebulization Inhalation Q6H (every 6 
hours) as needed for Bronchospasm.  
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation 
Inhalation Q6H (every 6 hours) as needed for wheezing.  
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) 
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for 
Constipation.  
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours) as needed for Pain: please give prior to ambulation for 
left ankle pain.  
9. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr 
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a 
day).  
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: 
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily): Apply 
to one to right knee and one to left ankle at 9am, remove at 9pm 
daily. 
.  
14. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
15. Insulin Regular Human 100 unit/mL Solution Sig: as directed 
per standard insulin sliding scale 1 to 12 Injection ASDIR (AS 
DIRECTED).  
16. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr 
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).  
17. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H 
(every 48 hours) for 4 days.  
18. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) 
pack PO DAILY (Daily) as needed for constipation.  
19. Guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6 
hours) as needed for cough.  
20. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 
times a day) for 5 days.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Primary:
Pneumonia
Chest pain
Secondary:
Coronoray artery disease, Chronic Atrial fibrillation, 
Hypertension, Diabetes mellitus type 2, Hypercholesterolemia, 
Constipation

 
Discharge Condition:
Pain free, oxygen saturation 96% on RA

 

###RESPONSE: Pneumonia {Pneumonia}, Chest pain {Chest pain}, Coronoray artery disease {Coronary arteriosclerosis}, Chronic Atrial fibrillation {Chronic atrial fibrillation}, Hypertension {Hypertensive disorder, systemic arterial}, Diabetes mellitus type 2 {Diabetes mellitus type 2}, Hypercholesterolemia {Hypercholesterolemia}, Constipation {Constipation}, Pain free {No present 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: Discharge Instructions:
You were admitted with chest pain and cough. You are being 
treated for mild lung infection and will need to continue taking 
your antibiotic as prescribed. We evaluated you also for any 
heart problem, however could not find any abnormality with your 
heart. You will need a follow up appointment scheduled with your 
cardiologist as an outaptient for ongoing managment of your 
congestive heart failure.

We increased your Isosorbid mononitrate to 60 mg daily
you need to continue taking Levofloxacine for 4 more days (Q48H)
 
 

###RESPONSE: chest pain {Chest pain}, cough {Cough}, lung infection {Infectious disease of lung}, antibiotic {Antibiotic therapy}, heart {Heart structure}, abnormality {No abnormality detected}, heart {Heart structure}, congestive heart failure {Congestive heart failure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: ___
 

###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:
fever, respiratory distress
 
Major Surgical or Invasive Procedure:
Intubation ___
Extubation ___ 

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, fever {Fever}, respiratory distress {Respiratory distress}, Intubation {Insertion of endotracheal tube}, Extubation {Removal of endotracheal tube}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
This is a ___ male with history of Alzheimer's,
previously on hospice care (recently discharged), who presents
with respiratory distress. Patient is nonverbal at baseline and
significantly altered and unable to provide additional history.
Today wife felt that he was increasingly sleepy and brought him
here for evaluation. He had a fever last night. Seen by ___ visiting clinician on ___ for aspiration/pneumonia, 
for
which he received 10 day course of levofloxacin. Wife states he
has not had a cough but he has been having noisy breathing. No
vomiting or diarrhea. As he is nonverbal he has not been able to
articulate any specific complaints.

In the ED, patient minimally responsive on initial evaluation 
and
hypoxic to the mid ___ on room air. He had difficulty increasing
oxygenation with nonrebreather and patient was too altered to
tolerate BiPAP. Therefore he was intubated. Received 3L LR,
vancomycin and cefepime in the ED. Chest x-ray suggestive of
aspiration pneumonia. WBC elevated and Hct/Hgb suggested
significant hemoconcentration.

On my evaluation, patient was intubated and unable to 
participate
in history. He has previously had MOLST form with DNR/DNI
completed ___. Per daughter, currently DNR/ok to intubate.

In the ED, initial vitals: T100.8 HR139 BP145/94 RR20 SpO2 90%
nrb  

Exam:  
General: Seated in bed, minimally responsive
Head/eyes: Normocephalic/atraumatic. Pupils equal round and
reactive to light.
ENT/neck: Dry mucous membranes
Chest/Resp: Tachypnea, poor air movement, rhonchorous
Cardiovascular: Tachycardic, regular
GI/abdominal: Soft, nondistended
Musc/Extr/Back: No peripheral edema. 
Skin: Warm and dry
Psych: Poor mentation

Labs:  Na 150  Cl 110  BUN34  Glu189  K4.0  Bicarb23  Cr1.2  
AGap=17 
Ca: 10.3 Mg: 2.7 P: 2.7
ALT: 21 AP: 87 Tbili: 0.7 Alb: 3.8 
AST: 15  Lip: 13     
WBC 27.9  Hgb17.7/Hct 54.8 Plt326 
Flu negative

Imaging: 
CXR ___: Lower lung opacities concerning for pneumonia versus
the sequelae of aspiration. Possible pulmonary vascular
congestion. 

Consults: None 

Interventions:  Intubation

VS Prior to Transfer: T98.9 HR80 BP93/62 RR16 SpO296% Intubation 


ROS: Positives as per HPI; otherwise negative.  
 

###RESPONSE: Alzheimer {Alzheimer's disease}, hospice care {Hospice care}, discharged {Discharge from hospice}, respiratory distress {Respiratory distress}, nonverbal {Does not speak}, baseline {Baseline state}, sleepy {Drowsy}, evaluation {Evaluation procedure}, fever {Fever}, aspiration {Aspiration pneumonia}, pneumonia {Pneumonia}, levofloxacin {Antibiotic therapy}, cough {Cough}, noisy breathing {Noisy respiration}, vomiting {Vomiting}, diarrhea {Diarrhea}, nonverbal {Does not speak}, evaluation {Evaluation procedure}, hypoxic {Hypoxia}, on room air {Breathing room air}, oxygenation with nonrebreather {Oxygen administration by mask}, BiPAP {Bilevel positive airway pressure titration}, intubated {Insertion of endotracheal tube}, vancomycin {Antibiotic therapy}, Chest x-ray {Plain chest X-ray}, aspiration pneumonia {Aspiration pneumonia}, WBC elevated {White blood cell count outside reference range}, Hct {Hematocrit determination}, Hgb {Measurement of total hemoglobin concentration}, evaluation {Evaluation procedure}, intubated {Insertion of endotracheal tube}, DNR {Not for resuscitation}, DNR {Not for resuscitation}, vitals {Vital signs finding}, nrb {Oxygen administration by mask}, General {General examination of patient}, Seated {Sitting position}, Head/eyes {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, Pupils equal round and
reactive to light {Pupils equal and reacting to light}, ENT/neck {Physical examination procedure}, Dry mucous membranes {Mucous membrane dryness}, Chest {Thoracic structure}, Resp {Examination of respiratory system}, Tachypnea {Tachypnea}, rhonchorous {Wheeze - rhonchi}, Cardiovascular {Cardiovascular physical examination}, Tachycardic {Tachycardia}, regular {Normal heart rate}, GI {Examination of digestive system}, abdominal {Examination of abdomen}, Soft {Abdomen soft}, nondistended {Normal abdominal contour}, Musc {Examination of muscle power}, Extr {Examination of limb}, peripheral edema {Peripheral edema}, Skin {Examination of skin}, Warm {Warm skin}, dry {Xeroderma}, Psych {Neurological mental status determination}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, WBC {White blood cell count}, Hct {Hematocrit determination}, Flu {Influenza}, Imaging {Imaging}, CXR {Plain chest X-ray}, Lower lung {Structure of lower lobe of lung}, opacities {Abnormally opaque structure}, pneumonia {Pneumonia}, sequelae {Sequelae of disorders}, aspiration {Aspiration pneumonia}, pulmonary vascular {Structure of pulmonary blood vessel}, congestion {Congestion}, Intubation {Insertion of endotracheal tube}, VS {Vital signs finding}, Intubation {Insertion of endotracheal tube}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Essential hypertension 
Hypercholesteremia 
Early onset Alzheimer's disease with behavioral disturbance 
Aspiration pneumonia of both lower lobes 
Slow transit constipation 
 

###RESPONSE: Essential hypertension {Essential hypertension}, Hypercholesteremia {Hypercholesterolemia}, Early onset Alzheimer's disease with behavioral disturbance {Early onset Alzheimer's disease with behavioral disturbance}, Aspiration pneumonia {Aspiration pneumonia}, lower lobes {Structure of lower lobe of lung}, Slow transit constipation {Slow transit constipation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Noncontributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM: 
======================== 
VS: Reviewed in Metavision, HR 78 BP 93/64, SpO2 96%, RR 15 
GEN: Intubated, sedated 
EYES: Pupils equal and nonreactive  
HENNT: Intubated, trachea midline 
CV: RRR, no m/r/g
RESP:  Mechanical breath sounds 
GI: Bowel sounds present 
MSK: No gross deformity, warm extremities 
SKIN: No rashes or skin breakdown  
NEURO: Intubated and sedated 
PSYCH: Unable to assess 

DISCHARGE PHYSICAL EXAM:
========================
Not examined fully as he is CMO; appeared comfortable, without 
labored or rapid respirations. No response to voice or touch. No 
grimacing, restlessness, or obvious signs of distress.

 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, GEN {General examination of patient}, Intubated {Insertion of endotracheal tube}, sedated {Sedated}, EYES {Ophthalmic examination and evaluation}, Pupils equal {Pupils equal}, NT {Abdominal tenderness}, Intubated {Insertion of endotracheal tube}, trachea {Tracheal structure}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, RESP {Examination of respiratory system}, GI {Examination of digestive system}, Bowel sounds present {Normal bowel sounds}, MSK {Musculoskeletal system physical examination}, deformity {Deformity}, warm {Warm skin}, SKIN {Examination of skin}, rashes {Eruption of skin}, skin breakdown {Broken skin}, NEURO {Neurological examination}, Intubated {Insertion of endotracheal tube}, sedated {Sedated}, PSYCH {Neurological mental status determination}, appeared comfortable {Comfortable appearance}, labored {Labored breathing}, rapid respirations {Tachypnea}, response to voice {Responds to voice}, touch {Finding of sensation of touch}, grimacing {Facial grimacing}, restlessness {Restlessness}, signs {Sign}, distress {Distress}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
===============
___ 05:30PM BLOOD WBC-27.9* RBC-5.73 Hgb-17.7* Hct-54.8* 
MCV-96 MCH-30.9 MCHC-32.3 RDW-13.5 RDWSD-47.8* Plt ___
___ 05:30PM BLOOD Neuts-90.4* Lymphs-3.2* Monos-4.2* 
Eos-0.0* Baso-0.4 Im ___ AbsNeut-25.18* AbsLymp-0.89* 
AbsMono-1.18* AbsEos-0.00* AbsBaso-0.12*
___ 05:59PM BLOOD ___ PTT-32.7 ___
___ 05:30PM BLOOD Glucose-189* UreaN-34* Creat-1.2 Na-150* 
K-4.0 Cl-110* HCO3-23 AnGap-17
___ 05:30PM BLOOD ALT-21 AST-15 AlkPhos-87 TotBili-0.7
___ 05:30PM BLOOD Lipase-13
___ 05:30PM BLOOD Albumin-3.8 Calcium-10.3 Phos-2.7 Mg-2.7*
___ 10:15AM BLOOD Triglyc-156*
___ 06:37PM BLOOD Type-ART pO2-155* pCO2-29* pH-7.48* 
calTCO2-22 Base XS-0
___ 05:34PM BLOOD Lactate-2.3*

LAST SET OF LABS BEFORE ___ MADE CMO (___):
==============================================
___ 11:53AM BLOOD WBC-8.7 RBC-3.71* Hgb-11.6* Hct-35.8* 
MCV-97 MCH-31.3 MCHC-32.4 RDW-13.0 RDWSD-45.8 Plt ___
___ 04:03AM BLOOD Glucose-85 UreaN-11 Creat-0.5 Na-141 
K-4.2 Cl-111* HCO3-21* AnGap-9*
___ 04:03AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.3

MICRO:
======
__________________________________________________________
___ 7:24 pm SPUTUM      Source: Endotracheal. 

                            **FINAL REPORT ___

   GRAM STAIN (Final ___: 
      >25 PMNs and <10 epithelial cells/100X field. 
      NO MICROORGANISMS SEEN. 

   RESPIRATORY CULTURE (Final ___: 
      Commensal Respiratory Flora Absent. 
      YEAST.    SPARSE GROWTH. 
__________________________________________________________
___ 8:00 am MRSA SCREEN      Source: Nasal swab. 

                            **FINAL REPORT ___

   MRSA SCREEN (Final ___:    No MRSA isolated. 
__________________________________________________________
___ 5:49 pm BLOOD CULTURE

                            **FINAL REPORT ___

   Blood Culture, Routine (Final ___:    NO GROWTH. 
__________________________________________________________
___ 5:30 pm BLOOD CULTURE

                            **FINAL REPORT ___

   Blood Culture, Routine (Final ___:    NO GROWTH. 

IMAGING:
========
___ Imaging CHEST (PORTABLE AP) 
1.  ET tube terminates 5.7 cm above the carina.  Consider slight 
advancement for more optimal positioning.  OG tube positioned 
appropriately. 
2.  Lower lung opacities concerning for pneumonia versus the 
sequelae of 
aspiration.  Possible pulmonary vascular congestion. 

___ Imaging CHEST (PORTABLE AP) 
Lungs are low volume with bibasilar atelectasis.  Mild 
interstitial edema is unchanged.  Support lines and tubes are 
stable.  Cardiomediastinal silhouette is also unchanged.  Small 
bilateral effusions left greater than right are unchanged.  No 
pneumothorax is seen. 

___-SPINE W/O CONTRAST 
1. No evidence of acute fracture or malalignment. 
2. Mild cervical spondylosis. 

___ Imaging CT HEAD W/O CONTRAST 
1. No evidence of an acute intracranial abnormality. 
2. Severe parenchymal atrophy. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Administration of albumin}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Triglyc {Triglycerides measurement}, pH {pH measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, GRAM STAIN {Gram stain method}, cells {Cell structure}, RESPIRATORY CULTURE {Respiratory microbial culture}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, Nasal {Nasal structure}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, Imaging {Imaging}, CHEST (PORTABLE AP {Plain x-ray of chest anteroposterior view}, carina {Structure of carina of trachea}, for more optimal positioning {Checking position of endotracheal tube}, OG tube positioned {Checking position of nasogastric tube using X-ray}, Lower lung {Structure of lower lobe of lung}, opacities {Abnormally opaque structure}, pneumonia {Pneumonia}, sequelae {Sequelae of disorders}, aspiration {Aspiration pneumonia}, pulmonary vascular {Structure of pulmonary blood vessel}, congestion {Congestion}, Imaging {Imaging}, CHEST (PORTABLE AP {Plain x-ray of chest anteroposterior view}, Lungs {Lung structure}, low volume {Decreased size}, bibasilar {Structure of base of lung}, atelectasis {Atelectasis}, Mild {Symptom mild}, interstitial edema {Edema}, Small {Symptom mild}, bilateral effusions {Bilateral pleural effusion}, left {Left pleura structure}, right {Right pleura structure}, pneumothorax {Pneumothorax}, SPINE {Computed tomography of spine}, W/O CONTRAST {Computed tomography without contrast}, No evidence {No abnormality detected}, fracture {Fracture}, malalignment {Misalignment}, Mild {Symptom mild}, cervical spondylosis {Cervical spondylosis}, Imaging {Imaging}, CT HEAD W/O CONTRAST {Computed tomography of head without contrast}, No evidence {No abnormality detected}, intracranial {Intracranial structure}, abnormality {No abnormality detected}, atrophy {Atrophy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Patient is ___ male with history of severe Alzheimer's, 
previously on hospice who presented with respiratory failure 
requiring urgent intubation. The patient's family was present 
for goals of care discussion, and it was ultimately decided to 
transition to comfort-focused care with hospice.

ACUTE PROBLEMS:
===============
# Hypoxemic respiratory failure
The patient was brought in from home with increasing somnolence, 
cough, and labored breathing. He was hypoxemic to the ___ on 
arrival to the emergency room. He was started on IV vancomycin 
and cefepime. CXR suggested aspiration pneumonia. He was 
intubated and transferred to the intensive care unit. The ICU 
team discussed goals of care with the patient's family, who 
decided that the patient would not want to be on a ventilator. 
He was extubated and transferred to the general floor for 
comfort care. Subsequent respiratory distress was management 
with IV morphine gtt and then SL liquid morphine.

# Hypovolemic hypernatremia
Patient was given IV fluids with subsequent improvement.

# Myoclonus
# Encephalopathy
Patient has dementia and is non-verbal at baseline, with acutely 
worsened mental status in setting of infection. He was found to 
have clonus of the extremities. Head CT and CT-spine were 
unremarkable. There was low concern for seizures per neurology. 

# Goals of care
The patient was previously on hospice prior to this admission. 
Due to respiratory failure, the family decided to change the 
patient's code status to DNR/DNI, comfort care, with plan for 
home hospice. The patient was maintained on oral morphine and 
Ativan for comfort. 

========================
TRANSITIONAL ISSUES
========================
[ ] Patient is discharged to home hospice with scripts for 
morphine and Ativan as needed for comfort.

[x] The patient is safe to discharge today, and I spent [x] 
<30min; [ ] >30min in discharge day management services.

___, MD
___
Pager ___
 

###RESPONSE: Alzheimer {Alzheimer's disease}, hospice {Hospice care}, respiratory failure {Respiratory failure}, intubation {Insertion of endotracheal tube}, discussion {Discussion}, hospice {Hospice care}, Hypoxemic respiratory failure {Hypoxemic respiratory failure}, somnolence {Drowsy}, cough {Cough}, labored breathing {Labored breathing}, hypoxemic {Hypoxemia}, IV {Administration of drug or medicament via intravenous route}, vancomycin {Antibiotic therapy}, CXR {Plain chest X-ray}, aspiration pneumonia {Aspiration pneumonia}, intubated {Insertion of endotracheal tube}, transferred to the intensive care unit {Patient transfer to intensive care unit}, extubated {Removal of endotracheal tube}, comfort care {Comfort measures}, respiratory distress {Respiratory distress}, IV {Administration of drug or medicament via intravenous route}, SL {Administration of substance via sublingual route}, liquid {Liquid}, Hypovolemic {Hypovolemia}, hypernatremia {Hypernatremia}, given IV fluids {Administration of intravenous fluids}, improvement {Patient's condition improved}, Myoclonus {Myoclonus}, Encephalopathy {Disorder of brain}, dementia {Dementia}, non-verbal {Does not speak}, baseline {Baseline state}, worsened mental status {Altered mental status}, infection {Infectious disease}, clonus {Clonus}, extremities {Limb structure}, Head CT {Computed tomography of head}, CT-spine {Computed tomography of spine}, unremarkable {No abnormality detected}, seizures {Seizure}, hospice {Hospice care}, respiratory failure {Respiratory failure}, DNR {Not for resuscitation}, comfort care {Comfort measures}, home hospice {Referral to hospice at home service}, oral {Administration of drug or medicament via oral route}, hospice {Referral to hospice at home service}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 5 mg PO DAILY 
2. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough 
3. Hyoscyamine 0.125 mg PO QID:PRN secretions 
4. amLODIPine 10 mg PO DAILY 
5. Pravastatin 20 mg PO QPM 
6. Lisinopril 2.5 mg PO DAILY 
7. Hydrochlorothiazide 25 mg PO DAILY 
8. Donepezil 10 mg PO QHS 

 
Discharge Medications:
1.  Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever  
2.  Atropine Sulfate 1% ___ DROP SL Q4H:PRN excess secretions  
3.  Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions  
4.  LORazepam Oral Solution 0.5 mg PO Q6H:PRN agitation, anxiety 

RX *lorazepam 2 mg/mL 0.25 ml by mouth Once every six hours 
Refills:*0 
5.  Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ 
mg SL Q2H:PRN respiratory distress, pain 
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.75-1.0 ml by 
mouth Once every two hours Refills:*0 
6.  Scopolamine Patch 1 PTCH TD Q72H  

 

###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:
-Aspiration pneumonia
-Acute hypoxemic respiratory failure 

 
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.

 

###RESPONSE: With Service {Referral to hospice at home service}, Aspiration pneumonia {Aspiration pneumonia}, Acute hypoxemic respiratory failure {Acute hypoxemic respiratory failure}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, Level of Consciousness {Assessment of consciousness level}, Lethargic {Lethargy}, Activity Status {Physical functional dependency}, Bedbound {Bed-ridden}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. ___ and ___,  

It was a pleasure caring for you at ___ 
___.  

WHY WERE YOU IN THE HOSPITAL?  
- You were admitted to the hospital for difficulty breathing.

WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? 
- You had a breathing tube placed and were connected to a 
ventilator for your difficulty breathing.
- Your family decided to remove the breathing tube and focus on 
making you comfortable.  
- You were connected with hospice care and arrangements were 
made for you to go home on hospice.

WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?  
- Enjoy spending time with your family and loved ones.
 
Sincerely,  

Your ___ Team
 

###RESPONSE: difficulty breathing {Difficulty breathing}, breathing tube placed {Insertion of endotracheal tube}, ventilator {Ventilator care}, difficulty breathing {Difficulty breathing}, remove the breathing tube {Removal of endotracheal tube}, hospice care {Hospice care}, hospice {Referral to hospice at home service}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
dyspnea, wheezing
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: dyspnea {Dyspnea}, wheezing {Wheezing}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ is a ___ pMHx COPD, asthma, GERD, and metastatic
carcinoma to the brain of unknown origin s/p resection and WBRT
in ___ who presents with dyspnea/wheezing.   

She states that she has had 2 weeks of progressive SOB which
began with 1 week of URI-type symptoms. She states that she has
had a new productive cough over the past week as well.  She is
normally on 10 mg prednisone daily for her severe COPD, but 
given
her respiratory symptoms, she self-increased her daily 
prednisone
to 20 mg daily last week.  She has not had any fevers.  On day 
of
presentation, she states that she was at a barbeque outdoors 
with
significant pollen exposure (an environmental allergy for her)
after which she became severely dyspneic.  She was brought by
ambulance who noted that the patient was only able to speak 2
word sentences at a timje.  

Upon arrival to the ED, initial VS 99, 100, 160/90, 24, 94% on
RA.  Her O2sats dropped to the upper ___ on RA while in the ED. 
Initial labs showed wnl chemistries, WBC 10.2, Hgb 14.6.  CXR
showed no focal consolidations.  The patient was given IV
methylpred x 1, azithromycin, and duonebs prior to transfer to
the floor.

Upon arrival to the floor, the patient reports ongoing wheezing
and no significant improvement of her respiratory symptoms after
receiving IV methylpred in the ED. She states some abdominal 
pain
associated with cough.  She has no other acute medical
complaints.
 
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: COPD {Chronic obstructive lung disease}, asthma {Asthma}, GERD {Gastroesophageal reflux disease}, metastatic
carcinoma to the brain {Metastatic malignant neoplasm to brain}, resection {Excision}, dyspnea {Dyspnea}, wheezing {Wheezing}, SOB {Dyspnea}, URI {Upper respiratory infection}, productive cough {Productive cough}, COPD {Chronic obstructive lung disease}, respiratory {Respiratory function finding}, fevers {Fever}, environmental allergy {Environmental allergy}, dyspneic {Dyspnea}, only able to speak 2
word sentences at a timje {Difficulty talking}, VS {Vital signs finding}, RA {Breathing room air}, RA {Breathing room air}, wnl {No abnormality detected}, WBC {White blood cell count}, Hgb {Measurement of total hemoglobin concentration}, CXR {Plain chest X-ray}, consolidations {Consolidation}, IV {Administration of drug or medicament via intravenous route}, wheezing {Wheezing}, improvement {Patient's condition improved}, respiratory symptoms {Respiratory function finding}, IV {Administration of drug or medicament via intravenous route}, abdominal 
pain {Abdominal pain}, 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:
(per chart, confirmed with pt):
- Asthma since childhood and COPD (multiple asthma attacks, 
previously seen by Dr. ___ ___ FEV1 71% 
predicted, FEV/FVC 46%, now follows with Dr. ___ 
- Bipolar disorder (history of delusions of parasitosis and 
depression, on SSI, resultant rash from scratching)
- Brain Metastases  (dx in ___ with headaches;, MRI showed 2.4 

x 1.1 cm size mass in the intraaxial location with surrounding 
edema, consistent with metastatic disease; s/p left occipital 
craniotomy and excision of the tumor on ___ Path showed 
metastatic poorly differentiated carcinoma with unclear etiology 

for a primary; ___ whole brain XRT; ___hest 
with new speculated RUL nodule and enlarged lymph node, 
enlarging on PET CT on ___
- knee pain
- recommended many times to have EGD and ___, pt declines 
- GERD 
- Substance abuse (crack cocaine)
 

###RESPONSE: Asthma {Asthma}, childhood {Childhood}, COPD {Chronic obstructive lung disease}, asthma attacks {Exacerbation of asthma}, Bipolar disorder {Bipolar disorder}, delusions of parasitosis {Delusions of parasitosis}, depression {Depressive disorder}, rash {Eruption of skin}, Brain Metastases {Metastatic malignant neoplasm to brain}, headaches {Headache}, MRI {Magnetic resonance imaging of head}, mass {Mass}, edema {Edema}, metastatic disease {Metastatic malignant neoplasm}, left occipital {Left occipital lobe structure}, craniotomy {Craniotomy}, excision {Excision}, tumor {Neoplasm}, metastatic {Metastatic malignant neoplasm}, poorly differentiated carcinoma {Poorly differentiated carcinoma}, brain {Brain structure}, XRT {X-ray beam therapy}, RUL {Structure of upper lobe of right lung}, nodule {Nodule}, enlarged lymph node {Lymphadenopathy}, PET CT {Positron emission tomography}, knee pain {Pain of knee region}, EGD {Esophagogastroduodenoscopy}, GERD {Gastroesophageal reflux disease}, Substance abuse {Substance abuse}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Aunt with lupus. Mother had lung cancer, sarcoid. Father with
diabetes.  Brother hit by car.
 

###RESPONSE: lupus {Lupus erythematosus}, lung cancer {Malignant tumor of lung}, sarcoid {Sarcoidosis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Vitals- 98.9 PO 131 / 94 R ___
GENERAL: well-appearing , appears comfortable, minimal increased 
WOB with ambulation, able to speak in full sentences
HEENT: MMM, NCAT, EOMI, anicteric sclera
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. 
No JVD.
RESP: decreased air entry bilaterally, scattered wheeze 
bilaterally, no accessory muscle 
ABDOMEN:  soft, NTND, normoactive bowel sounds
EXTREMITIES: wwp, no pitting edema of BLE
SKIN: no rash or lesions
NEUROLOGIC: AOx3, wnl gait, grossly nonfocal.
 

###RESPONSE: Vitals {Vital signs finding}, GENERAL {General examination of patient}, WOB {Labored breathing}, able to speak {Able to speak}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, NC {Normal head}, EOMI {Normal ocular motility}, anicteric sclera {White sclera}, CARDIAC {Cardiovascular physical examination}, Regular rhythm {Normal sinus rhythm}, normal rate {Normal heart rate}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, JVD {Jugular venous engorgement}, RESP {Examination of respiratory system}, decreased air entry {Decreased breath sounds}, wheeze {Wheezing}, accessory muscle {Accessory skeletal muscle}, ABDOMEN {Examination of abdomen}, soft {Abdomen soft}, ND {Swollen abdomen}, normoactive bowel sounds {Normal bowel sounds}, EXTREMITIES {Examination of limb}, wwp {Normal tissue perfusion}, edema {Edema}, BLE {Edema of bilateral lower legs}, SKIN {Examination of skin}, rash {Eruption of skin}, lesions {Lesion}, NEURO {Neurological examination}, GI {Examination of digestive system}, AOx3 {Oriented to person, time and place}, wnl {No abnormality detected}, gait {Gait normal}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Admission:
___ 10:40PM BLOOD WBC-10.2*# RBC-4.92 Hgb-14.6 Hct-44.7 
MCV-91 MCH-29.7 MCHC-32.7 RDW-14.8 RDWSD-49.6* Plt ___
___ 10:40PM BLOOD Glucose-147* UreaN-14 Creat-0.8 Na-144 
K-3.6 Cl-99 HCO3-31 AnGap-18

Imaging/
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Studies:  
___ CXR
No acute cardiopulmonary process.

Discharge:
___ 06:35AM BLOOD WBC-11.8* RBC-4.81 Hgb-13.9 Hct-43.4 
MCV-90 MCH-28.9 MCHC-32.0 RDW-14.9 RDWSD-49.5* Plt ___
___ 06:35AM BLOOD Glucose-128* UreaN-18 Creat-0.7 Na-137 
K-4.4 Cl-99 HCO3-26 AnGap-16
 

###RESPONSE: CXR {Plain chest X-ray}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Ms. ___ is a ___ pMHx COPD, asthma, GERD, and metastatic 
carcinoma to the brain of unknown origin s/p resection and WBRT 
in ___ who presented with an acute COPD exacerbation. No 
fevers, but cough, wheeze and dyspnea consistent with COPD 
exacerbation, likely precipitated by pollen exposure. Improved 
slowly. Completed a 5-day course of azithromycin and placed on a 
slow prednisone taper to be continued as an outpatient.  

 

###RESPONSE: COPD {Chronic obstructive lung disease}, asthma {Asthma}, GERD {Gastroesophageal reflux disease}, metastatic 
carcinoma to the brain {Metastatic malignant neoplasm to brain}, resection {Excision}, acute COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, fevers {Fever}, cough {Cough}, wheeze {Wheezing}, dyspnea {Dyspnea}, COPD 
exacerbation {Acute exacerbation of chronic obstructive airways disease}, 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: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 
Q4H:PRN 
2. Fluticasone-Salmeterol Diskus (500/50)  1 INH IH BID 
3. Montelukast 10 mg PO DAILY 
4. Omeprazole 20 mg PO DAILY 
5. Tiotropium Bromide 1 CAP IH DAILY 
6. Aspirin 81 mg PO DAILY 
7. Cetirizine 10 mg PO DAILY 
8. Multivitamins 1 TAB PO DAILY 
9. PredniSONE 20 mg PO DAILY 

 
Discharge Medications:
1.  Pseudoephedrine 30 mg PO Q6H:PRN nasal congestion 
RX *pseudoephedrine HCl [Nasal Decongestant (pseudoeph)] 30 mg 1 
tablet(s) by mouth every six (6) hours Disp #*10 Tablet 
Refills:*0 
2.  Omeprazole 40 mg PO DAILY 
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 
Capsule Refills:*0 
3.  PredniSONE 50 mg PO DAILY 
50 mg daily x 3 days, then decrease by 10 mg every 3 days until 
taking 10 mg daily  
Tapered dose - DOWN 
RX *prednisone 10 mg 5 tablet(s) by mouth daily Disp #*60 Tablet 
Refills:*0 
4.  Aspirin 81 mg PO DAILY  
5.  Cetirizine 10 mg PO DAILY  
6.  Fluticasone-Salmeterol Diskus (500/50)  1 INH IH BID  
7.  Montelukast 10 mg PO DAILY  
8.  Multivitamins 1 TAB PO DAILY  
9.  ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 
Q4H:PRN 
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs INH every four 
(4) hours Disp #*1 Inhaler Refills:*0 
10.  Tiotropium Bromide 1 CAP ___ 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:
Asthma exacerbation

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Asthma exacerbation {Exacerbation of asthma}, Mental Status {Neurological mental status determination}, Alert {Mentally alert}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___, 

You were admitted to the hospital with an asthma exacerbation. 
You were treated with steroids and breathing treatments and you 
improved.

Please try to avoid cigarettes as they make your breathing 
worse.  

Please continue to take the prednisone (steroids) taper as 
directed. 
 

###RESPONSE: asthma exacerbation {Exacerbation of asthma}, steroids {Steroid therapy}, breathing treatments {Inhalation therapy procedure}, improved {Patient's condition improved}, steroids {Steroid therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                        Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   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: 
aspirin
 
Attending: ___.
 
Chief Complaint:
Chest Pain
 
Major Surgical or Invasive Procedure:
Cardiac Catheterization

 

###RESPONSE: aspirin {Allergy to aspirin}, Chest Pain {Chest pain}, Cardiac Catheterization {Cardiac catheterization}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ HTN, DM, HL, CAD and b/l hearing loss pw chest pain and 
abnormal stress test. Patient reports exertional, substernal 
chest pain for the last 3 days. Relieved with rest. Denies 
radiation. Saw neurologist today for evaluation of memory loss, 
but when he described chest pain was referred for outpatient 
stress test. The stress test was abnormal and he was referred 
for ___. Patient reports ongoing ___ substernal chest pain 
without SOB on arrival to 
the ED.  

Patient takes Plavix for remote history of CAD. Denies ASA use.  

Chest pain nonreproducible in the ED.  

In the ED initial vitals were: 97.7 56 138/70 16 96% RA  
- Labs were significant for WBC 3.7 Hct 40.6 Plt 141, Cr 0.8, 
INR 0.9, Troponin <0.01  
- Patient was given Nitroglycerin SL, Aspirin 325, and started 
on a heparin gtt. His pain resolved after the SL nitro and 
aspirin  
Vitals prior to transfer were: 97.6 52 ___ 97% RA  
On the floor, the patient is sleeping comfortably. He denies 
chest pain, dyspnea, fevers, chills, night sweats, headache, 
vision changes, rhinorrhea, congestion, sore throat, cough, 
shortness of breath, chest pain, abdominal pain, nausea, 
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, 
dysuria, hematuria.  

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, HL {Hyperlipidemia}, CAD {Coronary arteriosclerosis}, b/l hearing loss {Bilateral hearing loss}, chest pain {Chest pain}, abnormal stress test {Cardiovascular stress test abnormal}, exertional {Chest pain on exertion}, substernal 
chest pain {Retrosternal pain}, Relieved with rest {Pain relief by rest}, radiation {Radiating pain}, evaluation {Evaluation procedure}, memory loss {Amnesia}, chest pain {Chest pain}, stress test {Cardiovascular stress testing}, stress test was abnormal {Cardiovascular stress test abnormal}, substernal chest pain {Retrosternal pain}, SOB {Dyspnea}, CAD {Coronary arteriosclerosis}, ASA use {Administration of aspirin}, Chest pain {Chest pain}, RA {Breathing room air}, Labs {Laboratory test}, WBC {White blood cell count}, Hct {Hematocrit determination}, Plt {Platelet count}, Cr {Creatinine measurement}, INR {Calculation of international normalized ratio}, Troponin {Troponin measurement}, Aspirin {Administration of aspirin}, heparin {Heparin therapy}, pain {Chest pain}, resolved {Problem resolved}, aspirin {Administration of aspirin}, Vitals {Vital signs finding}, RA {Breathing room air}, sleeping {Asleep}, chest pain {Chest pain}, dyspnea {Dyspnea}, fevers {Fever}, chills {Chill}, night sweats {Night sweats}, headache {Headache}, vision changes {Visual disturbance}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, sore throat {Sore throat}, cough {Cough}, shortness of breath {Dyspnea}, 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:
HYPERTENSION  
SEASONAL ALLERGIC RHINITIS  
HARD OF HEARING  
PROSTATE INTRAEPITHELIAL NEOPLASIA  
HYPERLIPIDEMIA  
GASTROESOPHAGEAL REFLUX  
CORONARY ARTERY DISEASE  
ERECTILE DYSFUNCTION  
GOUT  
AZOTEMIA  
ADENOMA  
VENTRICULAR ECTOPIC ACTIVITY  
 

###RESPONSE: HYPERTENSION {Hypertensive disorder, systemic arterial}, SEASONAL ALLERGIC RHINITIS {Seasonal allergic rhinitis}, HARD OF HEARING {Hearing loss}, PROSTATE INTRAEPITHELIAL NEOPLASIA {Prostatic intraepithelial neoplasia}, HYPERLIPIDEMIA {Hyperlipidemia}, GASTROESOPHAGEAL REFLUX {Gastroesophageal reflux disease}, CORONARY ARTERY DISEASE {Coronary arteriosclerosis}, ERECTILE DYSFUNCTION {Erectile dysfunction}, GOUT {Inflammatory disorder due to increased blood urate level}, AZOTEMIA {Azotemia}, ADENOMA {Adenoma}, VENTRICULAR ECTOPIC {Ventricular premature complex}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father: died in his ___ from iatrogenic injury, had some degree  

of loss of right hand function several years prior to his death, 
 
Mother: no medical issues  
Brother: died at ___ from cancer, not sure which type  
Sister: is ___, has memory problems,  
Son: healthy  
 
Physical ___:
PHYSICAL EXAM ON ADMISSION:  
Vitals - 97.9 152/92 56 18 99% RA  
GENERAL: Lying comfortably, in NAD  
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, 
patent nares, MMM, good dentition  
NECK: nontender supple neck, no LAD, no JVD  
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs  
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably 
without use of accessory muscles  
ABDOMEN: nondistended, +BS, nontender in all quadrants, no 
rebound/guarding, no hepatosplenomegaly  
EXTREMITIES: moving all extremities well, no cyanosis, clubbing 
or edema  
PULSES: 2+ DP and radial pulses bilaterally  
NEURO: CN II-XII intact  
SKIN: warm and well perfused, no excoriations or lesions, no 
rashes  

PHYSICAL EXAM ON DISCHARGE:  
Vitals - 98.0, 111-138/74-84, 52-59, rr18, 99% on RA
GENERAL: Sleeping peacefull in bed, in NAD  
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, 
patent nares, MMM, good dentition  
NECK: nontender supple neck, no LAD, no JVD  
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs  
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably 
without use of accessory muscles  
ABDOMEN: nondistended, +BS, nontender in all quadrants, no 
rebound/guarding, no hepatosplenomegaly  
EXTREMITIES: moving all extremities well, no cyanosis, clubbing 
or edema  
PULSES: 2+ DP and radial pulses bilaterally  
NEURO: CN II-XII intact  
SKIN: warm and well perfused, no excoriations or lesions, no 
rashes 
 

###RESPONSE: died {Dead}, injury {Traumatic or non-traumatic injury}, loss of right hand function {Difficulty performing hand functions}, death {Dead}, died {Dead}, cancer {Malignant neoplastic disease}, memory problems {Memory impairment}, Vitals {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, Lying {Lying in bed}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, AT/NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclera {White sclera}, pink conjunctiva {Conjunctival hyperemia}, nares {Structure of anterior naris}, MMM {Moist oral mucosa}, good dentition {Normal dentition}, NECK {Physical examination procedure}, nontender {Tenderness of neck}, supple neck {Normal movement of neck}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, S1/S2 {Heart sounds normal}, murmurs {Heart murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, LUNG {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, breathing comfortably {Breathing easily}, accessory muscles {Accessory skeletal muscle}, ABDOMEN {Examination of abdomen}, nondistended {Normal abdominal contour}, +BS {Normal bowel sounds}, nontender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, hepatosplenomegaly {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, moving all extremities {Does move all four limbs}, cyanosis {Cyanosis}, clubbing {Clubbing}, edema {Edema}, PULSES {Pulse finding}, 2+ DP {Dorsalis pulse present}, radial pulses {Radial pulse present}, NEURO {Neurological examination}, CN II-XII intact {Normal central nervous system}, SKIN {Examination of skin}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Skin lesion}, rashes {Eruption of skin}, Vitals {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, Sleeping {Asleep}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, AT/NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclera {White sclera}, pink conjunctiva {Conjunctival hyperemia}, nares {Structure of anterior naris}, MMM {Moist oral mucosa}, good dentition {Normal dentition}, NECK {Physical examination procedure}, nontender {Tenderness of neck}, supple neck {Normal movement of neck}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, S1/S2 {Heart sounds normal}, murmurs {Heart murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, LUNG {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, breathing comfortably {Breathing easily}, accessory muscles {Accessory skeletal muscle}, ABDOMEN {Examination of abdomen}, nondistended {Normal abdominal contour}, +BS {Normal bowel sounds}, nontender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, hepatosplenomegaly {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, moving all extremities {Does move all four limbs}, cyanosis {Cyanosis}, clubbing {Clubbing}, edema {Edema}, PULSES {Pulse finding}, 2+ DP {Dorsalis pulse present}, radial pulses {Radial pulse present}, NEURO {Neurological examination}, CN II-XII intact {Normal central nervous system}, SKIN {Examination of skin}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Skin lesion}, rashes {Eruption of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
LABS ON ADMISSION:

___ 05:45PM BLOOD WBC-3.7* RBC-4.09* Hgb-14.0 Hct-40.6 
MCV-100* MCH-34.3* MCHC-34.5 RDW-12.8 Plt ___
___ 05:45PM BLOOD Neuts-61.6 ___ Monos-8.1 Eos-4.8* 
Baso-0.5
___ 05:45PM BLOOD ___ PTT-29.9 ___
___ 05:45PM BLOOD Glucose-86 UreaN-26* Creat-0.8 Na-138 
K-4.4 Cl-94* HCO3-26 AnGap-22*
___ 02:00PM BLOOD ALT-30 AST-24 AlkPhos-44 Amylase-83 
TotBili-0.7
___ 07:50AM BLOOD CK-MB-5 cTropnT-<0.01
___ 05:45PM BLOOD cTropnT-<0.01
___ 07:50AM BLOOD CK-MB-5 cTropnT-<0.01
___ 07:50AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0 Cholest-159
___ 07:50AM BLOOD %HbA1c-7.2* eAG-160*
___ 07:50AM BLOOD Triglyc-386* HDL-33 CHOL/HD-4.8 
LDLcalc-49

LABS ON DISCHARGE:

___ 07:35AM BLOOD WBC-4.0 RBC-4.72 Hgb-15.7 Hct-47.6 
MCV-101* MCH-33.4* MCHC-33.0 RDW-13.3 Plt ___
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD Glucose-128* UreaN-24* Creat-1.3* Na-140 
K-4.9 Cl-103 HCO3-30 AnGap-12
___ 09:15AM BLOOD ALT-36 AST-38 AlkPhos-54 TotBili-0.8
___ 07:35AM BLOOD Calcium-9.6 Phos-3.2 Mg-2.1

STUDIES:
___ (outpatient) STRESS TEST
INTERPRETATION: This ___ year old man with a history of HTN, gout 
and 
HL was referred to the lab for evalution of chest discomfort. 
The 
patient exercised for 11 minutes of ___ protocol and stopped 
for 
fatigue. The estimated peak MET capacity was 11.9 which 
represents an 
excellent functional capacity for his age. Near peak exercise, 
the 
patient noted a non-progressive right sided chest discomfort. 
This 
resolved with rest by minute 2 of recovery. At peak exercise, 
there was 
1-1.5 mm horizontal ST segment depression in the inferolateral 
leads. 
This became downsloping in recovery and resovled with rest by 
minute 7. 
the rhythm was sinus with rare isolated apbs during exercise and 

frequent isolated vpbs in recovery. Resting HTN with an 
appropriate 
increase in systolic BP with exercise and slight blunting or HR 
on beta 
blocker therapy. 
IMPRESSION: Ischemic EKG changes with atypical chest discomfort. 

Nuclear report sent separately. 

___ EKG
Rate PR QRS QT/QTc P QRS T 
56 0 92 420/413 0 -3 55 
Sinus bradycardia. Baseline artifact. Initial deflections in 
leads III and aVF likely preclude prior inferior wall myocardial 
infarction, as reported on ___. No diagnostic interim 
change. Ventricular ectopy is absent. 

___ CARDIAC PERFUSION
IMPRESSION: 
1. Reversible, large, moderate severity perfusion defect 
involving the LCx territory. 
2. Normal left ventricular cavity size and systolic function. 
Compared with the study of ___, the defect is new. 

___ CXR
FINDINGS:   
The lungs remain clear. The cardiomediastinal silhouette is 
within normal 
limits. Atherosclerotic calcifications are noted at the aortic 
arch. No acute osseous abnormalities identified. 
IMPRESSION:  
No acute cardiopulmonary process. 

___ CARDIAC CATH
Coronary angiography:  right dominant
LMCA:  20% minor irregularities
LAD:   The LAD was heavily calcified with diffuse disease.  
There was a large diagonal branch with a 80-90% stenosis at its
origin.   Three was a large second diagonal branch with an 
60-70%
stenosis at its origin.   There was an 80% stenosis in the mid
LAD and diffusely 80-90% stenosis in the mid LAD.  The distal 
LAD
had minor lumen irregularities. 
LCX:  The LCX was a small vessel with an occlusion of the OMB.
RCA: The RCA was a large dominant vessel.  It had a 50% stenosis
in the distal RCA.  There was diffuse 60-70% disease throughout
the PLSA.  There was a 90% stenosis in RPL2 . There were right 
to
left collaterals to the OMB.
ASSESSMENT
1. Severe three vessel coronary artery disease

___ CARDIAC ECHO
The left atrium is normal in size. No atrial septal defect is 
seen by 2D or color Doppler. The estimated right atrial pressure 
is ___ mmHg. There is mild symmetric left ventricular 
hypertrophy with normal cavity size and global systolic function 
(LVEF>55%). Right ventricular chamber size and free wall motion 
are normal. The ascending aorta is mildly dilated. The aortic 
valve leaflets (3) are mildly thickened but aortic stenosis is 
not present. No aortic regurgitation is seen. The mitral valve 
leaflets are mildly thickened. Mild (1+) mitral regurgitation is 
seen. The estimated pulmonary artery systolic pressure is 
normal. There is no pericardial effusion. 
IMPRESSION: Preserved biventricular systolic function. Mildly 
dilated ascending aorta. Mild mitral regurgitation. Normal 
pulmonary artery systolic pressure.
Compared with the prior study (images unavailable for review) 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}, Plt {Platelet count}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, Amylase {Amylase measurement}, TotBili {Bilirubin, total measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Cholest {Cholesterol measurement}, HbA1c {Hemoglobin A1c measurement}, eAG {Glucose measurement estimated from glycated hemoglobin}, Triglyc {Triglycerides measurement}, HDL {High density lipoprotein measurement}, CHOL/HD {Cholesterol/High density lipoprotein ratio measurement}, LDLcalc {Calculated low density lipoprotein cholesterol level}, 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}, Plt {Platelet count}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, STRESS TEST {Electrocardiogram with exercise test}, HTN {Hypertensive disorder, systemic arterial}, gout {Inflammatory disorder due to increased blood urate level}, HL {Hyperlipidemia}, evalution {Evaluation procedure}, chest discomfort {Chest discomfort}, exercised {Exercises}, fatigue {Fatigue}, MET {Electrocardiogram with exercise test}, exercise {Exercises}, progressive {Patient's condition worsened}, right sided {Right thorax structure}, chest discomfort {Chest discomfort}, resolved {Problem resolved}, exercise {Exercises}, ST segment depression {ST segment depression}, resovled with rest {Pain relief by rest}, rhythm was sinus {Sinus rhythm}, exercise {Exercises}, frequent isolated vpbs {Multiple premature ventricular complexes}, HTN {Hypertensive disorder, systemic arterial}, exercise {Exercises}, therapy {Therapy}, Ischemic EKG changes {Electrocardiographic myocardial ischemia}, atypical {Atypical chest pain}, chest discomfort {Chest discomfort}, EKG {Electrocardiographic procedure}, Rate {Finding of heart rate}, PR {Finding of electrocardiogram PR interval}, QRS {Finding of electrocardiogram QRS complex}, P {Finding of electrocardiogram P wave}, QRS {Finding of electrocardiogram QRS complex}, T {Finding of electrocardiogram T wave}, Sinus bradycardia {Sinus bradycardia}, Baseline {Baseline state}, artifact {Artifact}, leads III {Lead III}, aVF {aVF}, inferior wall {Structure of myocardium of diaphragmatic region}, Ventricular ectopy {Ventricular premature complex}, CARDIAC PERFUSION {Radionuclide myocardial perfusion study}, perfusion defect {Myocardial perfusion defect}, LCx {Structure of circumflex branch of left coronary artery}, left ventricular cavity {Structure of cavity of left cardiac ventricle}, size {Normal size}, systolic function {Normal left ventricular systolic function and wall motion}, study {Evaluation procedure}, CXR {Plain chest X-ray}, lungs {Lung structure}, clear {No abnormality detected}, cardiomediastinal {Mediastinal structure}, normal {No abnormality detected}, Atherosclerotic {Atherosclerosis}, calcifications {Pathologic calcification, calcified structure}, aortic 
arch {Aortic arch structure}, No acute {No abnormality detected}, osseous {Bone structure}, No acute {No abnormality detected}, CARDIAC CATH {Cardiac catheterization}, Coronary angiography {Angiography of coronary artery}, LMCA {Structure of left coronary artery main stem}, irregularities {Luminal irregularities of coronary artery}, LAD {Structure of anterior descending branch of left coronary artery}, LAD {Structure of anterior descending branch of left coronary artery}, calcified {Pathologic calcification, calcified structure}, diffuse disease {Diffuse disease of coronary artery}, diagonal {Structure of diagonal branch of anterior descending branch of left coronary artery}, stenosis {Stenosis}, diagonal {Structure of diagonal branch of anterior descending branch of left coronary artery}, stenosis {Stenosis}, stenosis {Stenosis}, mid
LAD {Structure of mid portion of anterior descending branch of left coronary artery}, stenosis {Stenosis}, mid LAD {Structure of mid portion of anterior descending branch of left coronary artery}, distal 
LAD {Structure of distal portion of anterior descending branch of left coronary artery}, lumen irregularities {Luminal irregularities of coronary artery}, LCX {Structure of circumflex branch of left coronary artery}, LCX {Structure of circumflex branch of left coronary artery}, small vessel {Structure of small blood vessel (organ)}, occlusion {Complete obstruction}, OMB {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, RCA {Right coronary artery structure}, RCA {Right coronary artery structure}, vessel {Blood vessel structure}, stenosis {Stenosis}, distal RCA {Structure of distal portion of right coronary artery}, diffuse 60-70% disease {Diffuse disease of coronary artery}, stenosis {Stenosis}, RPL2 {Structure of posterior lateral branch of right coronary artery}, right {Right coronary artery structure}, OMB {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, ASSESSMENT {Evaluation procedure}, three vessel coronary artery disease {Triple vessel disease of the heart}, CARDIAC ECHO {Echocardiography}, left atrium {Left atrial structure}, normal in size {Normal size}, atrial septal defect {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, right atrial {Right atrial structure}, mild symmetric left ventricular 
hypertrophy {Mild left ventricular hypertrophy}, normal cavity size {Normal size}, systolic function {Normal left ventricular systolic function and wall motion}, Right ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion 
are normal {Normal ventricular wall motion}, ascending aorta is mildly dilated {Ascending aorta dilatation}, aortic 
valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve 
leaflets are mildly thickened {Thickened mitral leaflet}, Mild (1+) mitral regurgitation {Mild mitral valve regurgitation}, pulmonary artery {Pulmonary artery structure}, systolic pressure is 
normal {Normal systolic arterial pressure}, pericardial effusion {Pericardial effusion}, biventricular {Cardiac ventricular structure}, systolic function {Normal left ventricular systolic function and wall motion}, dilated ascending aorta {Ascending aorta dilatation}, Mild mitral regurgitation {Mild mitral valve regurgitation}, pulmonary artery {Pulmonary artery structure}, systolic pressure {Normal systolic arterial 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:
Mr. ___ is a ___ year old man with HTN, DM,HL, CAD and b/l hearing 
loss presenting with new onset exertional angina abnormal stress 
test who was found to have three vessel CAD.

# Unstable Angina/CAD: Mr. ___ had been experiencing progressive 
exertional, substernal chest pain and was sent for outpatient 
studies by his neurologist. He had an abnormal stress test and 
perfusion study showing a large reversible moderate severity 
perfusion defect involving the Lcx territory, so he was sent to 
the ER, where troponin was <0.01 and his EKG showed no ST 
segment elevations. He was admitted and underwent a cardiac 
catheterization that showed three vessel CAD.  He was then seen 
by cardiac surgery for evaluation of cardiac ___ bypass graft 
surgery.  This was scheduled for ___, after a 5 day 
plavix wash-out period.  He was discharged with chlorhexidine 
washes for ___ night and ___ morning, as well as 
mupirocen nasal cream BID, and the time and place to present for 
admission on ___ morning.  He was also set up for ___ as he 
expressed concern about being able to complete his pre-op 
regimen and take his medication as prescribed.  His Lisinopril 
was held from discharge until after surgery as he had a mild 
increase in creatinine.  His plavix was held.  His home atenoll 
was converted to metoprolol and aspirin was started; these 
medications were continued until surgery. His atorvastatin dose 
was increased to 80mg daily, which was also continued.

# Travel plasn:  A medical note was provided as he was no longer 
able to travel as anticipated. 

============================================
TRANSITIONAL ISSUES
============================================
Mr ___ is a ___ year old man with HTN, DM,HLD and b/l hearing loss 
presenting with new onset exertional angina who was found to 
have 3 vessel CAD.
- CAD: Seen by Cardiac surgery and planned for surgery on 
___. Will need chlorhexidine wash ___ 
morning before coming in. Will need to use Mupirocin cream ___ 
tube in each nostril) twice a day between now and then.
- Atenolol switched to metoprolol.
- HbA1c 7.1%

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, HL {Hyperlipidemia}, CAD {Coronary arteriosclerosis}, b/l hearing 
loss {Bilateral hearing loss}, exertional angina {Exercise-induced angina}, abnormal stress 
test {Cardiovascular stress test abnormal}, three vessel CAD {Triple vessel disease of the heart}, Unstable Angina {Preinfarction syndrome}, CAD {Coronary arteriosclerosis}, progressive {Patient's condition worsened}, exertional {Chest pain on exertion}, substernal chest pain {Retrosternal pain}, studies {Evaluation procedure}, abnormal stress test {Cardiovascular stress test abnormal}, perfusion study {Radionuclide myocardial perfusion study}, perfusion defect {Myocardial perfusion defect}, Lcx {Structure of circumflex branch of left coronary artery}, troponin {Troponin measurement}, EKG {Electrocardiographic procedure}, ST 
segment elevations {ST segment elevation}, cardiac 
catheterization {Cardiac catheterization}, three vessel CAD {Triple vessel disease of the heart}, evaluation {Evaluation procedure}, cardiac {Heart structure}, bypass graft {Coronary artery bypass grafting}, surgery {Surgical procedure}, nasal {Administration of drug or medicament via nasal route}, after surgery {Postoperative state}, increase in creatinine {Serum creatinine above reference range}, plavix {Administration of prophylactic clopidogrel}, held {Recommendation to stop drug treatment}, converted {Change of medication}, aspirin {Administration of aspirin}, medications {Administration of drug or medicament}, surgery {Surgical procedure}, increased {Increasing dosage of medication}, Travel {Travel abroad}, travel {Travel abroad}, HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, HLD {Hyperlipidemia}, b/l hearing loss {Bilateral hearing loss}, exertional angina {Exercise-induced angina}, 3 vessel CAD {Triple vessel disease of the heart}, CAD {Coronary arteriosclerosis}, surgery {Surgical procedure}, nostril {Structure of anterior naris}, HbA1c {Hemoglobin A1c 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: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY 
2. Atenolol 25 mg PO DAILY 
3. Atorvastatin 40 mg PO DAILY 
4. celecoxib 200 mg oral PRN gout attack 
5. Clopidogrel 75 mg PO DAILY 
6. Lisinopril 20 mg PO DAILY 
7. Colchicine 0.6 mg PO DAILY 

 
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY 
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY 
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet 
Refills:*0
3. Nitroglycerin SL 0.4 mg SL PRN chest pain 
RX *nitroglycerin [Nitrostat] 0.4 mg 1 tablet(s) sublingually 
every 5 minutes x 3 tablets Disp #*12 Tablet Refills:*0
4. Mupirocin Nasal Ointment 2% 1 Appl NU BID Duration: 5 Days 
RX *mupirocin calcium [Bactroban Nasal] 2 % 0.5 (One half) tube 
in each nostril twice a day Disp #*6 Tube Refills:*0
5. Allopurinol ___ mg PO DAILY 
6. Metoprolol Succinate XL 25 mg PO DAILY 
This replaces atenolol 
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp 
#*30 Tablet Refills:*0
7. Colchicine 0.6 mg PO DAILY 

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Coronary Artery Disease

 
Discharge Condition:
Mental Status: Confused - mildly, occasionally.  Oriented x3.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Home With Service {Home health aide service management}, Coronary Artery Disease {Coronary arteriosclerosis}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, Oriented x3 {Oriented to person, time and place}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___,

You were admitted to ___ due to 
chest pain.  A cardiac catheterization revealed that you have 
coronary artery disease in the main three vessels in your heart. 
 The recommended treatment is a coronary artery bypass graft 
(CABG) surgery.  You were seen by the Cardiac Surgeons who plan 
to perform the surgery on ___.

Do not take plavix, NSAIDS (including celecoxib, ibuprofen), or 
lisinopril until instructed to by your doctor after surgery. 
Atenolol was also switched to metoprolol.  Continue to take your 
other medications, including metoprolol and aspirin, as 
prescribed.

Please return to the hospital on ___ 6:00 AM as 
instructed by the Cardiac Surgery team, and follow their 
direction about soap scrubs and cream application in preparation 
for surgery.  Nurses ___ visit your home to check on you 
tomorrow. 

It was a pleasure taking care of you.
Sincerely,
Your ___ Team

 

###RESPONSE: chest pain {Chest pain}, cardiac catheterization {Cardiac catheterization}, coronary artery disease {Coronary arteriosclerosis}, three vessels in your heart {Triple vessel disease of the heart}, coronary artery bypass graft {Coronary artery bypass grafting}, CABG {Coronary artery bypass grafting}, surgery {Surgical procedure}, surgery {Coronary artery bypass grafting}, Do not take {Patient medication education}, after surgery {Postoperative state}, switched {Change of medication}, medications {Patient medication education}, aspirin {Administration of aspirin}, preparation 
for surgery {Preoperative education}, home {Home health aide service 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: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Shortness of breath.
 
Major Surgical or Invasive Procedure:
Cardiac cath on ___ with DES to circumflex artery.

 

###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, Shortness of breath {Dyspnea}, Cardiac cath {Cardiac catheterization}, circumflex artery {Structure of circumflex branch of left coronary artery}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ M with a history of PVD, AAA repair, s/p CEA, HTN who was 
seen by his outpatient Cardiologist 5 days ago. Per report, he 
had a stress echo (official results not available). Patient was 
set up for outpatient cath next week, but in the interim was 
admitted to ___ with pulmonary edema. He had acute shortness of 
breath on night of ___ and called EMS.  
.  
Presented to OSH complaining of shortness of breath x 5 days, 
that has been getting progressively worse. One day prior to 
admission to OSH he was short of breath climbing the stairs in 
his house. That evening, while watching TV he had sudden onset 
SOB. No CP, no palpitations. No nausea or vomiting. Patient did 
become diaphoretic.  
.  
EMS noted BP 225/94, HR 130s, tachypneic. He was started on 
CPAP, nebs, nitro gtt, lasix. Patient was admitted to the CCU at 
OSH. Required 5L O2 nasal cannula.  
Troponins of 0.112 --> 0.224 --> 0.305. CK 67-->48. CKMB 2.0--> 
2.6. Cardiac index 3.0 --> 5.4. Of note, patient has not been 
taking his home medications (including monopril, librium, and 
simvastatin) per MD from the ___. ___ reason for this is unclear. 
The patient is being transferred to ___ for catheterization.  
.  
On review of systems, he 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. He denies recent fevers, chills or rigors. 
He endoreses exertional buttock and calf pain. All of the other 
review of systems were negative.  
.  
Cardiac review of systems is notable for current absence of 
chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle 
edema, palpitations, syncope or presyncope.
 

###RESPONSE: PVD {Peripheral vascular disease}, AAA repair {Repair of aneurysm of abdominal aorta}, CEA {Carotid endarterectomy}, HTN {Hypertensive disorder, systemic arterial}, stress echo {Stress echocardiography}, cath {Cardiac catheterization}, pulmonary edema {Pulmonary edema}, shortness of 
breath {Dyspnea}, EMS {Emergency treatment management}, shortness of breath {Dyspnea}, short of breath {Dyspnea}, SOB {Dyspnea}, CP {Chest pain}, palpitations {Palpitations}, nausea {Nausea}, vomiting {Vomiting}, diaphoretic {Excessive sweating}, BP {Blood pressure finding}, HR {Finding of heart rate}, tachypneic {Tachypnea}, on 
CPAP {Dependence on continuous positive airway pressure ventilation}, lasix {Diuretic therapy}, O2 nasal cannula {Oxygen administration by nasal cannula}, Troponins {Troponin measurement}, Cardiac {Heart structure}, catheterization {Cardiac catheterization}, 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}, 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}, chest pain {Chest pain}, 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:
___ M with a history of PVD, AAA repair, s/p CEA, HTN who was 
seen by his outpatient Cardiologist 5 days ago. Per report, he 
had a stress echo (official results not available). Patient was 
set up for outpatient cath next week, but in the interim was 
admitted to ___ with pulmonary edema. He had acute shortness of 
breath on night of ___ and called EMS.  
.  
Presented to OSH complaining of shortness of breath x 5 days, 
that has been getting progressively worse. One day prior to 
admission to OSH he was short of breath climbing the stairs in 
his house. That evening, while watching TV he had sudden onset 
SOB. No CP, no palpitations. No nausea or vomiting. Patient did 
become diaphoretic.  
.  
EMS noted BP 225/94, HR 130s, tachypneic. He was started on 
CPAP, nebs, nitro gtt, lasix. Patient was admitted to the CCU at 
OSH. Required 5L O2 nasal cannula.  
Troponins of 0.112 --> 0.224 --> 0.305. CK 67-->48. CKMB 2.0--> 
2.6. Cardiac index 3.0 --> 5.4. Of note, patient has not been 
taking his home medications (including monopril, librium, and 
simvastatin) per MD from the ___. ___ reason for this is unclear. 
The patient is being transferred to ___ for catheterization.  
.  
On review of systems, he 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. He denies recent fevers, chills or rigors. 
He endoreses exertional buttock and calf pain. All of the other 
review of systems were negative.  
.  
Cardiac review of systems is notable for current absence of 
chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle 
edema, palpitations, syncope or presyncope.
 

###RESPONSE: PVD {Peripheral vascular disease}, AAA repair {Repair of aneurysm of abdominal aorta}, CEA {Carotid endarterectomy}, HTN {Hypertensive disorder, systemic arterial}, stress echo {Stress echocardiography}, cath {Cardiac catheterization}, pulmonary edema {Pulmonary edema}, shortness of 
breath {Dyspnea}, EMS {Emergency treatment management}, shortness of breath {Dyspnea}, short of breath {Dyspnea}, climbing the stairs {Difficulty walking up stairs}, SOB {Dyspnea}, CP {Chest pain}, palpitations {Palpitations}, nausea {Nausea}, vomiting {Vomiting}, diaphoretic {Excessive sweating}, BP {Blood pressure finding}, HR {Finding of heart rate}, tachypneic {Tachypnea}, on 
CPAP {Dependence on continuous positive airway pressure ventilation}, lasix {Diuretic therapy}, O2 nasal cannula {Oxygen administration by nasal cannula}, Troponins {Troponin measurement}, Cardiac {Heart structure}, catheterization {Cardiac catheterization}, 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}, 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}, chest pain {Chest pain}, 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: 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:
Nonecontributory.
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
On Admission:
___ 09:05PM   WBC-7.9 RBC-3.98* HGB-12.6* HCT-38.3* MCV-96 
MCH-31.7 MCHC-32.9 RDW-16.1*
___ 09:05PM   PLT COUNT-176
___ 09:05PM   GLUCOSE-117* UREA N-27* CREAT-1.0 SODIUM-140 
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
___ 09:05PM   MAGNESIUM-2.2
___ 09:05PM   CK-MB-NotDone cTropnT-0.01
___ 09:05PM   CK(CPK)-49
.
Cardiac cath:
1. Selective coronary angiography of this left dominant system 
revealed 
three vessel coronary artery disease. The LMCA was calcified 
with 
minimal disease.  The LAD had moderate disease, an ostial 90% 
stenosis 
at the diagonal artery near the ostium.  The LCX had an 80% 
stenosis at 
the mid segment.  The RCA was non dominant with diffuse high 
grade 
disease. 
2. Resting hemodynamics demonstrated elevated LV filling 
pressures, 
moderate pulmonary artery hypertension, and a low cardiac index 
(1.9). 
3. Stenting of mid LCX with Xience 3x8 
  
FINAL DIAGNOSIS:     
1. Two vessel coronary artery disease. 
2. Diastolic dysfunction. 
3. Moderate pulmonary hypertension. 
4. Stenting of LCX with drug eluting stent. 
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, coronary angiography {Angiography of coronary artery}, left {Catheterization of left heart}, three vessel coronary artery disease {Triple vessel disease of the heart}, LMCA {Structure of left coronary artery main stem}, calcified {Pathologic calcification, calcified structure}, minimal {Symptom mild}, disease {Disease}, LAD {Structure of anterior descending branch of left coronary artery}, disease {Disease}, ostial 90% 
stenosis {Coronary ostium stenosis}, diagonal artery {Structure of diagonal branch of anterior descending branch of left coronary artery}, LCX {Structure of circumflex branch of left coronary artery}, mid segment {Structure of mid portion of circumflex branch of left coronary artery}, RCA {Right coronary artery structure}, diffuse high 
grade 
disease {Diffuse disease of coronary artery}, hemodynamics {Hemodynamic measurements}, elevated {Increased pressure}, LV {Left cardiac ventricular structure}, pressures {Pressure}, moderate pulmonary artery hypertension {Moderate pulmonary hypertension}, low cardiac index {Decreased cardiac index}, Stenting {Insertion of arterial stent}, mid LCX {Structure of mid portion of circumflex branch of left coronary artery}, Two vessel coronary artery disease {Double coronary vessel disease}, Diastolic dysfunction {Diastolic dysfunction}, Moderate pulmonary hypertension {Moderate pulmonary hypertension}, Stenting {Insertion of arterial stent}, LCX {Structure of circumflex branch of left coronary artery}, drug eluting stent {Endovascular insertion of drug eluting stent}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ M with a history of PVD, AAA repair, s/p CEA, HTN who 
presented with acute SOB, likely flash pulmonary edema, but ? of 
NSTEMI with elevated trops at ___.  
.  
# CORONARIES: Patient recently admitted to ___ for shortness of 
breath and was found to have pulmonary edema with borderline 
Troponing I. He denied any chest pain, diaphoresis, leg 
swelling. He was discharged with cardiology follow up and now is 
admitted for further work up and cath. He was chest pain free 
overnight and in the cardiac cath was found to have ostial 90% 
stenosis at the diagonal artery near the ostium.  The LCX had an 
80% stenosis at the mid segment. Since he has RCA atrophied with 
a dominant LCV it was stented with a 3x5 Cypher stent. Since the 
ostial lession was very small Dr. ___ not to stent it. 
He was re-started on lisinopril, metoprolol and his statin, 
aspirin and plavix were continued.
.  
# PUMP: Patient had ECHO in ___ with normal cardiac function 
and per report had another at ___. He was euvolemic throughout 
the admission.   
.  
# RHYTHM: NSR throughout admission.  
.  
# Hypertension. Patient had hypertensive emergency with flash 
pulm edema on presentation to ___. He was weaned quickly off 
BIPAP and nitro gtt and has been stable for > 24 hrs. He 
diuresed well and on admission was euvolemic. Per his report his 
PCP at the ___ stopped his antihypertensive, fosinopril ___ 
months ago. He is currently normotensive and was transfered on 
captopril. We started metoprolol due to CAD and re-started 
low-dose lisinopril instead of captopril.
.  
# Hyperlipidemia: recently stopped lipitor for ? myalgias. 
Patient was discharged on pravastatin, since he rememebered 
similar problems with simavastain.
.  
FEN: Cardiac diet.
.
ACCESS: PIV's.
.
PROPHYLAXIS:  
-DVT ppx with heparin SQ  
-Pain management with tylenol.
.
CODE: Full code.
.
DISPO: Home.
 

###RESPONSE: PVD {Peripheral vascular disease}, AAA repair {Repair of aneurysm of abdominal aorta}, CEA {Carotid endarterectomy}, HTN {Hypertensive disorder, systemic arterial}, SOB {Dyspnea}, flash pulmonary edema {Acute pulmonary edema}, NSTEMI {Acute non-ST segment elevation myocardial infarction}, elevated trops {Troponin I above reference range}, shortness of 
breath {Dyspnea}, pulmonary edema {Pulmonary edema}, Troponing {Troponin measurement}, chest pain {Chest pain}, diaphoresis {Excessive sweating}, leg 
swelling {Leg swelling symptom}, cardiology {Cardiology service}, work up {Evaluation procedure}, cath {Cardiac catheterization}, chest pain {Chest pain}, cardiac cath {Cardiac catheterization}, ostial 90% 
stenosis {Coronary ostium stenosis}, diagonal artery {Structure of diagonal branch of anterior descending branch of left coronary artery}, LCX {Structure of diagonal branch of anterior descending branch of left coronary artery}, mid segment {Structure of mid portion of circumflex branch of left coronary artery}, RCA {Right coronary artery structure}, atrophied {Atrophy}, stented {Placement of stent in coronary artery}, Cypher stent {Endovascular insertion of drug eluting stent}, lession {Lesion}, stent {Placement of stent}, aspirin {Administration of aspirin}, ECHO {Echocardiography}, normal cardiac function {Normal cardiac function}, euvolemic {Normal blood volume}, NSR {Normal sinus rhythm}, Hypertension {Hypertensive disorder, systemic arterial}, hypertensive emergency {Hypertensive emergency}, flash 
pulm edema {Acute pulmonary edema}, weaned quickly off 
BIPAP {Dual pressure spontaneous ventilation support weaning protocol}, stable {Patient's condition stable}, diuresed {Diuretic therapy}, euvolemic {Normal blood volume}, PCP {Primary care management}, antihypertensive {Antihypertensive therapy}, normotensive {Normal blood pressure}, CAD {Coronary arteriosclerosis}, re-started 
low-dose lisinopril {Restart of medication}, Hyperlipidemia {Hyperlipidemia}, myalgias {Muscle pain}, problems {Problem}, Cardiac {Cardiac care}, diet {Dietary finding}, PROPHYLAXIS {Preventive procedure}, DVT {Deep venous thrombosis}, ppx {Administration of prophylactic anticoagulant}, heparin {Heparin therapy}, Pain management {Pain management}, tylenol {Administration of analgesic}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
ALENDRONATE - 70 mg po q ___  
CHLORDIAZEPOXIDE HCL - 25 mg po daily PRN anxiety  
FOSINOPRIL - 10 mg po qhs (STOPPED 2 Months prior)  
SIMVASTATIN - 40 mg po qhs (STOPPED 2 Months prior)  
MULTIVITAMIN po qd  
 
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) 
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every 
___.  
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Vitamin D 2,000 unit Capsule Sig: One (1) Capsule PO once a 
day.
Disp:*30 Capsule(s)* Refills:*0*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis:
Coronary Artery Disease s/p cardiac cath with DES to circumflex 
artery.

 
Discharge Condition:
Stable, 

 

###RESPONSE: Coronary Artery Disease {Coronary arteriosclerosis}, cardiac cath {Cardiac catheterization}, DES {Endovascular insertion of drug eluting stent}, circumflex 
artery {Structure of circumflex branch of left coronary artery}, Stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were electively admitted at the ___ for cardiac cath after 
your abnormal stress test. You had multiple-vessel disease and 
had a drug diluting (Xience) stent placed to one of your heart 
arteries (circumflex artery). You will need to be in aspirin and 
plavix for a year and have close cardiology follow up (See 
appointments below).
.
If you have chest pain, palpitations, shortness of breath, groin 
pain, bleeding or anything else that cocerns you, please come to 
our ER.
.
Your medications were left unchanged, but:
* You were started on lisinopril (5 mg Daily) to protect your 
heart and blood pressure control. If the ___ can provide you with 
a similar ACE inhibitor would be ok to switch, but talk to your 
PCP or Dr. ___ there first.
* You were started on pravastatin, that is similar to Lipitor or 
Crestor, but cause muscle pain less often. We will need to try 
several medications to see which one you are able to tolerate, 
but your cholesterol must be tightly controlled.
* You were started on low-dose beta-blocker to protect your 
heart. You are being discharge in low-dose atenolol.
* You are being put on maintainance dose of Vitamin D to 
decrease further your cardiovascular read.
* You were started on Aspirin and Plavix. YOU MUST NOT STOP them 
for any reason, unless specifically ordered by a physician. You 
cannot run out of this medicaion. Feel free to call Dr. ___ 
you have any problems filling it!
 

###RESPONSE: cardiac cath {Cardiac catheterization}, abnormal stress test {Cardiovascular stress test abnormal}, vessel disease {Coronary arteriosclerosis}, drug diluting (Xience) stent placed {Endovascular insertion of drug eluting stent}, heart 
arteries {Coronary artery structure}, circumflex artery {Structure of circumflex branch of left coronary artery}, aspirin {Administration of aspirin}, cardiology {Cardiology service}, appointments {Follow-up arranged}, chest pain {Chest pain}, palpitations {Palpitations}, shortness of breath {Dyspnea}, groin 
pain {Inguinal pain}, bleeding {Bleeding}, ER {Emergency treatment management}, to protect {Administration of prophylactic drug or medicament}, heart {Heart structure}, blood pressure {On treatment for hypertension}, talk {Discussion}, PCP {Primary care management}, muscle pain {Muscle pain}, protect {Administration of prophylactic drug or medicament}, heart {Heart structure}, cardiovascular read {Cardiovascular monitoring}, Aspirin {Administration of aspirin}, YOU MUST NOT STOP them {Recommendation to continue with drug treatment}, problems {Problem}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Wound erythema
 
Major Surgical or Invasive Procedure:
___: Feeding tube placement

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Wound erythema {Wound erythema}, Feeding tube placement {Insertion of feeding tube into small intestine}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ with history of ETOH cirrhosis s/p combined liver &
kidney transplant ___, ___ c/b biliary stricture and 
chronic rejection now s/p re-transplant ___ with multiple
re-admissions since then most recently for PNA (discharged
___ who now presents with ___ erythema and
purulent drainage c/f surgical site infection.  He first noticed
the erythema and drainage yesterday, and denies fevers, chills,
rigors, sweats, abdominal pain, nausea, SOB or change in bowel
and bladder habits. On exam he has multiple well-healed surgical
incisions excepting the medial RLQ oblique incision which has a 
1
cm draining superficial dehiscence in the middle of an otherwise
well-healing scar. There is erythema the length of the incision
and palpable induration. Purulent fluid is readily expressed,
particularly from the medial pole of the wound. WBC is 9.5, Cr
1.9 (last 1.6 on ___, LFTs are mildly elevated consistent with
the last measured values on ___. 

 

###RESPONSE: ETOH cirrhosis {Alcoholic cirrhosis}, liver {Transplanted liver present}, kidney transplant {Transplanted kidney present}, biliary stricture {Biliary stricture}, chronic rejection {Chronic graft rejection}, transplant {Transplantation}, PNA {Pneumonia}, erythema {Erythema}, purulent drainage {Purulent discharge}, surgical site infection {Surgical site infection}, erythema {Erythema}, drainage {Discharge}, fevers {Fever}, chills {Chill}, rigors {Rigor}, sweats {Sweating}, abdominal pain {Abdominal pain}, nausea {Nausea}, SOB {Dyspnea}, change in bowel {Altered bowel function}, bladder habits {Alteration in patterns of urinary elimination}, surgical
incisions {Surgical incision wound}, RLQ {Structure of right lower quadrant of abdomen}, incision {Abdomen incision}, draining {Wound discharge}, dehiscence {Dehiscence}, healing scar {Healing scar}, erythema {Erythema}, incision {Surgical incision wound}, induration {Induration}, Purulent fluid {Purulent discharge}, wound {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: Past Medical History:
___ gunshot wounds in ___ status post exploratory
laparotomy and colostomy.
___ colostomy was reversed.  
___, he had a history of small-bowel obstruction with
multiple surgeries that retrieved most of his small bowel.  
___, laparotomy again had multiple surgeries again for 
small
bowel obstruction.
___, he had a right knee arthroscopy.
___, diagnosis of cirrhosis and bleeding varices.  
___, he had hepatorenal syndrome and liver failure and he
had his combined liver and kidney transplant at ___.
H/o cholangitis, multiple ERCP with plastic/metal stents.
___ cystoscopy to remove a stent that was placed that was
causing urosepsis (this resulted in a lawsuit against ___).  
___, he underwent a lysis of adhesions at ___.
___ cholangitis/ s/p ERCP and stent placement.
___. Hepaticojejunostomy with Roux-en-Y.
___  PTC and liver biopsy with chronic rejection.
___ Orthotropic Deceased Donor Liver Transplant
Hepatic encephalopathy
Gout
Depression
Insomnia 
 

###RESPONSE: gunshot wounds {Gunshot wound}, exploratory
laparotomy {Exploratory laparotomy}, colostomy {Colostomy}, colostomy {Colostomy}, small-bowel obstruction {Small bowel obstruction}, surgeries {Surgical procedure}, small bowel {Structure of small intestine}, laparotomy {Laparotomy}, surgeries {Surgical procedure}, small
bowel obstruction {Small bowel obstruction}, knee arthroscopy {Arthroscopy of knee joint}, cirrhosis {Cirrhosis of liver}, bleeding varices {Bleeding varices}, hepatorenal syndrome {Hepatorenal syndrome}, liver failure {Hepatic failure}, liver {Transplanted liver present}, kidney transplant {Transplanted kidney present}, cholangitis {Cholangitis}, ERCP {Endoscopic retrograde cholangiopancreatography}, stents {Placement of stent}, cystoscopy {Transurethral cystoscopy}, stent {Removal of stent}, lysis of adhesions {Lysis of adhesions}, cholangitis {Cholangitis}, ERCP {Endoscopic retrograde cholangiopancreatography}, stent placement {Placement of stent}, liver biopsy {Biopsy of liver}, chronic rejection {Chronic rejection of liver transplant}, Orthotropic Deceased Donor Liver Transplant {Orthotopic transplantation of whole liver}, Hepatic encephalopathy {Hepatic encephalopathy}, Gout {Inflammatory disorder due to increased blood urate level}, Depression {Depressive disorder}, Insomnia {Insomnia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 - dementia (___)
Father - diabetes/prostate cancer (___)
2 Children, 3 Grandchildren all healthy
 

###RESPONSE: dementia {Dementia}, diabetes {Diabetes mellitus}, prostate cancer {Carcinoma of prostate}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:  97.3  83  123/81  14  100%RA
GEN: NAD, well-nourished, appropriately groomed.
NEURO: AOx3, CN II-XII grossly intact
HEENT: Sclerae anicteric, trachea midline, no JVD
CV: RRR no MRG, 2+ peripheral pulses bilaterally  
RESP: CTAB no WRC, no respiratory distress
GI: Extensive abdominal scarring from previous surgical
incisions. Medial RLQ oblique incision with a 1 cm draining
superficial dehiscence in the middle of an otherwise 
well-healing
scar. Erythema the length of the incision with palpable
induration. Purulent fluid readily expressed, particularly from
the medial pole of the wound. Abdomen otherwise soft, non-tender
and non-distended. No rebound tenderness or guarding. Dull to
percussion. Bowel sounds normoactive. Rectal exam deferred
EXT: WWP no CCE

LAB VALUES:

Lactate: 5.5

139  111  35 
-------------< 138 
5.5  16  1.9   

ALT: 57 AP: 231 Tbili: 2.2 Alb: 3.7 
AST: 25 Lip: 19     

9.5 ___ > 10.1 / 31.2 < 205 ___ 
 
N:83.1 L:9.0 M:6.7 E:0.2 Bas:0.2 ___: 0.8 Absneut: 7.88
Abslymp: 0.85 Absmono: 0.64 Abseos: 0.02 Absbaso: 0.02  

___: 12.2  PTT: 24.7  INR: 1.1  

IMAGING/STUDIES:

N/A

 

###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, GEN {General examination of patient}, NAD {No abnormality detected}, well-nourished {Well nourished}, NEURO {Neurological examination}, AOx3 {Oriented to person, time and place}, CN II {Optic nerve structure}, XII {Hypoglossal nerve structure}, grossly intact {Normal nervous system function}, HEENT {Physical examination procedure}, Sclerae anicteric {White sclera}, trachea {Tracheal structure}, JVD {Jugular venous engorgement}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, 2+ peripheral pulses {Peripheral pulses normal}, RESP {Examination of respiratory system}, CTAB {Normal breath sounds}, distress {Distress}, GI {Examination of digestive system}, abdominal scarring {Abdominal skin scar}, surgical
incisions {Surgical incision wound}, RLQ {Structure of right lower quadrant of abdomen}, incision {Abdomen incision}, draining {Wound discharge}, dehiscence {Dehiscence}, healing
scar {Healing scar}, Erythema {Erythema}, incision {Surgical incision wound}, induration {Induration}, Purulent fluid {Purulent discharge}, wound {Wound}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, percussion {Percussion}, Bowel sounds {Normal bowel sounds}, Rectal exam {Rectal examination}, EXT {Examination of limb}, WWP {Normal tissue perfusion}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 11:57AM BLOOD WBC-9.5# RBC-3.24* Hgb-10.1* Hct-31.2* 
MCV-96 MCH-31.2 MCHC-32.4 RDW-17.0* RDWSD-58.5* Plt ___
___ 03:55AM BLOOD WBC-5.3 RBC-2.87* Hgb-9.0* Hct-26.8* 
MCV-93 MCH-31.4 MCHC-33.6 RDW-16.8* RDWSD-56.2* Plt ___
___ 11:26AM BLOOD WBC-6.0# RBC-3.53* Hgb-10.9* Hct-33.4* 
MCV-95 MCH-30.9 MCHC-32.6 RDW-18.7* RDWSD-63.1* Plt ___
___ 11:57AM BLOOD Glucose-138* UreaN-35* Creat-1.9* Na-139 
K-5.5* Cl-111* HCO3-16* AnGap-18
___ 03:55AM BLOOD Glucose-101* UreaN-32* Creat-1.6* Na-137 
K-5.1 Cl-110* HCO3-15* AnGap-17
___ 04:40AM BLOOD Glucose-112* UreaN-33* Creat-1.7* Na-136 
K-5.1 Cl-109* HCO3-15* AnGap-17
___ 11:26AM BLOOD Glucose-111* UreaN-43* Creat-1.8*# Na-139 
K-4.8 Cl-112* HCO3-17* AnGap-15
___ 11:26AM BLOOD ALT-34 AST-13 AlkPhos-185* TotBili-1.7*
___ 03:55AM BLOOD tacroFK-12.6
___ 04:20AM BLOOD tacroFK-11.6
___ 04:40AM BLOOD tacroFK-8.1

 
 
___ 11:57 am BLOOD CULTURE

   Blood Culture, Routine (Pending): 

 
 
___ 12:25 pm SWAB

                            **FINAL REPORT ___

   GRAM STAIN (Final ___: 
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR 
LEUKOCYTES. 
      2+   ___ per 1000X FIELD):   GRAM POSITIVE ROD(S). 

   WOUND CULTURE (Final ___: 
      LACTOBACILLUS SPECIES.    MODERATE GROWTH. 
      ENTEROCOCCUS SP..    SPARSE GROWTH. 
      MIXED BACTERIAL FLORA. 
         This culture contains mixed bacterial types (>=3) so an
         abbreviated workup is performed. Any growth of 
P.aeruginosa,
         S.aureus and beta hemolytic streptococci will be 
reported. IF
         THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT 
in this
         culture. 
         Work-up of organism(s) listed discontinued (excepted 
screened
         organisms) due to the presence of mixed bacterial flora 
detected
         after further incubation. 

                              SENSITIVITIES: MIC expressed in 
MCG/ML
                      
_________________________________________________________
                             ENTEROCOCCUS SP.
                             |   
AMPICILLIN------------  =>32 R
LINEZOLID-------------     2 S
PENICILLIN G----------  =>64 R
VANCOMYCIN------------  =>32 R

   ANAEROBIC CULTURE (Final ___:    NO ANAEROBES ISOLATED. 


 
 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, CULTURE {Blood culture}, Blood Culture {Blood culture}, GRAM STAIN {Gram stain method}, CULTURE {Microbial culture}, culture {Microbial culture}, culture {Microbial culture}, CULTURE {Microbial culture}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ PMH EtOH cirrhosis, s/p combo liver/kidney trx (___) 
c/bbiliary strict and chronic rejection requiring 
___, recently hospitalized for PNA, was 
readmitted for incision wound infection. Wound was I&D'd in the 
ED and he was admitted to transplant surgery where he was 
started on broad spectrum antibiotics pending blood and 
incision/wound cultures. The wound was packed with Iodiform. 

Wound culture initially isolated 2+ GPRs. He was afebrile and 
would improved. Final culture data was unable until after 
patient discharged on Augmentin to complete a weeks course. 
Wound measured 2cm x 1cm. Normal saline damp to dry dressings 
were to be done bid. Blood cultures drawn were unfinalized, but 
negative to date. Of note, after patient was discharged, his 
wound culture was finalized as VRE. The plan was to switch to 
Linezolid for 7 days. His outpatient coordinator was notified 
and was to call in the Linezolid to pharmacy and call the 
patient. 

While in patient, nutrition recommended tube feeds for poor po 
intake. A post pyloric feeding tube was placed and tube feeds 
were started (Nepro). ___ provided teaching to the patient and 
his wife on ___ and supplies were delivered to the patient. 

Vital signs remained stable, LFTs improved some more. At time of 
discharge to home, his immunosuppression was set as tacrolimus 
3mg twice daily as his tacrolimus level was not back. Tacrolimus 
level was inaccurately reported and it was felt that the level 
reported was his roommate's and vice versa. So, his dose was 
increased to 3.5mg twice daily for a presumed level of 6.9 which 
was on the low side and was more consistent with the prior day 
of 8.1. Also, fluconazole was renally dosed and decreased to 
200mg daily to start ___. Next lab draw was set for ___. 

___ services were arranged in addition to ___. He was 
discharged to home appearing alert and in NAD. 

 

###RESPONSE: EtOH cirrhosis {Alcoholic cirrhosis}, liver {Transplanted liver present}, kidney {Transplanted kidney present}, PNA {Pneumonia}, incision wound infection {Postoperative wound infection}, Wound {Wound}, I&D {Incision AND drainage}, antibiotics {Antibiotic therapy}, incision/wound cultures {Wound microscopy, culture and sensitivities}, wound {Wound}, Wound culture {Wound microscopy, culture and sensitivities}, improved {Patient's condition improved}, culture {Microbial culture}, Wound {Wound}, Blood cultures {Blood culture}, wound culture {Wound microscopy, culture and sensitivities}, poor po 
intake {Decrease in appetite}, post pyloric feeding {Insertion of feeding tube into small intestine}, teaching {Patient education}, Vital signs {Vital signs finding}, stable {Normal vital signs}, improved {Patient's condition improved}, immunosuppression {Immunosuppression}, alert {Mentally alert}, NAD {No abnormality detected}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. NPH 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Sodium Bicarbonate 650 mg PO TID 
3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 
4. Omeprazole 40 mg PO DAILY 
5. PredniSONE 12.5 mg PO DAILY 
6. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) 
7. Tacrolimus 3.5 mg PO Q12H 
8. ValGANCIclovir 450 mg PO EVERY OTHER DAY 
9. Allopurinol ___ mg PO DAILY 
10. amLODIPine 10 mg PO DAILY 
11. Cyanocobalamin 1000 mcg PO EVERY 4  WEEKS (___) 
12. Docusate Sodium 100 mg PO BID 
13. Escitalopram Oxalate 15 mg PO DAILY 
14. Fluconazole 400 mg PO Q24H 
15. Multivitamins 1 TAB PO DAILY 
16. Mycophenolate Sodium ___ 720 mg PO BID 
17. Senna 8.6 mg PO BID:PRN constipation 
18. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 
19. TraZODone 25 mg PO QHS:PRN insomnia 

 
Discharge Medications:
1.  Amoxicillin-Clavulanic Acid ___ mg PO Q12H 
End date ___ 
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by 
mouth twice a day Disp #*9 Tablet Refills:*0 
2.  Fluconazole 200 mg PO Q24H  
3.  NPH 10 Units Breakfast
Insulin SC Sliding Scale using REG Insulin 
4.  Omeprazole 20 mg PO DAILY  
5.  PredniSONE 10 mg PO DAILY Duration: 7 Days 
follow taper  
6.  Sulfameth/Trimethoprim DS 1 TAB PO EVERY OTHER DAY  
7.  Tacrolimus 3.5 mg PO Q12H  (changed to 3.5 twice daily from 
3mg twice daily on ___ for level of 6.9
8.  Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 
Maximum 6 of the 325 mg tablets daily  
9.  Allopurinol ___ mg PO DAILY  
10.  amLODIPine 10 mg PO DAILY  
11.  Cyanocobalamin 1000 mcg PO EVERY 4  WEEKS (___)  
12.  Docusate Sodium 100 mg PO BID 
Hold for loose bowel movements or more than 2 bowel movements 
daily  
13.  Escitalopram Oxalate 15 mg PO DAILY  
14.  Multivitamins 1 TAB PO DAILY  
15.  Mycophenolate Sodium ___ 720 mg PO BID  
16.  Senna 8.6 mg PO BID:PRN constipation 
Hold for loose bowel movements or more than 2 bowel movements 
daily  
17.  Sodium Bicarbonate 650 mg PO TID  
18.  TraMADol 50 mg PO Q4H:PRN Pain - Moderate  
19.  TraZODone 25 mg PO HS:PRN insomnia  
20.  ValGANCIclovir 450 mg PO EVERY OTHER DAY  
21.Tube Feed Orders
Tubefeeding: Nepro or Equivalent
 Full strength;  Goal rate: 50 ml/hr
 Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 50 ml water q6h
Dispense 1 month supply;   Refill: 5

 

###RESPONSE: mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Severe malnutrition (decreased grip strength)
liver transplant
transplant incision abscess

 
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}, Severe malnutrition {Nutritional marasmus}, liver transplant {Transplanted liver present}, transplant incision abscess {Postoperative wound abscess}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Please call the transplant clinic at ___ for fever > 
101, chills, nausea, vomiting, diarrhea, constipation, inability 
to tolerate food, fluids or medications, feeding tube clogs, 
yellowing of skin or eyes, increased abdominal pain, incisional 
redness, drainage or bleeding, dizziness or weakness, decreased 
urine output or dark, cloudy urine, swelling of abdomen or 
ankles, or any other concerning symptoms.

You will have labwork drawn every ___ and ___ as 
arranged by the transplant clinic, with results to the 
transplant clinic (Fax ___ . CBC, Chem 10, AST, ALT, 
Alk Phos, T Bili, Trough Tacro level. 

**On the days you have your labs drawn, do not take your 
Tacrolimus until your labs are drawn. Bring your Tacrolimus with 
you so you may take your medication as soon as your labwork has 
been drawn.

Please note that the Fluconazole dose has been decreased to 
200mg daily. 

You have been prescribed an antibiotic (augmentin) for your 
abdominal incision infection

Follow your medication card, keep it updated with any dosage 
changes, and always bring your card with you to any clinic or 
hospital visits.

You may shower. Allow the water to run over your incision and 
pat area dry. No rubbing, no lotions or powder near the 
incision. 

Continue NS damp to dry dressing to the incision open area. 
Monitor for increased redness, drainage, foul odor or other 
concerns.
Complete Augmentin course as prescribed.

No tub baths or swimming
No driving if taking narcotic pain medications

Avoid direct sun exposure. Wear protective clothing and a hat, 
and always wear sunscreen with SPF 30 or higher when you go 
outdoors.

Drink enough fluids to keep your urine light in color. 
You have had a feeding tube placed and have started tube feeds 
to help with nutrition. Please continue the tube feeds as 
ordered in addition to flushes. Monitor for clogging of the tube 
or any increase in diarrhea or blood sugars that are hard to 
manage.

Check your blood sugars and blood pressure at home. Report 
consistently elevated values to the transplant clinic

Do not increase, decrease, stop or start medications without 
consultation with the transplant clinic at ___. There 
are significant drug interactions with anti-rejection 
medications which must be considered in medication management 
following transplant

Refer to transplant binder, and there is always someone on call 
at the transplant clinic with any questions that may arise

 

###RESPONSE: clinic {Outpatient care management}, fever {Fever}, chills {Chill}, nausea {Nausea}, vomiting {Vomiting}, diarrhea {Diarrhea}, constipation {Constipation}, fluids {Tolerating oral fluid}, feeding tube clogs {Blocked endotracheal tube}, yellowing of skin {Yellow skin}, eyes {Scleral icterus}, abdominal pain {Abdominal pain}, redness {Redness of skin over lesion}, drainage {Discharge}, bleeding {Bleeding}, dizziness {Dizziness}, weakness {Asthenia}, decreased 
urine output {Decreased urine output}, cloudy urine {Cloudy urine}, swelling of abdomen {Swollen abdomen}, ankles {Ankle region structure}, CBC {Complete blood count}, antibiotic {Antibiotic therapy}, abdominal incision {Abdomen incision}, infection {Local infection of wound}, incision {Surgical incision wound}, incision {Surgical incision wound}, dressing {Application of dressing}, incision {Surgical incision wound}, redness {Redness of skin over lesion}, drainage {Discharge}, odor {Wound odor}, taking narcotic pain medications {Narcotics education}, diarrhea {Diarrhea}, blood sugars {Glucose measurement, blood}, blood sugars {Glucose measurement, blood}, blood pressure {Blood pressure monitoring}, drug interactions {Drug interaction}, transplant {Transplantation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: CARDIOTHORACIC
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Fatigue, dyspnea on exertion and lightheadedness.
 
Major Surgical or Invasive Procedure:
___ - aortic valve replacement, coronary artery bypass 
grafts x2(LIMA>LAD,SVG>RCA) 
___ - Left and right heart catheterization, coronary 
angiogram left ventriculogram

 

###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, Fatigue {Fatigue}, dyspnea on exertion {Dyspnea on exertion}, lightheadedness {Lightheadedness}, aortic valve replacement {Replacement of aortic valve}, coronary artery bypass 
grafts {Coronary artery bypass grafting}, LIMA {Structure of left internal thoracic artery}, LAD {Structure of anterior descending branch of left coronary artery}, SVG {Aortocoronary artery bypass graft with saphenous vein graft}, RCA {Right coronary artery structure}, Left {Catheterization of left heart}, right heart catheterization {Catheterization of right heart}, coronary 
angiogram {Angiography of coronary artery}, left ventriculogram {Left ventriculogram}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 ___ year old white male with known aortic stenosis is 
followed with serial echocardiograms. Most recently these 
revealed an aortic valve area of 0.7cm2, a bicuspid valve and 
LVEF of 30%. She was referred for surgical evaluation after 
recent new onset heart failure.

 

###RESPONSE: aortic stenosis {Aortic valve stenosis}, echocardiograms {Echocardiography}, aortic valve {Aortic valve structure}, surgical {Surgical procedure}, evaluation {Evaluation procedure}, heart failure {Heart failure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Hypertension
Noninsulin dependent diabetes mellitus
Aortic Stenosis/Aortic Insufficiency
Mitral Regurgitation
Gastroesophageal Reflux Disease
degenerative joint disease
tonsillectomy

 

###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, Noninsulin dependent diabetes mellitus {Diabetes mellitus type 2}, Aortic Stenosis {Aortic valve stenosis}, Aortic Insufficiency {Aortic valve regurgitation}, Mitral Regurgitation {Mitral valve regurgitation}, Gastroesophageal Reflux Disease {Gastroesophageal reflux disease}, degenerative joint disease {Osteoarthritis}, tonsillectomy {Tonsillectomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother died of MI at ___; father died of CVA at ___

 

###RESPONSE: died {Dead}, MI {Myocardial infarction}, died {Dead}, CVA {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:

Pulse:91 Resp: 20     O2 sat: 100% RA
B/P  Right: 108/63   Left: 104/65
Height: 68""   Weight: 175 lbs

General:NAD; slow to process and answer questions
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable;teeth
in poor repair
Neck:  Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur ___ SEm radiates throughout
precordium to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x]  Edema - none
Varicosities: None [x]chronic mild venous stasis brawniness 
above
ankles bil.
Neuro: Grossly intact;MAE ___ strengths;nonfocal exam; has mild
cognitive deficits
Pulses:
Femoral      Right: 2+  Left: 2+
DP           Right: NP  Left: NP
___           Right: 1+  Left: 1+
Radial       Right: 2+  Left: 2+

Carotid: murmur radiates to both carotids

 

###RESPONSE: Pulse {Finding of pulse rate}, Resp {Examination of respiratory system}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, B/P {Blood pressure finding}, Right {Right upper arm structure}, Left {Left upper arm structure}, Height {Height / growth finding}, Weight {Weight finding}, General {General examination of patient}, NAD {No abnormality detected}, Skin {Examination of skin}, Dry {Xeroderma}, intact {Intact skin}, HEENT {Physical examination procedure}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, anicteric sclera {White sclera}, unremarkable {No abnormality detected}, teeth {Structure of dentition}, repair {Surgical repair}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Full ROM {Normal movement of neck}, JVD {Jugular venous engorgement}, Chest {Examination of respiratory system}, Lungs {Examination of respiratory system}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, Irregular {Irregular heart beat}, Murmur {Murmur}, precordium {Structure of precordium}, carotids {Carotid artery structure}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-distended {Normal abdominal contour}, non-tender {Abdominal tenderness}, bowel sounds {Normal bowel sounds}, HSM {Hepatosplenomegaly}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, Extremities {Examination of limb}, Warm {Warm skin}, well-perfused {Normal tissue perfusion}, Edema {Edema}, Varicosities {Venous varices}, chronic {Chronic disease}, mild {Symptom mild}, venous stasis {Venous stasis}, ankles {Ankle region structure}, Neuro {Neurological examination}, Grossly intact {Normal nervous system function}, MAE {Does move all four limbs}, mild {Symptom mild}, cognitive deficits {Impaired cognition}, Femoral {Structure of femoral artery}, Right: 2 {Pulse present in right femoral artery}, Left: 2 {Pulse present in left femoral artery}, DP {Structure of dorsalis pedis artery}, Right: NP {Absence of pulse in right dorsalis pedis artery}, Left: NP {Absence of pulse in left dorsalis pedis artery}, Radial {Structure of radial artery}, Right {Structure of right radial artery}, 2+ {Normal radial pulse}, Left {Structure of left radial artery}, 2+ {Normal radial pulse}, Carotid {Carotid artery structure}, murmur {Murmur}, carotids {Carotid artery structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ ECHO
PREBYPASS 
No atrial septal defect is seen by 2D or color Doppler. There is 
mild symmetric left ventricular hypertrophy. The left 
ventricular cavity is moderately dilated. There is severe global 
left ventricular hypokinesis (LVEF = ___ %). The right 
ventricular cavity is mildly dilated with moderate impairment 
with focal hypokinesis of the apical free wall. The ascending 
aorta is moderately dilated. The descending thoracic aorta is 
mildly dilated. There are simple atheroma in the descending 
thoracic aorta. There are three aortic valve leaflets. The 
aortic valve leaflets are moderately thickened. There is severe 
aortic valve stenosis (valve area 0.8-1.0cm2). Moderate to 
severe (3+) aortic regurgitation is seen. The mitral valve 
leaflets are mildly thickened. Mild (1+) mitral regurgitation is 
seen. 
POSTBYPASS
The patient is receiving dobutamine at 7ucg/kg/min.
RV systolic function is improved. There is now mild RV 
hypokinesis with minimal focality. LV systolic function is 
marginally improved, LVEF ~25%. There is a well seated, well 
fumctioning bioprosthesis in the aortic position. There is a 
mild perivalvular leak. TR is now mild (1+). The remaining study 
is otherwise unchanged from prebypass. 
 
___ 06:00AM BLOOD WBC-10.0 RBC-3.42* Hgb-8.7* Hct-26.8* 
MCV-78* MCH-25.3* MCHC-32.4 RDW-16.0* Plt ___
___ 07:00AM BLOOD WBC-16.0* RBC-3.71* Hgb-9.1* Hct-29.8* 
MCV-80* MCH-24.6* MCHC-30.6* RDW-15.6* Plt ___
___ 06:00AM BLOOD Glucose-166* UreaN-26* Creat-1.1 Na-139 
K-3.5 Cl-98 HCO3-33* AnGap-12
___ 06:45PM BLOOD UreaN-31* Creat-1.1 K-3.7
___ 05:41PM BLOOD Type-ART pO2-72* pCO2-45 pH-7.37 
calTCO2-27 Base XS-0
___ 12:30PM BLOOD %HbA1c-7.6*
 

###RESPONSE: ECHO {Echocardiography}, atrial septal defect {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, left 
ventricular cavity is moderately dilated {Dilatation of left cardiac ventricle}, left ventricular {Left cardiac ventricular structure}, hypokinesis {Behavior showing reduced motor activity}, right 
ventricular cavity is mildly dilated {Dilatation of right cardiac ventricle}, impairment {Impairment}, hypokinesis {Behavior showing reduced motor activity}, apical {Structure of apex of heart}, wall {Cardiac wall structure}, ascending 
aorta {Ascending aorta structure}, dilated {Dilatation}, descending thoracic aorta {Structure of descending thoracic aorta}, dilated {Dilatation}, atheroma {Atheroma}, descending 
thoracic aorta {Structure of descending thoracic aorta}, aortic valve leaflets {Structure of cardiac valve leaflet}, aortic valve leaflets {Structure of cardiac valve leaflet}, thickened {Increased thickness}, severe 
aortic valve stenosis {Severe stenosis of aortic valve}, aortic regurgitation {Aortic valve regurgitation}, mitral valve 
leaflets are mildly thickened {Thickened mitral leaflet}, Mild (1+) mitral regurgitation {Mild mitral valve regurgitation}, RV {Right cardiac ventricular structure}, improved {Patient's condition improved}, RV 
hypokinesis {Hypokinetic right ventricular wall}, LV {Left cardiac ventricular structure}, improved {Patient's condition improved}, aortic {Aortic structure}, perivalvular leak {Prosthetic cardiac paravalvular leak}, 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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, K {Blood potassium measurement}, pH {pH 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 ___ on ___ for a cardiac 
catheterization in anticipation of his aortic valve surgery. His 
cardiac catheterization revealed three vessel coronary artery 
disease. Mr. ___ was worked-up in the usual preoperative 
manner and was ready for surgery. 

On ___ he was taken to the Operating Room where he 
underwent coronary artery bypass grafting to two vessels and an 
aortic valve replacement using a tissue prosthesis. (Please see 
operative note for details.) He weaned from bypass on 
Dobutamine,Propofol and Neosynephrine in stable condition. 
Postoperatively he was taken to the intensive care unit for 
monitoring. 

Over the next ___ hours he had awoke neurologically intact and 
was extubated. Pressors were weaned off and he remained stable. 
Beta blockade and aspirin were resumed. On postoperative day 
one, he was transferred to the step down unit for further 
recovery. He was gently diuresed towards his preoperative 
weight. The physical therapy service was consulted for 
assistance with his postoperative strength and mobility. 
Oxygenation remained low and a CXR revealed what appeared to be 
a large left effusion. A left lung thoracentesis was performed 
on ___ yielding 500 mL of serosanguinous fluid.  A repeat CXR 
demonstrated an elevated left diaphragm with atelectasis and 
resolution of the effusion.  His oxygenation improved and he 
felt better.

He was discharged to a rehabilitation facility for further 
recovery prior to going home.  He will continue on diuretics for 
a week as he remained above his preoperative weight.  
Arrangements were made for follow up with his cardiology, 
medical and surgical providers.
 

###RESPONSE: cardiac 
catheterization {Cardiac catheterization}, aortic valve surgery {Aortic valve and adjacent structure operations}, cardiac catheterization {Cardiac catheterization}, three vessel coronary artery 
disease {Triple vessel disease of the heart}, surgery {Surgical procedure}, coronary artery bypass grafting to two vessels {Coronary artery bypass grafts x 2}, aortic valve replacement {Replacement of aortic valve}, tissue {Body tissue structure}, operative {Surgical procedure}, stable condition {Patient's condition stable}, taken to the intensive care unit {Patient transfer to intensive care unit}, monitoring {Monitoring procedure}, neurologically intact {Normal nervous system function}, extubated {Removal of endotracheal tube}, Pressors {Hypotensive therapy}, stable {Patient's condition stable}, aspirin {Administration of aspirin}, postoperative {Postoperative state}, diuresed {Diuretic therapy}, weight {Weight finding}, physical therapy {Physical therapy assessment}, postoperative {Postoperative state}, CXR {Plain chest X-ray}, left {Left lung structure}, effusion {Pleural effusion}, left lung {Left lung structure}, thoracentesis {Thoracentesis}, CXR {Plain chest X-ray}, elevated {Elevation}, left diaphragm {Structure of left dome of diaphragm}, atelectasis {Atelectasis}, effusion {Pleural effusion}, improved {Patient's condition improved}, rehabilitation {Rehabilitation therapy}, diuretics {Diuretic therapy}, weight {Weight finding}, cardiology {Cardiology service}, surgical {Surgical procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Furosemide 20mg daily, citalopram 20mg daily, glipizide 5mg 
daily, metformin 1000mg daily, omeprazole 20mg daily, 
simvastatin 80mg daily, diphenoxylate-atropine 25prn-prn  

 
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) 
Tablet, Delayed Release (E.C.) PO DAILY (Daily).  
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 
4 hours) as needed for pain.  
5. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
Q4H (every 4 hours) as needed for pain.  
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) 
ML PO HS (at bedtime) as needed for constipation.  
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal 
DAILY (Daily) as needed for constipation.  
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
9. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
10. Ipratropium-Albuterol ___ mcg/Actuation Aerosol Sig: Two 
(2) Puff Inhalation Q4H (every 4 hours).  
11. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a 
day.  
12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

13. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 
times a day).  
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 
days.  
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal 
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 
days.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___ 
 
Discharge Diagnosis:
coronary aretery disease
s/p coronary artery bypass
acute systolic heart failure
Hypertension
Non insulin dependent Diabetes Mellitus
Aortic Stenosis/Aortic Insufficiency
Mitral Regurgitation
Gastroesophageal Reflux Disease
degenerative joint disease

 
Discharge Condition:
Good

 

###RESPONSE: coronary aretery disease {Coronary arteriosclerosis}, coronary artery bypass {Coronary artery bypass grafting}, acute systolic heart failure {Acute systolic heart failure}, Hypertension {Hypertensive disorder, systemic arterial}, Non insulin dependent Diabetes Mellitus {Diabetes mellitus type 2}, Aortic Stenosis {Aortic valve stenosis}, Aortic Insufficiency {Aortic valve regurgitation}, Mitral Regurgitation {Mitral valve regurgitation}, Gastroesophageal Reflux Disease {Gastroesophageal reflux disease}, degenerative joint disease {Osteoarthritis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Monitor wounds for signs of infection. These include redness, 
drainage or increased pain.  
Report any fever greater then 100.5. 
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 
week. 
No lotions, creams or powders to incision. 
Shower daily,gently pat the wound dry.
No bathing or swimming for 1 month. 
Take all medications as directed. 
No driving for 1 month or while taking narcotics.. 
.
 

###RESPONSE: Monitor {Monitoring for signs and symptoms of infection}, wounds {Wound}, signs of infection {Monitoring for signs and symptoms of infection}, redness {Redness of skin over lesion}, drainage {Wound discharge}, increased pain {Increased pain}, fever {Fever}, weight gain {Weight gain}, incision {Surgical incision wound}, wound {Wound}, medications {Patient medication education}, while taking narcotics {Narcotherapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___               Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
___
 
Major Surgical or Invasive Procedure:
- Exploratory laparotomy, resection of hepatic flexure, and 
right colostomy ___ (___)

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Exploratory laparotomy {Exploratory laparotomy}, resection {Excision}, hepatic flexure {Structure of right colic flexure}, colostomy {Colostomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ presenting to ___ as transferred from OSH s/p MVC. On 
arrival the patient had AMS and could not provide any history. 
Per EMS and OSH records the patient was driving a truck while 
shooting up heroin and struck a tree. At OSH, underwent imaging 
that showed non-displaced sacral fracture, L5 transverse process 
fracture and abdominal free air. He was transferred to ___ for 
trauma evaluation, and taken to the OR emergently for Ex-lap. 
Postoperatively, he was transferred to the trauma ICU for close 
monitoring.
 

###RESPONSE: AMS {Altered mental status}, imaging {Imaging}, non-displaced {Undisplaced fracture}, sacral fracture {Fracture of sacrum}, transverse process 
fracture {Closed fracture lumbar vertebra, transverse process}, abdominal free air {Pneumoperitoneum}, Ex-lap {Exploratory laparotomy}, Postoperatively {Postoperative state}, monitoring {Monitoring procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
None
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Non contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Admission Physical Exam
VS - T: 97.8 HR: 106 BP: 132/79 RR: 20 100% on PSV
General: Intubated and sedated
HEENT: PERRL, NCAT
Neck: Ecchymosis over left neck, supple
CV: Mild tachycardia, regular rhythm
Lungs: CTAB
Abdomen: Soft, colostomy pink without any output
GU: Foley in place
Ext: Warm, well perfused
Neuro: Moving all extremities, localizes pain
Skin: No rash
 

###RESPONSE: Physical Exam {Physical examination procedure}, VS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, General {General examination of patient}, Intubated {Intubation}, sedated {Sedated}, HEENT {Physical examination procedure}, PERRL {Pupils equal and reacting to light}, NC {Normal head}, Neck {Physical examination procedure}, Ecchymosis {Ecchymosis}, supple {Normal movement of neck}, CV {Cardiovascular physical examination}, tachycardia {Tachycardia}, regular rhythm {Normal sinus rhythm}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, colostomy {Colostomy present}, pink {Pink skin}, GU {Examination of genitourinary system}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, Neuro {Neurological examination}, all extremities {All extremities}, pain {Pain}, Skin {Examination of skin}, 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: Pertinent Results:
___ 06:15PM   GLUCOSE-131* UREA N-27* CREAT-1.2 SODIUM-145 
POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-24 ANION GAP-18
___ 06:15PM   CALCIUM-8.1* PHOSPHATE-4.4 MAGNESIUM-1.5*
___ 06:15PM   WBC-2.8*# RBC-3.11*# HGB-9.6*# HCT-30.0*# 
MCV-97# MCH-30.9 MCHC-32.0 RDW-12.9 RDWSD-45.3
___ 06:15PM   PLT SMR-LOW PLT COUNT-87*#
___ 06:15PM   ___ PTT-43.4* ___
___ 01:21PM   COMMENTS-GREEN TOP
___ 01:21PM   LACTATE-2.9*
___ 01:06PM URINE  HOURS-RANDOM
___ 01:06PM URINE  UCG-NEGATIVE
___ 01:06PM URINE  bnzodzpn-POS barbitrt-NEG opiates-POS 
cocaine-POS amphetmn-POS oxycodn-NEG mthdone-NEG
___ 01:06PM URINE  COLOR-Amber APPEAR-Clear SP ___
___ 01:06PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-100 
GLUCOSE-NEG KETONE-40 BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG
___ 01:06PM URINE  RBC-126* WBC-3 BACTERIA-NONE YEAST-NONE 
EPI-0
___ 01:06PM URINE  HYALINE-19*
___ 01:06PM URINE  CA OXAL-MOD
___ 01:06PM URINE  MUCOUS-RARE
___ 01:00PM   GLUCOSE-129* UREA N-27* CREAT-1.1 SODIUM-142 
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-20* ANION GAP-22*
___ 01:00PM   estGFR-Using this
___ 01:00PM   ALT(SGPT)-61* AST(SGOT)-81* CK(CPK)-918* ALK 
PHOS-122 TOT BILI-1.2
___ 01:00PM   LIPASE-13
___ 01:00PM   ALBUMIN-4.2
___ 01:00PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG 
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:00PM   WBC-8.2 RBC-5.96 HGB-18.3* HCT-53.9* MCV-90 
MCH-30.7 MCHC-34.0 RDW-12.7 RDWSD-41.2
___ 01:00PM   NEUTS-84* BANDS-5 LYMPHS-7* MONOS-4* EOS-0 
BASOS-0 ___ MYELOS-0 AbsNeut-7.30* AbsLymp-0.57* 
AbsMono-0.33 AbsEos-0.00* AbsBaso-0.00*
___ 01:00PM   HYPOCHROM-NORMAL ANISOCYT-NORMAL 
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL 
POLYCHROM-NORMAL
___ 01:00PM   PLT SMR-NORMAL PLT COUNT-207
___ 01:00PM   ___ PTT-32.4 ___
 

###RESPONSE: GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, CALCIUM {Blood calcium measurement}, PHOSPHATE {Phosphate, total measurement}, MAGNESIUM {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PLT {Platelet count}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}, URINE {Urinalysis}, URINE {Urinalysis}, UCG-NEGATIVE {Urine chorionic gonadotrophin measurement}, URINE {Urinalysis}, URINE {Urinalysis}, COLOR {Color finding}, PROTEIN {Measurement of protein in urine}, GLUCOSE {Glucose measurement, urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, URINE {Urinalysis}, RBC {Red blood cell count}, WBC {White blood cell count}, AST {Aspartate aminotransferase measurement}, URINE {Urinalysis}, URINE {Urinalysis}, URINE {Urinalysis}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, CK(CPK {Creatine kinase measurement}, PHOS {Phosphate, total measurement}, TOT BILI {Bilirubin, total measurement}, LIPASE {Triacylglycerol lipase measurement}, ALBUMIN {Albumin measurement}, ETHANOL {Blood ethanol measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PLT {Platelet count}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ presenting to ___ as transferred from OSH s/p MVC. On 
arrival the patient had AMS and could not provide any history. 
Per EMS and OSH records the patient was driving a truck while 
shooting up heroin and struck a tree. At OSH, underwent imaging 
that showed non-displaced sacral fracture, L5 transverse process 
fracture and abdominal free air secondary to an ascending colon 
perforation. He was transferred to ___ for trauma evaluation, 
and taken to the OR emergently for Ex-lap. Postoperatively, he 
was transferred to the trauma ICU for close monitoring. His ICU 
course is summarized below with transitional issues consistent 
of  a) postoperative fevers, seconadry to a feculent peritonitis 
and GNRs bacteremia treated with Zosyn. b) intermittent 
agitation secondary to withdrawal symptims in setting of chronic 
heroin use.  Per APS and psychiatry, he was started on methadone 
10TID, Haldol 2.5 q2H prn for agitation, added a basal rate of 
.05 to dPCA, in addition to resumed his home psychiatric meds. 
The patient was extubated onPD#1,  advanced diet to clears, and 
transferred to the surgical ward for further management. His 
hospital course is summarized below
 

###RESPONSE: AMS {Altered mental status}, imaging {Imaging}, non-displaced {Undisplaced fracture}, sacral fracture {Fracture of sacrum}, transverse process 
fracture {Closed fracture lumbar vertebra, transverse process}, abdominal free air {Pneumoperitoneum}, ascending colon 
perforation {Traumatic perforation of ascending colon}, trauma {Traumatic injury}, evaluation {Evaluation procedure}, Ex-lap {Exploratory laparotomy}, Postoperatively {Postoperative state}, monitoring {Monitoring procedure}, postoperative fevers {Postoperative fever}, feculent peritonitis {Fecal peritonitis}, GNRs bacteremia {Bacteremia caused by Gram-negative bacteria}, agitation {Feeling agitated}, withdrawal symptims {Withdrawal symptom}, chronic 
heroin use {Chronic drug abuse}, agitation {Feeling agitated}, extubated {Removal of endotracheal tube}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion Dose is Unknown  PO BID 
2. Lorazepam Dose is Unknown  PO QHS 
3. Gabapentin 300 mg PO TID 
4. MethylPHENIDATE (Ritalin) 20 mg PO DAILY 
5. QUEtiapine Fumarate 25 mg PO Frequency is Unknown 
6. Venlafaxine XR 225 mg PO Frequency is Unknown 

 
Discharge Medications:
1. Venlafaxine XR 225 mg PO DAILY 
2. QUEtiapine Fumarate 25 mg PO QHS 
3. Gabapentin 400 mg PO TID 
4. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN pain 
___ will receive a 1 week supply. Please call the Surgery Clinic 
to make an appointment for refills 
5. MethylPHENIDATE (Ritalin) 20 mg PO DAILY 
6. Morphine SR (MS ___ 60 mg PO Q12H 
Taper:
60mg BID x 3 days
45mg BID x 3 days
30mg BID x 3 days
15mg BID x 3 days
15mg QD x 3 days 
7. Wheelchair
Wheelchair

 

###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:
Traumatic injury, colonic perforation, scapular fracture, sacral 
fracture, L5 transverse process fracture

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or 
wheelchair.

 

###RESPONSE: Traumatic injury {Traumatic injury}, colonic perforation {Perforation of colon}, scapular fracture {Fracture of scapula}, sacral 
fracture {Fracture of sacrum}, transverse process fracture {Closed fracture lumbar vertebra, transverse process}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Out of Bed with assistance {Difficulty getting off a bed}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. ___,

___ were admitted to ___ and 
underwent an exploratory laparotomy, resection of
hepatic flexure, and right colostomy. ___ are recovering well 
and are now ready for discharge. Please follow the instructions 
below to continue your recovery:

Monitoring Ostomy output/ Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other 
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day. 

*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with 
each episode of loose stool. Do not exceed 16mg/24 hours.

OSTOMY DISCHARGE INSTRUCTIONS:

Patient D/C instructions:
 
___ have a new colostomy. The most common complication from a 
new colostomy placement is dehydration. The output from the 
stoma is stool from the small intestine and the water content is 
very high. The stool is no longer passing through the large 
intestine which is where the water from the stool is reabsorbed 
into the body and the stool becomes formed. ___ must measure 
your colostomy output for the next few weeks. The output from 
the stoma should not be more than 1200cc or less than 500cc. If 
___ find that your output has become too much or too little, 
please call the office for advice. The office nurse or nurse 
practitioner can recommend medications to increase or slow the 
colostomy output. Keep yourself well hydrated, if ___ notice 
your colostomy output increasing, take in more electrolyte drink 
such as Gatorade. Please monitor yourself for signs and symptoms 
of dehydration including: dizziness (especially upon standing), 
weakness, dry mouth, headache, or fatigue. If ___ notice these 
symptoms please call the office or return to the emergency room 
for evaluation if these symptoms are severe. ___ may eat a 
regular diet with your new colostomy. However it is a good idea 
to avoid fatty or spicy foods and follow diet suggestions made 
to ___ by the ostomy nurses.
 
Please monitor the appearance of the ostomy and stoma and care 
for it as instructed by the wound/ostomy nurses. ___ stoma 
(intestine that protrudes outside of your abdomen) should be 
beefy red or pink, it may ooze small amounts of blood at times 
when touched and this should subside with time. The skin around 
the ostomy site should be kept clean and intact. Monitor the 
skin around the stoma for bulging or signs of infection listed 
above. Please care for the ostomy as ___ have been instructed by 
the wound/ostomy nurses. ___ will be able to make an appointment 
with the ostomy nurse in the clinic 7 days after surgery. ___ 
will have a visiting nurse at home for the next few weeks 
helping to monitor your ostomy until ___ are comfortable caring 
for it on your own. 
 
 
Currently your colostomy is allowing the surgery in your large 
intestine to heal, which does take some time. ___ will come back 
to the hospital for reversal of this colostomy when decided by 
Dr. ___ will follow-up in the clinic, and the 
surgeon will decide when will be the best time for your second 
surgery. Until this time there is healthy intestine that is 
still functioning as it normally would and it will produce mucus 
and some may leak or ___ may feel as though ___ need to have a 
bowel movement and ___ may sit on the toilet and empty this 
mucus, it is normal. 
 
 
Rehab D/C instructions:
 
To the Rehab:
Thank ___ for participating in the care of this patient.  This 
patient has had multiple teaching sessions with both the 
Wound/Ostomy nurses and with the staff nurses and should have a 
good idea of how to care for their own ostomy.  They have also 
been given several items that will assist them in their own 
care, such as instruction sheets, ostomy supplies, and ostomy 
output measuring tools.  However, we would like to stress a few 
important points to assist ___ in the care of this patient.

Bowel Function:  
Ø  It is important to encourage the patient to monitor their 
bowel function closely every day.  The patient should continue 
to record their colostomy output (as much as physically 
possible) and the amount of fluid they have taken in, just as 
they were taught in the hospital.  A urinal or “hat” should be 
used to record their ostomy output daily.  
o   The patient has been taught to use a daily measurement chart 
to record their I&O’s.  This chart should be continued to be 
used at least until their follow-up appointment. If their ostomy 
output is less than 500 ml or greater than 1200 ml of liquid 
stool in a day, it is very important to call the doctor’s office 
with this information. 
o   Continue to reinforce to the patient that the major risk 
with an colostomy is dehydration related to fluid loses. Daily 
fluid intake is ___ glasses of fluids, including electrolyte 
enhanced beverages.  In the hot weather, encourage them to take 
in increased amounts of fluid and closely measure 
their colostomy output.  
o   Watch for signs and symptoms of dehydration including: dry 
mouth or tongue, decrease in urination, urine darker in color, 
dizzy when he/she stands, cramps in his/her abdomen or legs, 
dizziness, increased thirst, or weakness. 
Stoma Care:
Ø  It is also important to monitor the appearance of the stoma. 
The tissue of the stoma should be moist, pink or red in color. 
o   If the stoma has color changes from pink / red to dark 
purplish /blue in color, becomes swollen, or a large amount of 
continuous bleeding into the pouch, and or at the Mucocutaneous 
Junction (Stomal Incision). this is not normal. Call the 
patient’s doctor’s office for assistance.  
 If ___ or the patient has any questions regarding the care of 
the patient’s ostomy, please refer to the instructions provided 
to the patient by the wound/ostomy nurses. 
___ the patient develops the following bowel symptoms please call 
the surgeon’s office or go to the nearest emergency room if 
severe: increasing abdominal distension and cramps, nausea, 
vomiting, inability to tolerate food or liquids, decrease 
in ostomy output, or have no output from ostomy for ___ hours

Please call the Acute Care Surgery Clinic if ___ develop fevers, 
chills, nausea, vomiting, decreased or no ostomy output, or 
other concerns. The phone number is ___.

 

###RESPONSE: exploratory laparotomy {Exploratory laparotomy}, resection {Excision}, hepatic flexure {Structure of right colic flexure}, colostomy {Colostomy}, ready for discharge {Ready for discharge}, loose stool {Loose stool}, colostomy {Colostomy}, colostomy {Colostomy}, placement {Implantation procedure}, dehydration {Dehydration}, stoma {Stoma}, stool {Stool finding}, small intestine {Structure of small intestine}, large 
intestine {Structure of large intestine}, measure 
your colostomy output {Monitoring of stoma output}, stoma {Stoma}, colostomy {Colostomy}, colostomy output increasing {High output stoma}, monitor yourself for signs and symptoms 
of dehydration {Dehydration monitoring}, dizziness {Dizziness}, standing {Orthostatic body position}, weakness {Asthenia}, dry mouth {Xerostomia}, headache {Headache}, fatigue {Fatigue}, evaluation {Evaluation procedure}, regular diet {Normal diet}, colostomy {Colostomy}, stoma {Stoma}, stoma {Stoma}, intestine {Intestinal structure}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, Monitor {Monitoring for signs and symptoms of infection}, skin {Examination of skin}, stoma {Stoma}, bulging {Bulging}, signs of infection {Monitoring for signs and symptoms of infection}, colostomy {Colostomy}, surgery {Surgical procedure}, large 
intestine {Structure of large intestine}, colostomy {Colostomy}, intestine {Intestinal structure}, teaching {Patient education}, record their colostomy output {Monitoring of stoma output}, liquid 
stool {Liquid stool}, colostomy {Colostomy}, dehydration {Dehydration}, measure 
their colostomy output {Monitoring of stoma output}, signs {Sign}, dehydration {Dehydration}, dry 
mouth {Xerostomia}, tongue {Tongue structure}, decrease in urination {Decreased urine output}, urine darker in color {Urine: dark/concentrated}, dizzy {Dizziness}, stands {Orthostatic body position}, cramps {Cramp}, abdomen {Stomach cramps}, legs {Cramp in lower limb}, dizziness {Dizziness}, increased thirst {Increased thirst}, weakness {Asthenia}, stoma {Stoma}, tissue {Body tissue structure}, stoma {Stoma}, stoma {Stoma}, swollen {Swelling}, bleeding {Bleeding}, Mucocutaneous 
Junction {Structure of mucocutaneous junction}, Incision {Surgical incision wound}, abdominal distension {Swollen abdomen}, cramps {Cramp}, nausea, 
vomiting {Nausea and vomiting}, inability to tolerate food or liquids {Nausea and vomiting}, fevers {Fever}, chills {Chill}, nausea, vomiting {Nausea and vomiting}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: UROLOGY
 

###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: 
ciprofloxacin
 
Attending: ___.
 
Chief Complaint:
SCROTAL/PERINEAL ABSCESS
 
Major Surgical or Invasive Procedure:
1. Exam under anesthesia.
2. Debridement of scrotal and perineal abscess.

 

###RESPONSE: ciprofloxacin {Allergy to ciprofloxacin}, SCROTAL {Abscess of scrotum}, PERINEAL {Perineal structure}, ABSCESS {Abscess}, Exam under anesthesia {Physical examination under general anesthesia}, Debridement {Debridement}, scrotal {Abscess of scrotum}, perineal {Perineal structure}, abscess {Abscess}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ h/o afib on Coumadin, MI s/p stent, CHF (LVEF ___,
HLD, HTN, solitary kidney (donated), Crohn's, BPH managed with
chronic indwelling foley; transferred from ___ with 
right
scrotal abscess.  

Patient presented to his see his urologist (___)
at ___ yesterday for a poorly draining foley.  Following
the catheter change, there was reportedly drainage of purulent
material and as such he was transferred to their ED for further
evaluation.  He was admitted to the medicine service there for
treatment of his infection.  On admission, ___ 24, febrile to
102. UA data not available in outside records, though started on
ceftriaxone/flagyl for empiric treatment. 

When found to have right scrotal fluctuance, there was an
ultrasound performed that showed right scrotal abscess with
concern for fluid and gas extending into the perineum.  Due to
concern for Fournier's gangrene, he was transferred to ___ for
further assessment.
 

###RESPONSE: afib {Atrial fibrillation}, MI {Myocardial infarction}, s/p stent {Placement of stent in coronary artery}, CHF {Congestive heart failure}, HLD {Hyperlipidemia}, HTN {Hypertensive disorder, systemic arterial}, Crohn's {Crohn's disease}, BPH {Benign prostatic hyperplasia}, foley {Catheterization of urinary bladder}, scrotal abscess {Abscess of scrotum}, see his urologist {Seen by urologist}, poorly draining foley {Decreased urine output}, catheter change {Replacement of indwelling catheter of urinary bladder}, drainage of purulent
material {Purulent discharge}, evaluation {Evaluation procedure}, infection {Infectious disease}, febrile {Fever}, UA {Urinalysis}, scrotal {Scrotal structure}, fluctuance {Fluctuant}, ultrasound {Ultrasonography}, scrotal abscess {Abscess of scrotum}, perineum {Perineal structure}, Fournier's gangrene {Fournier's gangrene}, assessment {Evaluation procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Afib on coumadin                                                 

MI s/p stent ___ ago
HLD
HTN
Single kidney 
Crohn's disease
Anal fissure

L donor nephrectomy
Hernia repair  
 

###RESPONSE: Afib {Atrial fibrillation}, MI {Myocardial infarction}, s/p stent {Placement of stent in coronary artery}, HLD {Hyperlipidemia}, HTN {Hypertensive disorder, systemic arterial}, kidney {Kidney structure}, Crohn's disease {Crohn's disease}, Anal fissure {Anal fissure}, L {Left kidney structure}, donor nephrectomy {Donor nephrectomy}, Hernia repair {Hernia repair}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Son- DM and renal failure                          
 

###RESPONSE: DM {Diabetes mellitus}, renal failure {Renal failure syndrome}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
Perineal incision packed w/ ___ plain nugauze. Edges pink, 
clean, w/out evidence infection, necrosis.
Perineal ___ drain in place; ___ wick removed. Hemiscrotum 
Incision c/d/i w/out evidence hematoma or infection
Lower extremities w/out edema or pitting and no report of calf 
pain
Foley catheter in place; secured to medial thigh

 

###RESPONSE: Physical Exam {Physical examination procedure}, WdWn {Well nourished}, NAD {No abnormality detected}, AVSS {Vital signs finding}, Interactive {Does communicate}, cooperative {Cooperative mental state}, soft {Abdomen soft}, Nt {Abdominal tenderness}, Nd {Swollen abdomen}, Perineal incision {Incision of perineum}, packed w/ ___ plain nugauze {Application of gauze swab}, infection {Local infection of wound}, necrosis {Necrosis}, Perineal {Perineal structure}, drain in place {Insertion of drain}, Incision {Incision}, hematoma {Hematoma}, infection {Infectious disease}, Lower extremities {Lower limb structure}, edema {Edema}, pitting {Pitting edema}, pain {Pain}, Foley {Catheterization of urinary bladder}, medial thigh {Structure of medial surface of thigh}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 07:10AM BLOOD WBC-12.3* RBC-3.33* Hgb-8.3* Hct-26.2* 
MCV-79* MCH-24.9* MCHC-31.7* RDW-17.6* RDWSD-50.4* Plt ___
___ 06:58AM BLOOD WBC-9.9 RBC-3.12* Hgb-8.0* Hct-25.0* 
MCV-80* MCH-25.6* MCHC-32.0 RDW-18.0* RDWSD-53.3* Plt ___
___ 06:30PM BLOOD WBC-12.7* RBC-3.34* Hgb-8.3*# Hct-27.0*# 
MCV-81* MCH-24.9* MCHC-30.7* RDW-18.0* RDWSD-53.1* Plt ___
___ 06:30PM BLOOD Neuts-74.2* Lymphs-15.5* Monos-6.7 
Eos-3.0 Baso-0.2 Im ___ AbsNeut-9.45* AbsLymp-1.97 
AbsMono-0.85* AbsEos-0.38 AbsBaso-0.03
___ 07:10AM BLOOD Glucose-100 UreaN-12 Creat-1.0 Na-135 
K-4.3 Cl-99 HCO3-29 AnGap-11
___ 06:58AM BLOOD Glucose-75 UreaN-12 Creat-0.8 Na-136 
K-4.0 Cl-105 HCO3-24 AnGap-11
___ 06:30PM BLOOD Glucose-89 UreaN-15 Creat-0.8 Na-135 
K-4.1 Cl-105 HCO3-25 AnGap-9
___ 07:10AM BLOOD Phos-3.9 Mg-1.6
___ 06:40PM BLOOD Lactate-0.8

___ 05:18PM URINE Color-Straw Appear-Clear Sp ___
___ 06:40PM URINE Color-Straw Appear-Clear Sp ___
___ 05:18PM URINE Blood-NEG Nitrite-NEG Protein-NEG 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 06:40PM URINE Blood-TR Nitrite-NEG Protein-NEG 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 05:18PM URINE RBC-2 WBC-16* Bacteri-FEW Yeast-NONE 
Epi-0
___ 06:40PM URINE RBC-5* WBC-50* Bacteri-FEW Yeast-NONE 
Epi-0

___ BLOOD CULTURE Blood Culture, Routine-PENDING 
INPATIENT 
___ URINE URINE CULTURE-FINAL INPATIENT 
___ BLOOD CULTURE Blood Culture, Routine-PENDING 
INPATIENT 
___ SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL; 
ANAEROBIC CULTURE-FINAL {BACTEROIDES FRAGILIS GROUP}; FUNGAL 
CULTURE-PRELIMINARY EMERGENCY WARD 
___ URINE URINE CULTURE-FINAL EMERGENCY WARD 
___ BLOOD CULTURE Blood Culture, Routine-PENDING 
EMERGENCY WARD 
___ BLOOD CULTURE Blood Culture, Routine-PENDING 
EMERGENCY WARD 
___ 10:30 pm SWAB      PERINEAL SWAB. 

   GRAM STAIN (Final ___: 
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR 
LEUKOCYTES. 
      NO MICROORGANISMS SEEN. 

   WOUND CULTURE (Final ___:    NO GROWTH. 

   ANAEROBIC CULTURE (Final ___: 
      BACTEROIDES FRAGILIS GROUP.    SPARSE GROWTH. 
         BETA LACTAMASE POSITIVE. 

   FUNGAL CULTURE (Preliminary): 
      NO FUNGUS ISOLATED. 
      A swab is not the optimal specimen for recovery of 
mycobacteria or
      filamentous fungi.  A negative result should be 
interpreted with
      caution.  Whenever possible tissue biopsy or aspirated 
fluid should
      be submitted. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, 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}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, URINE Color-Straw {Normal urine color}, URINE Color-Straw {Normal urine color}, URINE Blood {Blood in urine}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, URINE Blood {Blood in urine}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, RBC {Red blood cell count}, WBC {White blood cell count}, RBC {Red blood cell count}, WBC {White blood cell count}, CULTURE {Blood culture}, Blood Culture {Blood culture}, URINE {Urine culture}, URINE CULTURE {Urine culture}, CULTURE {Blood culture}, Blood Culture {Blood culture}, GRAM STAIN {Gram stain method}, WOUND {Wound}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, URINE {Urine culture}, URINE CULTURE {Urine culture}, CULTURE {Blood culture}, Blood Culture {Blood culture}, CULTURE {Blood culture}, Blood Culture {Blood culture}, PERINEAL {Perineal structure}, GRAM STAIN {Gram stain method}, WOUND {Wound}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, FUNGUS ISOLATED {Sample fungus isolated}, tissue {Body tissue structure}, biopsy {Biopsy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 patient was admitted to the urology service following 
debridement of scrotal and perineal abscess.  See operative 
report for full details.  The patient tolerated the procedure 
well and recovered in the PACU before transfer to the surgical 
floor.  He was admitted on zosyn/clindamycin for antibiotic 
therapy, with BID packing changes of anterior and posterior 
perineal wounds.  On POD1, he was attempted to be narrowed to 
unasyn, though spiked a fever to ___ and was again re-broadened 
to zosyn/clindamycin.  On POD2, he was narrowed to Bactrim 
empirically for better MRSA coverage and remained afebrile 
through the time of discharge.

With respect to anticoagulation, the patient was seen by the 
cardiology service, and the decision was made to restart the 
patient's ASA and Plavix immediately postoperatively, as he 
remained on it to the time of surgery and experienced no 
bleeding complications.  He did, however, remain off of his 
Coumadin for the duration of his hospital stay, and was 
instructed to restart at home dose 2d after discharge.

His foley catheter remained in place for the duration of his 
stay.  His diet was advanced as tolerated following surgery.  At 
discharge, patient's pain was well controlled with oral pain 
medications, tolerating regular diet, ambulating without 
assistance, and voiding without difficulty. Incision at 
discharge without erythema or hematoma.  He will follow-up with 
his home urologist, ___ at ___, as 
directed and complete a course of Bactrim.  He will also follow 
up with general surgery for perineal ___ removal.   ___ was 
set up to assist with packing changes and drain care.

 

###RESPONSE: debridement {Debridement}, scrotal {Abscess of scrotum}, perineal {Perineal structure}, abscess {Abscess}, operative {Surgical procedure}, procedure {Procedure}, PACU {Postanesthesia care}, surgical {Surgical procedure}, antibiotic 
therapy {Antibiotic therapy}, packing changes {Change of dressing}, perineal {Perineal structure}, wounds {Wound}, fever {Fever}, MRSA {Methicillin resistant Staphylococcus aureus infection}, afebrile {Fever}, anticoagulation {Anticoagulant therapy}, cardiology service {Cardiology service}, surgery {Surgical procedure}, bleeding {Bleeding}, foley {Catheterization of urinary bladder}, diet {Dietary finding}, surgery {Surgical procedure}, pain was well controlled {Demonstrates adequate pain control}, oral {Administration of drug or medicament via oral route}, pain 
medications {Administration of analgesic}, regular diet {Normal diet}, ambulating without 
assistance {Independent walking}, voiding without difficulty {Normal micturition}, Incision {Incision}, erythema {Erythema}, hematoma {Hematoma}, follow-up {Follow-up status}, follow 
up {Follow-up status}, surgery {Surgical procedure}, perineal {Perineal structure}, removal {Removal}, packing changes {Change of dressing}, drain care {Drainage tube 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: Medications on Admission:
The Preadmission Medication list may be inaccurate and requires 
futher investigation.
1. Metoprolol Tartrate 25 mg PO BID 
2. Simvastatin 80 mg PO QPM 
3. Clopidogrel 75 mg PO DAILY 
4. Aspirin 325 mg PO DAILY 
5. Warfarin 5 mg PO DAILY16 
6. Feosol (ferrous sulfate;<br>iron, carbonyl) 325 mg (65 mg 
iron) oral BID 

 
Discharge Medications:
1. Aspirin 325 mg PO DAILY 
2. Clopidogrel 75 mg PO DAILY 
3. Metoprolol Tartrate 25 mg PO BID 
4. Simvastatin 80 mg PO QPM 
5. Sulfameth/Trimethoprim DS 1 TAB PO BID 
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg ONE 
tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0
6. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours 
7. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN Pain  
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4hrs Disp #*35 Tablet 
Refills:*0
8. Docusate Sodium 100 mg PO BID 
RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth 
twice a day Disp #*60 Capsule Refills:*0
9. Acetaminophen 650 mg PO TID 
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Duration: 3 
Doses 
ONE Tablet(s) sublingually as instructed for chest pain x three 
PRN 
11. Feosol (ferrous sulfate;<br>iron, carbonyl) 325 mg (65 mg 
iron) oral BID 
12. Warfarin 5 mg PO DAILY16 
resume on ___.  
13. MESALAMINE
You may resume your mesalamine unless otherwise explicitly 
advised.

 

###RESPONSE: mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
PREOPERATIVE DIAGNOSES:
1. Scrotal abscess.
2. Perineal abscess.

POSTOPERATIVE DIAGNOSES:
1. Scrotal abscess.
2. Perineal abscess.

 
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}, Scrotal abscess {Abscess of scrotum}, Perineal {Perineal structure}, abscess {Abscess}, Scrotal abscess {Abscess of scrotum}, Perineal {Perineal structure}, abscess {Abscess}, Mental Status {Mental state finding}, Level of Consciousness {Finding of level of consciousness}, 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 will be discharged home with ___ services for wound care 
and packing changes. 

-Please also reference the instructions provided by nursing on 
Foley care/hygiene.  

For your safety and the safety of others; PLEASE DO NOT drive, 
operate dangerous machinery, or consume alcohol while taking 
narcotic pain medications and while you have the 
drain/foley/scrotal packing.

-Your FOLEY should be secured to the catheter secure on your 
thigh at ALL times.

-Follow up with UROLOGY for wound check and post-op evaluation 
as directed.  Surgery service will arrange outpatient follow-up 
for the ___ drain removal. 

-ALWAYS call to inform, review and discuss any medication 
changes and your post-operative course with your primary care 
doctor.

-___ scrotum/phallus supported/elevated. Use a 
jock-supporter/strap or jockey-type briefs or tight, 
tighty-whities to facilitate this; Subsequently you may 
transition to loose fitting briefs or boxer-briefs for 
support--they should be cotton and/or breathable.

-Do NOT use penis for intercourse/sex until explicitly advised 
by your urologist that is may be ok to do so.

-You may want to coordinate your showers with your ___ provider 
and the planned dressing changes.

-You may shower, but do NOT bathe, swim or otherwise immerse 
your incision.

-Tylenol should be your first line pain medication, a narcotic 
pain medication has been prescribed for breakthough pain >4. 
Replace Tylenol with narcotic pain medication. Max daily Tylenol 
dose is from 3gm to 4gm depending on your kidney function, note 
that narcotic pain medication also contains Tylenol 
(acetaminophen)

-Colace has been prescribed to avoid post-surgical constipation 
and constipation related to narcotic pain medication, 
discontinue if loose stool or diarrhea develops. Colace is a 
stool ""softener""- it is NOT a laxative

-Resume your home medications, except as noted.

-DO NOT RESUME medications like VIAGRA, LEVITRA or CIALIS.

-If you have fevers > 101.5 F, vomiting, or increased redness, 
swelling, or discharge from your incision, call your doctor or 
go to the nearest emergency room.
 

###RESPONSE: wound care {Wound care}, packing changes {Change of dressing}, instructions provided by nursing {Nursing care education, guidance, counseling}, Foley care/hygiene {Urinary catheter care education}, while taking 
narcotic pain medications {Narcotics education}, foley {Catheterization of urinary bladder}, scrotal {Scrotal structure}, packing {Packing of wound}, FOLEY {Catheterization of urinary bladder}, thigh {Thigh structure}, Follow up {Follow-up status}, wound check {Wound assessment}, post-op {Postoperative state}, evaluation {Evaluation procedure}, Surgery service {Surgical follow-up}, outpatient follow-up  {Outpatient care management}, drain removal {Removal of drain}, medication 
changes  {Change of medication}, post-operative course {Postoperative state}, scrotum {Scrotal structure}, phallus supported {Fitting of external prosthetic device on penis}, elevated {Elevation}, supporter {Support}, support {Support}, penis {Penile structure}, intercourse/sex until explicitly advised {Recommendation to limit sexual activity}, dressing changes {Change of dressing}, incision {Incision}, pain medication {Administration of analgesic}, pain medication {Administration of analgesic}, breakthough pain {Breakthrough pain}, pain medication {Administration of analgesic}, kidney {Kidney structure}, pain medication {Administration of analgesic}, post-surgical {Postoperative state}, constipation {Constipation}, constipation {Constipation}, pain medication {Administration of analgesic}, loose stool {Loose stool}, diarrhea {Diarrhea}, fever {Fever}, vomiting {Vomiting}, redness {Redness of skin over lesion}, swelling {Swelling}, incision {Incision}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: NEUROLOGY
 

###RESPONSE: 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 / Morphine / adhesive tape / Iodine-Iodine 
Containing
 
Attending: ___
 
Chief Complaint:
Headache
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Penicillins {Allergy to penicillin}, Morphine {Allergy to morphine}, adhesive tape {Allergy to adhesive agent}, Iodine-Iodine {Allergy to iodine compound}, Headache {Headache}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Patient is a ___ yo woman with PMHx sig. for CVA, CAD s/p 
multiple PCIs, DM, and HTN who presented to ___ 
___ for a severe headache, blurry vision, and concern 
for increased gait instability.  Her headache started 4 AM this 
morning, waking her up from sleep.  The headache starts in the 
back and goes all over her head, described as a ""very bad"" pain, 
rating ___.  Her headache is triggered wtih getting up, 
relieved by sitting down.  Her headaches ia also associated with 
nausea and dry heaves, no vomiting.  When she got out of bed, 
she leaned forward, falling into the door.  She was lightheaded 
and leaning to right and left.  Of note, pt had previously been 
on coumadin for ___ years; this was discontinued 3 months ago.

At OSH, she was hypertensive to sbp 200, which resolved on its 
own.  She had a neg head CT scan and was transferred for neuro 
eval and MRI. 

In the ED, initial VS were: 98.4 76 146/99 18 95% RA.  Labs were 
notable for ESR 16.  She had an LP.  MRI head showed ""No 
evidence of acute infarct. Tiny DWI signal intensity at the 
right frontal lobe (10:18) is likely T2 shinethrough. Chronic 
microvascular ischemic changes seen in the paraventricular white 
matter. no aneurysm or dissection seen. No evidence of 
hemorrhage.""  The patient received percocet. Vitals prior to 
transfer to the floor were:  98.4 76 146/99 18 95% RA.  

Currently, she feels that her gait is back to baseline.
 
Review of Systems:  
(+) Per HPI plus:  night sweats, rhinorrhea, postnasal drip 
cough, chronic joint pains, residual weakness in L leg and arm 
and tingling in L leg from stroke 
(-) Denies fever, chills, night sweats, recent weight loss or 
gain. Denies sinus tenderness, or congestion. Denies chest pain 
or tightness, palpitations. Denies  shortness of breath Denies 
nausea, vomiting, diarrhea, constipation,  or abdominal pain. No 
dysuria, urinary frequency. Denies rashes. All other review of 
systems negative.  

 

###RESPONSE: CVA {Cerebrovascular accident}, CAD {Coronary arteriosclerosis}, PCIs {Percutaneous coronary intervention}, DM {Diabetes mellitus}, HTN {Hypertensive disorder, systemic arterial}, headache {Headache}, blurry vision {Blurring of visual image}, gait instability {Unsteady when walking}, headache {Headache}, headache {Headache}, head {Head structure}, pain {Pain}, headache {Headache}, sitting {Sitting position}, headaches {Headache}, nausea {Nausea}, dry heaves {Retching}, vomiting {Vomiting}, lightheaded {Lightheadedness}, hypertensive {Hypertensive disorder, systemic arterial}, resolved {Problem resolved}, head CT {Computed tomography of head}, MRI {Magnetic resonance imaging}, VS {Vital signs finding}, Labs {Laboratory test}, LP {Lumbar puncture}, MRI head {Magnetic resonance imaging of head}, acute infarct {Acute infarct}, right frontal lobe {Right frontal lobe structure}, microvascular {Structure of small blood vessel (organ)}, ischemic changes {Ischemia}, white 
matter {Cerebral white matter structure}, aneurysm {Aneurysm}, dissection {Dissecting hemorrhage}, hemorrhage {Hemorrhage}, Vitals {Vital signs finding}, baseline {Baseline state}, Review of Systems {Review of systems}, night sweats {Night sweats}, rhinorrhea {Nasal discharge}, postnasal drip {Posterior rhinorrhea}, cough {Cough}, joint pains {Joint pain}, weakness {Asthenia}, L leg {Structure of left lower limb}, arm {Left upper arm structure}, tingling {Pins and needles}, L leg {Structure of left lower limb}, stroke {Cerebrovascular accident}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, sinus tenderness {Tenderness over frontal sinus}, congestion {Nasal congestion}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, shortness of breath {Dyspnea}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, dysuria {Dysuria}, urinary frequency {Increased frequency of urination}, rashes {Eruption of skin}, review of 
systems {Review of systems}, negative {No abnormality detected}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
CVA in ___, residual weakness in L leg and arm and tingling in 
L leg
CAD s/p multiple PCIs
DM2
HTN
h/o breast cancer, s/p lumpectomy in ___
 

###RESPONSE: CVA {Cerebrovascular accident}, weakness {Asthenia}, L leg {Structure of left lower limb}, arm {Left upper arm structure}, tingling {Pins and needles}, L leg {Structure of left lower limb}, CAD {Coronary arteriosclerosis}, PCIs {Percutaneous coronary intervention}, DM2 {Diabetes mellitus type 2}, HTN {Hypertensive disorder, systemic arterial}, breast cancer {Malignant neoplasm of breast}, lumpectomy {Excision of mass}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Two sons have had CABG.
 

###RESPONSE: CABG {Coronary artery bypass grafting}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Vitals:  147/67, 70, 98RA
Gen: NAD, AOX3  
HEENT: PERRL, EOMI, MMM, sclera anicteric, not injected  
Neck: no LAD, no JVD  
Cardiovascular: RRR normal s1, s2, no murmurs appreciated  
Respiratory: bibasilar crackles, no wheezing  
Abd: normoactive bowel sounds, soft, non-tender, non distended 
Extremities: No edema, 2+ DP pulses  
Neurological: CN II-XII intact, normal attention, sensation 
normal, babinski down-going bilaterally, MS ___ in BUEs and BLEs 
though slightly weaker on LLE, ataxic gait leaning to both 
sides, unable to perform Romberg as unstead with eyes open  
Integument: Warm, moist, no rash or ulceration  
Psychiatric: appropriate, pleasant, not anxious
 

###RESPONSE: Vitals {Vital signs finding}, RA {Breathing room air}, Gen {General examination of patient}, NAD {No abnormality detected}, AOX3 {Oriented to person, time and place}, HEENT {Physical examination procedure}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, sclera anicteric {White sclera}, Neck {Physical examination procedure}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, Cardiovascular {Cardiovascular physical examination}, RRR {Normal heart rate}, normal s1, s2 {Heart sounds normal}, murmurs {Murmur}, Respiratory {Examination of respiratory system}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, wheezing {Wheezing}, Abd {Examination of abdomen}, normoactive bowel sounds {Normal bowel sounds}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, distended {Swollen abdomen}, Extremities {Examination of limb}, edema {Edema}, DP {Structure of dorsalis pedis artery}, Neurologic {Neurological examination}, CN II-XII intact {Normal central nervous system}, sensation 
normal {Normal sensation}, babinski down-going {Plantar reflex normal}, LLE {Structure of left lower limb}, ataxic gait {Ataxic gait}, Romberg {Romberg sign}, Integument {Examination of skin}, Warm {Warm skin}, rash {Eruption of skin}, ulceration {Ulcer}, anxious {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: Pertinent Results:
Admission labs:
___ 08:24PM   WBC-8.6 RBC-4.09* HGB-13.6 HCT-38.8 MCV-95 
MCH-33.2* MCHC-34.9 RDW-13.5
___ 08:24PM   NEUTS-52.4 ___ MONOS-5.4 EOS-3.8 
BASOS-1.3
___ 08:24PM   GLUCOSE-89 UREA N-22* CREAT-1.3* SODIUM-141 
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-17
___ 08:24PM   ___ PTT-22.6 ___

Discharge Labs
___ 06:50AM BLOOD WBC-10.6 RBC-3.70* Hgb-12.2 Hct-35.9* 
MCV-97 MCH-33.0* MCHC-34.1 RDW-14.0 Plt ___
___ 07:14AM BLOOD ___ PTT-95.9* ___
___ 08:24PM BLOOD ESR-16
___ 06:50AM BLOOD Glucose-87 UreaN-27* Creat-1.5* Na-147* 
K-4.1 Cl-113* HCO3-25 AnGap-13
___ 06:50AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.2
___ 08:24PM BLOOD CRP-1.3

___ 10:46AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:46AM URINE Blood-SM Nitrite-NEG Protein-150 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
___ 10:46AM URINE ___ Bacteri-MANY 
Yeast-NONE ___

MRI ___
IMPRESSION:
1. Punctate acute infarcts in the right hemisphere, which could 
be along ACA/MCA and MCA/PCA watershed territories or be within 
the MCA territory.
2. Chronic infarct of the superior right frontal lobe, MCA 
territory.
3. Multifocal high-grade stenoses involving the right MCA M2 
divisions. Other milder probably atherosclerotic disease as 
described above.
4. Findings compatible with underlying chronic small vessel 
ischemic disease.

CTA ___
IMPRESSION: Mild stenoses of the superior and inferior M2 
divisions of the right MCA, improved compared to recent MRA. 
This could be due to improvement in vasospasm or technical 
differences in evaluation of stable atherosclerotic 
irregularity.

Carotid Doppler ___
Right ICA stenosis <40%.
Left ICA stenosis 60-69%.

Echocardiogram ___
The left atrium is normal in size. No atrial septal defect or 
patent foramen ovale is seen by 2D, color Doppler or saline 
contrast with maneuvers. Left ventricular wall thickness, cavity 
size and regional/global systolic function are normal (LVEF 
>55%). Tissue Doppler imaging suggests an increased left 
ventricular filling pressure (PCWP>18mmHg). There is an abnormal 
systolic flow contour at rest, but no left ventricular outflow 
obstruction. There is no ventricular septal defect. Right 
ventricular chamber size and free wall motion are normal. 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. No aortic regurgitation is seen. 
The mitral valve leaflets are mildly thickened. The pulmonary 
artery systolic pressure could not be determined. There is no 
pericardial effusion. 
IMPRESSION: No cardiac source of embolism seen. Normal global 
and regional biventricular systolic function. Calcified aortic 
and mitral valves without significant stenosis or regurgitation. 
Negative bubble study. 

EKG ___
Sinus rhythm. Normal tracing. Compared to the previous tracing 
of ___
ventricular ectopy and left atrial abnormality are no longer 
seen.
___
___ yo woman with PMHx sig. for CVA, CAD s/p multiple PCIs, DM, 
and HTN who presented to ___ for a 
severe headache, blurry vision, and concern for increased gait 
instability.

She was transferred to ___ for further neurologic evaluation 
and MRI given concern for severe headache or neck pain ___ 
radiating to bioccipital and bitemporal areas, with hypertension 
to 200 mmHg and vomiting at ___. along with history of a 
prior stroke, despite normal CT there. 

MRI revealed punctate infarcts of the right hemisphere within 
MCA or distal MCA watersheds. Therefore, Mrs. ___ was 
admitted to Neurology for further workup.

Headache improved and no new neurologic deficits were noted - 
gait instability at baseline per patient. 

CTA was reassuring with respect to intracranial MCA stenosis, 
despite such on MRA. Carotid ultrasound revealed less than 40% R 
internal carotid stenosis. There was no known history of atrial 
fibrillation and echo demonstrated no thrombi or atrial septal 
defect. 

Headache may have related to underlying vasospasm, explaining 
improved MCA territory stenosis from MRA to CTA. Headache may 
have also related to uncontrolled hypertension. GIven that no 
embolic source was found, this was seen as the most likely 
explanation. Verapamil was started and initial heparin IV 
therapy was stopped. On final assessment probable migraine with 
vasospasm was thought most likely. Aspirin and simvastatin are 
to continued. She is discharged for follow-up with Dr. ___ 
in clinic. 
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, PTT {Partial thromboplastin time, activated}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, 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}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, MRI {Magnetic resonance imaging of head}, acute infarcts {Acute infarct}, right hemisphere {Right cerebral hemisphere structure}, ACA {Structure of anterior cerebral artery}, MCA {Structure of middle cerebral artery}, MCA {Structure of middle cerebral artery}, PCA {Structure of posterior cerebral artery}, MCA {Structure of middle cerebral artery}, infarct {Infarct}, right frontal lobe {Right frontal lobe structure}, MCA {Structure of middle cerebral artery}, stenoses {Stenosis}, M2 
divisions {Structure of middle cerebral artery M2 segment}, atherosclerotic disease {Atherosclerosis}, small vessel {Structure of small blood vessel (organ)}, ischemic disease {Ischemia}, CTA {Computed tomography angiography with contrast}, stenoses {Stenosis}, M2 
divisions {Structure of middle cerebral artery M2 segment}, right MCA {Structure of right middle cerebral artery}, improved {Patient's condition improved}, MRA {Magnetic resonance angiography of vascular structure of head}, vasospasm {Vasospasm}, atherosclerotic {Atherosclerosis}, Carotid {Carotid artery structure}, Doppler {Doppler ultrasound}, ICA stenosis {Internal carotid artery stenosis}, ICA stenosis {Internal carotid artery stenosis}, Echocardiogram {Echocardiography}, left atrium {Left atrial structure}, normal in size {Normal size}, atrial septal defect {Atrial septal defect}, patent foramen ovale {Patent foramen ovale}, color Doppler {Color Doppler ultrasound}, 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}, Tissue Doppler imaging {Doppler ultrasonography of heart tissue}, left 
ventricular {Left cardiac ventricular structure}, left ventricular outflow 
obstruction {Left ventricular outflow tract obstruction}, ventricular septal defect {Ventricular septal defect}, Right 
ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Finding of right ventricular wall motion}, aorta at the sinus, {Structure of sinus of Valsalva}, arch {Aortic arch structure}, aortic valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve leaflets {Structure of leaflet of mitral valve}, pulmonary 
artery {Pulmonary artery structure}, pericardial effusion {Pericardial effusion}, embolism {Embolism}, Normal global 
and regional biventricular systolic function {Normal left ventricular systolic function and wall motion}, Calcified {Pathologic calcification, calcified structure}, aortic {Aortic valve structure}, mitral valves {Mitral valve structure}, stenosis {Stenosis}, regurgitation {Mitral valve regurgitation}, EKG {Electrocardiographic procedure}, Sinus rhythm {Sinus rhythm}, ventricular ectopy {Ventricular premature complex}, left atrial abnormality {Left atrial abnormality}, CVA {Cerebrovascular accident}, CAD {Coronary arteriosclerosis}, PCIs {Percutaneous coronary intervention}, DM {Diabetes mellitus}, HTN {Hypertensive disorder, systemic arterial}, headache {Headache}, blurry vision {Blurring of visual image}, gait 
instability {Unsteady when walking}, neurologic evaluation {Neurological examination}, MRI {Magnetic resonance imaging}, headache {Headache}, neck pain {Neck pain}, radiating {Radiating pain}, bioccipital {Occipital region structure}, bitemporal {Structure of temporal region}, hypertension {Hypertensive disorder, systemic arterial}, vomiting {Vomiting}, stroke {Cerebrovascular accident}, MRI {Magnetic resonance imaging}, infarcts {Infarct}, right hemisphere {Right cerebral hemisphere structure}, MCA {Structure of middle cerebral artery}, MCA {Structure of middle cerebral artery}, watersheds {Watershed infarct}, Headache {Headache}, improved {Patient's condition improved}, neurologic deficits {Neurological deficit}, gait instability {Unsteady when walking}, CTA {Computed tomography angiography with contrast}, intracranial {Intracranial structure}, MCA {Structure of middle cerebral artery}, stenosis {Stenosis}, Carotid ultrasound {Ultrasonography of carotid artery}, carotid stenosis {Carotid artery stenosis}, atrial 
fibrillation {Atrial fibrillation}, echo {Echocardiography}, thrombi {Thrombus}, atrial septal 
defect {Atrial septal defect}, Headache {Headache}, vasospasm {Vasospasm}, improved {Patient's condition improved}, MCA {Structure of middle cerebral artery}, stenosis {Stenosis}, MRA {Magnetic resonance angiography of vascular structure of head}, CTA {Computed tomography angiography with contrast}, Headache {Headache}, hypertension {Hypertensive disorder, systemic arterial}, heparin IV 
therapy {Heparin therapy}, migraine {Migraine}, vasospasm {Vasospasm}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Metformin 500 mg bid
Isosorbide mono 20 mg daily
Metoprolol 100 mg TID
Simvastatin 40 mg daily
Lisinopril 40 mg daily
Furosemide 40 mg daily
Caltrate 600 + D
Asa 81 mg daily
 
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily).
Disp:*50 Tablet, Chewable(s)* Refills:*2*
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).
Disp:*40 Tablet(s)* Refills:*2*
3. verapamil 240 mg Cap,24 hr Sust Release Pellets Sig: One (1) 
Cap,24 hr Sust Release Pellets PO once a day.
Disp:*30 Cap,24 hr Sust Release Pellets(s)* Refills:*2*
4. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO 
three times a day.  
5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) 
Tablet PO BID (2 times a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Acute:
-Punctate acute infarcts in the right hemisphere, which could be 
along ACA/MCA and MCA/PCA watershed territories or be within the 
MCA territory. 
-Vasospasm 
  

 
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}, acute infarcts {Acute infarct}, right hemisphere {Right cerebral hemisphere structure}, ACA {Structure of anterior cerebral artery}, MCA {Structure of middle cerebral artery}, MCA {Structure of middle cerebral artery}, PCA {Structure of posterior cerebral artery}, MCA {Structure of middle cerebral artery}, Vasospasm {Vasospasm}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted to the hospital with unusual headache. Your 
brain MRI showed a very small infarct in the frontal and 
parietal areas; called ""watershed infarct"" that was likely due 
to vasoconstriction. You will need to be on a medication called 
verapamil to prevent further strokes.
 

###RESPONSE: headache {Headache}, brain MRI {Magnetic resonance imaging of brain}, infarct {Infarct}, frontal {Frontal region structure}, parietal areas {Parietal region structure}, watershed infarct {Watershed infarct}, strokes {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: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Patient admitted for weight reduction surgery.
 
Major Surgical or Invasive Procedure:
Status Post Laparoscopic Gastric Band

 

###RESPONSE: surgery {Surgical 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:
___ has class III  morbid obesity with weight of 288.4 lbs
as of ___ (his initial screen weight on ___ was 285.9
lbs), height of 61 inches and BMI of 54.7. His previous weight
loss efforts have included 7 months of Weight Watchers in ___
losing 25 lbs that he maintained for 2 months and 5 months of
Slim-Fast in ___ without any results. He has not taken
prescription weight loss medications or used over-the-counter 
appetite suppressants/herbal supplements. He does not remember
his weight at age ___ or his lowest adult weight but he weighed
232 lbs on ___ and 289 lbs on ___, his highest adult
weight.
 

###RESPONSE: morbid obesity {Morbid obesity}, weight
loss {Weight loss}, prescription {Prescription}, weight loss {Weight loss}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
hypothyroidism with h/o Graves'  
disease s/p ablation, severe sleep disordered breathing with  
recommendation for CPAP by recent sleep study, fatty liver by  
ultrasound, hyperlipidemia, neurofibromatosis, testicular  
torsion, colitis likely diverticular disease hospitalized x 2 
and  
lower back and knee pain  

 

###RESPONSE: hypothyroidism {Hypothyroidism}, Graves'  
disease {Graves' disease}, ablation {Destructive procedure}, sleep study {Sleep studies}, fatty liver {Steatosis of liver}, ultrasound {Ultrasonography}, hyperlipidemia {Hyperlipidemia}, neurofibromatosis {Neurofibromatosis}, testicular  
torsion {Torsion of testis}, colitis {Colitis}, diverticular disease {Diverticular disease}, lower back {Low back pain}, knee pain {Pain of knee region}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Family history is noted for mother living with heart
disease, thyroid disease and obesity; grandparent deceased of
heart disease.
 

###RESPONSE: heart
disease {Heart disease}, thyroid disease {Disorder of thyroid gland}, obesity {Obesity}, heart disease {Heart 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: Physical Exam:
His blood pressure was 127/82, pulse 94, respirations 16 and O2
saturation 94% on room air. On physical examination ___ 
was
casually dressed and in no distress. His skin was warm, dry, no
rashes, + neurofibromas on face (small), trunk/abdomen medium
size with ___ spots on abdomen (large at RMQ, smaller
area LLQ); tattoos bilateral lower extremities with lesion right
anterior mid-shin. Anicteric sclerae, conjunctiva clear, pupils
were equal round and reactive to light, fundi difficult to
visualize, mucous membranes were moist, tongue pink and
oropharynx was without exudates or hyperemia. Trachea was in the
midline and the neck was supple without adenopathy, thyromegaly
or carotid bruits. Chest was symmetric and the lungs were clear
to auscultation, no wheezes, air movement was fair to good.
Cardiac exam was regular rate and rhythm, normal S1 and S2, no
murmurs, rubs or gallops. The abdomen was obese but soft and
non-tender, non-distended, + bowel sounds, no masses or hernias,
there was small healed incision scar umbilicus. There was no
spinal tenderness or flank pain. There was no edema of the lower
extremities, no venous stasis or clubbing, perfusion was good.
There was no evidence of joint swelling or inflammation of the
joints. There were no focal neurological deficits and his gait
was normal.  
 

###RESPONSE: blood pressure {Blood pressure finding}, pulse {Normal pulse}, O2
sat {Oxygen saturation measurement}, on room air {Breathing room air}, physical examination {Physical examination procedure}, distress {Distress}, skin {Examination of skin}, warm {Warm skin}, rashes {Eruption of skin}, neurofibromas on face {Neurofibroma of face}, trunk {Trunk structure}, abdomen {Skin structure of anterior abdominal wall}, abdomen {Skin structure of anterior abdominal wall}, tattoos {Tattoo of skin}, lower extremities {Lower limb structure}, lesion {Lesion}, shin {Shin structure}, Anicteric {White sclera}, conjunctiva {Conjunctival structure}, pupils {Pupil finding}, mucous membranes were moist {Moist oral mucosa}, oropharynx {Oropharyngeal structure}, exudates {Exudate}, hyperemia {Hyperemia}, Trachea {Tracheal structure}, neck {Neck structure}, supple {Normal movement of neck}, adenopathy {Lymphadenopathy}, thyromegaly {Goiter}, carotid bruits {Carotid bruit}, Chest {Examination of respiratory system}, lungs were clear
to auscultation {Normal breath sounds}, wheezes {Wheezing}, Cardiac {Cardiovascular physical examination}, regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, abdomen {Examination of abdomen}, obese {Obese}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds {Normal bowel sounds}, hernias {Herniated structure}, incision {Incision}, scar {Scar}, umbilicus {Umbilical structure}, tenderness {Tenderness}, pain {Pain}, edema {Edema}, lower
extremities {Lower limb structure}, venous stasis {Venous stasis}, clubbing {Clubbing}, perfusion {Perfusion}, joint swelling {Joint swelling}, joints {Joint structure}, neurological deficits {Neurological deficit}, gait {Gait normal}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 12:36PM BLOOD Hct-43.9
___ 07:05AM BLOOD WBC-6.0 RBC-4.53* Hgb-12.1* Hct-37.3* 
MCV-82 MCH-26.7* MCHC-32.5 RDW-13.7 Plt ___
___ 07:05AM BLOOD Plt ___
 

###RESPONSE: Hct {Hematocrit 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}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Patient admitted and underwent a laparoscopic gastric band. He 
tolerated this procedure very well. Postoperative course was 
complicated by urinary retention. Urology was consulted as 
reinsertion of foley catheter was difficult. He will go home 
with a foley catheter and appointment has been made for him with 
urology to discontinue catheter in one week.

Pain is well controlled on roxicet. Slowly progressed to 
bariatric stage 3 with good tolerance. Discharge instructions 
reviewed and discussed.

Will follow up with Dr. ___ in 2 weeks.
 

###RESPONSE: laparoscopic gastric band. {Laparoscopic adjustable gastric banding}, procedure {Procedure}, urinary retention {Retention of urine}, foley {Catheterization of urinary bladder}, foley {Catheterization of urinary bladder}, Pain is well controlled {Demonstrates adequate pain control}, Discharge instructions {Final inpatient visit with instructions at discharge}, 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:
Levothyroxine 300 mcg daily for  
hypothyroid; Citalopram 20 mg daily for depression (not taking); 
 
Simvastatin 40 mg daily for hyperlipidemia; Ibuprofen 800 mg  
three times daily with meals as needed for back, knee pain;  
Betamethasone 0.05% lotion to affected skin at bedtime;  
multivitamins with minerals daily and vitamin D  

 
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY 
(Daily).  
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
4. Oxycodone-Acetaminophen ___ mg/5 mL Solution Sig: ___ MLs 
PO Q4H (every 4 hours) as needed for pain.
Disp:*500 ML(s)* Refills:*0*
5. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day as 
needed for constipation.
Disp:*500 ml* Refills:*0*
6. Multivitamin     Tablet Sig: One (1) Tablet PO once a day.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis: obesity

 
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent

 

###RESPONSE: obesity {Obesity}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:

###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 Instructions: Please call your surgeon or return to 
the emergency department if you develop a fever greater than 
101.5, chest pain, shortness of breath, severe abdominal pain, 
pain unrelieved by your pain medication, severe nausea or 
vomiting, severe abdominal bloating, inability to eat or drink, 
foul smelling or colorful drainage from your incisions, redness 
or swelling around your incisions, or any other symptoms which 
are concerning to you.

Diet: Stay on Stage III diet until your follow up appointment. 
Do not self advance
diet, do not drink out of a straw or chew gum.

Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1.  You are being discharged on medications to treat the pain 
from your operation. These medications will make you drowsy and 
impair your ability to drive a motor vehicle or operate 
machinery safely. You MUST refrain from such activities while 
taking these medications.
2. You should begin taking a chewable complete multivitamin with 
minerals once a day. No gummy vitamins.
3. You should take a stool softener, Colace, twice daily for 
constipation as needed, or until you resume a normal bowel 
pattern.
4. You must not use NSAIDS (non-steroidal anti-inflammatory 
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and 
Naproxen. These agents will cause bleeding and ulcers in your 
digestive system.

Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may 
resume moderate
exercise at your discretion, no abdominal exercises.

Wound Care:
You may shower, no tub baths or swimming. 
If there is clear drainage from your incisions, cover with 
clean, dry gauze. 
Your steri-strips will fall off on their own. Please remove any 
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling, 
redness, or drainage from the incision sites. 

 

###RESPONSE: Discharge Instructions {Final inpatient visit with instructions at discharge}, fever {Fever}, chest pain {Chest pain}, shortness of breath {Dyspnea}, abdominal pain {Abdominal pain}, pain {Pain}, pain medication {Administration of analgesic}, nausea {Nausea}, vomiting {Vomiting}, abdominal bloating {Abdominal bloating}, drainage {Discharge}, incisions {Incision}, redness {Redness of skin over lesion}, swelling {Swelling}, incisions {Incision}, Diet {Dietary finding}, diet {Dietary finding}, diet {Dietary finding}, pain {Pain}, operation {Surgical procedure}, drowsy {Drowsy}, impair your ability to drive a motor vehicle or operate 
machinery safely {Patient should not drive or operate machinery}, take a stool softener {Administration of laxative}, constipation {Constipation}, a normal bowel 
pattern {Normal bowel habits}, bleeding {Bleeding}, ulcers {Ulcer}, digestive system {Structure of digestive system}, exercise {Exercises}, abdominal exercises {Abdominal exercises}, drainage {Discharge}, incisions {Incision}, cover with 
clean, dry gauze {Application of dressing}, surgery {Surgical procedure}, increased pain {Increased pain}, swelling {Swelling}, redness {Redness of skin over lesion}, drainage {Discharge}, incision {Incision}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
Sulfa (Sulfonamide Antibiotics) / Codeine / Azithromycin / 
Tequin / Keflex / Penicillins
 
Attending: ___.
 
Chief Complaint:
Chest pain
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, Codeine {Allergy to codeine}, Azithromycin {Allergy to azithromycin}, Keflex {Allergy to cefalexin}, Penicillins {Allergy to penicillin}, Chest pain {Chest pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ y/o man with long hx of GERD who presented to the ED after 
experiencing intermittant chest pain associated with dizziness 
over the preceding two days.  He was unsure if this was GERD 
associted pain or not, and felt recent initiation of SSRI may 
have contributed, but symptoms persisted, so he called ___ at 
the recommendation of an RN from his PCP's office.   He was 
given ASA (4 baby asa) by EMS and he reported immediate relief 
of his chest pain.  

In the ED, found to have VSS.  ECG with ? old inferior infarct.  
No ischemic changes.  Trop flat times two.  Had planned obs and 
stress test, but not able to do on ___, so admitted. 

ROS: at current: denies dizziness, sob, nausea, cp.  Denies 
recent blood in stool or tarry stools.  All other systems 
reviewed and negative. 
 

###RESPONSE: GERD {Gastroesophageal reflux disease}, chest pain {Chest pain}, dizziness {Dizziness}, GERD {Gastroesophageal reflux disease}, pain {Pain}, PCP {Primary care management}, relief {Feeling relief}, chest pain {Chest pain}, VSS {Vital signs finding}, ECG {Electrocardiographic procedure}, old inferior infarct {Old inferior myocardial infarction}, No ischemic changes {Electrocardiogram: no myocardial ischemia}, stress test {Electrocardiogram with exercise test}, dizziness {Dizziness}, sob {Dyspnea}, nausea {Nausea}, blood in stool {Hematochezia}, tarry stools {Melena}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
HTN
GERD
HCL
 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, GERD {Gastroesophageal reflux 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:
Cancer - lung and liver.  No hx. CAD in parents or siblings.
 

###RESPONSE: Cancer {Malignant neoplasm}, lung {Malignant tumor of lung}, liver {Malignant neoplasm of liver}, 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:
AF and VSS. BP 156/98.  
NAD
Alert, oriented
Independently ambulatory
No JVD
RRR no MRG
CTA througout
Soft, nt, nd, bs present
No edema
Distal pulses 2+
No rash
 

###RESPONSE: AF {Atrial fibrillation}, VSS {Vital signs finding}, BP {Blood pressure finding}, NAD {No abnormality detected}, Alert {Mentally alert}, oriented {Orientated}, Independently ambulatory {Independent walking}, JVD {Jugular venous engorgement}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, CTA {Normal breath sounds}, Soft {Abdomen soft}, nt {Abdominal tenderness}, nd {Swollen abdomen}, bs present {Normal bowel sounds}, edema {Edema}, Distal pulses 2+ {Peripheral pulse present}, 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: Pertinent Results:
___ 03:00PM   PLT COUNT-197
___ 03:00PM   NEUTS-64.3 ___ MONOS-9.4 EOS-1.6 
BASOS-0.5
___ 03:00PM   WBC-6.7 RBC-4.69 HGB-14.0 HCT-39.4* MCV-84 
MCH-30.0 MCHC-35.6* RDW-13.6
___ 03:00PM   D-DIMER-<150
___ 03:00PM   cTropnT-<0.01
___ 03:00PM   estGFR-Using this
___ 03:00PM   GLUCOSE-92 UREA N-20 CREAT-0.9 SODIUM-142 
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-26 ANION GAP-17
___ 09:15PM   cTropnT-<0.01

ECG: NSR.  S1Q3T3 (old).  No acute ischemic changes.

___ ___ M  ___  ___ 
 
Cardiology Report Stress Study Date of ___   
 
  
EXERCISE RESULTS 

 
*** Not Signed Out *** 
RESTING DATA 
EKG:  SINUS, ERWP, NSSTTW   
HEART RATE:  75 BLOOD PRESSURE:  144/70 
  
PROTOCOL GERVINO - TREADMILL 
STAGE TIME SPEED ELEVATION HEART BLOOD RPP 
  (MIN) (MPH) (%) RATE PRESSURE   
1 ___ 1.0 5 82 148/74 ___ 
2 ___ 1.6 6 79 150/70 ___ 
3 ___ 2.2 7 86 156/60 ___ 2.8 8 94 156/60 ___ 
  
TOTAL EXERCISE TIME:  12 % MAX HRT RATE ACHIEVED:  66 
 
SYMPTOMS: NONE   
ST DEPRESSION: NONE 
 
  
INTERPRETATION: ___ yo man with h/o HTN and ECG with questionable 
old 
IMI was referred to evaluate an atypical chest discomfort and 
lightheadedness. The patient completed 12 minutes of a Gervino 
protocol 
representing an average exercise tolerance for his age; ~ 6.2 
METS. The 
exercise test was stopped at the patient's request secondary to 
fatigue. 
No chest, back, neck or arm discomforts were reported. No 
significant ST 
segment changes were noted. The rhythm was sinus with rare 
isolated APDs 
and VPDs noted. In the absence of beta blocker therapy, the 
heart rate 
response to exercise was blunted. In addition, a blunted blood 
pressure 
response to exercise was noted. 
  
IMPRESSION: Average exercise tolerance. No anginal symptoms or 
ischemic 
ST segment changes. Blunted hemodynamic response to exercise 
(see 
above). 
 

 

###RESPONSE: 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}, cTropnT {Troponin T cardiac measurement}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, ECG {Electrocardiographic procedure}, NSR {Normal sinus rhythm}, No acute ischemic {Electrocardiogram: no myocardial ischemia}, Cardiology {Cardiology service}, Stress Study {Electrocardiogram with exercise test}, EXERCISE {Electrocardiogram with exercise test}, EKG {Electrocardiographic procedure}, SINUS {Sinus rhythm}, HEART RATE {Finding of heart rate}, ELEVATION {Elevation}, HEART {Finding of heart rate}, PRESSURE {Blood pressure finding}, EXERCISE {Electrocardiogram with exercise test}, ST DEPRESSION {ST segment depression}, HTN {Hypertensive disorder, systemic arterial}, ECG {Electrocardiographic procedure}, old 
IMI {Old inferior myocardial infarction}, chest discomfort {Chest discomfort}, lightheadedness {Lightheadedness}, exercise tolerance {Exercise tolerance finding}, exercise test {Electrocardiogram with exercise test}, fatigue {Fatigue}, chest {Thoracic structure}, back {Structure of back of trunk}, neck {Neck structure}, arm {Upper limb structure}, discomforts {Discomfort}, ST 
segment changes {Electrocardiographic ST segment changes}, rhythm {Normal sinus rhythm}, sinus {Sinus rhythm}, therapy {Therapy}, heart rate {Finding of heart rate}, exercise {Electrocardiogram with exercise test}, blood 
pressure {Blood pressure monitoring}, exercise {Electrocardiogram with exercise test}, exercise tolerance {Exercise tolerance finding}, anginal symptoms {Angina}, ischemic {Ischemia}, ST segment changes {Electrocardiographic ST segment changes}, hemodynamic {Hemodynamic monitoring}, exercise {Exercises}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Impression:

Chest pain, intermittant, associated with lightheadeness, not 
associated with activity, concerning for anginal pain; could be 
due to gastritis or a side effect of new SSRI administration in 
the past 10 days.  Fact that pt. reports that sysptoms 
alleviated immediatley by the administration of asa by EMS 
personnel unusual - no EMS documentation in pt. record.  I 
remain concerned that this was more likely ntg administration 
concurrently that may have resolved pain. 

Stable and chronic issues include: HTN, HCL.

Hospital course: 

Troponin T negative times three.  Exercise stress test (non 
imaging) was performed, result above.  Pt. had no symptoms of 
chest pain or dizziness during this episode.  On further review, 
pt. reported that chest pain and dizziness are most notable when 
taking celexa - especially if he takes it on an empty stomach.  
He also states that his chest pain is most consistent with his 
acid reflux - and that this and dizziness are alleviated by 
eating.  

He endorses lonliness.  I have suggested that he continue to 
take the SSRI, as the side effects of dizziness and GI upset 
often resolve with continued administration of this medication.  
He agrees with this. 

 

###RESPONSE: Chest pain {Chest pain}, lightheadeness {Lightheadedness}, anginal pain {Angina}, gastritis {Gastritis}, side effect {Medication side effects present}, resolved {Problem resolved}, pain {Pain}, Stable {Patient's condition stable}, chronic issues {Chronic disease}, HTN {Hypertensive disorder, systemic arterial}, Troponin T {Troponin T measurement}, Exercise stress test {Electrocardiogram with exercise test}, imaging {Imaging}, chest pain {Chest pain}, dizziness {Dizziness}, chest pain {Chest pain}, dizziness {Dizziness}, stomach {Stomach structure}, chest pain {Chest pain}, acid reflux {Acid reflux}, dizziness {Dizziness}, lonliness {Feeling lonely}, side effects {Medication side effects present}, dizziness {Dizziness}, GI upset {Gastrointestinal irritation}, administration of this medication {Administration of drug or medicament}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
 citalopram 
10 mg Tablet 
1 Tablet(s) by mouth once a day  ___
New ___,
 ___ 30 Tablet 3 (Three) ___ Care)  
  gemfibrozil 
600 mg Tablet 
1 Tablet(s) by mouth once a day (Prescribed by Other Provider; 
Dose adjustment - no new Rx)  ___
Recorded Only ___,
 ___        
  hydrochlorothiazide 
12.5 mg Capsule 
1 Capsule(s) by mouth daily  ___
Renewed ___,
 ___ 90 Capsule 3 (Three) ___ Care)  
  omeprazole 
40 mg Capsule, Delayed Release(E.C.) 
1 Capsule(s) by mouth once a day (Prescribed by Other Provider: 
___  ___
Recorded Only ___,
 ___        
  ranitidine HCl 
150 mg Tablet 
1 Tablet(s) by mouth at bedtime (Prescribed by Other Provider)  
___
Recorded Only ___,
 ___        
  terazosin 
2 mg Capsule 
1 Capsule(s) by mouth at bedtime (Prescribed by Other Provider: 
___  ___
Recorded Only ___,
 ___        
  * OTCs *             
  acetaminophen [Tylenol Extra Strength] 
500 mg Tablet 
2 Tablet(s) by mouth q4hr as needed for pain (___)  ___
Recorded Only ___,
 ___        
  carboxymethylcellulose sodium [Lubricant Eye Drops] 
0.5 % Drops 
1 gtt ___ four times a day as needed for dry eyes (Prescribed by 
Other Provider: ___  ___
Recorded Only ___,
 ___        
  cholecalciferol (vitamin D3) 
1,000 unit Tablet 
1 Tablet(s) by mouth once a day (___)  ___
Recorded Only ___,
 ___        
  glucosamine-chondroitin 
500 mg-400 mg Capsule 
3 Capsule(s) by mouth once a day (___)  ___
Recorded Only ___,
 ___        
  guar gum [Benefiber (guar gum)] 
1 gram Tablet 
1 Tablet(s) by mouth once a day (___)  ___
Recorded Only ___,
 ___        
  multivitamin-minerals-lutein [Centrum Silver] 
Tablet 
1 Tablet(s) by mouth once a day (___)  ___
Recorded Only ___,
 ___        
  saw ___ 
500 mg Capsule 
1 Capsule(s) by mouth once a day (___)  ___
Recorded Only ___,
 ___        
  ___ by Drug Class            

 
Discharge Medications:
1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).  
2. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times 
a day).  
3. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO 
DAILY (Daily).  
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at 
bedtime).  
6. terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at 
bedtime).  
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours) as needed for pain.  
8. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: ___ 
Drops Ophthalmic PRN (as needed) as needed for dry eyes.  
9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
10. multivitamin     Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
11. Benefiber (guar gum)  Oral
12. saw ___  Oral
13. Centrum Silver  Oral
14. hydrocortisone 1 % Cream Sig: One (1) application Topical 
twice a day for 1 weeks: to rash.
Disp:*1 tube* Refills:*0*

 

###RESPONSE: mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
acid reflux
dizziness (occasionally) likely related to side effect of celexa

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent

 

###RESPONSE: acid reflux {Acid reflux}, dizziness {Dizziness}, side effect {Medication side effects present}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
See below
 

###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: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                        Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: NEUROLOGY
 

###RESPONSE: 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:
Seizures, confusion
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, Seizures {Seizure}, confusion {Clouded consciousness}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ is a ___ year old ___ woman with a PMHx of 
TIIDM, pituitary mass s/p resection ___, and hyperlipidemia who 
presents as a direct admission to the EMU due to her history of 
seizures, recent lapses in memory, and fatigue for better 
characterization of her seizures and medication adjustment. She 
is followed outpatient by Dr. ___. The HPI is 
obtained from previous notes and from interview with patient 
through an interpreter.

In brief, Ms. ___ initially presented to the Access Neurology 
clinic in ___ with five episodes of loss of 
consciousness which were thought to be seizures. These episodes 
were not well characterized, but per her son-in-law, occurred 
while at work in a ___ restaurant, while she was sleeping at 
home, and at ___, when she was found at the store with no 
shoes and no recollection of how she got to the store. The 
patient does not recall these episodes, but states that her 
husband described the final two episodes as foaming at the mouth 
and jerking of her hands. She was started initially by her PCP 
on ___ 750 BID. 

After self-discontinuing this medication due to GI side effects 
attributed to it, she experienced one more episode in ___. She has not had any episodes with jerking of her 
extremities or loss of awareness, such as the ___ 
incident since re-starting her Keppra after this. She does 
however complain of light-headedness, fatigue, and brief memory 
lapses. She characterizes the memory lapses as being in a room 
and forgetting why she is there, or holding an object in her 
hands such as plates and forgetting why she is holding them and 
what she is doing with them. This happens ___ times per day and 
did not occur prior to her first seizure. She denies vertigo, 
poor sleep, ___, jamais ___, paresthesias. However she does 
endorse a rising sense of fear in her abdomen that is sometimes 
associated with these episodes. 

Routine EEG in ___ showed an electrographic seizure from 
the right temporal region as well as periodic discharges. MRI 
from ___ is reviewed in detail below, but in brief 
showed no evidence of hemorrhage, edema, mass, mass effect and 
showed a nonspecific right temporal superficial soft tissue 
density which was previously noted on head CT. 

Given these new episodes of memory lapse, continued seizure 
activity on EEG despite levetiracetam, and possible toxicity 
from levetiracetam resulting in fatigue and dizziness, Ms. ___ 
is admitted for EEG monitoring and medication adjustment. 

Her further is also notable for a history of a resection of 
pituitary mass in ___. She reports having double vision prior 
to discovery of the mass. It also appears that she received 
radiation therapy post-operatively. It is unclear at this time 
what evaluation or monitoring has been done from an 
endocrinologic perspective since her arrival to the ___. 
Furthermore, she has been incidentally found to have a right 
frontotemporal nonspecific superficial soft tissue density on 
imaging, the etiology of which is unclear but could be related 
to her surgery. 

On neuro ROS, she endorses having headache ___ times per week 
with associated visual phenomenon of seeing ""shadows"" in her 
vision. The headache is most prominent across the front of her 
forehead and extends to her temples bilaterally. While she 
endorses having had diplopia prior to her pituitary surgery, she 
currently denies diplopia. She additionally denies dysarthria, 
dysphagia, difficulties producing or comprehending speech.

On general review of systems, the pt denies chest pain, SOB. She 
endorses dry mouth.
 

###RESPONSE: TIIDM {Diabetes mellitus type 2}, pituitary mass {Mass of pituitary}, resection {Excision}, hyperlipidemia {Hyperlipidemia}, seizures {Seizure}, lapses in memory {Memory lapses}, fatigue {Fatigue}, seizures {Seizure}, medication adjustment {Change of medication}, loss of 
consciousness {Loss of consciousness}, seizures {Seizure}, sleeping {Asleep}, mouth {Mouth region structure}, jerking {Spasmodic movement}, hands {Hand structure}, PCP {Primary care management}, GI side effects {Gastrointestinal tract drug side effect}, jerking {Spasmodic movement}, extremities {All extremities}, light-headedness {Lightheadedness}, fatigue {Fatigue}, memory 
lapses {Memory lapses}, memory lapses {Memory lapses}, hands {Hand structure}, seizure {Seizure}, vertigo {Vertigo}, poor sleep {Difficulty sleeping}, paresthesias {Paresthesia}, fear {Fear}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, EEG {Electroencephalogram}, electrographic seizure {Electroencephalogram abnormality with seizure}, right temporal region {Right temporal lobe structure}, MRI {Magnetic resonance imaging}, no evidence {No abnormality detected}, hemorrhage {Hemorrhage}, edema {Edema}, mass {Mass of body structure}, right temporal {Right temporal lobe structure}, soft tissue {Structure of soft tissue}, density {Density outside reference range}, head CT {Computed tomography of head}, memory lapse {Memory lapses}, seizure {Seizure}, EEG {Electroencephalogram}, toxicity {Poisoning}, fatigue {Fatigue}, dizziness {Dizziness}, EEG monitoring {Continuous processed electroencephalogram}, medication adjustment {Review of medication}, resection of 
pituitary mass {Operation on lesion of pituitary gland}, double vision {Diplopia}, mass {Mass of body structure}, radiation therapy {Radiation oncology AND/OR radiotherapy}, post-operatively {Postoperative state}, evaluation {Evaluation procedure}, monitoring {Monitoring procedure}, right 
frontotemporal {Right temporal and frontal lobes (combined site)}, soft tissue {Structure of soft tissue}, density {Density outside reference range}, imaging {Imaging}, surgery {Surgical procedure}, ROS {Review of systems}, headache {Headache}, visual {Visual hallucinations}, vision {Visual disturbance}, headache is most prominent across the front of her 
forehead {Frontal headache}, extends to her temples bilaterally {Temporal headache}, diplopia {Diplopia}, pituitary surgery {Operation on pituitary gland}, diplopia {Diplopia}, dysarthria {Dysarthria}, dysphagia {Dysphagia}, difficulties producing or comprehending speech {Difficulty comprehending speech}, general {General examination of patient}, review of systems {Review of systems}, chest pain {Chest pain}, SOB {Dyspnea}, dry mouth {Mucous membrane dryness}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1. Diabetes Type II
2. Pituitary Mass s/p resection in ___ in ___
3. Vitamin D deficiency
4. Hyperlipidemia
 

###RESPONSE: Diabetes Type II {Diabetes mellitus type 2}, Pituitary Mass {Mass of pituitary}, resection {Excision}, Vitamin D deficiency {Vitamin D deficiency}, Hyperlipidemia {Hyperlipidemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
No known family history of seizure disorder. 
 

###RESPONSE: seizure disorder {Seizure 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: Physical Exam:
ON ADMISSION
===========
Vitals: 98.3 119/78 58 18 94RA 
General: awake, cooperative, NAD.
HEENT: Dry mouth. NC/AT, no scleral icterus noted.
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted

Neurologic:

-Mental Status: Alert, oriented to self, hospital, and date. 
Able
to relate history through interpreter. Attentive, able to name
___ backward without difficulty. Language appears to be fluent
per interpreter. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.

-Cranial Nerves:
II, III, IV, VI:  PERRL 3 to 2mm and brisk. EOMI. Left gaze
fatigable nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.

-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L  5    ___   ___  5   5    5  5     5     5   5
R  5    ___   ___  5   5    5  5     5     5   5

-Sensory: No deficits to light touch. No extinction to DSS.

-Coordination: No intention tremor. No dysmetria on FNF

-Gait: Deferred

ON DISCHARGE
============
Vitals: 97.6 115/77 65 16 94% RA
General: awake, cooperative, NAD.
HEENT: Dry mouth. NC/AT, no scleral icterus noted.
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted

Neurologic:

-Mental Status: Alert, oriented to self, hospital, and date. 
Able to relate history through interpreter. Attentive, able to 
name ___ backward without difficulty. Language appears to be 
fluent per interpreter. Able to follow both midline and 
appendicular commands. There was no evidence of apraxia or 
neglect.

-Cranial Nerves:
II, III, IV, VI:  PERRL 3 to 2mm and brisk. EOMI. No nystagmus. 
Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.

-Motor: Normal bulk, tone throughout. Slight right sided 
pronator drift.
No adventitious movements, such as tremor, noted. No asterixis 
noted.
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L  5    ___   ___  5   5    5  5     5     5   5
R  5    ___   ___  5   5    5  5     5     5   5

-Sensory: No deficits to light touch. No extinction to DSS.

-Coordination: No intention tremor. No dysmetria on FNF.
 

###RESPONSE: Vitals {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, awake {Awake}, cooperative {Cooperative mental state}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, Dry mouth {Mucous membrane dryness}, NC {Normal head}, scleral icterus {Scleral icterus}, Neck {Physical examination procedure}, supple {Normal movement of neck}, nuchal rigidity {Nuchal rigidity}, Pulm {Examination of respiratory system}, breathing comfortably {Breathing easily}, on room air {Breathing room air}, Cardiac {Cardiovascular physical examination}, RRR {Normal heart rate}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, Extremities {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, Skin {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, Mental Status {Neurological mental status determination}, Alert {Mentally alert}, oriented {Oriented to person}, Attentive {Well controlled integrated attention}, fluent {Does speak fluently}, no evidence {No abnormality detected}, apraxia {Apraxia}, neglect {Neglect of part of body}, PERRL {Pupils equal and reacting to light}, brisk {Brisk pupil movement}, EOMI {Normal ocular motility}, nystagmus {Nystagmus}, Normal saccades {Normal ocular motility}, VFF to confrontation {Normal visual field}, Facial {Face structure}, sensation intact to light touch {Light touch sensation present}, facial droop {Weakness of face muscles}, facial musculature symmetric {Facial symmetry}, Hearing intact {Hearing normal}, Palate elevates {Able to elevate soft palate}, trapezii {Structure of trapezius muscle}, SCM {Structure of sternocleidomastoid muscle}, Tongue protrudes {Able to protrude tongue}, Motor {Motor testing}, Normal bulk, tone {Normal tone in skeletal muscle}, pronator drift {Downward drift of outstretched supinated arm}, adventitious movements {Involuntary movement}, tremor {Tremor}, asterixis {Asterixis}, Sensory {Sensory testing}, No deficits to light touch {Normal light touch sensation}, intention tremor {Intention tremor}, dysmetria {Dysmetria}, FNF {Finger-to-nose test}, Vitals {Vital signs finding}, General {General examination of patient}, awake {Awake}, cooperative {Cooperative mental state}, NAD {Distress}, HEENT {General examination of patient}, Dry mouth {Mucous membrane dryness}, scleral icterus {Scleral icterus}, supple {Normal movement of neck}, nuchal rigidity {Nuchal rigidity}, Pulmonary {Examination of respiratory system}, breathing comfortably on room air {Breathing room air}, Cardiac {Cardiovascular physical examination}, RRR {Normal heart rate}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, Extremities {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, Skin {Examination of skin}, rashes {Eruption of skin}, lesions {Skin lesion}, Neurologic {Neurological examination}, Mental Status {Neurological mental status determination}, Alert {Mentally alert}, oriented {Oriented to person}, Attentive {Well controlled integrated attention}, fluent {Does speak fluently}, per interpreter {Interpreter present}, no evidence {No abnormality detected}, apraxia {Apraxia}, neglect {Neglect of part of body}, Cranial Nerves {Examination of cranial nerve}, PERRL {Pupils equal and reacting to light}, brisk {Brisk pupil movement}, EOMI {Normal ocular motility}, nystagmus {Nystagmus}, Normal saccades {Normal ocular motility}, VFF to confrontation {Normal visual field}, Facial {Face structure}, sensation intact to light touch {Light touch sensation present}, facial droop {Weakness of face muscles}, facial musculature symmetric {Facial symmetry}, Hearing intact {Hearing normal}, Palate elevates {Able to elevate soft palate}, trapezii {Structure of trapezius muscle}, SCM {Structure of sternocleidomastoid muscle}, Tongue protrudes in midline {Able to protrude tongue fully}, Motor {Motor testing}, Normal bulk, tone {Normal tone in skeletal muscle}, right sided {Structure of right half of body}, pronator drift {Downward drift of outstretched supinated arm}, adventitious movements {Involuntary movement}, tremor {Tremor}, asterixis {Asterixis}, Sensory {Sensory testing}, No deficits to light touch {Normal light touch sensation}, intention tremor {Intention tremor}, dysmetria {Dysmetria}, FNF {Finger-to-nose test}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 08:35AM BLOOD WBC-5.5 RBC-4.63 Hgb-13.6 Hct-40.5 MCV-88 
MCH-29.4 MCHC-33.6 RDW-12.7 RDWSD-40.2 Plt ___
___ 08:35AM BLOOD Glucose-311* UreaN-13 Creat-1.0 Na-140 
K-3.7 Cl-98 HCO3-22 AnGap-20*
___ 08:35AM BLOOD ALT-31 AST-25 LD(LDH)-179 AlkPhos-77 
TotBili-0.7
___ 08:35AM BLOOD Albumin-4.4 Calcium-9.2 Phos-3.8 Mg-2.2
___ 08:35AM BLOOD FSH-4.8 LH-2.2 Prolact-2.9* TSH-1.0
___ 12:01PM URINE Color-Straw Appear-Clear Sp ___
___ 12:01PM URINE Blood-NEG Nitrite-NEG Protein-NEG 
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 
Leuks-MOD*
___ 12:01PM URINE RBC-1 WBC-19* Bacteri-NONE Yeast-NONE 
Epi-1
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, TSH {Thyroid stimulating hormone measurement}, URINE Color-Straw {Normal urine color}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, RBC {Red blood cell count}, WBC {White blood cell count}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Ms. ___ is a ___ ___ speaking only woman with a past 
medical history significant for a pituitary mass resected in 
___ in ___ that she was told was benign; type 2 diabetes; 
hyperlipidemia who started having episodes of memory lapses over 
the last one to ___ years. For example, she would be performing 
activity such as doing the dishes and then suddenly not remember 
why she had dishes in her hands. She was evaluated by Dr. 
___ in ___ ___ Department and an EEG was obtained on 
___, which revealed one electrographic seizure with a 
right temporal onset and without clear clinical correlate and 
temporal intermittent rhythmic delta activity as well as 
frequent left anterior temporal epileptiform discharges 
occurring in 1 Hz periodic runs as well as intermittent focal 
slowing of the left frontotemporal region indicative of focal 
cerebral dysfunction. Her Keppra was continued at that time at 
750 mg b.i.d. She has continued to have episodes of 
forgetfulness and has subsequently been let go from her job. She 
was admitted to the EMU for cvEEG in order to evaluate for any 
evidence of subclinical seizures as well as her medication 
optimization. In addition to her home dose of lamotrigine 1500 
mg daily, she was started on lacosamide 50 mg twice daily, which 
was subsequently increased to 150 mg twice daily, or 300 mg 
daily dose. One seizure was detected at 1738 on ___ with ___ Hz 
rhythmic discharges that rapidly lateralized over the left 
temporal region with no obvious clinical correlate. This lasted 
approximately 10 seconds. She also had frequent independent 
right and left mesiotemporal epileptiform discharges admixed 
with sharp bursts of rhythmic theta but no other seizures. 

TRANSITIONAL ISSUES:
-Consider wean from Keppra, given her report of increased 
fatigue since starting Keppra. 
-FSH, LH, TSH, and prolactin were all measured for further 
evaluation of her endocrine status after resection of pituitary 
mass. All levels were lower than reference ranges. 
 

###RESPONSE: pituitary mass {Mass of pituitary}, type 2 diabetes {Diabetes mellitus type 2}, hyperlipidemia {Hyperlipidemia}, memory lapses {Memory lapses}, evaluated {Evaluation procedure}, EEG {Electroencephalogram}, electrographic seizure {Electroencephalogram abnormality with seizure}, right temporal {Right temporal lobe structure}, temporal {Right temporal lobe structure}, intermittent rhythmic delta activity {Focal episodic delta activity}, left {Structure of left half of head}, temporal epileptiform discharges {Periodic lateralized epileptiform discharges}, left frontotemporal region {Left temporal and frontal lobes (combined site)}, evaluate {Evaluation procedure}, seizures {Seizure}, medication 
optimization {Review of medication}, increased {Increasing dosage of medication}, seizure {Seizure}, left 
temporal region {Left temporal lobe structure}, right {Right temporal lobe structure}, left mesiotemporal {Left temporal lobe structure}, epileptiform discharges {Periodic lateralized epileptiform discharges}, sharp bursts {Focal sharp waves}, seizures {Seizure}, fatigue {Fatigue}, FSH {Follicle stimulating hormone measurement}, LH {Luteinizing hormone measurement}, TSH {Thyroid stimulating hormone measurement}, evaluation {Evaluation procedure}, resection of pituitary 
mass {Excision of lesion of pituitary gland}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 750 mg PO BID 
2. Aspirin 81 mg PO DAILY 
3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 
4. Simvastatin 20 mg PO QPM 
5. Mirtazapine 15 mg PO QHS 
6. Vitamin D ___ UNIT PO 1X/WEEK (___) 

 
Discharge Medications:
1.  LACOSamide 100 mg PO BID 
RX *lacosamide [Vimpat] 150 mg 1 tablet(s) by mouth twice a day 
Disp #*60 Tablet Refills:*0 
2.  Aspirin 81 mg PO DAILY  
3.  LevETIRAcetam 750 mg PO BID  
4.  MetFORMIN XR (Glucophage XR) 500 mg PO DAILY  
5.  Mirtazapine 15 mg PO QHS  
6.  Simvastatin 20 mg PO QPM  
7.  Vitamin D ___ UNIT PO 1X/WEEK (___)  

 

###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:
Epilepsy.  Intractable temporal lobe epilepsy.

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Epilepsy {Epilepsy}, temporal lobe epilepsy {Temporal lobe epilepsy}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms ___,

It was a pleasure taking care of you at ___ 
___.

You were in the hospital so we could monitor you for seizures. 
We also wanted to see if your episodes of confusion were due to 
seizures.

You had one seizure while at ___. You did not have any 
episodes of confusion. We added a new medication called 
Lacosamide to help prevent seizures.

When you leave the hospital, it will be very important to take 
BOTH seizure medications. You will follow up with Dr ___ to 
discuss possibly stopping your Keppra.

Best wishes,
Your ___ team
 

###RESPONSE: seizures {Seizure}, confusion {Clouded consciousness}, seizures {Seizure}, seizure {Seizure}, confusion {Clouded consciousness}, new medication {New medication commenced}, seizures {Seizure}, seizure {Seizure}, medications {Administration of drug or medicament}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
s/p fall
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, fall {Falls}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ is transferred here for left-sided rib fractures, 8,9 and 
10.
No associated hemothorax or pneumothorax. On CT. He fell
yesterday while in the shower. Reports he was getting out when 
he
slipped and he grabbed onto the shower curtain to slow his fall
down. He landed on his left chest. He reports abdominal
discomfort as well. Reports mild left elbow discomfort. He 
denies
head strike. He takes aspirin. His initial history of
hypertension, hyperlipidemia. Sent here for trauma eval. His 
pain
is controlled currently received oxycodone Toradol the outside
hospital.

 

###RESPONSE: left-sided {Bone structure of left rib}, rib fractures {Fracture of multiple ribs}, hemothorax {Hemothorax}, pneumothorax {Pneumothorax}, fell {Falls}, fall {Falls}, left chest {Structure of left half of chest wall}, abdominal
discomfort {Abdominal discomfort}, mild {Symptom mild}, left elbow {Left elbow region structure}, discomfort {Discomfort}, head strike {Injury of head}, aspirin {Administration of aspirin}, hypertension {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, trauma {Traumatic injury}, eval {Evaluation procedure}, pain
is controlled {Pain control}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
noncontributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Admission Physical:
98.3 81 116/90 20 96% 2L NC
General: comfortable, NAD on o2
___: RRR, no chest wall deformities
Pulm: clear bilaterally, adequate inspiratory effort, tender 
left
side
abdomen: soft, NT
Ext: no deformities or abrasions, moves all extremities not
tender to palpation

Discharge Physical:
VS: 97.8, 121/73, 72, 18, 92 RA
Gen: A&O x3, sitting up at edge of bed, NARD, speaking and 
breathing comfortably
CV: HRR
Pulm: LS ctab. TTP over left rib cage
Abd: Soft, NT/ND
Ext: No edema
 

###RESPONSE: NC {Normal head}, General {General examination of patient}, comfortable {Comfortable appearance}, NAD {No abnormality detected}, o2 {Oxygen therapy}, RRR {Normal heart rate}, chest wall deformities {Deformity of chest wall}, Pulm {Examination of respiratory system}, clear {Normal breath sounds}, tender {Abdominal tenderness}, left
side {Structure of left half of chest wall}, abdomen {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, deformities {Deformity}, abrasions {Abrasion}, all extremities {All extremities}, tender {Abdominal tenderness}, palpation {Palpation}, RA {Breathing room air}, O x3 {Oriented to person, time and place}, sitting {Sitting position}, NARD {Respiratory distress}, breathing comfortably {Breathing easily}, HRR {Normal heart rate}, Pulm {Examination of respiratory system}, ctab {Normal breath sounds}, TTP {Chest wall tenderness}, left {Structure of left half of chest wall}, rib cage {Thoracic cage structure}, Abd {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, Ext {Examination of limb}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 05:30AM BLOOD WBC-7.8 RBC-4.20* Hgb-12.7* Hct-37.8* 
MCV-90 MCH-30.2 MCHC-33.6 RDW-13.2 RDWSD-43.2 Plt ___
___ 03:02PM BLOOD WBC-10.3* RBC-4.49* Hgb-13.4* Hct-40.8 
MCV-91 MCH-29.8 MCHC-32.8 RDW-13.2 RDWSD-43.8 Plt ___
___ 05:30AM BLOOD Glucose-98 UreaN-12 Creat-1.0 Na-146 
K-3.7 Cl-108 HCO3-23 AnGap-15
___ 03:02PM BLOOD Glucose-102* UreaN-19 Creat-1.0 Na-145 
K-3.8 Cl-109* HCO3-21* AnGap-15
___ 05:30AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.2

Imaging: 
CT C spine:
1. No evidence of fracture or malalignment.
2. Moderate cervical spondylosis.
CT head
Minimal subgaleal hematoma along the posterior vertex. 
Otherwise,
no evidence
of an acute intracranial abnormality.
CT A/P: 
1. Acute lateral left eighth and ninth rib fractures are
unchanged. No
associated pleural effusion or pneumothorax visualized.
2. No other acute traumatic abnormality in the abdomen or 
pelvis.
Normal
spleen.
3. Chronic appearing right diaphragmatic hernia containing a
portion of the
liver.
4. Severe calcified coronary atherosclerosis.
5. 2 cm right common iliac artery aneurysm.
6. Diverticulosis without diverticulitis
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Plt {Platelet count}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Plt {Platelet count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, 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}, No evidence {No abnormality detected}, fracture {Fracture}, malalignment {Misalignment}, cervical spondylosis {Cervical spondylosis}, CT head {Computed tomography of head}, subgaleal hematoma {Epicranial subaponeurotic hematoma}, vertex {Vertex structure}, no evidence {No abnormality detected}, intracranial {Intracranial structure}, abnormality {No abnormality detected}, CT A/P {Computed tomography of abdomen and pelvis}, left {Bone structure of left rib}, eighth {Bone structure of eighth rib}, ninth {Bone structure of ninth rib}, rib fractures {Fracture of two ribs}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, traumatic {Traumatic injury}, abnormality {No abnormality detected}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, pelvis {Structure of pelvis}, Normal {No abnormality detected}, spleen {Splenic structure}, Chronic {Chronic disease}, right {Structure of right half of body}, diaphragmatic hernia {Diaphragmatic hernia}, liver {Liver structure}, calcified {Pathologic calcification, calcified structure}, coronary atherosclerosis {Atherosclerosis of coronary artery}, right common iliac artery aneurysm {Aneurysm of right common iliac artery}, Diverticulosis {Diverticulosis of colon}, diverticulitis {Diverticulitis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ Y/o M with h/o HTN presents to the ED as a transfer from 
___ with a left rib fracture s/p fall. The patient's lab 
work was unremarkable.
His CT Head showed a minimal subgaleal hematoma along the 
posterior vertex
but was otherwise unremarkable. His CT C-spine showed no 
evidence of
fracture or malalignment. The patient's CT chest was notable for 
acute lateral
left eighth and ninth rib fractures without an associated 
pleural effusion or
pneumothorax visualized. trauma surgery was consulted and will 
admit for
further pain management and monitoring in setting of multiple 
rib fractures with
hypoxia.

By HD2, pain was well controlled. The patient was ambulating 
independently in room and halls therefore ___ did not evaluate 
him. Oxygen was successfully weaned off and the patient had an 
oxygen saturation of 93-94% on room air at the time of 
discharge. 
During this hospitalization, the patient ambulated early and 
frequently, was adherent with respiratory toilet and incentive 
spirometry, and actively participated in the plan of care. 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: HTN {Hypertensive disorder, systemic arterial}, left {Bone structure of left rib}, rib fracture {Fracture of rib}, fall {Falls}, lab 
work {Laboratory test}, unremarkable {No abnormality detected}, CT Head {Computed tomography of head}, subgaleal hematoma {Epicranial subaponeurotic hematoma}, vertex {Vertex structure}, unremarkable {No abnormality detected}, CT C-spine {Computed tomography of cervical spine}, no 
evidence {No abnormality detected}, fracture {Fracture}, malalignment {Misalignment}, CT chest {Computed tomography of chest}, left {Bone structure of left rib}, eighth {Bone structure of eighth rib}, ninth {Bone structure of ninth rib}, rib fractures {Fracture of two ribs}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, trauma {Traumatic injury}, pain management {Pain management}, monitoring {Monitoring procedure}, multiple 
rib fractures {Fracture of multiple ribs}, hypoxia {Hypoxia}, pain was well controlled {Demonstrates adequate pain control}, ambulating 
independently {Independent walking}, evaluate {Evaluation procedure}, oxygen saturation {Finding of oxygen saturation}, on room air {Breathing room air}, respiratory toilet {Airway toilet}, incentive 
spirometry {Incentive spirometry}, subcutaneous heparin {Subcutaneous injection of heparin}, afebrile {Temperature normal}, stable vital signs {Normal vital signs}, tolerating a regular 
diet {Tolerating normal diet}, ambulating {Fully mobile}, voiding without assistance {Continence independent}, pain was well 
controlled {Demonstrates adequate pain control}, teaching {Patient education}, follow-up {Follow-up encounter}, instructions {Education}, 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:
none
 
Discharge Medications:
1.  Acetaminophen 650 mg PO Q6H 
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) 
hours Disp #*30 Tablet Refills:*0 
2.  Docusate Sodium 100 mg PO BID  
3.  Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours 
Disp #*20 Tablet Refills:*0 
4.  Lidocaine 5% Patch 1 PTCH TD QAM L rib fx's  
5.  OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - 
Moderate 
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours 
Disp #*10 Tablet Refills:*0 
6.  Polyethylene Glycol 17 g 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 lateral left eighth and ninth rib fractures 

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: left {Bone structure of left rib}, eighth {Bone structure of eighth rib}, ninth {Bone structure of ninth rib}, rib fractures {Fracture of two ribs}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
* Your injury caused 2 left sided rib fractures which can cause 
severe pain and subsequently cause you to take shallow breaths 
because of the pain.
 
* You should take your pain medication as directed to stay ahead 
of the pain otherwise you won't be able to take deep breaths. If 
the pain medication is too sedating take half the dose and 
notify your physician.
 
* Pneumonia is a complication of rib fractures.  In order to 
decrease your risk you must use your incentive spirometer 4 
times every hour while awake.  This will help expand the small 
airways in your lungs and assist in coughing up secretions that 
pool in the lungs.
 
* You will be more comfortable if you use a cough pillow to hold 
against your chest and guard your rib cage while coughing and 
deep breathing.
 
* Symptomatic relief with ice packs or heating pads for short 
periods may ease the pain.
 
* Narcotic pain medication can cause constipation therefore you 
should take a stool softener twice daily and increase your fluid 
and fiber intake if possible.
 
* Do NOT smoke
 
* If your doctor allows, non-steroidal ___ drugs 
are very effective in controlling pain ( ie, Ibuprofen, Motrin, 
Advil, Aleve, Naprosyn) but they have their own set of side 
effects so make sure your doctor approves.
 
* Return to the Emergency Room right away for any acute 
shortness of breath, increased pain or crackling sensation 
around your ribs (crepitus).

 

###RESPONSE: injury {Traumatic or non-traumatic injury}, left sided {Bone structure of left rib}, rib fractures {Fracture of two ribs}, severe pain {Severe pain}, cause you to take shallow breaths {Respiratory health self management education}, pain {Pain}, pain medication {Administration of analgesic}, pain {Pain}, able to take deep breaths {Able to take deep breaths}, pain medication {Administration of analgesic}, notify {Informing doctor}, Pneumonia {Pneumonia}, rib fractures {Fracture of multiple ribs}, decrease your risk {Preventive procedure}, use your incentive spirometer {Incentive spirometry}, awake {Awake}, airways {Airway structure}, lungs {Lung structure}, in coughing up secretions {Encouragement of deep breathing and coughing exercises}, lungs {Lung structure}, comfortable {Comfortable appearance}, chest {Thoracic structure}, rib cage {Thoracic cage structure}, coughing and 
deep breathing {Deep breathing and coughing exercises}, relief {Pain relief}, ice packs {Application of ice}, heating pads {Heat therapy}, pain {Pain}, Narcotic pain medication can cause {Narcotics education}, constipation {Constipation}, take a stool softener {Administration of laxative}, increase your fluid {Fluid intake encouragement}, fiber intake {High fiber diet education}, Do NOT smoke {Smoking cessation education}, non-steroidal ___ drugs {Non-steroidal anti-inflammatory agent therapy}, controlling pain {Pain control}, side 
effects {Medication side effects present}, Return to the Emergency Room {Emergency treatment management}, shortness of breath {Dyspnea}, increased pain {Increased pain}, crackling {Respiratory crackles}, sensation {Sensation of movement}, ribs {Bone structure of rib}, crepitus {Bone crepitus}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___.                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Positive blood cultures 
 
Major Surgical or Invasive Procedure:
___: ___ removal

 

###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, Positive blood cultures {Organism isolated in blood by culture}, removal {Removal}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
The patient is a ___ yo woman with ALL, now DAY ___ s/p 
allogeneic stem cell transplant, who is admitted for evaluation 
of a positive blood culture. pt was last admitted on ___ 
with similar issues. she was noted to have coag -ve staph and 
was started on 1g of vanco daily. her subsequently cultures came 
back negative. she was discharged home with a course of vanco 
which she finished ___. she was seen in clinic yesterday 
without complaints of fever, chill or rigor. she did however 
have surveillance cultures drawn from her line which today grew 
GPC. she was called to come into the ed where she was noted to 
be afebrile and hemodynamically stable. no clear source of 
infection noted. line site appears intact. pt was started on 
vancomycin and admitted for further care. 
 

###RESPONSE: ALL {Precursor cell lymphoblastic leukemia}, allogeneic stem cell transplant {Allogeneic peripheral blood stem cell transplant}, evaluation {Evaluation procedure}, positive blood culture {Organism isolated in blood by culture}, cultures {Microbial culture}, vanco {Antibiotic therapy}, seen in clinic {Seen in clinic}, fever {Fever}, chill {Chill}, rigor {Rigor}, surveillance cultures {Surveillance culture}, hemodynamically stable {Hemodynamically stable}, infection {Infectious disease}, intact {No abnormality detected}, vancomycin {Antibiotic therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Acute lymphocytic leukemia
The patient initially presented in ___ to an OSH with vague LUQ 
discomfort. Initial abdominal imaging demonstrated gallstones. 
In ___, she presented with chest pain radiating to her left 
arm, shortness of breath, and weakness with WBC 123, Hct 19.6, 
and Plt 23. Acute MI was ruled out. Abdominal US demonstrated 
splenomegaly. She was transferred to ___ for further 
evaluation and treatment of leukemia. She was started on 
hydroxyurea and dexamethasone with allopurinol and bicarbonate 
prophylaxis. Bone marrow biopsy and peripheral smear were 
consistent with ALL with 9;22 translocation. Initial evaluation 
with echocardiogram and LP were unremarkable. After two cycles 
of Hyper CVAD, parts A and B, she underwent a matched unrelated 
allogeneic stem cell transplantation wtih cyclophosphamide and 
ATG conditioning on the XOMA trial on ___.

ADDITIONAL MEDICAL HISTORY:  
1. HTN  

 

###RESPONSE: Acute lymphocytic leukemia {Precursor cell lymphoblastic leukemia}, LUQ {Structure of left upper quadrant of abdomen}, discomfort {Discomfort}, abdominal imaging {Imaging of abdomen}, gallstones {Gallbladder calculus}, chest pain {Chest pain}, radiating to her left 
arm {Pain radiating to left arm}, shortness of breath {Dyspnea}, weakness {Asthenia}, WBC {White blood cell count}, Hct {Hematocrit determination}, Acute MI {Acute myocardial infarction}, Abdominal US {Ultrasonography of abdomen}, splenomegaly {Splenomegaly}, evaluation {Evaluation procedure}, leukemia {Leukemia}, prophylaxis {Administration of prophylactic drug or medicament}, Bone marrow biopsy {Bone marrow sampling}, ALL {Precursor cell lymphoblastic leukemia}, evaluation {Evaluation procedure}, echocardiogram {Echocardiography}, LP {Lumbar puncture}, unremarkable {No abnormality detected}, matched {Major crossmatch}, unrelated {Unrelated}, allogeneic stem cell transplantation {Allogeneic peripheral blood stem cell transplant}, HTN {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
Mom - HTN, hypercholesterolemia
Dad - MI at ___ y.o., deceased at ___ y.o. from cardiac disease
Sister - healthy
___ any oncologic history, including leukemias or lymphomas.
 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, hypercholesterolemia {Hypercholesterolemia}, MI {Myocardial infarction}, deceased {Dead}, cardiac disease {Heart disease}, leukemias {Leukemia}, lymphomas {Malignant lymphoma}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VITALS: 96.9, 82, 154/76, 16, 99% on ra  
GEN: NAD, A&Ox3  
HEENT: Clear OP, MMM.  
NECK: Supple, No LAD, No JVD. Bilateral new lines  
CV: RR, NL rate. NL S1, S2.  
LUNGS: CTA, BS ___, No W/R/C  
ABD: Soft, NT, ND. NL BS. No HSM  
EXT: No edema. 2+ DP pulses ___  
SKIN: No lesions  
NEURO: A&Ox3. Appropriate. CN ___ intact.  

 

###RESPONSE: VITALS {Vital signs finding}, ra {Breathing room air}, GEN {General examination of patient}, NAD {No abnormality detected}, Ox3 {Oriented to person, time and place}, HEENT {Physical examination procedure}, Clear OP {Pharynx normal}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, CV {Cardiovascular physical examination}, RR {Finding of rate of respiration}, NL rate {Normal heart rate}, S2 {Normal second heart sound, S>2<}, LUNGS {Examination of respiratory system}, CTA {Normal breath sounds}, ABD {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, NL BS {Normal bowel sounds}, HSM {Hepatosplenomegaly}, EXT {Examination of limb}, edema {Edema}, 2+ DP pulses {All pulses present in bilateral lower limbs}, SKIN {Examination of skin}, lesions {Lesion}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, CN {Cranial nerve structure}, intact {Normal sensation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 12:05AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 
LEUK-NEG
___ 12:40AM   WBC-8.1 RBC-2.77* HGB-8.7* HCT-25.1* MCV-91 
MCH-31.3 MCHC-34.5 RDW-18.3*
___ 12:40AM   ALBUMIN-4.2 CALCIUM-9.4 MAGNESIUM-2.2
___ 12:40AM   LIPASE-32
___ 12:40AM   ALT(SGPT)-27 AST(SGOT)-65* ALK PHOS-121* TOT 
BILI-0.3
___ 12:40AM   GLUCOSE-98 UREA N-40* CREAT-1.9* SODIUM-134 
POTASSIUM-6.3* CHLORIDE-105 TOTAL CO2-17* ANION GAP-18
___ 05:50AM   GLUCOSE-79 UREA N-36* CREAT-1.9* SODIUM-134 
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-19* ANION GAP-16
___ 05:50AM   ALBUMIN-4.1 CALCIUM-9.7 MAGNESIUM-2.0
___ 05:50AM   WBC-7.5 RBC-2.76* HGB-8.7* HCT-24.6* MCV-89 
MCH-31.6 MCHC-35.4* RDW-18.1*

___ 1:50 pm BLOOD CULTURE     Site: ___
Blood Culture, Routine (Preliminary): 
STAPHYLOCOCCUS, COAGULASE NEGATIVE.    ISOLATED FROM ONE SET 
ONLY. 
SENSITIVITIES PERFORMED ON REQUEST.. 

Blood cx ___ and ___ NGTD

___ CATHETER TIP-IV Source: tunneled catheter. WOUND 
CULTURE: No significant growth. 

___ 09:00AM BLOOD Cyclspr-171

___
TTE: The left atrium is normal in size. No atrial septal defect 
is seen by 2D or color Doppler. Left ventricular wall thickness, 
cavity size and regional/global systolic function are normal 
(LVEF 70%). There is no ventricular septal defect. Right 
ventricular chamber size and free wall motion are normal. The 
aortic valve leaflets (3) appear structurally normal with good 
leaflet excursion and no aortic regurgitation. No masses or 
vegetations are seen on the aortic valve. The mitral valve 
appears structurally normal with trivial mitral regurgitation. 
There is no mitral valve prolapse. No mass or vegetation is seen 
on the mitral valve. The estimated pulmonary artery systolic 
pressure is normal. No vegetation/mass is seen on the pulmonic 
valve. There is no pericardial effusion. 
Compared with the findings of the prior study (images reviewed) 
of ___, the findings are similar.

IMPRESSION: no obvious vegetations

 

###RESPONSE: PROTEIN {Measurement of protein in urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium 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}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, CULTURE {Blood culture}, Blood Culture {Blood culture}, SENSITIVITIES {Antimicrobial susceptibility test}, Blood cx {Blood culture}, CULTURE {Microbial culture}, TTE {Transthoracic echocardiography}, left atrium {Left atrial structure}, normal in size {Normal size}, atrial septal defect {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, Left ventricular wall {Left cardiac ventricular structure}, thickness {Normal thickness}, cavity {Structure of cavity of left cardiac ventricle}, regional/global systolic function are normal {Normal left ventricular systolic function and wall motion}, ventricular septal defect {Ventricular septal defect}, Right 
ventricular chamber {Right cardiac ventricular structure}, wall motion are normal {Normal ventricular wall motion}, aortic valve {Aortic valve structure}, leaflets {Structure of cardiac valve leaflet}, structurally normal {Aortic valve normal}, leaflet {Structure of cardiac valve leaflet}, aortic regurgitation {Aortic valve regurgitation}, mass {Mass}, vegetations {Vegetation}, aortic valve {Aortic valve structure}, mitral valve 
appears structurally normal {Mitral valve normal}, mitral regurgitation {Mitral valve regurgitation}, mitral valve prolapse {Mitral valve prolapse}, mass {Mass}, vegetation {Vegetation}, mitral valve {Mitral valve structure}, pulmonary artery {Pulmonary artery structure}, systolic 
pressure is normal {Normal systolic arterial pressure}, vegetation {Vegetation}, mass {Mass}, pulmonic 
valve {Pulmonary valve structure}, pericardial effusion {Pericardial effusion}, vegetations {Vegetation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ woman DAY ___ s/p MUD allo SCT for ALL, recent admission 
for coag negative staph positive blood cultures for which she 
was completed a course of vancomycin now with repeat coag 
negative staph positive blood cultures on surveillance cultures. 
  
1. Coagulase negative Staph bacteremia: Patient has had repeat 
positive blood cultures but has been asymptomatic without 
fevers. The most likely source is her ___ catheter which was 
removed on ___. Repeat blood cultures were drawn and are no 
growth to date. She was started on and discharged on a course of 
vancomycin 1g IV q 48 hours. Level will be checked in clinic 
prior to dose administration. If ___ remain negative, she 
will obtain PICC line as outpatient. TTE was done which did not 
show any eveidence of endocarditis and no vegetations.  

2. Renal dysfunction: Patient has had fluctuating renal function 
and has been seen by renal who recommended stopping her calcium 
channel blocker. renal function during hospital stay at recent 
baseline and improved slightly with IV fluids. She is planned to 
receive IVF as outpt when she receives her vanco. 

3. Anemia: HCT slightly decreased fom baseline. She was ordered 
for transfusion if 1 unit PRBC at follow up on ___ in clinic.   


4. Nausea: Continued on Prednisone 2.5 mg PO daily for ? GVH.  

5. ALL s/p allo BMT: Cyclosporine level checked and was 171. 
Continued on home doses. Continued on Acyclovir, Fluconazole.   
  
6. Hypertension: Patient hypertensive with SBP 150s-170s, HR 
___ during admission. Metoprolol titrated up from 37.5 PO 
BID to 50 PO BID. ___ require further titration as outpatient. 
 

 

###RESPONSE: MUD {Allogeneic unrelated bone marrow transplant}, allo SCT {Allogeneic peripheral blood stem cell transplant}, ALL {Precursor cell lymphoblastic leukemia}, positive blood cultures {Organism isolated in blood by culture}, vancomycin {Antibiotic therapy}, positive blood cultures {Organism isolated in blood by culture}, surveillance cultures {Surveillance culture}, bacteremia {Bacteremia}, positive blood cultures {Organism isolated in blood by culture}, asymptomatic {Asymptomatic}, fevers {Fever}, catheter which was 
removed {Removal of catheter}, blood cultures {Blood culture}, vancomycin {Antibiotic therapy}, IV {Administration of drug or medicament via intravenous route}, clinic {Outpatient care management}, obtain PICC line {Insertion of peripherally inserted central catheter}, TTE {Transthoracic echocardiography}, endocarditis {Endocarditis}, vegetations {Vegetation}, Renal dysfunction {Renal impairment}, renal function {Finding of renal function}, renal function {Finding of renal function}, baseline {Baseline state}, improved {Patient's condition improved}, IV fluids {Administration of intravenous fluids}, IVF {Administration of intravenous fluids}, outpt {Outpatient care management}, vanco {Antibiotic therapy}, Anemia {Anemia}, HCT slightly decreased {Hematocrit below reference range}, baseline {Baseline state}, transfusion if 1 unit PRBC {Transfusion of packed red blood cells}, follow up {Follow-up arranged}, clinic {Outpatient care management}, Nausea {Nausea}, ALL {Precursor cell lymphoblastic leukemia}, allo BMT {Allogeneic bone marrow transplantation}, Hypertension {Hypertensive disorder, systemic arterial}, hypertensive {Hypertensive disorder, systemic arterial}, HR {Finding of heart rate}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
Prednisone 2.5 mg PO DAILY (Daily).  
Lorazepam 1 mg Tablet Sig: ___ Tablets PO every six (6) hours as 
needed.  
Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 
times a day).  
Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a 
day).  
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day) as needed.  
Multivitamin Capsule Sig: One (1) Capsule PO once a day.  
Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed 
for constipation.  
Cyclosporine Modified 25 mg Capsule Sig: Four (4) Capsule PO qam 
at 10am.  
Cyclosporine 25 mg Capsule Sig: Five (5) Capsule PO QPM  
(once a day (in the evening)): Please take at 10pm.  
Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every  
24 hours).  

 
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times 
a day).  
2. Cyclosporine Modified 25 mg Capsule Sig: Four (4) Capsule PO 
qam.  
3. Neoral 25 mg Capsule Sig: Five (5) Capsule PO qpm.  
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day) as needed.  
5. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 
hours) as needed.  
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 
hours).  
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

9. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
10. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO 
twice a day.
Disp:*120 Tablet(s)* Refills:*2*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 
(2 times a day) as needed.  
12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 
24 hours).  
13. Acyclovir 200 mg Capsule Sig: One (1) Capsule PO twice a 
day.  
14. Vancomycin in Normal Saline 1 gram/250 mL Solution Sig: One 
(1) gram Intravenous q48 hours.  

 

###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
1. Bacteremia
2. ALL s/p allo SCT
Secondary Diagnosis
1. HTN

 
Discharge Condition:
Hemodynamically stable, afebrile, repeat blood cultures negative 
to date

 

###RESPONSE: Bacteremia {Bacteremia}, ALL {Precursor cell lymphoblastic leukemia}, allo SCT {Allogeneic peripheral blood stem cell transplant}, HTN {Hypertensive disorder, systemic arterial}, Hemodynamically stable {Hemodynamically stable}, blood cultures {Blood culture}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted to the hospital because you had a positive 
blood culture.  This may have been an infection from your 
___ line which was removed while you were in the hospital. 
To treat this infection, we started you on an antibiotic called 
Vancomycin which will need to be continued. You will receive 
this Antibiotic in clinic on ___ and ___. At 
that time, if your repeat cultures have been negative, we will 
most likely place a PICC line so you can get this antibiotic at 
home. You will also need to have the vanocmycin level drawn in 
clinic. In clinic, you will also receive blood for low blood 
counts as well as IV fluids if you are dehydrated. We also did 
an ultrasound of your heart to look for a source of your 
infections but this report was not available yet at the time of 
discharge. 

We made the following changes to your medications. 
1. We added Vancomycin 1 gram IV every 48 hours which you will 
receive in clinic. 
2. We increased your Metoprolol to 50mg twice a day

Please call your primary oncologist or the heme/onc or ___ 
fellow on call if you develop fever >100.4, chills, nausea, 
vomiting or are unable to take in enough food or liquid. 

 

###RESPONSE: positive 
blood culture {Organism isolated in blood by culture}, infection {Infectious disease}, line which was removed {Removal of catheter}, infection {Infectious disease}, antibiotic {Antibiotic therapy}, Vancomycin {Antibiotic therapy}, Antibiotic {Antibiotic therapy}, clinic {Outpatient care management}, cultures {Microbial culture}, place a PICC line {Insertion of peripherally inserted central catheter}, antibiotic {Antibiotic therapy}, vanocmycin level {Vancomycin measurement}, clinic {Outpatient care management}, clinic {Outpatient care management}, receive blood {Transfusion of blood product}, low blood 
counts {Red blood cell count below reference range}, IV fluids {Administration of intravenous fluids}, dehydrated {Dehydration}, ultrasound of your heart {Echocardiography}, infections {Infectious disease}, changes to your medications {Change of medication}, Vancomycin {Antibiotic therapy}, IV {Administration of drug or medicament via intravenous route}, clinic {Outpatient care management}, call {Informing doctor}, fever {Fever}, chills {Chill}, nausea, 
vomiting {Nausea and vomiting}, unable to take in enough food {Eating problem}, liquid {Problem with drinking fluid}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Nausea, vomiting, abdominal pain
 
Major Surgical or Invasive Procedure:
Femoral line
Dialysis

 

###RESPONSE: Nausea, vomiting {Nausea and vomiting}, abdominal pain {Abdominal pain}, Dialysis {Dialysis 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:
___ year-old man very well known to ___ physicians with 
frequent admissions for gastroparesis, malignant hypertension, 
hyperglycemia, recently discharged on ___ and now presents 
with nausea, vomitting, and abdominal pain which are typical 
features of the gastroparetic syndrome. He states that his pain 
began at 0300 on day of admission and was associated with nausea 
and vomiting. Was uncontrolled by home medications. He pain is 
now rated at ___. When questioned about his clonidine patch, he 
states that he removed it on ___ due to low blood pressure. 
In ED, vitals: T 100.2, SBP in the 180s, HR 116. He was given 
labetalol in the ED. Initially had lactate level of 2.6 which 
decreased to 1.8 prior to admission. Blood cultures were drawn 
and nephrology has been made aware of his prescence.
 

###RESPONSE: gastroparesis {Gastroparesis}, malignant hypertension {Malignant hypertension}, hyperglycemia {Hyperglycemia}, nausea {Nausea}, vomitting {Vomiting}, abdominal pain {Abdominal pain}, gastroparetic syndrome {Gastroparesis}, pain {Abdominal pain}, nausea 
and vomiting {Nausea and vomiting}, pain {Pain}, low blood pressure {Low blood pressure}, vitals {Vital signs finding}, T {Body temperature finding}, HR {Finding of heart rate}, lactate level {Lactic acid measurement}, Blood cultures {Blood culture}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
# Diabetes Mellitus Type I  
- Gastroparesis with chronic hospitalizations  
- ESRD on HD since ___  
- Autonomic dysfunction, frequent HTN emergency & orthostatic  
hypotension  
- Peripheral neuropathy  
# Coronary artery disease  
- STEMI ___ in setting of cocaine, s/p BMS to LAD  
# Aortic valve endocarditis (___) and ___  
- In the context of coag neg staph bacteremia ___ and  
___ and positive intravenous catheter tip ___ had 
 
his HD catheter changed over a wire. known MRSE bacteremia for  
which he completed a course of vancomycin for possible  
endocarditis on ___.  
MSSA Bacteremia: had an episode of MSSA endocardititis on ___ 
admission, treated w/ nafcillin (___nded on  
# Hypertension  
# History of line sepsis with coag negative staph and priors  
with klebsiella and enterobacteremia  
# Esophageal ulceration: H pylori neg, active esophagitis seen  
on EGD ___, h/o ___ tear  
# History of substance abuse (cocaine, marijuana, alcohol)  
# History of thrombosed AV fistula in LUE ___, gore-tex in  
place  
# Fungemia completed caspofungin IV on ___  
# GI bleed associated with hypotension-colonscopy showed  
friable and inflammed ascending and transverse colon,suggestive  

either of ischemia or infection ___  

 

###RESPONSE: Diabetes Mellitus Type I {Diabetes mellitus type 1}, Gastroparesis {Gastroparesis}, ESRD on HD {End stage renal failure on dialysis}, HTN emergency {Hypertensive emergency}, orthostatic  
hypotension {Orthostatic hypotension}, Peripheral neuropathy {Peripheral nerve disease}, Coronary artery disease {Coronary arteriosclerosis}, STEMI {Acute ST segment elevation myocardial infarction}, LAD {Structure of anterior descending branch of left coronary artery}, Aortic valve {Aortic valve structure}, endocarditis {Endocarditis}, bacteremia {Bacteremia}, bacteremia {Bacteremia}, endocarditis {Endocarditis}, MSSA {Infection caused by methicillin susceptible Staphylococcus aureus}, Bacteremia {Bacteremia}, MSSA {Infection caused by methicillin susceptible Staphylococcus aureus}, endocardititis {Endocarditis}, Hypertension {Hypertensive disorder, systemic arterial}, line sepsis {Line sepsis associated with dialysis catheter}, Esophageal ulceration {Ulcer of esophagus}, esophagitis {Esophagitis}, EGD {Esophagogastroduodenoscopy}, substance abuse {Substance abuse}, cocaine {Cocaine abuse}, marijuana {Marijuana user}, alcohol {Alcohol abuse}, thrombosed AV fistula {Arteriovenous fistula thrombosis}, LUE {Structure of left upper limb}, Fungemia {Fungemia}, GI bleed {Gastrointestinal hemorrhage}, hypotension {Low blood pressure}, colonscopy {Colonoscopy}, ascending {Ascending colon structure}, transverse colon {Transverse colon structure}, ischemia {Ischemia}, infection {Infectious disease}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father deceased of ESRD and DM. Mother aged ___ with 
hypertension. Two sisters, one with diabetes. Six brothers, one 
with diabetes. There is no family history of premature coronary 
artery disease or sudden death. 
 

###RESPONSE: deceased {Dead}, ESRD {End-stage renal disease}, DM {Diabetes mellitus}, hypertension {Hypertensive disorder, systemic arterial}, diabetes {Diabetes mellitus}, diabetes {Diabetes mellitus}, coronary 
artery disease {Coronary arteriosclerosis}, sudden death {Dead - sudden death}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VITALS: 98.2 ___ 28 98% RA
GEN: Appears uncomfortable and is writhing in bed
HEENT: Proptosis, EOMI, PERRL
PULM: Sparse crackles bibasilar at posterior fields
CARD: Tachycardic, nl S1, nl S2, III/VI SEM heard best at LUSB
ABD: BS+, tender, mildly distended, tympanitic
EXT: No lower extremity edema, femoral CVC
NEURO: AOx3, Non-Focal
 

###RESPONSE: VITALS {Vital signs finding}, RA {Breathing room air}, GEN {General examination of patient}, HEENT {Physical examination procedure}, Proptosis {Exophthalmos}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, PULM {Examination of respiratory system}, crackles {Respiratory crackles}, bibasilar {Structure of base of lung}, CARD {Cardiovascular physical examination}, Tachycardic {Tachycardia}, nl S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, III {Third heart sound}, SEM {Ejection murmur}, LUSB {Structure of upper parasternal region}, ABD {Examination of abdomen}, BS+ {Normal bowel sounds}, tender {Abdominal tenderness}, distended {Swollen abdomen}, tympanitic {Abdomen tympanitic}, edema {Edema}, femoral {Structure of femoral artery}, CV {Cardiovascular physical examination}, NEURO {Neurological examination}, AOx3 {Oriented to person, time and place}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ CXR AP CHEST: 
Bilateral pulmonary vascular congestion is mild. There is no 
pleural effusion. No definite evidence of pneumonia is 
identified. Mild cardiomegaly is unchanged.
IMPRESSION: Mild pulmonary vascular congestion.
<br>
___ Blood cultures x 2 showed no growth to date at 
discharge.
 

###RESPONSE: CXR {Plain chest X-ray}, pulmonary vascular {Structure of pulmonary blood vessel}, congestion {Congestion}, pleural effusion {Pleural effusion}, pneumonia {Pneumonia}, cardiomegaly {Cardiomegaly}, pulmonary vascular {Structure of pulmonary blood vessel}, congestion {Congestion}, Blood cultures {Blood culture}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
## Gastroparesis:
Nausea, vomiting, and abdominal pain all likely related to 
extensive history of gastroparesis. Has inpatient regimen that 
usually works for him. And during the hospitalization he was 
initially NPO and was receiving Dilaudid ___ mg IV Q4H PRN pain, 
Lorazepam ___ mg IV Q4H PRN nausea, metoclopramide 10 mg PO QID, 
ondansetron 4 mg IV Q8H PRN nausea. After several days of 
limited PO intake, the patient was able to eat and keep solid 
food down reliably and was discharged with improved 
symptomatology.
<br>
## Labile Blood Pressure:
In emergency department, BP was 180s systolic and responded to 
labetalol. Originally 190 systolic on transfer to floor. He was 
stabilized s/p application of clonidine patch at admission and 
blood pressures remained stable throughout the rest of the 
admission. He was discharged on a clonidine patch 0.3 mg/24 hr 
(change every ___, and labetalol dose of 200 mg PO BID.
<br>
## Fever:
Low grade fever in ED. Afebrile through remainder of 
hospitalization. At discharge his blood cultures drawn on 
___ showed no growth. 
<br>
## Type 1 DM, Uncontrolled with Complications:
Patient was put on home regimen of glargine 4 U at bedtime or 2 
U if NPO. He was monitored using fingersticks QID with regular 
insulin sliding scale. He triggered need for SSI only once 
during his stay.
<br>
## ESRD, Anemia of Chronic Kidney Disease:
Nephrology was made aware of patient admission and they followed 
and dialyzed ___ as per his normal HD schedule ___.
<br>
## ? of Opioid addiction: 
Could explain abdominal complaints and likely confounds the 
gastroparesis picture. Clonidine should help with abdominal 
cramping related to opiate withdrawal if this is the case. 
Although this has been addressed at prior hospitalizations by 
means of pain service consults, the patient has failed to 
follow-up as an outpatient. He was discharged on a limited 
supply of oral dilaudid.
<br>
## CAD s/p MI:
No acute issues during this hospitalization. We continued 
patient's home doses of simvastatin 40 mg daily, aspirin 325mg 
daily and plavix 75mg daily.
<br>
## Chronic diastolic heart failure with EF 45%:
Appeared stable during this admission.
<br>
Overall, patient was stable upon discharge.

 

###RESPONSE: Gastroparesis {Gastroparesis}, Nausea, vomiting {Nausea and vomiting}, abdominal pain {Abdominal pain}, gastroparesis {Gastroparesis}, NPO {Nil by mouth}, pain {Pain}, nausea {Nausea}, nausea {Nausea}, able to eat {Able to eat}, improved {Patient's condition improved}, BP {Blood pressure finding}, blood pressures remained stable {Stable blood pressure}, Low grade fever {Low grade pyrexia}, Afebrile {Fever}, blood cultures  {Blood culture}, NPO {Nil by mouth}, insulin sliding scale {Sliding scale insulin regime}, SSI {Sliding scale insulin regime}, HD {Hemodialysis}, Opioid addiction {Opioid abuse}, gastroparesis {Gastroparesis}, abdominal 
cramping {Stomach cramps}, opiate withdrawal {Opioid withdrawal syndrome}, stable {Patient's condition stable}, stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly 
Transdermal QSAT (every ___.  
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each 
hemodialysis).  
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).  
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
7. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a 
day).  
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 
hours): For ___, please take every 4 hours. On ___, please 
take every 6 hours. On ___, please take every 8 hours. On ___ 
and ___, please take every 12 hours.  Disp:*20 Tablet(s)* 
Refills:*0*
9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times 
a day. Disp:*120 Tablet(s)* Refills:*2*
10. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, 
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).  
11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, 
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
12. Cefazolin 10 gram Recon Soln Sig: One (1) Recon Soln 
Injection QSAT (every ___ for 1 weeks.  
13. Cefazolin 10 gram Recon Soln Sig: One (1) Recon Soln 
Injection QHD (each hemodialysis) for 1 weeks.  
14. Insulin Regular Human 100 unit/mL Cartridge Sig: Twelve (12) 
units Injection once a day: Please continue your previous 
outpatient insulin regimen.
 
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each 
hemodialysis).  
4. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).  
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).  
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 
times a day (before meals and at bedtime)).  
8. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, 
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).  
9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly 
Transdermal QWED (every ___.  
10. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, 
Rapid Dissolve PO q8hrs:prn.  
11. Lantus 100 unit/mL Solution Sig: Four (4) units Subcutaneous 
qpm.  
12. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO q4hrs:prn as 
needed for pain: do not take while driving. 
only take as instructed.
Disp:*10 Tablet(s)* Refills:*0*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
gastroparesis. 
hypertension
diabetes
autonomic dysfunction
coronary artery disease
end stage renal disease

 
Discharge Condition:
abdominal pain improved. able to tolerate a normal diet

 

###RESPONSE: gastroparesis {Gastroparesis}, hypertension {Hypertensive disorder, systemic arterial}, diabetes {Diabetes mellitus}, coronary artery disease {Coronary arteriosclerosis}, end stage renal disease {End-stage renal disease}, abdominal pain {Abdominal pain}, improved {Patient's condition improved}, normal diet {Normal diet}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted for abdominal pain due to your gastroparesis. 
Your pain improved with pain medication, anti nausea medications 
and bowel rest. You were able to tolerate a normal diet. 
.
Please continue to take your medications as prescribed.
. 
Please seek medical attention if you have worsening abdominal 
pain and are not able to tolerate your diet or if you have other 
worrisome medical symptoms.
 

###RESPONSE: abdominal pain {Abdominal pain}, gastroparesis {Gastroparesis}, pain improved {Sensation of pain reduced}, pain medication {Administration of analgesic}, nausea {Nausea}, bowel rest {Nil by mouth}, normal diet {Normal diet}, worsening {Increased pain}, abdominal 
pain {Abdominal pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: 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: 
Sulfa (Sulfonamide Antibiotics) / Lasix / fried clams
 
Attending: ___.
 
Chief Complaint:
LUE numbness, tingling

 
Major Surgical or Invasive Procedure:
Banding left upper arm AV graft
 

###RESPONSE: LUE {Structure of left upper limb}, numbness, tingling {Numbness and tingling sensation of skin}, Banding {Banding of arteriovenous fistula}, left upper arm {Left upper arm structure}, AV graft {Arteriovenous graft}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 ESRD on HD, s/p left upper arm AV graft in late ___, 
presents to ED with pain in her left hand distal to her fistula. 
Pt reports pain happens while she undergoes HD. Today it was 
also associated with numbness and tingling. She has experienced 
similar pain after HD before and is being considered for 
banding. 

 

###RESPONSE: ESRD {End-stage renal disease}, HD {Hemodialysis}, left upper arm {Left upper arm structure}, AV graft {Arteriovenous graft}, pain {Pain in scrotum}, left hand {Structure of left hand}, pain {Pain}, HD {Hemodialysis}, numbness and tingling {Numbness and tingling sensation of skin}, pain {Pain}, HD {Hemodialysis}, banding {Banding}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1) ESRD secondary to hypertensive nephropathy, started HD ___  

2) Renal artery stenosis s/p bilateral renal artery stents  
3) HTN  
4) HLD  
5) Hypothyroidism 

PSH: left AV graft placement ___, b/l renal artery stents  

 

###RESPONSE: ESRD secondary to hypertensive nephropathy {End stage renal disease due to hypertension}, HD {Hemodialysis}, Renal artery stenosis {Renal artery stenosis}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, Hypothyroidism {Hypothyroidism}, AV graft placement {Arteriovenous fistulization}, renal artery stents {Insertion of stent into arteriovenous fistula}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
No family history of kidney disease. Mother with HTN.
 

###RESPONSE: kidney disease {Kidney disease}, HTN {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
On discharge:

Vitals- 

GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: LUE w/o edema, palpable thrill in graft and distal radial 
pulse, extremity slightly cooler than RUE (unchanged), Nail beds 
slightly cyanotic compared to RUE (unchanged), capillary refill 
slightly slower than RUE (unchanged)
 No ___ edema, ___ warm and well perfused

 

###RESPONSE: Vitals {Vital signs finding}, GEN {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, scleral icterus {Scleral icterus}, mucus membranes moist {Moist oral mucosa}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, M {Heart murmur}, G {Gallop rhythm}, R {Pericardial friction rub}, PULM {Examination of respiratory system}, Clear to auscultation b/l {Normal breath sounds}, W {Wheezing}, R {Respiratory crackles}, R {Wheeze - rhonchi}, ABD {Examination of abdomen}, Soft {Abdomen soft}, nondistended {Normal abdominal contour}, nontender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, normoactive bowel sounds {Normal bowel sounds}, Ext {Examination of limb}, LUE {Structure of left upper limb}, edema {Edema}, thrill {Thrill}, graft {Arteriovenous graft}, radial {Structure of radial artery}, pulse {Normal pulse}, extremity {Limb structure}, RUE {Structure of right upper limb}, RUE {Structure of right upper limb}, capillary refill {Capillary refill}, RUE {Structure of right upper limb}, edema {Edema}, warm {Warm skin}, well perfused {Normal tissue perfusion}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 04:25PM   PLT COUNT-182
___ 04:25PM   NEUTS-82.0* LYMPHS-9.9* MONOS-3.3 EOS-3.6 
BASOS-1.2
___ 04:25PM   WBC-10.9 RBC-3.73*# HGB-11.5* HCT-37.2# 
MCV-100* MCH-30.7 MCHC-30.9* RDW-15.7*
___ 04:25PM   CALCIUM-9.5 PHOSPHATE-3.5 MAGNESIUM-2.0
___ 04:25PM   estGFR-Using this
___ 04:25PM   GLUCOSE-103* UREA N-25* CREAT-2.6* SODIUM-140 
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-29 ANION GAP-16
 

###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}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, CALCIUM {Blood calcium measurement}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Mrs. ___ was admitted to the ___ Surgery service on 
___ for banding of her left upper arm AV graft. There were 
no complications and the patient tolerated the procedure well. 
After the procedure there was a palpable radial pulse and thrill 
over the graft. The patient reported resolution of her pain and 
tingling symptoms that she had prior to the procedure. On the 
morning of POD 1, she noticed a ""heavy feeling"" and coolness of 
her left middle finger. There was no pain or tenderness. After 
examination it was determined that she can go home with close 
follow up within one week to determine if the graft needs to be 
compeltely ligated or not and to call if her symptoms return and 
get worse. She was discharged back to her skilled nursing 
facility after a session of HD in the morning of POD 1 and when 
she was feeling well and tolerating regular diet.
Her asprin and plavix were restarted on POD 1.

 

###RESPONSE: banding {Banding}, left upper arm {Left upper arm structure}, AV graft {Arteriovenous graft}, procedure {Procedure}, procedure {Procedure}, palpable radial pulse {Radial pulse present}, thrill {Thrill}, graft {Arteriovenous graft}, pain {Pain}, tingling {Pins and needles}, procedure {Procedure}, heavy feeling {Heavy feeling}, coolness {Cool skin}, left middle finger {Structure of left middle finger}, pain {Pain}, tenderness {Tenderness}, graft {Structure of transplant}, HD {Hemodialysis}, regular diet {Normal diet}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
aricept 5 HS, mirtazapine 7.5 HS, levothyroxine 50', calcitriol 
0.25', captopril 12.5''', amlodipine 5', simvastatin 10', plavix 
75', asa 81', oxycodone 2.5 Q6H PRN, colace 100'', Vit D3 800', 
Vit B12 1000'   

 
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
2. captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times 
a day).  
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
5. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 
 
6. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).  

7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours) as needed for pain: no more than 2000mg per day.  
9. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every ___ hours as 
needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO once a day.  
11. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.  
12. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a 
day.  
13. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a 
day.  
14. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a 
day.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
steal syndrome 
esrd on hemodialysis

 
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}, steal syndrome {Arterial steal syndrome}, esrd on hemodialysis {End stage renal failure on dialysis}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - requires assistance or aid {Finding of walking aid use}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted to the hospital for banding of your left arm 
fistula because it was causing you some discomfort. Please call 
Dr. ___ office ___ if you have any of the 
warning signs listed. ___, ___ may be 
contacted
Resume your usual hemodialysis schedule via the tunnelled 
dialysis line 
****
___  ___ will be resumed

 

###RESPONSE: banding {Banding}, left arm {Left upper arm structure}, fistula {Arteriovenous fistula}, discomfort {Discomfort}, signs {Sign}, hemodialysis {Hemodialysis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                      Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
tramadol / Compazine
 
Attending: ___
 
Chief Complaint:
Trauma
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: tramadol {Allergy to tramadol}, Compazine {Allergy to prochlorperazine}, Trauma {Traumatic injury}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mr. ___ is a ___ yo M w/ h/o Hep C and IVDU who presented to 
the ED with multiple blast injuries in the face and chest.  Of 
note, patient reports that he was blown off by the lid of a 
highly pressurized natural gas tank in his pickup truck and 
sustained multiple injuries from the blast, including the R side 
of his
face, rib cage, and L leg.  He denies loss of consciousness at 
the scene, but reports severe R-sided chest pain and blurry 
vision in the right eye, as well as numbness in the posterior 
aspect of the arm around the elbow.  

 

###RESPONSE: Hep C {Viral hepatitis type C}, IVDU {Intravenous drug user}, blast injuries {Blast injury}, face {Injury of face}, chest {Chest injury}, multiple injuries {Multiple injuries}, R side 
of his
face {Structure of right half of face}, rib cage {Thoracic cage structure}, L leg {Structure of left lower limb}, loss of consciousness {Loss of consciousness}, R-sided chest pain {Right sided chest pain}, blurry 
vision {Blurring of visual image}, right eye {Right eye structure}, numbness {Numbness}, posterior 
aspect of the arm {Structure of posterior surface of upper arm}, elbow {Right elbow region structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Hep C 
Overactive bladder 

Past surgical History: 
Splenectomy (in his ___ 
Hernia repair ___ years old)
 

###RESPONSE: Hep C {Viral hepatitis type C}, Overactive bladder {Overactive bladder}, Splenectomy {Splenectomy}, Hernia repair {Hernia repair}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Non contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Physical exam on Admission:
BP 155/108  HR 76   RR 20   O2 sat 95% on RA 
GEN: Alert, awake, lying uncomfortably in pain.
HEENT: Multiple small lacerations on the R side of the face 
around the eye.  Full ROM in the neck. No C spine tenderness. 
PULM: Pain to palpation of R chest wall.  Inspiratory effort 
limited by pain.
ABD: Soft, NTND.  No signs of laceration, hematoma, or trauma in 
the abdomen.    
MSK: No paraspinal tenderness. 2-3 cm laceration in the L 
anterior shin. Full ROM in L ankle. Tenderness in the posterior 
R arm with diffuse patchy ecchymosis. 

Physical exam on Discharge:
97.3, BP 119/78  HR 63   RR 18   O2 sat 98% on RA 
GEN: Alert and oriented x3
HEENT: Multiple small lacerations on the R side of the face 
around the eye.  Full ROM in the neck. No C spine tenderness. 
Cardio: RRR
PULM: Pain to palpation of R chest wall.  Clear bilateral air 
entry
ABD: Soft, NTND.  No signs of laceration, hematoma, or trauma is 
the abdomen.    
Extremities: WWP, CCE
 

###RESPONSE: BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, GEN {General examination of patient}, Alert {Mentally alert}, awake {Awake}, lying {Lying in bed}, pain {Pain}, HEENT {Physical examination procedure}, small lacerations on the R side of the face {Superficial laceration of face}, Full ROM {Normal movement of neck}, neck {Neck structure}, tenderness {Tenderness}, PULM {Examination of respiratory system}, Pain {Pain}, palpation {Palpation}, R chest wall {Structure of right half of chest wall}, pain {Pain}, ABD {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, laceration {Laceration}, hematoma {Hematoma}, trauma in 
the abdomen {Injury of abdomen}, MSK {Musculoskeletal system physical examination}, paraspinal {Structure of paravertebral region}, tenderness {Tenderness}, laceration in the L 
anterior shin {Laceration of shin}, Full ROM {Range of joint movement normal}, L ankle {Structure of left ankle}, Tenderness {Tenderness}, posterior 
R arm {Structure of soft tissue of right upper arm}, ecchymosis {Ecchymosis}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, GEN {General examination of patient}, Alert {Mentally alert}, oriented x3 {Oriented to person, time and place}, small lacerations on the R side of the face {Superficial laceration of face}, Full ROM {Normal movement of neck}, neck {Neck structure}, C spine tenderness {Cervical spine tender}, Cardio {Cardiovascular physical examination}, RRR {Normal heart rate}, PULM {Examination of respiratory system}, Pain to palpation {Chest wall tenderness}, R chest wall {Structure of right half of chest wall}, Clear bilateral air 
entry {Normal breath sounds}, ABD {Examination of abdomen}, Soft {Abdomen soft}, NTND {Abdominal tenderness}, laceration {Laceration}, hematoma {Hematoma}, trauma is 
the abdomen {Injury of abdomen}, Extremities {Examination of limb}, WWP {Normal tissue perfusion}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Imaging Results: 
___ HEAD W/O CONTRAST 
IMPRESSION:  No acute hemorrhage or acute fracture.  Right 
periorbital soft tissue swelling 
with numerous superficial radiodense foci likely representing 
foreign bodies 
versus skin debris.  Please correlate clinically. 

___ CT CHEST/ABD/PELVIS W/  
IMPRESSION: 
1. Right-sided rib fractures involving the eighth and ninth ribs 
which appear comminuted displaced as well as fractured right 
tenth rib at the  costovertebral junction.  Associated tiny 
right pneumothorax, right hemothorax 
and soft tissue gas in the right posterior chest wall. 
2. Scarring and nodular pleural thickening in the right lung 
with associated  volume loss likely reflect chronic insult, 
please correlate clinically. 
3. Subtle peribronchovascular ground-glass opacities in the 
right lower lobe  may reflect trace aspiration or bronchiolitis. 

4. Moderate emphysema. 

___ CT C-SPINE W/O CONTRAST
IMPRESSION: 
 1. No fracture or malalignment within the cervical spine. 
2. Aerosolized fluid within the upper esophagus which appears 
patulous, may predispose to aspiration. 

___ CHEST (PA & LAT)
IMPRESSION:  Known tiny right pneumothorax is not conspicuous on 
radiograph. 
  

___ CT ORBITS, SELLA & IAC 
IMPRESSION: 
1. The right globe is intact without evidence of hemorrhage or 
retained  foreign body. 
2. Soft tissue swelling involving the right periorbital region. 
3. Multiple punctate hyperdense foci along the skin and 
subcutaneous tissues  overlying the right cheek, right 
periorbital region and right nasal bone, likely retained foreign 
bodies. 

___ CHEST (PORTABLE AP) 
IMPRESSION:  Compared to the examination from 1 day prior, there 
is likely an unchanged tiny right apical pneumothorax.  
Loculated right-sided lateral pleural effusion appears slightly 
increased.  Streaky opacities at the right lung base are likely 
atelectatic.  No new consolidation is seen there is no 
left-sided effusion pneumothorax.  Cardiomediastinal silhouette 
is unchanged. 

___ CHEST (PA & LAT) 
IMPRESSION:  Comparison to ___.  The appearance of 
the right loculated pleural 
effusion is stable.  However, on today's image, no pneumothorax 
is appreciated.  Areas of scarring throughout the right lung are 
unchanged.  No change in appearance of the normal cardiac 
silhouette and of the normal left lung. 

Laboratory Results:

___ 10:30AM BLOOD WBC-12.1* RBC-4.72 Hgb-14.9 Hct-43.6 
MCV-92 MCH-31.6 MCHC-34.2 RDW-14.8 RDWSD-50.0* Plt ___
___ 07:30PM BLOOD WBC-11.7* RBC-4.24* Hgb-13.1* Hct-39.0* 
MCV-92 MCH-30.9 MCHC-33.6 RDW-14.9 RDWSD-50.0* Plt ___
___ 06:20PM BLOOD WBC-20.0* RBC-4.69 Hgb-14.8 Hct-43.8 
MCV-93 MCH-31.6 MCHC-33.8 RDW-14.6 RDWSD-50.1* Plt ___
___ 06:20PM BLOOD Neuts-54.3 ___ Monos-6.4 Eos-2.1 
Baso-0.6 Im ___ AbsNeut-10.84* AbsLymp-7.11* AbsMono-1.29* 
AbsEos-0.43 AbsBaso-0.13*
___ 10:30AM BLOOD Plt ___
___ 07:30PM BLOOD Plt ___
___ 06:20PM BLOOD Plt Smr-HIGH* Plt ___
___ 06:20PM BLOOD ___ PTT-26.8 ___
___ 10:30AM BLOOD Glucose-99 UreaN-9 Creat-0.8 Na-138 K-4.8 
Cl-98 HCO3-27 AnGap-13
___ 07:30PM BLOOD Glucose-88 UreaN-8 Creat-0.8 Na-138 K-4.5 
Cl-100 HCO3-27 AnGap-11
___ 06:20PM BLOOD Glucose-96 UreaN-13 Creat-1.2 Na-143 
K-4.8 Cl-101 HCO3-29 AnGap-13
___ 06:20PM BLOOD ALT-34 AST-57* CK(CPK)-247 AlkPhos-102 
TotBili-0.2
___ 10:30AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.1
___ 07:30PM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9
___ 06:20PM BLOOD Albumin-4.1
 

###RESPONSE: HEAD {Imaging of head}, AST {Aspartate aminotransferase measurement}, acute hemorrhage {Acute hemorrhage}, fracture {Fracture}, Right 
periorbital soft tissue swelling {Periorbital edema of right eye}, foreign bodies {Foreign body}, Right-sided {Bone structure of right rib}, rib fractures {Bone structure of right rib}, eighth {Bone structure of eighth rib}, ninth ribs {Bone structure of ninth rib}, comminuted displaced {Fracture, closed, comminuted, with displacement}, right {Bone structure of right rib}, tenth rib {Bone structure of tenth rib}, costovertebral junction {Costovertebral joint structure}, pneumothorax {Pneumothorax}, right {Right pleura structure}, hemothorax {Hemothorax}, soft tissue {Structure of soft tissue}, right posterior chest wall. {Structure of right half of posterior chest wall}, Scarring {Pleural scarring}, nodular {Nodule of lung}, pleural thickening {Thickening of pleura}, right lung {Right lung structure}, chronic {Chronic disease}, ground-glass opacities {Ground glass lung opacity}, right lower lobe {Structure of lower lobe of right lung}, aspiration {Aspiration pneumonia}, bronchiolitis {Bronchiolitis}, emphysema {Emphysema}, AST {Aspartate aminotransferase measurement}, fracture {Fracture}, malalignment {Misalignment}, cervical spine {Structure of cervical vertebral column}, fluid {Accumulation of fluid}, upper esophagus {Cervical esophagus structure}, aspiration {Aspiration pneumonia}, CHEST (PA & LAT {Plain chest X-ray}, pneumothorax {Pneumothorax}, radiograph {Plain chest X-ray}, SELLA {Computed tomography of pituitary fossa}, IAC {Structure of internal acoustic meatus of temporal bone}, right globe {Structure of right orbit proper}, intact {No abnormality detected}, hemorrhage {Hemorrhage}, retained  foreign body {Retained foreign body}, Soft tissue swelling {Soft tissue swelling}, right periorbital region {Structure of periorbital region of left eye}, skin and 
subcutaneous tissues {Skin and/or subcutaneous tissue structure}, right cheek {Structure of skin of right cheek}, right nasal bone {Bone tissue structure of nasal bone}, retained foreign 
bodies {Retained foreign body}, CHEST (PORTABLE AP {Plain x-ray of chest anteroposterior view}, right apical {Structure of apex of right lung}, pneumothorax {Pneumothorax}, right-sided {Right pleura structure}, pleural effusion {Pleural effusion}, opacities {Abnormally opaque structure}, right lung base {Structure of base of right lung}, atelectatic {Atelectasis}, consolidation {Consolidation}, left-sided {Left pleura structure}, effusion {Pleural effusion}, pneumothorax {Pneumothorax}, Cardiomediastinal {Mediastinal structure}, CHEST (PA & LAT {Plain chest X-ray}, right {Right pleura structure}, loculated pleural 
effusion {Loculated pleural effusion}, stable {Patient's condition stable}, pneumothorax {Pneumothorax}, scarring {Pleural scarring}, right lung {Right lung structure}, normal {Normal size}, cardiac {Heart structure}, normal {Normal size}, left lung {Left lung structure}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, 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}, 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}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, CK(CPK {Creatine kinase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Albumin {Albumin 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:
The patient presented to Emergency Department on ___. The 
trauma general surgery team evaluated the patient and performed 
a primary and a secondary survey. He was found to have rib 
fractures and periorbital swelling. Ophthalmology evaluated the 
patient and recommended  - Dedicated CT orbits will better 
characterize superficial shrapnel burden however there is no 
clinical evidence of intraocular FB or clinically significant 
intraorbital FB- Artificial tears to right eye QID, more as 
needed for irritation - GenTeal gel QHS to right eye  - can 
apply erythromycin ophthalmic ointment to lids if irritated- 
Follow up in ophthalmology clinic 2 weeks, sooner PRN. The 
recommendations were following. The patient was then admitted to 
the Acute Care Surgery Unit for further management of the 
overall injuries. 

During the hospital course review of systems had as follow:

Neuro: The patient was alert and oriented throughout 
hospitalization and pain was well controlled.

CV: The patient remained stable from a cardiovascular 
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary 
standpoint; vital signs were routinely monitored. Good pulmonary 
toilet, early ambulation and incentive spirometry were 
encouraged throughout hospitalization. 

GI/GU/FEN: The patient was tolerating a regular diet. Patient's 
intake and output were closely monitored

ID: The patient's fever curves were closely watched for signs of 
infection, of which there were none.

HEME: The patient's blood counts were closely watched for signs 
of bleeding, of which there were none.

Prophylaxis: The patient received subcutaneous heparin and ___ 
dyne boots were used during this stay and was encouraged to get 
up and ambulate as early as possible.

At the time of discharge, the patient was doing well, afebrile 
and hemodynamically stable.  The patient was tolerating a diet, 
ambulating, voiding without assistance, and pain was well 
controlled.  The patient received discharge teaching and 
follow-up instructions with understanding verbalized and 
agreement with the discharge plan.
 

###RESPONSE: rib 
fractures {Fracture of multiple ribs}, periorbital swelling {Periorbital edema}, CT orbits {Computed tomography of orbit}, right eye {Right eye structure}, right eye {Right eye structure}, Neuro {Neurological examination}, alert {Mentally alert}, oriented {Orientated}, pain was well controlled {Demonstrates adequate pain control}, CV {Cardiovascular physical examination}, stable {Patient's condition stable}, cardiovascular {Cardiovascular physical examination}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, Pulmonary {Examination of respiratory system}, stable {Patient's condition stable}, pulmonary {Respiratory assessment}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, pulmonary 
toilet {Airway toilet}, incentive spirometry {Incentive spirometry}, GI {Gastrointestinal investigation}, GU {Examination of genitourinary system}, tolerating a regular diet {Tolerating normal diet}, intake and output {Measuring intake and output}, monitored {Monitoring procedure}, fever {Fever}, watched for signs of 
infection {Monitoring for signs and symptoms of infection}, HEME {Hematology test}, blood counts {Blood test}, signs {Sign}, bleeding {Bleeding}, Prophylaxis {Preventive procedure}, subcutaneous heparin {Subcutaneous injection of heparin}, ambulate {Ambulation training}, afebrile {Temperature normal}, hemodynamically stable {Hemodynamically stable}, tolerating a diet {Tolerating diet}, ambulating {Fully mobile}, voiding without assistance {Continence independent}, pain was well 
controlled {Demonstrates adequate pain control}, 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:
Methadone per patient 102 mg
 
Discharge Medications:
1.  Acetaminophen ___ mg PO Q6H:PRN Pain - Mild  
2.  Artificial Tears ___ DROP BOTH EYES Q6H dryness  
3.  Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE QID 
RX *erythromycin 5 mg/gram (0.5 %) 0.5 (One half) on lid every 
four (4) hours Disp #*3.5 Gram Gram Refills:*0 
4.  OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe 
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp 
#*10 Tablet Refills:*0 

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Right sided ___ ribs fractures 
Right ___ swelling 
Left shin laceration
Right pneumothorax and hemothorax

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Right sided {Bone structure of right rib}, ribs fractures {Fracture of multiple ribs}, Right {Structure of right orbital region}, swelling {Orbital swelling}, Left {Structure of shin of left lower leg}, shin laceration {Laceration of shin}, Right pneumothorax {Right pneumothorax}, hemothorax {Hemothorax}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___,

You were admitted to ___ falling a trauma. You were found to 
have rib fractures and ___ swelling. You have recovered 
well and are now ready for discharge. 

* Your injury caused right sided ___ rib fractures which 
can cause severe pain and subsequently cause you to take shallow 
breaths because of the pain.
 
* You should take your pain medication as directed to stay ahead 
of the pain otherwise you won't be able to take deep breaths. If 
the pain medication is too sedating take half the dose and 
notify your physician.
 
* Pneumonia is a complication of rib fractures.  In order to 
decrease your risk you must use your incentive spirometer 4 
times every hour while awake.  This will help expand the small 
airways in your lungs and assist in coughing up secretions that 
pool in the lungs.
 
* You will be more comfortable if you use a cough pillow to hold 
against your chest and guard your rib cage while coughing and 
deep breathing.
 
* Symptomatic relief with ice packs or heating pads for short 
periods may ease the pain.
 
* Narcotic pain medication can cause constipation therefore you 
should take a stool softener twice daily and increase your fluid 
and fiber intake if possible.
 
* Do NOT smoke
 
* If your doctor allows, non-steroidal ___ drugs 
are very effective in controlling pain ( ie, Ibuprofen, Motrin, 
Advil, Aleve, Naprosyn) but they have their own set of side 
effects so make sure your doctor approves.
 
* Return to the Emergency Room right away for any acute 
shortness of breath, increased pain or crackling sensation 
around your ribs (crepitus).

You were also found to have a right sided ___ swelling. 
If you have any worsening symptoms or change in vision please 
return to your closest emergency department.

 

###RESPONSE: trauma {Traumatic injury}, rib fractures {Fracture of multiple ribs}, swelling {Swelling}, ready for discharge {Ready for discharge}, injury {Traumatic injury}, right sided {Bone structure of right rib}, rib fractures {Fracture of multiple ribs}, severe pain {Severe pain}, pain {Pain}, pain medication {Administration of analgesic}, pain {Pain}, able to take deep breaths {Able to take deep breaths}, pain medication {Administration of analgesic}, Pneumonia {Pneumonia}, rib fractures {Fracture of multiple ribs}, use your incentive spirometer {Incentive spirometry}, airways {Airway structure}, lungs {Lung structure}, coughing up secretions {Encouragement of deep breathing and coughing exercises}, lungs {Lung structure}, chest {Thoracic structure}, rib cage {Thoracic cage structure}, coughing and 
deep breathing {Deep breathing and coughing exercises}, relief {Pain relief}, ice packs {Application of ice}, heating pads {Heat therapy}, pain {Pain}, constipation {Constipation}, take a stool softener {Administration of laxative}, increase your fluid {Fluid intake encouragement}, fiber intake {High fiber diet education}, Do NOT smoke {Smoking cessation education}, controlling pain {Pain control}, shortness of breath {Dyspnea}, increased pain {Increased pain}, crackling sensation {Subcutaneous emphysema}, ribs {Bone structure of rib}, crepitus {Bone crepitus}, right sided {Structure of right orbital region}, swelling {Periorbital edema}, change in vision {Visual disturbance}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
Ace Inhibitors
 
Attending: ___.
 
Chief Complaint:
tongue swelling
 
Major Surgical or Invasive Procedure:
Intubation

 

###RESPONSE: Ace Inhibitors {Allergy to acetylcholinesterase inhibitor}, tongue swelling {Tongue swelling}, Intubation {Intubation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ yo male with history of ESRD s/p living unrelated kidney 
transplant in ___ presented to the ER in the middle of the 
night with tongue swelling. Per report, the pt noted he woke up 
from his sleep at 3 Am and felt that his mouth had been forced 
open.  
In the ER he was statting 93% on RA and could barely speak. He 
received 125 mg IV solumedrol, 50 mg IV benadryl, 20 mg IV 
pepcid and 0.3 cc of 1:1000 epinephrine sc, but his symptoms 
only got worse. He was thought to have angioedema and 
fiberoptically intubated by anesthesia.  
.  
Upon arrival to the floor the pt was intubated and sedated. 
Additional history obtained from his mother who lives with him. 
She did not know his medication list, but stated this had never 
happened to the pt before and she did not think there had been 
any recent medication changes. Only notable thing was that pt 
ate ""hot sauce"" last night which was different for him.  
.
Medications brought in by family following admission, includes 
(recently added) benazepril.  
 

###RESPONSE: ESRD {End-stage renal disease}, kidney 
transplant {Transplant of kidney}, tongue swelling {Tongue swelling}, mouth {Mouth region structure}, RA {Breathing room air}, angioedema {Angioedema}, intubated {Intubation}, anesthesia {Under anesthesia}, sedated {Sedated}, medication changes {Change of medication}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
HTN  
ESRD s/p living unrelated kidney transplant in ___  
sleep apnea on CPAP  
DM2  
H./o colon cancer s/p right colectomy by Dr. ___ ___. 
No chemotherapy.  
History of bilateral lower extremity edema.  
s/p L AV fistula  
hypercholesterolemia  
admission for ___ cellulitis ion ___  
h/o GIB  

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, ESRD {End-stage renal disease}, kidney transplant {Transplant of kidney}, sleep apnea {Sleep apnea}, on CPAP {Dependence on continuous positive airway pressure ventilation}, DM2 {Diabetes mellitus type 2}, colon cancer {Malignant neoplasm of colon}, right colectomy {Right colectomy}, chemotherapy {Chemotherapy}, bilateral lower extremity edema {Edema of bilateral lower limbs}, AV fistula {Arteriovenous fistula}, hypercholesterolemia {Hypercholesterolemia}, cellulitis {Cellulitis}, GIB {Gastrointestinal hemorrhage}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
unknown
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VS: T: 06.9 HR: 71 BP: 120/79 RR: 14 O2 Sat: 100% on vent  
AC: 600x14 FIO2 1 PEEP 5  
GEN: intubated, moving around, couging  
HEENT: intubated, edematous tongue  
Neck: supple  
Cardio: RRR, nl S1 S2, no m/r/g  
Pulm: CTAB ant, no w/r/r,no stridor  
Abd: soft, NT, ND, + BS  
Ext: no edema, 2+ DP pulses  
Neuro: sedated, moving around, grimacing and coughing, moving 
upper and lower ext; PERRL  
Skin: no rashes or hives  

 

###RESPONSE: VS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, GEN {General examination of patient}, couging {Cough}, HEENT {Physical examination procedure}, edema {Edema}, Neck {Physical examination procedure}, supple {Normal movement of neck}, Cardio {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, no m/r/g {Heart sounds normal}, Pulm {Examination of respiratory system}, CTAB {Normal breath sounds}, no w/r/r {Normal breath sounds}, stridor {Stridor}, Abd {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, + BS {Normal bowel sounds}, Ext {Examination of limb}, edema {Edema}, 2+ DP pulses {All pulses present in bilateral lower limbs}, Neuro {Neurological examination}, sedated {Sedated}, coughing {Cough}, upper {Examination of lower limb}, lower ext {Lower limb structure}, PERRL {Pupils equal and reacting to light}, Skin {Examination of skin}, rashes {Eruption of skin}, hives {Wheal}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:15AM BLOOD WBC-4.9 RBC-3.86* Hgb-13.3* Hct-39.0* 
MCV-101* MCH-34.3* MCHC-34.0 RDW-14.9 Plt Ct-58*
___ 06:14AM BLOOD WBC-7.1# RBC-4.06* Hgb-14.0 Hct-40.2 
MCV-99* MCH-34.4* MCHC-34.8 RDW-15.4 Plt Ct-67*
___ 12:27AM BLOOD WBC-3.4* RBC-4.20* Hgb-14.9 Hct-41.9 
MCV-100* MCH-35.4* MCHC-35.5* RDW-14.6 Plt Ct-64*
___ 05:04AM BLOOD WBC-3.6* RBC-4.07* Hgb-14.4 Hct-41.0 
MCV-101* MCH-35.4* MCHC-35.1* RDW-14.7 Plt Ct-78*
___ 06:15AM BLOOD Glucose-223* UreaN-48* Creat-2.2* Na-141 
K-3.5 Cl-101 HCO3-29 AnGap-15
___ 06:14AM BLOOD Glucose-267* UreaN-38* Creat-2.0* Na-143 
K-4.3 Cl-102 HCO3-29 AnGap-16
___ 12:27AM BLOOD Glucose-268* UreaN-35* Creat-1.9* Na-139 
K-4.1 Cl-103 HCO3-24 AnGap-16
___ 06:15AM BLOOD tacroFK-10.4
___ 08:55AM BLOOD Type-ART FiO2-100 pO2-443* pCO2-40 
pH-7.43 calTCO2-27 Base XS-2 AADO2-252 REQ O2-48 
Intubat-INTUBATED
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, 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}, 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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
# Angioedema: Initially unclear precipitant for angioedema, 
however, after family brought in meds following admission, an 
ACE inhibitor was among them (had not previously been known to 
be on ACE) and most likely due to this. No family or personal 
history of angioedema.  No rash or hypotension.  IV steroids 
(with transition to PO taper) started along with benadryl and 
pepcid.  He was extubated easily on ___ following resolution 
of the swelling.  ACE inhibitor was added to his allergy list.  
He was discharged on a prednisone taper.

# ESRD s/p txplnt in ___: Pt with unrelated living donor 
txplnt.  Azathioprine and prograf were continued.  The renal 
transplant team followed him during admission.
  
# HTN: Rrestarted home regimen with exception of ACE inhibitor.
 
# DM: SSI and qid ___. 

# Sleep apnea: not using CPAP regularly at home.

 

###RESPONSE: Angioedema {Angioedema}, angioedema {Angioedema}, angioedema {Angioedema}, rash {Eruption of skin}, hypotension {Low blood pressure}, steroids {Steroid therapy}, extubated {Removal of endotracheal tube}, swelling {Swelling}, allergy {Allergic disposition}, ESRD {End-stage renal disease}, txplnt {Transplant of kidney}, renal 
transplant {Transplant of kidney}, HTN {Hypertensive disorder, systemic arterial}, regimen {Therapeutic regimen}, DM {Diabetes mellitus}, SSI {Sliding scale insulin regime}, Sleep apnea {Sleep apnea}, CPAP {Continuous positive airway pressure ventilation treatment}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
(meds brought in by family)
Benazepril-HCTZ 1 tablet PO QD  
Bactrim SS PO QD  
Vitamin D 1.25 MG PO QD  
HCTZ 25 mg PO QD  
Azathioprine 100 mg PO QD  
Prograf 3 mg PO BID (vs. 1 mg PO BID - unclear)
Amlodipine 10 mg PO QD  
Carvedilol 25 mg PO BID  
Lipitor 80 mg PO QD  
Aspirin 81 mg PO QD  

 
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
4. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.  
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) 
Tablet, Delayed Release (E.C.) PO once a day.  
6. Azathioprine 100 mg Tablet Sig: One (1) Tablet PO once a day. 
 
7. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 
12 hours).  
8. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.  
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once 
a day.  
10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
11. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
12. Prednisone 10 mg Tablet Sig: as below Tablet PO Daily () for 
3 days: Take 3 tablets for one day (30mg), followed by 2 tablets 
for one day (20mg) and 1 tablet for one day (10mg).
Disp:*6 Tablet(s)* Refills:*0*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary:
Angioedema likely secondary to ACE-I
Secondary:
ESRD s/p living transplant on chronic immunosupression
Type II Diabetes
Hypertension

 
Discharge Condition:
Stable with decreased tongue swelling

 

###RESPONSE: Angioedema {Angioedema}, ESRD {End-stage renal disease}, transplant {Transplant of kidney}, immunosupression {Immunosuppression}, Type II Diabetes {Diabetes mellitus type 2}, Hypertension {Hypertensive disorder, systemic arterial}, Stable {Patient's condition stable}, tongue swelling {Tongue swelling}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted to the hospital with a likely allergic 
reaction to a medication you were taking, benzapril.

While you were in the hospital, you required intubation to help 
you breath because of your swollen tongue.  We treated you with 
steroids and your tongue swelling improved.

If you develop any shortness of breath, chest pain, swelling, 
rash or any other concerning symptoms, you should call your 
doctor or come to the emergency room.
 

###RESPONSE: allergic 
reaction {Allergic reaction}, intubation {Intubation}, swollen tongue {Tongue swelling}, steroids {Steroid therapy}, tongue swelling {Tongue swelling}, improved {Patient's condition improved}, shortness of breath {Dyspnea}, chest pain {Chest pain}, swelling {Swelling}, 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: 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: 
codeine
 
Attending: ___.
 
Chief Complaint:
Transaminitis
 
Major Surgical or Invasive Procedure:
Diagnostic LHC ___
LHC w/ LAD PCI ___

 

###RESPONSE: codeine {Allergy to codeine}, Transaminitis {Aspartate transaminase level above reference range}, LHC {Catheterization of left heart}, LHC {Catheterization of left heart}, LAD {Structure of anterior descending branch of left coronary artery}, PCI {Percutaneous coronary intervention}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ is a ___ female
with history of alcoholic cirrhosis decompensated by grade I
varices and two recent hospitalizations for hepatic
encephalopathy, alcohol use disorder in remission, and
non-obstructive coronary artery disease referred directly from
___ clinic for incidental cholestatic injury, rising MELD
and imminent transplant candidacy in that regard, and serial lab
monitoring.

Patient was first hospitalized from ___ for hepatic
encephalopathy secondary to lactulose non-adherence and
pan-sensitive E. coli UTI. She incidentally developed acute on
chronic anemia, prompting endoscopy, which revealed one cord of
grade I varices and portal hypertensive gastropathy without
stigmata of bleeding. She was likewise hospitalized from ___
for hepatic encephalopathy secondary to dehydration. Her
mentation promptly resolved with hydration and was discharged on
rifaximin. 

She explains, ""I felt really good [after discharge]"" for an
estimated 1.5 to 2 weeks, when ""things [then] went downhill,""
meaning ""no energy"" and jaundice. She is not sleeping well due 
to
intense pruritus and is napping during the day. Her daughter
adds, ""It doesn't take much to get her exhausted [now]...like 
one
errand."" She endorses anorexia and dysgeusia in recent days, and
estimates a 5-pound weight loss since last hospitalization. She
has not been confused and is taking her lactulose, noting ___
bowel movements some days and ___ on others. She has vague,
occasional ""crampy"" abdominal pain, which is not particularly
bothersome.

She recently completed a course of amoxicillin for a dental
procedure, but denies other new medications or over-the-counter
protein supplements or vitamins. Her colestipol was recently
intensified, but she thinks her fatigue and jaundice pre-dated
this. She continues to abstain from alcohol. Her routine
surveillance labs on ___ revealed worsening hyperbilirubinemia
(i.e., total bilirubin 11 to 23.4, then 21.7 today), prompting
expedited follow-up today. She underwent MRCP and was then
admitted directly for serial lab monitoring. 

 

###RESPONSE: alcoholic cirrhosis {Alcoholic cirrhosis}, varices {Esophageal varices}, hepatic
encephalopathy {Hepatic encephalopathy}, alcohol use {Current drinker of alcohol}, disorder in remission {Disorder in remission}, coronary artery disease {Coronary arteriosclerosis}, cholestatic injury {Injury of biliary tree}, monitoring {Monitoring procedure}, hepatic
encephalopathy {Hepatic encephalopathy}, E. coli UTI {Urinary tract infection caused by Escherichia coli}, chronic anemia {Chronic anemia}, endoscopy {Endoscopy}, varices {Esophageal varices}, portal hypertensive gastropathy {Portal hypertensive gastropathy}, bleeding {Bleeding}, hepatic encephalopathy {Hepatic encephalopathy}, dehydration {Dehydration}, resolved {Problem resolved}, hydration {Administration of fluid therapy}, felt really good {Patient feels well}, jaundice {Jaundice}, sleeping {Asleep}, pruritus {Itching of skin}, anorexia {Loss of appetite}, dysgeusia {Taste sense altered}, weight loss {Weight loss}, confused {Clouded consciousness}, crampy {Stomach cramps}, abdominal pain {Abdominal pain}, dental
procedure {Dental surgical procedure}, fatigue {Fatigue}, jaundice {Jaundice}, abstain from alcohol {Does abstain from drinking}, hyperbilirubinemia {Hyperbilirubinemia}, total bilirubin {Bilirubin, total measurement}, MRCP {Magnetic resonance cholangiopancreatography}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Alcoholic Cirrhosis c/b ascites, esophageal varices
Colonic adenoma 
Essential hypertension
Melanocytic nevus
Low back pain
GERD
Anemia 
Cholecystectomy

 

###RESPONSE: Alcoholic Cirrhosis {Alcoholic cirrhosis}, ascites {Ascites}, esophageal varices {Esophageal varices}, Colonic {Colon structure}, adenoma {Adenoma}, Essential hypertension {Essential hypertension}, Melanocytic nevus {Pigmented nevus}, Low back pain {Low back pain}, GERD {Gastroesophageal reflux disease}, Anemia {Anemia}, 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: 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: ___ kidney disease, deceased
Father: ___, deceased
Brother: CAD with stent
 

###RESPONSE: kidney disease {Kidney disease}, deceased {Dead}, deceased {Dead}, CAD {Coronary arteriosclerosis}, stent {Insertion of arterial stent}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION EXAM:
VITALS: T 98.3, HR 78, BP 133/71. RR 17, O2 100% RA  
GENERAL: no apparent distress, jaundiced, thin 
HEENT: temporal wasting, scleral icterus, oropharynx clear, 
moist
mucous membranes  
NECK: supple, JVP 8 cm, no cervical lymphadenopathy 
HEART: RRR, S1/S2, III/VI systolic murmur heard across the
precordium
PULM: unlabored, CTAB  
ABDOMEN: surgical scar, soft, minor distention, non-tender,
palpable liver edge 
EXTREMITIES: warm, well perfused, without edema, intrinsic hand
muscle wasting 
NERUO: no asterxis, non-focal
SKIN: no rash or lesion

DISCHARGE EXAM:
VITALS: T 98.4 BP 115/55 HR 78 RR 18  O2 Sat 99% on RA
Wt: 141.1 lb/61 kg  
GENERAL: NAD, months backward w 1 error.
HEENT: AT/NC, anicteric sclera, MMM
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, moderately distended, without fluid
wave, nontender in all quadrants, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Warm and well perfused, mildly jaundiced (stable this
admission), no excoriations or lesions, no rashes

 

###RESPONSE: T {Body temperature finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, RA {Breathing room air}, GENERAL {General examination of patient}, distress {Distress}, jaundiced {Jaundice}, HEENT {Physical examination procedure}, temporal {Structure of temporal region}, scleral icterus {Scleral icterus}, oropharynx clear {Pharynx normal}, moist
mucous membranes {Moist oral mucosa}, NECK {Physical examination procedure}, supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, cervical lymphadenopathy {Cervical lymphadenopathy}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmur {Murmur}, precordium {Structure of precordium}, PULM {Examination of respiratory system}, unlabored {Breathing easily}, CTAB {Normal breath sounds}, ABDOMEN {Examination of abdomen}, surgical scar {Surgical scar}, soft {Abdomen soft}, distention {Swollen abdomen}, ,
palpable liver edge {Liver edge palpable}, EXTREMITIES {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, edema {Edema}, hand {Hand structure}, muscle wasting {Muscle atrophy}, NERUO {Neurological examination}, asterxis {Asterixis}, SKIN {Examination of skin}, rash {Eruption of skin}, lesion {Skin lesion}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 Sat {Oxygen saturation measurement}, RA {Breathing room air}, GENERAL {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, anicteric sclera {White sclera}, MMM {Moist oral mucosa}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, murmurs {Heart murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, breathing comfortably {Breathing easily}, accessory muscles {Accessory skeletal muscle}, GI {Examination of digestive system}, abdomen soft {Abdomen soft}, distended {Swollen abdomen}, fluid {Effusion}, tender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXTREMITIES {Examination of limb}, cyanosis {Cyanosis}, clubbing {Clubbing}, edema {Edema}, NEURO {Neurological examination}, Alert {Mentally alert}, moving all 4 extremities {Does move all four limbs}, face
symmetric {Facial symmetry}, DERM {Examination of skin}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, jaundiced {Jaundice}, excoriations {Excoriation}, lesions {Skin lesion}, rashes {Eruption of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
===============
___ 01:50PM   GLUCOSE-113*
___ 01:50PM   UREA N-32* CREAT-1.2* SODIUM-131* 
POTASSIUM-5.2 CHLORIDE-95* TOTAL CO2-21* ANION GAP-15
___ 01:50PM   ALT(SGPT)-36 AST(SGOT)-83* ALK PHOS-178* TOT 
BILI-21.7*
___ 01:50PM   ALBUMIN-3.7
___ 01:50PM   HBsAg-NEG HAV Ab-NEG
___ 01:50PM   ASA-NEG ACETMNPHN-NEG
___ 01:50PM   WBC-5.8 RBC-2.96* HGB-9.0* HCT-25.4* MCV-86 
MCH-30.4 MCHC-35.4 RDW-27.5* RDWSD-84.0*
___ 01:50PM   NEUTS-75.2* LYMPHS-13.8* MONOS-9.3 EOS-0.9* 
BASOS-0.3 IM ___ AbsNeut-4.34 AbsLymp-0.80* AbsMono-0.54 
AbsEos-0.05 AbsBaso-0.02
___ 01:50PM   PLT COUNT-129*
___ 01:50PM   ___
___ 10:32AM   CREAT-1.3* SODIUM-129*
___ 10:32AM   estGFR-Using this
___ 10:32AM   ALT(SGPT)-31 AST(SGOT)-72* ALK PHOS-158* TOT 
BILI-23.4*
___ 10:32AM   ALBUMIN-3.6
___ 10:32AM   ___

DISCHARGE LABS:
=================
___ 07:50AM BLOOD WBC-4.5 RBC-2.46* Hgb-7.6* Hct-22.0* 
MCV-89 MCH-30.9 MCHC-34.5 RDW-24.3* RDWSD-78.9* Plt Ct-65*
___ 07:50AM BLOOD ___ PTT-35.5 ___
___ 07:50AM BLOOD Glucose-136* UreaN-38* Creat-1.2* Na-132* 
K-4.4 Cl-99 HCO3-20* AnGap-13
___ 07:50AM BLOOD ALT-65* AST-139* AlkPhos-279* 
TotBili-11.5*
___ 07:50AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.___ yo F with hx alcoholic cirrhosis c/b grade I varices, 
malnutrition, and two recent hospitalizations for hepatic 
encephalopathy referred directly from ___ clinic with 
elevated bilirubin for expedited liver transplant work-up found 
to have non-obstructive CAD in LAD, and on ___ had rotational 
athrectomy and 2 drug-eluting stents placed, and resolving 
transaminitis.

ACUTE ISSUES
#) Alcoholic cirrhosis, Child B/MELD ___ on admission, 26 on 
___
Patient initially presented from clinic with worsening 
cholestasis of uncertain etiology. MRCP was negative for 
cholangitis among other obstructive pathologies and infectious 
work up has been negative. She recently had 3 teeth extracted, 
so transient bacteremia may have contributed. No new medications 
other than amoxicillin for dental prophylaxis and recent 
intensification of colestipol. Now that patient is on aspirin 
and Plavix, further evaluation of liver transplant will not 
occur for 3 mo. 
*Volume: She was hypervolemic, with increasing ascites based on 
visual exam and weights. Continued Lasix and spironolactone as 
tolerated by kidney.
She received albumin. 
*Infection: patient had ascites, but no fever, leukocytosis; 
paracentesis was not performed as no strong clinical indication, 
and currently on dual antiplatelet therapy
*Bleeding: history of grade I varices. There was concern for 
hemorrhage and CBC and coagulation parameters were at or above
baseline.
*Coagulopathy: INR 1.6; Platelets 65, up from 61 ___.
*Encephalopathy: history of hepatic encephalopathy, though was
entirely appropriate and oriented here. She was continued on 
lactulose and rifaximin. 
*Nutrition: nutrition evaluation for history of malnutrition.
previously Started on Zinc Sulfate. She continued her home 
dicyclomine. Her home ___ was held. 

#) Coronary artery disease, non-obstructive: by CT coronary
(CAD-RADS ___. Unremarkable nuclear exercise tolerance test. 
Grade II diastolic dysfunction without focal wall motion 
abnormality. Diagnostic
catheterization ___ showed severe proximal LAD stenosis (80%) 
and mild LCx disease. Per Cardiology recommendation and 
agreement of Liver transplant
team, was started on Plavix and aspirin. On ___, she underwent 
rotational athrectomy and had 2 drug eluting stents placed ___ 
for a single vessel mid-LAD epicardial CAD. This procedure will 
temporarily preclude her status 
for liver transplant due the necessity of Plavix for the next 3
months. EF 73%n (___). She was started on atorvastatin. 

___
Cr increased from 0.9-1.0 baseline to 1.2. Given severe 
cirrhosis, hepatorenal disease was considered. She received 25 g 
albumin x1 with improvement. 

#Anemia
Hgb stable. No evidence of acute bleeding

#Hyponatremia
Improving on discharge. Likely hypervolemic hyponatremia in 
context of
decompensated cirrhosis.

CHRONIC ISSUES:
===============
#GERD: pantoprazole changed to omeprazole 40 mg daily because of 
better side effect profile with dual antiplatelet therapy 

TRANSTIONAL ISSUES
==================
[] Pt will require 3mo aspirin+plavix following ___ cardiac 
cath with placement of two drug-eluting stents in LAD.
[] Please check labs on ___. 
[] Will f/u ___ with Liver and ___ with Cards.

CODE: Full
CONTACT: Health care proxy chosen: Yes 
Name of health care proxy: ___ 
___: daughter 
Phone number: ___ 
___ on date: ___ 
 

###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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, PHOS {Phosphate, total measurement}, ALBUMIN {Albumin measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, PHOS {Phosphate, total measurement}, ALBUMIN {Albumin measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, alcoholic cirrhosis {Alcoholic cirrhosis}, varices {Esophageal varices}, malnutrition {Nutritional disorder}, hepatic 
encephalopathy {Hepatic encephalopathy}, elevated bilirubin {Bilirubin level above reference range}, liver transplant {Transplantation of liver}, work-up {Evaluation procedure}, CAD {Coronary arteriosclerosis}, LAD {Structure of anterior descending branch of left coronary artery}, rotational 
athrectomy {Atherectomy by rotary cutter}, drug-eluting stents placed {Endovascular insertion of drug eluting stent}, transaminitis {Aspartate transaminase level above reference range}, Alcoholic cirrhosis {Alcoholic cirrhosis}, cholestasis {Cholestasis}, MRCP {Magnetic resonance cholangiopancreatography}, cholangitis {Cholangitis}, infectious {Infectious disease}, work up {Evaluation procedure}, teeth extracted {Tooth extraction}, bacteremia {Bacteremia}, prophylaxis {Preventive procedure}, aspirin {Administration of aspirin}, evaluation {Evaluation procedure}, liver transplant {Transplantation of liver}, hypervolemic {Hypervolemia}, ascites {Ascites}, visual exam {Inspection}, weights {Weight finding}, kidney {Kidney structure}, received albumin {Administration of albumin}, Infection {Infectious disease}, ascites {Ascites}, fever {Fever}, leukocytosis {Leukocytosis}, paracentesis {Abdominal paracentesis}, antiplatelet therapy {Platelet aggregation inhibitor therapy}, Bleeding {Bleeding}, varices {Esophageal varices}, hemorrhage {Hemorrhage}, CBC {Complete blood count}, coagulation {Blood coagulation panel}, baseline {Baseline state}, Coagulopathy {Blood coagulation disorder}, Platelets {Finding of platelet count}, Encephalopathy {Disorder of brain}, hepatic encephalopathy {Hepatic encephalopathy}, oriented {Orientated}, Nutrition {Nutritional finding}, nutrition {Nutritional finding}, evaluation {Evaluation procedure}, malnutrition {Nutritional disorder}, Coronary artery disease {Coronary arteriosclerosis}, CT coronary {Computed tomography angiography of coronary artery with contrast}, CAD {Coronary arteriosclerosis}, RADS {Reactive airway disease}, exercise tolerance test {Exercise tolerance test}, diastolic dysfunction {Diastolic dysfunction}, focal wall motion 
abnormality {Left ventricular wall motion abnormality}, catheterization {Cardiac catheterization}, proximal LAD stenosis {Stenosis of proximal portion of anterior descending branch of left coronary artery}, LCx {Structure of circumflex branch of left coronary artery}, disease {Disease}, Cardiology {Cardiology service}, Liver transplant {Transplantation of liver}, aspirin {Administration of aspirin}, rotational athrectomy {Atherectomy by rotary cutter}, drug eluting stents placed {Endovascular insertion of drug eluting stent}, single vessel {Single coronary vessel disease}, mid-LAD {Structure of mid portion of anterior descending branch of left coronary artery}, CAD {Coronary arteriosclerosis}, liver transplant {Transplantation of liver}, hepatorenal disease {Hepatorenal syndrome}, albumin {Administration of albumin}, improvement {Patient's condition improved}, Anemia {Anemia}, Hgb {Measurement of total hemoglobin concentration}, stable {Patient's condition stable}, acute bleeding {Acute hemorrhage}, Hyponatremia {Hyponatremia}, hypervolemic {Hypervolemia}, hyponatremia {Hyponatremia}, decompensated cirrhosis {Decompensated cirrhosis of liver}, GERD {Gastroesophageal reflux disease}, antiplatelet therapy {Platelet aggregation inhibitor therapy}, aspirin {Administration of aspirin}, cardiac 
cath {Cardiac catheterization}, placement {Implantation procedure}, drug-eluting stents {Endovascular insertion of drug eluting stent}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO DAILY:PRN nausea 
2. Lactulose 30 mL PO TID 
3. DICYCLOMine 10 mg PO BID:PRN abdominal pain 
4. colestipol 4 mg oral BID 
5. DiphenhydrAMINE 25 mg PO QHS 
6. Ferrous Sulfate 325 mg PO DAILY 
7. Furosemide 20 mg PO DAILY 
8. Spironolactone 25 mg PO BID 
9. Multivitamins 1 TAB PO DAILY 
10. Omeprazole 20 mg PO DAILY 
11. Rifaximin 550 mg PO BID 
12. Viactiv (calcium-vitamin D3-vitamin K) 500-500-40 
mg-unit-mcg oral DAILY 

 
Discharge Medications:
1.  Aspirin 81 mg PO DAILY 
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth 
daily Disp #*30 Tablet Refills:*0 
2.  Atorvastatin 40 mg PO QPM 
RX *atorvastatin 40 mg 1 tablet(s) by mouth Nightly Disp #*30 
Tablet Refills:*0 
3.  Clopidogrel 75 mg PO DAILY 
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 
Tablet Refills:*0 
4.  HydrOXYzine 25 mg PO QHS:PRN itching, sleeping 
RX *hydroxyzine HCl 25 mg 1 tab by mouth at bedtime Disp #*30 
Tablet Refills:*0 
5.  Zinc Sulfate 220 mg PO DAILY 
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth daily 
Disp #*30 Capsule Refills:*0 
6.  DICYCLOMine 10 mg PO BID:PRN abdominal pain  
7.  DiphenhydrAMINE 25 mg PO QHS  
8.  Ferrous Sulfate 325 mg PO DAILY  
9.  Furosemide 20 mg PO DAILY  
10.  Lactulose 30 mL PO TID  
11.  Multivitamins 1 TAB PO DAILY  
12.  Omeprazole 20 mg PO DAILY  
13.  Ondansetron 4 mg PO DAILY:PRN nausea  
14.  Rifaximin 550 mg PO BID  
15.  Spironolactone 25 mg PO BID  
16.  Viactiv (calcium-vitamin D3-vitamin K) 500-500-40 
mg-unit-mcg oral DAILY  
17. HELD- colestipol 4 mg oral BID  This medication was held. Do 
not restart colestipol until cleared by your doctors. 

 

###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:
Cirrhosis with portal hypertension
Decompensated liver failure with ascites, jaundice and 
coagulopathy
Coronary artery disease

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Cirrhosis {Cirrhosis of liver}, portal hypertension {Portal hypertension}, liver failure {Hepatic failure}, ascites {Ascites}, jaundice {Jaundice}, coagulopathy {Blood coagulation disorder}, Coronary artery disease {Coronary arteriosclerosis}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,

You were admitted to ___ with abnormal liver tests. We think 
this may have been related to your recent dental surgery. Your 
numbers improved without intervention. While here, you had a 
catheterization of your heart which showed one of your heart 
vessels was partially blocked. You had two stents put in to keep 
it open. Your liver tests were improving and you continued to be 
well on discharge. Please get your labs drawn before your 
appointment with Dr. ___ see him ___. It was a pleasure 
being involved in your care. 

Wishing you the best, 

Your ___ Team 
 

###RESPONSE: abnormal liver tests {Liver function tests outside reference range}, dental surgery {Dental surgical procedure}, improved {Patient's condition improved}, catheterization of your heart {Cardiac catheterization}, heart 
vessels {Coronary artery structure}, stents {Insertion of arterial stent}, liver tests {Hepatic function panel}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
Iodine Containing Agents Classifier / Spironolactone / Asacol
 
Attending: ___
 
Chief Complaint:
Fevers, tremors, chills. 
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Iodine {Allergy to iodine compound}, Spironolactone {Allergy to spironolactone}, Fevers {Fever}, tremors {Tremor}, chills {Chill}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
patient is a ___ man with history of atrial fibrillation 
on coumadin and ulcerative colitis s/p recent admission for 
lower GIB (on prednisone taper) who presents from home with 
fevers and chills.
.
On initial evaluation in the ED, his vitals were T 101, HR 84, 
BP 146/112, RR 16, sat 96% ___. Labs notable for white count of 
1.3 (69% polys, 14% lymphs, no bands) - down from recent 1.3 - 
with hct 33 (stable at baseline), lactate 3.0, normal LFTs, INR 
2.4 (on coumadin). Creatinine was 1.3 (at baseline). CXR showed 
no acute cardiopulmonary process. UA was normal. Blood and urine 
cultures were drawn and patient given vancomycin 1g and Zosyn in 
addition to 500 mg Tylenol. GI was contacted in the ED and 
advised admit to medicine, can consult if needed. Patient was 
then admitted for further work-up.
.
Of note, patient was recently admitted ___ for diarrhea 
that was felt to be secondary to UC. Patient underwent 
colonoscopy on ___ that showed luminal narrowing at the sigmoid 
with mild colitis; biopsies showed active colitis with no 
evidence of malignancy. He was started on prednisone 40 mg daily 
and asacol 800 mg tid with marked improvement in his symptoms. 
Infectious GI workup was negative; biopsy for CMV was negative. 
Patient was discharged with a slow prednisone taper and 
increased dose of Asacol to 1600 mg tid. Omeprazole was also 
added during that admission. Hydrochlorothiazide, lisinopril, 
and colchicine were all stopped. 
 

###RESPONSE: atrial fibrillation {Atrial fibrillation}, ulcerative colitis {Ulcerative colitis}, lower GIB {Lower gastrointestinal hemorrhage}, fevers {Fever}, chills {Chill}, evaluation {Evaluation procedure}, vitals {Vital signs finding}, T {Body temperature finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, sat {Finding of oxygen saturation}, Labs {Laboratory test}, lactate {Lactic acid measurement}, normal LFTs {Liver function tests within reference range}, CXR {Plain chest X-ray}, UA {Urinalysis}, normal {No abnormality detected}, urine 
cultures {Urine culture}, diarrhea {Diarrhea}, UC {Ulcerative colitis}, colonoscopy {Colonoscopy}, narrowing {Narrowing}, sigmoid {Sigmoid colon structure}, colitis {Colitis}, biopsies {Biopsy}, colitis {Colitis}, no 
evidence of malignancy {No evidence of malignant neoplasm}, Infectious GI {Infection of gastrointestinal tract}, biopsy {Biopsy}, CMV {Cytomegalovirus infection}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1. Atrial fibrillation
2. Hypertension 
3. Peripheral vascular disease
4. Chronic renal insufficiency: Baseline Cr=1.3-1.6
5. Impaired fasting glucose 
6. Chronic lower extremity edema 
7. h/o prostate cancer
8. Hyperlipidemia 
9. Gout
10. Erectile dysfunction
11. OSA 
12. History of melanoma
13. Restless leg syndrome
14. Osteoarthritis
15. h/o tremor
 

###RESPONSE: Atrial fibrillation {Atrial fibrillation}, Hypertension {Hypertensive disorder, systemic arterial}, Peripheral vascular disease {Peripheral vascular disease}, Chronic renal insufficiency {Chronic renal insufficiency}, Impaired fasting glucose {Impaired fasting glycemia}, Chronic {Chronic edema}, lower extremity edema {Edema of lower extremity}, prostate cancer {Carcinoma of prostate}, Hyperlipidemia {Hyperlipidemia}, Gout {Inflammatory disorder due to increased blood urate level}, Erectile dysfunction {Erectile dysfunction}, OSA {Obstructive sleep apnea syndrome}, melanoma {Malignant melanoma of skin}, Restless leg syndrome {Restless legs}, Osteoarthritis {Osteoarthritis}, tremor {Tremor}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 - died of stomach cancer.  
Father - ___ Disease 
Mother - ___ Disease.
 

###RESPONSE: died {Dead}, stomach cancer {Malignant tumor of stomach}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Vitals: 97 86 110/70 18 97RA
General: Pleasant, laughing, elderly man in NAD
HEENT: MMM
Neck: Supple
Lungs: CTAB, no WRR
Heart: RRR, no RMG, no JVD
Abdomen: Soft, NTND, +BS
Extremities: No edema 
 

###RESPONSE: Vitals {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, laughing {Laughing}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, WRR {Finding of rate of respiration}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, no RMG {Heart sounds normal}, JVD {Jugular venous engorgement}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, +BS {Normal bowel sounds}, Extremities {Examination of limb}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 08:55AM BLOOD WBC-1.3*# RBC-3.64* Hgb-10.7* Hct-33.0* 
MCV-91 MCH-29.4 MCHC-32.4 RDW-15.0 Plt ___
___ 08:55AM BLOOD Neuts-69.4 Lymphs-14.8* Monos-4.2 
Eos-10.9* Baso-0.8
___ 08:55AM BLOOD ___ PTT-33.7 ___
___ 08:55AM BLOOD Glucose-234* UreaN-35* Creat-1.3* Na-137 
K-4.2 Cl-99 HCO3-26 AnGap-16
___ 08:55AM BLOOD ALT-39 AST-25 LD(LDH)-225 AlkPhos-70 
Amylase-31 TotBili-0.4
___ 06:50AM BLOOD Calcium-7.9* Phos-1.9* Mg-1.6
___ 11:15AM BLOOD %HbA1c-7.2* eAG-160*
___ 09:05AM BLOOD Lactate-3.0* K-4.1
___ 08:05PM BLOOD Lactate-3.5*
___ 10:05AM BLOOD Lactate-2.5*
___ 07:15AM BLOOD Lactate-1.8

___   Radiology ABDOMEN (SUPINE & ERECT  There are 
multiple segments of dilated small bowel. Air is seen within the
colon. No ___ colon identified. No pathologically dilated 
bowel. Findings
concerning for small-bowel obstruction, however. Surgical clips 
are
identified in the pelvis.  
   
___   Radiology CHEST (PA & LAT)  PA AND LATERAL CHEST 
RADIOGRAPHS: The cardiomediastinal silhouette is stable.
There is stable mild hilar prominence. The lungs are well 
expanded and clear.
The pleural surfaces are smooth without pleural effusions or 
pneumothorax.
IMPRESSION: No acute cardiopulmonary abnormality.
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, 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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, eAG {Glucose measurement estimated from glycated hemoglobin}, K {Blood potassium measurement}, ABDOMEN {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, small bowel {Structure of small intestine}, colon {Colon structure}, colon {Colon structure}, dilated 
bowel {Dilatation of intestine}, small-bowel obstruction {Small bowel obstruction}, pelvis {Structure of pelvis}, CHEST (PA & LAT) {Diagnostic radiography of chest, combined posteroanterior and lateral}, PA AND LATERAL CHEST 
RADIOGRAPHS {Diagnostic radiography of chest, combined posteroanterior and lateral}, stable {Patient's condition stable}, stable {Patient's condition stable}, hilar {Structure of hilum of lung}, lungs {Lung structure}, pleural surfaces {Pleural membrane structure}, pleural effusions {Pleural effusion}, pneumothorax {Pneumothorax}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
ASSESSMENT AND PLAN: ___ man with recent diagnosis of 
ulcerative colitis presenting with fevers and rigors.
.
# Fevers, chills, near neutropenia. Patient initially with ___ 
SIRS criteria positive with leukopenia and fever, however no 
clear source for infection as pt without symptoms. Suspected GI 
source as a possible cause, possibly a superimposed infectious 
colitis on top of patient's ulcerative colitis. Emperic 
vancomycin and zosyn was started given the patient was 
borderline neutrapenic (ANC of 897 initially), however abx were 
dc'd as pts neutropenia improved with cessation of asacol and pt 
was without abd pain or focal sxs to suggest a source. Urine and 
stool cxs were negative, blood cxs still pending on discharge 
and will need to be followed up on dc.
.
# Neutropenia. Probably secondary to Asacol. Resolved after 
DC'ing asachol. 
.
# Ulcerative colitis. Continued prednidone, pt dc'd on 35 mg q 
day with instructions to decrease to 30 mg in one week and 
continue until told to stop by GI. DC'd mesalamine. Continued 
omeprazole for gastric protection.  He was also dc'd on humalog 
sliding scale given elevated sugars while in house.  He will 
receive teaching by ___ and can be weaned off insulin as an 
outpt as prednisone is weaned.
.
# Atrial fibrillation. Patient with CHADs score of 2. Continued 
coumadin while inpt, however held on discharged for 
supratherapeutic INR.  He will f/u in ___ clinic two 
days post discharge.

# Hypertension. Held Lasix in the setting of acute infection. 
Was restarted on ___ home dose, may need to be uptitrated in the 
outpt setting.
.
# Gout. During his previous admission, patient suffered an acute 
flare of gout in his left finger and bilateral toes. His 
symptoms improved with prednisone. No sx of gout this admission. 
Continued febuxostat.

# CKD baseline creatinine 1.1-1.3 probably HTN induced. Remained 
at baseline.
 

###RESPONSE: ulcerative colitis {Ulcerative colitis}, fevers {Fever}, rigors {Rigor}, Fevers {Fever}, chills {Chill}, neutropenia {Neutropenia}, SIRS {Systemic inflammatory response syndrome}, leukopenia {Leukopenia}, fever {Fever}, infectious 
colitis {Infectious colitis}, ulcerative colitis {Ulcerative colitis}, neutrapenic {Neutropenia}, neutropenia {Neutropenia}, improved {Patient's condition improved}, abd pain {Abdominal pain}, Urine {Urine culture}, Neutropenia {Neutropenia}, Ulcerative colitis {Ulcerative colitis}, sliding scale {Sliding scale insulin regime}, elevated sugars {Glucose level above reference range}, Atrial fibrillation {Atrial fibrillation}, Hypertension {Hypertensive disorder, systemic arterial}, acute infection {Acute infectious disease}, Gout {Inflammatory disorder due to increased blood urate level}, acute 
flare of gout {Acute gout}, left finger {Structure of all fingers of left hand}, toes {Structure of all toes}, improved {Patient's condition improved}, gout {Inflammatory disorder due to increased blood urate level}, CKD {Chronic kidney disease}, creatinine {Serum creatinine within reference range}, HTN {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
- atenolol 25 mg daily
- febuxostat 80 mg daily
- clobetasol 0.05% ointment topical daily prn
- furosemide 40 mg daily
- omeprazole 40 mg daily
- warfarin 2.5-5.0 mg daily as directed
- lovastatin 40 mg daily at bedtime
- prednisone taper (current dose should be 10 mg daily)
- mesalamine 1600 mg tid 
 
Discharge Medications:
1. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.  
2. Prednisone 10 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): 
decrease your dose to 30 mg/day in 7 days, continue at that dose 
until you are told to change/stop by your doctor.
Disp:*30 Tablet(s)* Refills:*2*
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.  
4. Lasix 40 mg Tablet Sig: ___ Tablet PO once a day.  
5. Febuxostat 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 
 
6. Clobetasol 0.05 % Ointment Sig: One (1)  Topical once a day.  

7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO once a day.  
8. Insulin Lispro 100 unit/mL Solution Sig: One (1)  
Subcutaneous ASDIR (AS DIRECTED): per sliding scale  until your 
doctor tells you to stop.
Disp:*100 units* Refills:*2*
9. Outpatient Lab Work
Please go to coagulation clinic on ___ to have your INR 
checked
10. Lancets     Misc Sig: One (1)  Miscellaneous four times a 
day.
Disp:*120 * Refills:*2*
11. Syringe (Disposable)     Syringe Sig: One (1) 0.5 cc syringe 
Miscellaneous four times a day: 0.5 cc syringe.
Disp:*120 syringes* Refills:*2*
12. test strip  Sig: One (1) strip  four times a day: Please 
provide 120 test strips, 2 refills.
Disp:*120 * Refills:*2*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
1) Fever
2) Ulcerative colitis 
3) Diarrhea 
4) Neutropenia
5) Steroid-induced hyperglycemia

 
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}, Fever {Fever}, Ulcerative colitis {Ulcerative colitis}, Diarrhea {Diarrhea}, Neutropenia {Neutropenia}, Steroid-induced hyperglycemia {Steroid-induced hyperglycemia}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
It was a pleasure to take care of you here at ___. You were 
admitted for fevers and chills. Fortunately a complete 
infectious work up was negative. You remained without a fever. 
You were started on antiobiotics but these were discontinued as 
you continued to improve and had no source of infection. Your 
fevers and chills were thought to be most likely secondary to a 
viral syndrome or your ulcerative colitis. 
.
We have made the following changes to your medications: 
-STOP taking mesalamine as it lowered your white cell count
-CONTINUE taking prednisone.  You should continue taking 35 mg 
for 7 days, then decrease your dose by 5 mg and continue taking 
30 mg until your doctor tells you to stop.
-STOP taking warfarin until you are told to start by 
anticoagulation clinc (you should have your INR drawn on ___
-decrease your furosemide (lasix) to 20 daily
-start taking insulin per sliding scale instructions four times 
a day
.
Please call your doctor or return to the hospital if your 
symptoms worsen or if you develop new symptoms including chest 
pain or shortness of breath. 
 

###RESPONSE: fevers {Fever}, chills {Chill}, infectious {Infectious disease}, fever {Fever}, antiobiotics {Antibiotic therapy}, infection {Infectious disease}, fevers {Fever}, chills {Chill}, viral syndrome {Nonspecific syndrome suggestive of viral illness}, ulcerative colitis {Ulcerative colitis}, changes to your medications {Change of medication}, cell count {Cell count}, lasix {Diuretic therapy}, sliding scale {Sliding scale insulin regime}, chest 
pain {Chest pain}, shortness of breath {Dyspnea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                      Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Fragmin / levofloxacin
 
Attending: ___.
 
Chief Complaint:
fever, cough, pleuritic pain
 
Major Surgical or Invasive Procedure:
none
 

###RESPONSE: Fragmin {Allergy to dalteparin}, levofloxacin {Allergy to levofloxacin}, fever {Fever}, cough {Cough}, pleuritic pain {Pleuritic pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mr. ___ is a ___ history of HIV (""Good CD4 count"", VL 
undetecable) who presents with 2 days of fevers, shourtness of 
beath, yellow productive cough, pleuritic chest pain on his 
right side. He reports fever of 104 on ___ and then onset of 
cough productive of yellow/greenish sputum, shortness of breath 
and pleuritic chest pain.  Decrease appetite with poor po 
intake. No recent travel outside the the country; no sick 
contact; no unprotected sexual intercourse. 

In the ED, initial vitals were: 101 96 126/63 22 96% RA 
- Labs were significant for WBC 24k with left shift.  Chem 10 
remarkable for Na 131, BUN/Cr ___.  Flu negative. CXR 
revealed multifocal pneumonia. Patient received vancomycin and 
levofloxacin, albuterol/ipratropium nebs and admitted for 
further care. 

On the floor, the patient is complaining of ongoing right sided 
pleuritic chest pain. He is comfortable on room air. 

Of note, Mr. ___ endorses a history of previous pneumonias that 
have required hospitalization but never intubation. He has been 
treated with levofloxavin several times but recently noted the 
developement of a rash. 

REVIEW OF SYSTEMS:
(+) Per HPI  
(-) Denies headache, sinus tenderness, rhinorrhea or congestion. 
 Denies nausea, vomiting, diarrhea, constipation or abdominal 
pain. No recent change in bowel or bladder habits. No dysuria. 
Denies arthralgias or myalgias. 

 

###RESPONSE: HIV {Human immunodeficiency virus infection}, Good {Patient's condition satisfactory}, VL {Viral load}, undetecable {No abnormality detected}, fevers {Fever}, shourtness of 
beath {Dyspnea}, yellow productive cough {Productive cough-yellow sputum}, pleuritic chest pain {Pleuritic pain}, right {Skin structure of right half of chest}, fever {Fever}, cough productive of yellow {Productive cough-yellow sputum}, greenish sputum {Productive cough -green sputum}, shortness of breath {Dyspnea}, pleuritic chest pain {Pleuritic pain}, Decrease appetite {Decrease in appetite}, poor po 
intake {Inadequate oral food intake for physiological needs}, travel outside the the country {Travel abroad}, unprotected sexual intercourse {Unprotected sexual intercourse}, vitals {Vital signs finding}, RA {Breathing room air}, WBC {White blood cell count}, left shift {Left shifted white blood cells}, Flu {Influenza}, negative {No abnormality detected}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, vancomycin {Antibiotic therapy}, levofloxacin {Antibiotic therapy}, right sided {Right pleura structure}, pleuritic chest pain {Pleuritic pain}, on room air {Breathing room air}, pneumonias {Pneumonia}, intubation {Insertion of endotracheal tube}, levofloxavin {Antibiotic therapy}, rash {Eruption of skin}, headache {Headache}, sinus tenderness {Tenderness over frontal sinus}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal 
pain {Abdominal pain}, change in bowel {Altered bowel function}, bladder habits {Alteration in patterns of urinary elimination}, dysuria {Dysuria}, arthralgias {Joint pain}, myalgias {Muscle pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 with undetectable viral load and CD4 of 395 as of ___.
- Depression
- HSV
- recurrent pneumonias
- Positive PPD s/p INH therapy

 

###RESPONSE: HIV {Human immunodeficiency virus infection}, undetectable {No abnormality detected}, viral load {Viral load}, Depression {Depressive disorder}, recurrent pneumonias {Recurrent pneumonia}, Positive PPD {Mantoux: positive}, INH therapy {Tuberculosis management program}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
No family history of allergies to medications. Otherwise 
non-contributory
 

###RESPONSE: allergies to medications {Non-allergic hypersensitivity to drug or medicament}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:
=============================
Vitals: 98.1  168/75  76  97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous mebranes, no tonsilla 
exudates
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs
Lungs: Unlabored breathing, rhonchi left lower and right lower 
lobes with positive egophony, no wheezing 
Abdomen: Soft, non-tender, non-distended
Ext: Warm, well perfused
Skin: no rashes

DISCHARGE PHYSICAL EXAM: 
============================
Vitals: 98.7 ___ 66-70 18 97RA ___ 
IO - MN: 895/500
General: Alert, oriented, no acute distress, speaking in full 
sentences
HEENT: Sclera anicteric, dry mucous mebranes, no tonsilla 
exudates
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs
Lungs: Unlabored breathing, rhonchi left lower and right lower 
lobes with positive egophony, no wheezing 
Abdomen: Soft, non-tender, non-distended
Ext: Warm, well perfused
Skin: No rashes complete resolution of pruritic erythematous 
papules over arms, neck and legs. 

 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, dry mucous mebranes {Mucous membrane dryness}, tonsilla 
exudates {Exudate on tonsils}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, Lungs {Examination of respiratory system}, labored breathing {Labored breathing}, rhonchi {Wheeze - rhonchi}, left lower {Structure of lower lobe of left lung}, right lower 
lobes {Structure of lower lobe of right lung}, egophony {Egophony}, wheezing {Wheezing}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, Skin {Examination of skin}, rashes {Eruption of skin}, PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, RA {Breathing room air}, IO {Measuring intake and output}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, dry mucous mebranes {Mucous membrane dryness}, tonsilla 
exudates {Exudate on tonsils}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, Lungs {Examination of respiratory system}, labored breathing {Labored breathing}, rhonchi {Wheeze - rhonchi}, left lower {Structure of lower lobe of left lung}, right lower 
lobes {Structure of lower lobe of right lung}, egophony {Egophony}, wheezing {Wheezing}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, Skin {Examination of skin}, rashes {Eruption of skin}, resolution {Problem resolved}, pruritic {Pruritic disorder of skin}, erythema {Erythema}, papules {Papule of skin}, arms {Upper limb structure}, neck {Neck structure}, legs {Lower limb structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS: 
======================
___ 08:45PM BLOOD WBC-24.8*# RBC-4.50* Hgb-13.7* Hct-39.1* 
MCV-87 MCH-30.4 MCHC-34.9 RDW-13.7 Plt ___
___ 08:45PM BLOOD Neuts-83.5* Lymphs-11.1* Monos-4.7 
Eos-0.6 Baso-0.1
___ 08:45PM BLOOD Glucose-133* UreaN-19 Creat-0.9 Na-131* 
K-4.2 Cl-96 HCO3-21* AnGap-18
___ 05:10AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.7
___ 08:52PM BLOOD Lactate-1.6

IMAGING: 
======================
CXR ___: Multifocal  pneumonia,  right  greater  than  left.

MICRO: 
======================
__________________________________________________________
___ 5:27 am SPUTUM      Source: Expectorated. 

   GRAM STAIN (Final ___: 
      <10 PMNs and >10 epithelial cells/100X field. 
      Gram stain indicates extensive contamination with upper 
respiratory
      secretions. Bacterial culture results are invalid. 
      PLEASE SUBMIT ANOTHER SPECIMEN. 

   RESPIRATORY CULTURE (Final ___: 
      TEST CANCELLED, PATIENT CREDITED. 

   LEGIONELLA CULTURE (Preliminary): 
__________________________________________________________
___ 4:57 am URINE      Source: ___. 

                            **FINAL REPORT ___

   Legionella Urinary Antigen  (Final ___: 
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. 
           (Reference Range-Negative). 
      Performed by Immunochromogenic assay. 
      A negative result does not rule out infection due to other 
L.
      pneumophila serogroups or other Legionella species. 
Furthermore, in
      infected patients the excretion of antigen in urine ___ 
vary. 
__________________________________________________________
___ 8:45 pm BLOOD CULTURE

   Blood Culture, Routine (Pending): 
__________________________________________________________
___ 9:34 pm BLOOD CULTURE

   Blood Culture, Routine (Pending): 

DISCHARGE LABS: 
======================
___ 05:50AM BLOOD WBC-7.6# RBC-3.70* Hgb-11.2* Hct-33.1* 
MCV-89 MCH-30.2 MCHC-33.8 RDW-13.7 Plt ___
___ 05:50AM BLOOD Neuts-62.4 ___ Monos-5.9 Eos-1.0 
Baso-0.3
___ 05:50AM BLOOD ___ PTT-28.1 ___
___ 05:50AM BLOOD Glucose-91 UreaN-11 Creat-0.5 Na-139 
K-3.9 Cl-107 HCO3-22 AnGap-14
___ 05:50AM BLOOD ALT-20 AST-23 LD(LDH)-129 AlkPhos-69 
TotBili-0.2
___ 05:50AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.___ history of HIV (CD4 395, VL undetecable) who presents with 2 
days of fevers, shortness of beath, yellow productive cough, 
pleuritic chest pain with CXR showing multifocal pneumonia. 

# Multifocal Community Acquired Pneumonia: Most likely from 
non-opportunistic organisms such as strep pneumonia or 
atypicals. Per patient he has been very compliant with his HIV 
med and last CD4 count was 395 and VL undetectable therefore 
making opportunistic infection such as PCP less likely. He is 
currently hemodynamically stable with normal lactate and normal. 
Creatinine suggesting good organ perfusion. He recieved 
levofloxacin and subsequently developed a rash, which has also 
been documented before so we will transition to alternate 
antibiotic regimen for CAP.
- Will treat for 8 day course of Augmentin + Azithromycin
- Urine strep Ag pending at time of discharge.

# Rash: Resolved. Mr. ___ developed a pruritic rash over arms, 
neck and leg after administration of vancomycin and levofloxacin 
in the ED. He improved with benadryl. He has a previous history 
of rash documented at ___ that occurred after 
administration of levofloxacin and fragmin. He tolerated 
levofloxacin subsequently without rash so this medication was 
continued at that time. The recurrence of this rash with 
levofloxacin is concerning for a true allergy. As such we will 
avoid this medication and transition to alternate treatment as 
above.
- levofloxacin allergy recorded at ___ and ___ 
___

# Hyponatremia: Sodium 131 on admission. This has been seen on 
prior hospitalization. Likely hypovolemic hyponatremia as 
improved with aggressive IV fluids. Sodium on discharge 136.
# HIV: continue Stribild
# Depression: continue Zoloft

TRANSITIONAL:
- complete 8 day course of augmentin and azithromycin
- Per previous records, CT scan in ___ showed RUL nodule that 
was most likely infectious in etiology. It was recommended that 
followup CT be obtained when infectious symptoms had resolved.

# CODE STATUS: Full Code 
# CONTACT: Landlord ___ 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, IMAGING {Imaging}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, right {Right lung structure}, left {Left pleura structure}, SPUTUM {Microbial culture of sputum}, Expectorated {Does expectorate}, GRAM STAIN {Gram stain method}, cells {Cell structure}, Gram stain {Gram stain method}, upper 
respiratory {Upper respiratory tract structure}, Bacterial culture {Bacterial culture}, RESPIRATORY {Structure of respiratory system}, CULTURE {Microbial culture}, LEGIONELLA {Legionella infection}, CULTURE {Microbial culture}, URINE {Evaluation of urine specimen}, Legionella {Legionella antigen assay}, Urinary {Evaluation of urine specimen}, NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN {Legionella pneumophila serogroup 1 antigen not detected}, Negative {No abnormality detected}, negative {No abnormality detected}, infection {Infectious disease}, urine {Evaluation of urine specimen}, CULTURE {Blood culture}, Blood Culture {Blood culture}, CULTURE {Blood culture}, Blood Culture {Blood culture}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Serum lactate dehydrogenase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, HIV {Human immunodeficiency virus infection}, fevers {Fever}, shortness of beath {Dyspnea}, yellow productive cough {Productive cough-yellow sputum}, pleuritic chest pain {Pleuritic pain}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, Community Acquired Pneumonia {Community acquired pneumonia}, pneumonia {Pneumonia}, atypicals {Atypical pneumonia}, very compliant {Drug compliance good}, HIV {Human immunodeficiency virus infection}, med {Administration of drug or medicament}, VL {Viral load}, undetectable {No abnormality detected}, infection {Infectious disease}, PCP {Primary care management}, stable {Patient's condition stable}, normal {No abnormality detected}, lactate {Lactic acid measurement}, normal {No abnormality detected}, Creatinine {Creatinine measurement}, good organ perfusion {Normal organ or tissue vascular perfusion}, levofloxacin {Antibiotic therapy}, rash {Eruption of skin}, antibiotic {Antibiotic therapy}, regimen {Therapeutic regimen}, CAP {Community acquired pneumonia}, Urine {Evaluation of urine specimen}, Rash {Eruption of skin}, Resolved {Problem resolved}, pruritic rash {Pruritic rash}, arms {Upper limb structure}, neck {Cervical region back structure}, leg {Lower limb structure}, vancomycin {Antibiotic therapy}, levofloxacin {Antibiotic therapy}, improved {Patient's condition improved}, rash {Eruption of skin}, levofloxacin {Antibiotic therapy}, levofloxacin {Antibiotic therapy}, rash {Eruption of skin}, medication {Antibiotic therapy}, recurrence {Recurrent disease}, rash {Eruption of skin}, levofloxacin {Allergy to levofloxacin}, allergy {Allergic disposition}, medication {Antibiotic therapy}, levofloxacin allergy {Allergy to levofloxacin}, Hyponatremia {Hyponatremia}, hypovolemic {Hypovolemia}, hyponatremia {Hyponatremia}, improved {Patient's condition improved}, IV fluids {Administration of intravenous fluids}, HIV {Human immunodeficiency virus infection}, Depression {Depressive disorder}, augmentin {Antibiotic therapy}, azithromycin {Antibiotic therapy}, CT scan {Computed tomography of abdomen}, RUL {Structure of upper lobe of right lung}, nodule {Nodule of lung}, infectious {Infectious disease}, infectious {Infectious disease}, resolved {Problem resolved}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Stribild 1 TAB PO DAILY 
2. Sertraline 25 mg PO DAILY 

 
Discharge Medications:
1. Sertraline 25 mg PO DAILY 
2. Stribild 1 TAB PO DAILY 
3. Acetaminophen 1000 mg PO Q8H:PRN pain 
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp 
#*30 Tablet Refills:*0
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by 
mouth every 12 hours Disp #*13 Tablet Refills:*0
5. Azithromycin 250 mg PO Q24H Duration: 4 Doses 
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*4 
Tablet Refills:*0

 

###RESPONSE: mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
PRIMARY: Community Acquired Pneumonia
SECONDARY: HIV (well controlled), Depression

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Community Acquired Pneumonia {Community acquired pneumonia}, HIV {Human immunodeficiency virus infection}, well controlled {Disease condition determination, well controlled}, Depression {Depressive disorder}, 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 - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___, 

It was a pleasure meeting and taking care of you. You were 
admitted with fever, cough and shortness of breath. You were 
found to have a pneumonia on a chest radiograph. You were 
initially treated with an antibiotic called levofloxacin, but 
developed a rash to this medication. We believe you are allergic 
to this medication as you have had a rash with it before. 
Instead of this medication, you should take medications called 
augmentin (a seven day course) and azithromycin (a four day 
course) to complete 8 total days of antibiotics. You should also 
followup with Dr. ___ as an outpatient. 

We wish you the best, 

Your ___ team  
 

###RESPONSE: fever {Fever}, cough {Cough}, shortness of breath {Dyspnea}, pneumonia {Pneumonia}, chest radiograph {Plain chest X-ray}, antibiotic {Antibiotic therapy}, rash {Eruption of skin}, medication {Antibiotic therapy}, allergic 
to this medication {Allergy to levofloxacin}, rash {Eruption of skin}, antibiotics {Antibiotic therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
syncopal episode with LOC, 2nd degree AV Block
chronic atrial fibrillation with slow ventricular rate
 
Major Surgical or Invasive Procedure:
insertion of single chamber pacemaker

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, syncopal {Syncope}, LOC {Loss of consciousness}, AV Block {Atrioventricular block}, chronic atrial fibrillation {Chronic atrial fibrillation}, slow ventricular rate {Bradycardia}, insertion of single chamber pacemaker {Insertion of single chamber cardiac pacemaker pulse generator}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 ___ old male with a PMH significant for afib on 
warfarin, HTN, hyperlipidemia and insulin dependent DM who 
presented to the ED ___ after a fall with LOC. He awoke and 
went to the bathroom, on his way back to the bed he
blacked out and awoke on the floor. His wife heard the fall and 
found him awake and alert on the floor. He does not remember 
falling. He denies any lightheadedness, dizziness, 
nausea,flushing, palpitations, or sudden weakness prior to the 
fall. His wife did not note any jerking of his extremities and 
there was no bowel or bladder incontinence, and he was not 
confused
immediately afterwards. He has never had any past episodes of 
loss of consciousness. He normally walks for exercise and does 
not note any chest pain, SOB, or lightheadedness with walking 1 
mile. He reports remote transient episodes of lightheadedness 
but no syncope and was thereafter diagnosed with atrial 
fibrillation and started on Coumadin after that.

 

###RESPONSE: afib {Atrial fibrillation}, on 
warfarin {Warfarin therapy}, HTN {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, insulin dependent DM {Diabetes mellitus type 1}, fall {Falls}, LOC {Loss of consciousness}, blacked out {Syncope}, fall {Falls}, awake {Awake}, alert {Mentally alert}, lightheadedness {Lightheadedness}, dizziness {Dizziness}, nausea {Nausea}, flushing {Flushing}, palpitations {Palpitations}, weakness {Asthenia}, fall {Falls}, jerking {Spasmodic movement}, extremities {All extremities}, bowel {Incontinence of feces}, bladder incontinence {Urinary incontinence}, not 
confused {Not confused}, loss of consciousness {Loss of consciousness}, exercise {Exercises}, chest pain {Chest pain}, SOB {Dyspnea}, lightheadedness {Lightheadedness}, lightheadedness {Lightheadedness}, syncope {Syncope}, atrial 
fibrillation {Atrial fibrillation}, Coumadin {Anticoagulant 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:
1. Diabetes: ___, his hemoglobin A1c was 7.8. Follows with 
___.  
2. Hypercholesterolemia: ___ total cholesterol of 173, HDL 
46, LDL 114, triglycerides 63.  
3. Hypertension:  
4. Atrial fibrillation: dx ___. He underwent Holter monitor and 
a stress test. On coumadin.  
5. Erectile dysfunction: takes Viagra prn - has not taken this 
in over one month  
6. Cervical spondylosis  
 

###RESPONSE: Diabetes {Diabetes mellitus}, hemoglobin {Hemoglobin finding}, Hypercholesterolemia {Hypercholesterolemia}, LDL {Low density lipoprotein cholesterol measurement}, Hypertension {Hypertensive disorder, systemic arterial}, Atrial fibrillation {Atrial fibrillation}, stress test {Electrocardiogram with exercise test}, coumadin {Anticoagulant therapy}, Erectile dysfunction {Erectile dysfunction}, Cervical spondylosis {Cervical spondylosis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father with alcoholism and DM. Mother is healthy at  
age ___. Grandfather with diabetes in his ___.  
 

###RESPONSE: alcoholism {Alcoholism}, DM {Diabetes mellitus}, diabetes {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:
On Admission ___:
*Pertinent exam findings:
VS: 97.6  158/90  59  18  98% RA
Gen: A&OX3, NAD
Neuro: Grossly intact. Swelling and erythema around L eye. 
Neck/JVD: JVP normal
CV: RR, nl S1, S2. No murmurs. 
Chest: CTAB
ABD: soft NT, ND
Extr: No edema. WWP

On Discharge:
VS T 98.3 HR 56 RR 20 BP 116/65 98% RA
Gen: A&Ox3, NAD
Neuro: Grossly intact, no focal deficits, thoughts linear. 
Improved edema and erythema about the left orbit. Steri-strips 
intact. Moves all extremities w/o difficulty. L arm in sling.
CV: RRR, S1, S2, no m/r/g
Chest: CTAB
ABD: soft, NT, obese +BS
Extr: Mild effusion noted about left knee, small 1 cm abrasion, 
cutaneous skin loss, no erythema or excess warmth, no drainage. 
+DP b/l

 

###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, Gen {General examination of patient}, A {Mentally alert}, OX3 {Oriented to person, time and place}, NAD {No abnormality detected}, Neuro {Neurological examination}, Grossly intact {Normal nervous system function}, Swelling {Swelling of structure of eye}, erythema {Erythema}, L eye {Left eye structure}, JVD {Jugular venous engorgement}, JVP normal {Normal jugular venous pressure}, CV {Cardiovascular physical examination}, RR {Finding of rate of respiration}, nl S1, S2 {Heart sounds normal}, murmurs {Heart murmur}, Chest {Examination of respiratory system}, CTAB {Normal breath sounds}, ABD {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, Extr {Examination of limb}, edema {Edema}, WWP {Normal tissue perfusion}, VS {Vital signs finding}, T {Body temperature finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, BP {Blood pressure finding}, RA {Breathing room air}, Gen {General examination of patient}, A {Mentally alert}, Ox3 {Oriented to person, time and place}, NAD {No abnormality detected}, Neuro {Neurological examination}, Grossly intact {Normal nervous system function}, no focal deficits {Normal nervous system function}, Improved {Patient's condition improved}, edema {Edema}, erythema {Erythema}, left orbit {Structure of left orbital region}, Steri-strips 
intact {Application of adhesive skin closure}, Moves all extremities {Does move all four limbs}, L arm {Left upper arm structure}, in sling {Application of sling}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, S1, S2 {Heart sounds normal}, no m/r/g {Heart sounds normal}, Chest {Examination of respiratory system}, CTAB {Normal breath sounds}, ABD {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, obese {Obese abdomen}, +BS {Normal bowel sounds}, Extr {Examination of limb}, Mild {Symptom mild}, effusion {Effusion of joint of left knee}, left knee {Structure of left knee region}, abrasion {Dermabrasion}, cutaneous skin {Skin structure}, erythema {Erythema}, warmth {Joint warm}, drainage {Wound discharge}, +DP b/l {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:
___ 05:35AM BLOOD WBC-6.6 RBC-5.32 Hgb-11.7* Hct-38.1* 
MCV-72* MCH-22.0* MCHC-30.7* RDW-16.5* RDWSD-41.8 Plt ___
___ 12:00PM BLOOD WBC-7.8 RBC-5.67 Hgb-12.5* Hct-41.1 
MCV-73* MCH-22.0* MCHC-30.4* RDW-16.8* RDWSD-42.5 Plt ___
___ 12:00PM BLOOD Neuts-75.7* Lymphs-15.3* Monos-7.3 
Eos-0.8* Baso-0.5 Im ___ AbsNeut-5.91 AbsLymp-1.19* 
AbsMono-0.57 AbsEos-0.06 AbsBaso-0.04
___ 05:35AM BLOOD Plt ___
___ 05:35AM BLOOD ___
___ 12:00PM BLOOD ___ PTT-40.6* ___
___ 05:35AM BLOOD Glucose-219* UreaN-19 Creat-0.9 Na-138 
K-4.3 Cl-104 HCO3-26 AnGap-12
___ 12:00PM BLOOD Glucose-255* UreaN-14 Creat-0.9 Na-134 
K-4.5 Cl-98 HCO3-25 AnGap-16
___ 05:35AM BLOOD ALT-12 AST-17 LD(LDH)-170 AlkPhos-76 
TotBili-0.5
___ 05:35AM BLOOD Albumin-3.6 Calcium-8.4 Phos-3.6 Mg-2.0

DISCHARGE LABS:

ECHO ___:
The left atrial volume index is moderately increased. No left 
atrial mass/thrombus seen (best excluded by transesophageal 
echocardiography). Mild symmetric left ventricular hypertrophy 
with normal cavity size, and regional/global systolic function 
(biplane LVEF = 66 %). There is no left ventricular outflow 
obstruction at rest or with Valsalva. There is no ventricular 
septal defect. Right ventricular chamber size and free wall 
motion are normal. Right ventricular chamber size is normal with 
normal free wall contractility. The ascending aorta and aortic 
arch are mildly dilated. The aortic valve leaflets (3) appear 
structurally normal with good leaflet excursion and no aortic 
stenosis or aortic regurgitation. The mitral valve leaflets are 
structurally normal. No mitral regurgitation is seen. Trivial 
mitral regurgitation is seen. The pulmonary artery systolic 
pressure could not be determined. There is an anterior space 
which most likely represents a prominent fat pad. 

 IMPRESSION: Mild symmetric left ventricular hypertrophy with 
preserved regional and global biventricular systolic function. 
Mildly dilated ascending aorta. Left atrial dilation. No 
structural cardiac cause of syncope identified. 
 These findings are c/w hypertensive heart.

 CLINICAL IMPLICATIONS: 
 The patient has a mildly dilated ascending aorta. Based on ___ 
ACCF/AHA Thoracic Aortic Guidelines, a follow-up echocardiogram 
is suggested in ___ years

CXR PA & LATERAL ___:
COMPARISON:  Chest radiograph ___, CT trachea ___ 
  
FINDINGS:  
  
Low lung volumes are present.  Heart size appears mildly 
enlarged.  
Mediastinal and hilar contours are grossly unchanged.  Crowding 
of 
bronchovascular structures is present without overt pulmonary 
edema.  Patchy opacities in the lung bases may reflect areas of 
atelectasis, though infection is difficult to exclude in the 
correct clinical setting.  No pleural effusion or pneumothorax 
is present.  Mild multilevel degenerative changes are noted in 
the thoracic spine. 
  
IMPRESSION:  
  
Low lung volumes with patchy bibasilar airspace opacities most 
likely 
reflective of atelectasis.  Infection cannot be excluded in the 
correct 
clinical setting. 

KNEE XRAY (3 views) ___:
COMPARISON:  ___ left knee radiographs 
  
FINDINGS:  
  
No acute fracture or dislocation is identified.  Mild 
tricompartmental 
degenerative changes with osteophytic spurring are demonstrated, 
most 
pronounced in the patellofemoral and lateral compartments of the 
knee.  A 
moderate size joint effusion is present.  Vascular 
calcifications are seen 
diffusely.  No concerning lytic or sclerotic osseous 
abnormalities is 
identified.  There are no radiopaque foreign bodies. 
  
IMPRESSION:  
  
No acute fracture or dislocation.  Moderate size joint effusion. 

  

CT HEAD w/o CONTRAST ___:
FINDINGS:  
  
There is no evidence of acute infarction, hemorrhage, edema, or 
mass.  There is mild prominence of the ventricles and sulci 
suggestive of involutional changes. Scattered subcortical and 
periventricular white matter hypodensities are nonspecific, 
however likely represent the sequela of chronic small vessel 
ischemic disease. 
  
There is soft tissue swelling overlying the left orbit, but the 
globe appears intact.  No retrobulbar hematoma is seen.  There 
is no evidence of fracture. There is partial opacification of 
the right mastoid air cells suggestive of mild ongoing 
inflammation.  The visualized portion of the paranasal 
sinuses,left mastoid air cells, and middle ear cavities are 
clear. 
  
IMPRESSION:  
  
Left periorbital soft tissue swelling without fracture.  No 
acute intracranial process. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Lactate dehydrogenase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, left atrial {Left atrial structure}, volume {Cardiac chamber structure}, left 
atrial {Left atrial structure}, mass {Mass}, thrombus {Thrombus}, transesophageal 
echocardiography {Transesophageal echocardiography}, Mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, normal cavity {Normal size cardiac chamber}, regional/global systolic function {Normal left ventricular systolic function and wall motion}, left ventricular outflow 
obstruction {Left ventricular outflow tract obstruction}, Valsalva {Structure of left sinus of Valsalva}, ventricular 
septal defect {Ventricular septal defect}, Right ventricular chamber {Right cardiac ventricular structure}, wall 
motion are normal {Normal ventricular wall motion}, Right ventricular chamber {Right cardiac ventricular structure}, size is normal {Normal size}, wall {Cardiac wall structure}, ascending aorta {Ascending aorta structure}, aortic 
arch {Aortic arch structure}, dilated {Dilatation}, aortic valve leaflets {Structure of cardiac valve leaflet}, structurally normal {Aortic valve normal}, leaflet {Structure of cardiac valve leaflet}, aortic 
stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve leaflets {Structure of leaflet of mitral valve}, structurally normal {Mitral valve normal}, mitral regurgitation {Mitral valve regurgitation}, Trivial 
mitral regurgitation {Mild mitral valve regurgitation}, pulmonary artery {Pulmonary artery structure}, fat pad {Structure of normal fat pad}, Mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, preserved regional and global biventricular systolic function {Normal cardiac function}, dilated ascending aorta {Ascending aorta dilatation}, Left atrial dilation {Left atrial dilatation}, cardiac {Heart structure}, syncope {Syncope}, hypertensive heart {Hypertensive heart disease}, dilated ascending aorta {Ascending aorta dilatation}, Thoracic Aortic {Thoracic aorta structure}, follow-up {Follow-up consultation}, echocardiogram {Echocardiography}, Chest radiograph {Plain chest X-ray}, trachea {Tracheal structure}, lung volumes {Finding of respiratory volume}, Heart {Heart structure}, enlarged {Enlargement}, Mediastinal {Mediastinal structure}, hilar {Structure of hilum of lung}, pulmonary 
edema {Pulmonary edema}, opacities {Abnormally opaque structure}, lung bases {Structure of base of lung}, atelectasis {Atelectasis}, infection {Infectious disease}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, Mild {Symptom mild}, degenerative changes {Degeneration of intervertebral disc}, thoracic spine {Structure of thoracic vertebral column}, lung volumes {Finding of respiratory volume}, bibasilar {Structure of base of lung}, opacities {Abnormally opaque structure}, atelectasis {Atelectasis}, Infection {Infectious disease}, left knee {Structure of left knee region}, radiographs {Plain radiography}, fracture {Fracture}, dislocation {Dislocation}, Mild {Symptom mild}, degenerative changes {Degenerative abnormality}, osteophytic {Osteophyte}, patellofemoral {Structure of left patellofemoral joint}, lateral compartments of the 
knee {Structure of lateral compartment of knee}, joint effusion {Effusion of joint of left knee}, Vascular 
calcifications {Vascular calcification}, lytic {Lysis}, sclerotic {Sclerosis}, osseous {Bone structure}, abnormalities {No abnormality detected}, foreign bodies {Foreign body}, fracture {Fracture}, dislocation {Dislocation}, joint effusion {Effusion of joint of left knee}, no evidence {No abnormality detected}, infarction {Infarct}, hemorrhage {Hemorrhage}, edema {Edema}, mass {Mass}, mild {Symptom mild}, ventricles {Brain ventricle structure}, sulci {Structure of sulcus of brain}, involutional changes {Involution}, periventricular white matter {Structure of periventricular white matter}, chronic {Chronic disease}, small vessel {Structure of small blood vessel (organ)}, ischemic disease {Ischemia}, soft tissue swelling {Soft tissue swelling}, left orbit {Structure of left orbit proper}, globe {Structure of eye proper}, intact {No abnormality detected}, retrobulbar hematoma {Retrobulbar hematoma}, no evidence {No abnormality detected}, fracture {Fracture}, right {Structure of right mastoid bone}, mastoid air cells {Structure of mastoid cell}, mild {Symptom mild}, inflammation {Mild inflammation}, paranasal 
sinuses {Nasal sinus structure}, left {Structure of left mastoid bone}, mastoid air cells {Structure of mastoid cell}, middle ear cavities {Middle ear structure}, are 
clear {No abnormality detected}, Left periorbital {Structure of periorbital region of left eye}, soft tissue swelling {Soft tissue swelling}, fracture {Fracture}, intracranial {Intracranial structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
The ___ hospital course was remarkable in relation to his 
slow atrial fibrillation and second degree AV Block. He had 
multiple pauses on telemetry 20 seconds or more and was 
recommended for pacemaker insertion. He initially declined  the 
procedure but after further consideration and discussion with 
Dr. ___ the risks therein, proceeded with implantation. 
 He remained therapeutic with his Coumadin and will continue to 
be followed with his PCP at discharge. He was placed on IV 
antibiotics and will transition to PO antibiotics at discharge. 
He had multiple studies and exams performed while here and his 
CT was negative for acute changes. His left eye remained stable 
and swelling and ecchymosis was gradually and noticeably 
improving.  He continued to complain of left knee pain. He 
reported hitting the tibial tuberosity which remained tender to 
palpation but without erythema or excess warmth.  Knee xrays 
showed only chronic changes in relation to osteoarthritis 
(tri-compartmental and prominent about the patello-femoral 
compartment).  He has baseline numbness of his bilateral hands 
related to his canal narrowing as seen on MRI in ___.  
Surgery was discussed but he has foregone this for now, 
preferring to wait and observe for worsening symptoms. He was 
counseled to reconsider this decision and to avoid delay of any 
worsening symptoms, increasing numbness, strength and 
coordination. Physical Therapy was consulted and felt continued 
home therapy was appropriate to help with falls prevention, gait 
training, conditioning and safety, especially in light of his 
weight bearing restrictions on the left upper extremity 
following his pacemaker. 

His device was interrogated on the day of discharge and a CXR 
was completed confirming proper placement of the device and 
leads. He was seen by Physical Therapy given his recent syncopal 
episode and underlying musculoskeletal symptoms and deemed 
appropriate for discharge on ___.  He will follow up with 
Device Clinic in one week, has been recommended to have his INR 
checked on ___ which is followed through the ___ 
___ clinic, and continue follow up with his PCP, ___. 
___.  Additionally, given his chronic atrial fibrillation he has 
been recommended to have follow up with ___ Cardiology as 
well, for a first available appointment. This has been requested 
through Care Connections to the Cardiology team and he will be 
contacted with an appointment at home when known.
 

###RESPONSE: atrial fibrillation {Atrial fibrillation}, AV Block {Atrioventricular block}, telemetry {Cardiac telemetry}, pacemaker insertion {Implantation of cardiac pacemaker}, procedure {Surgical procedure}, discussion {Discussion}, Coumadin {Anticoagulant therapy}, PCP {Primary care management}, IV 
antibiotics {Intravenous antibiotic therapy}, PO antibiotics {Oral antibiotic therapy}, exams {Physical examination procedure}, CT {Computed tomography}, left eye {Left eye structure}, stable {Patient's condition stable}, swelling {Swelling of structure of eye}, ecchymosis {Ecchymosis}, left knee {Structure of left knee region}, pain {Pain of knee region}, tibial tuberosity {Structure of tibial tuberosity}, tender to 
palpation {Tenderness}, erythema {Erythema}, warmth {Joint warm}, Knee xrays {Radiologic examination of knee}, chronic {Chronic disease}, osteoarthritis {Osteoarthritis}, patello-femoral 
compartment {Structure of patellofemoral joint}, baseline {Baseline state}, numbness {Numbness of hand}, hands {Hand structure}, canal {Spinal canal structure}, narrowing {Narrowing}, MRI {Magnetic resonance imaging}, Surgery {Surgical procedure}, numbness {Numbness}, coordination {Finding related to coordination / incoordination}, Physical Therapy {Physical therapy assessment}, therapy {Therapy}, falls prevention {Fall prevention}, gait 
training {Gait training procedure}, weight bearing {Weight-bearing}, left upper extremity {Structure of left upper limb}, pacemaker {Implantation of cardiac pacemaker}, CXR {Plain chest X-ray}, placement of the device {Implantation of cardiac pacemaker}, Physical Therapy {Physical therapy assessment}, syncopal {Syncope}, musculoskeletal {Musculoskeletal system physical examination}, Clinic {Outpatient care management}, clinic {Outpatient care management}, PCP {Primary care management}, chronic atrial fibrillation {Chronic atrial fibrillation}, Cardiology {Cardiology service}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Quinapril 40 mg PO DAILY 
2. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 
3. MetFORMIN (Glucophage) 1000 mg PO DAILY 
4. Warfarin 2 mg PO 1X/WEEK (___) 
5. Simvastatin 40 mg PO QPM 
6. liraglutide 1.2 mg subcutaneous DAILY 
7. 70/30 24 Units Breakfast
70/30 24 Units Bedtime
8. Tamsulosin 0.8 mg PO QHS 
9. Alphagan P (brimonidine) 0.1 % ophthalmic 1 drop both eyes 
twice daily  
10. Warfarin 5 mg PO 6X/WEEK (___) 

 
Discharge Medications:
1.  Cephalexin 500 mg PO Q8H Duration: 3 Days 
Take all of this medication as prescribed  
2.  70/30 24 Units Breakfast
70/30 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin 
3.  Simvastatin 80 mg PO QPM  
4.  Alphagan P (brimonidine) 0.1 % ophthalmic 1 drop both eyes 
twice daily   
5.  liraglutide 1.2 mg subcutaneous DAILY  
6.  MetFORMIN (Glucophage) 1000 mg PO DAILY 
Resume ___  
7.  Quinapril 40 mg PO DAILY  
8.  Tamsulosin 0.8 mg PO QHS  
9.  Timolol Maleate 0.5% 1 DROP BOTH EYES BID  
10.  Warfarin 5 mg PO 6X/WEEK (___)  
11.  Warfarin 2 mg PO 1X/WEEK (___)  

 

###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:
syncope with loss of consciousness
atrial fibrillation with slow ventricular response

 
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}, syncope {Syncope}, loss of consciousness {Loss of consciousness}, atrial fibrillation {Atrial fibrillation}, slow ventricular response {Slow ventricular response}, 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:
You were admitted to the hospital following a visit to the ED 
after a syncopal episode with a loss of consciousness. You were 
monitored on telemetry and were found to have a slow atrial 
fibrillation rate response with multiple pauses and referred for 
pacemaker implant as this could result in complete heart block. 
A single chamber pacemaker was placed on ___.  You were 
continued on all of your current medications, including your 
Coumadin. You will need to follow up in Device Clinic in one 
week (appt. information noted below). You were placed on IV 
antibiotics while here and will continue oral antibiotics for 
three days to prevent surgical site infection. It is important 
to take all of this medication as prescribed. Your Coumadin 
should continue to be followed as per your chronic schedule. You 
will need to follow up with your PCP as well within 30 days 
(appointment information included below). Your next INR should 
be drawn as per the ___ clinic, we are 
recommending a draw on ___.  Your INR at discharge on 
___ was 1.9 and you will take your chronic dosing which is 5 mg 
for 6 days a week with 2 mg on ___.  

You had hit your head during your syncopal episode as well as 
your eye and sustained an injury to your left orbit but no 
fracture or hematoma.  You had resultant bruising from this 
injury but remained otherwise stable.  A CT of your head was 
performed and there was no internal hemorrhage. (results of CT 
are below). Additionally you complained of left knee pain and 
radiographs were done which showed no acute fracture. You do 
have chronic osteoarthritis most pronounced about the knee cap 
(patello-femoral area) which is chronic. You were seen by 
Physical Therapy for evaluation prior to discharge to home. You 
should follow up with your PCP and obtain referral to an 
orthopedic physician for further workup and care for your 
osteoarthritis of the knee. We recommend the use of ice, 20 
minutes at a time per hour up to 5 times daily, along with 
Tylenol for pain.

You were seen by Physical Therapy and evaluated for safe 
discharge to home. Based upon their recommendations, they are 
recommending home physical therapy to work on gait training, use 
of assistive device (cane) and strengthening and falls 
prevention. Services have been requested on your behalf prior to 
your discharge from the hospital from ___ Services.

  You also reported continuing numbness of bilateral hands and 
reported you had prior to admission and an MRI was performed in 
___ which was reviewed showing cervical spondylosis and 
canal narrowing and have not pursued surgical consultation. It 
is recommended that you continue follow up with your PCP and 
obtain surgical referral if your decision changes in that regard 
or if your symptoms worsen. This is critical as your MRI does 
canal narrowing.
 

###RESPONSE: Discharge Instructions {Final inpatient visit with instructions at discharge}, syncopal {Syncope}, loss of consciousness {Loss of consciousness}, monitored {Monitoring procedure}, telemetry {Cardiac telemetry}, atrial 
fibrillation {Atrial fibrillation}, pacemaker implant {Implantation of cardiac pacemaker}, complete heart block {Complete atrioventricular block}, single chamber pacemaker was placed {Insertion of single chamber cardiac pacemaker pulse generator}, medications {Prescription of drug}, Coumadin {Anticoagulant therapy}, Clinic {Outpatient care management}, IV 
antibiotics {Intravenous antibiotic therapy}, oral antibiotics {Oral antibiotic therapy}, surgical site infection {Surgical site infection}, take all of this medication {Patient medication education}, Coumadin {Anticoagulant therapy}, PCP {Primary care management}, t INR should 
be drawn {Monitoring of international normalized ratio}, will take your chronic dosing {Patient medication education}, syncopal {Syncope}, eye {Structure of eye proper}, injury {Traumatic or non-traumatic injury}, left orbit {Structure of left orbital region}, fracture {Fracture}, hematoma {Hematoma}, bruising {Contusion}, injury {Traumatic or non-traumatic injury}, stable {Patient's condition stable}, CT of your head {Computed tomography of head}, internal hemorrhage {Intracranial hemorrhage}, CT {Computed tomography of head}, left knee {Structure of left knee region}, pain {Pain of knee region}, radiographs {Plain radiography}, fracture {Fracture}, chronic osteoarthritis {Chronic osteoarthritis}, knee cap {Bone structure of patella}, patello-femoral {Structure of patellofemoral joint}, chronic {Chronic disease}, Physical Therapy for evaluation {Physical therapy assessment}, PCP {Primary care management}, referral to an 
orthopedic physician {Referral to orthopedic service}, workup {Evaluation procedure}, osteoarthritis of the knee {Osteoarthritis of knee}, ice {Application of ice}, pain {Pain of knee region}, Physical Therapy and evaluated {Physical therapy assessment}, physical therapy {Physical therapy education}, gait training {Gait training procedure}, use 
of assistive device (cane) {Use of cane education}, strengthening {Provision of advice about muscle strengthening exercise}, falls 
prevention {Education about fall prevention}, numbness of bilateral hands {Numbness of hand}, MRI {Magnetic resonance imaging of head}, cervical spondylosis {Cervical spondylosis}, canal {Spinal canal structure}, narrowing {Narrowing}, surgical {Surgical procedure}, consultation {Consultation}, PCP {Primary care management}, surgical {Surgical procedure}, referral {Patient referral}, MRI {Magnetic resonance imaging}, canal {Spinal canal structure}, narrowing {Narrowing}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: OBSTETRICS/GYNECOLOGY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
elevated blood pressures with a headache and visual changes on 
postpartum day 9.
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: elevated blood pressures {Finding of increased blood pressure}, headache {Headache}, visual changes {Visual disturbance}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ is a ___ yo Gravida 1 Para ___ s/p low 
transverse c-section ___ for non-reassuring fetal heart 
tracing after induction of labor for elevated BPs. She presented 
to the ED with headache and visual changes. She reported that 
she had intermittent elevated BPs at the end of her pregnancy, 
but never required any antihypertensive medications. She had no 
laboratory abnormalities. Her postop/postpartum course was 
benign. She noticed a headache starting approx 4 days prior to 
presentantion, with intermittent periods of more intense pain 
located in the occipital region with occasional pulsations. It 
was always responsive to extra-strength tylenol and motrin. She 
attributed headache to fatigue and recent surgery until today 
when she noticed floaters in her left visual field that lasted 
for approx 10 mins. She called her ob who asked her to come to 
the ED.

 

###RESPONSE: Gravida 1 {Primigravida}, Para {Parity finding}, low 
transverse c-section {Emergency lower segment cesarean section}, fetal heart 
tracing {Finding of fetal heart rate}, induction of labor {Induction of labor}, elevated BPs {Finding of increased blood pressure}, headache {Headache}, visual changes {Visual disturbance}, elevated BPs {Finding of increased blood pressure}, pregnancy {Pregnancy}, headache {Headache}, pain {Pain}, occipital region {Occipital region structure}, headache {Headache}, fatigue {Fatigue}, surgery {Surgical procedure}, floaters in her left visual field {Floaters in visual field}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
ObHx: LTCS x 1 as above, ___ ___
MedHx: Hiatal hernia
SurgHx: LTCS

 

###RESPONSE: Hiatal hernia {Hiatal hernia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
NC
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
In ED:
BP  173/78 --> 10mg IV hydralazine --> 137/64
O2 sat 100% RA

Caucasian woman in NAD, breastfeeding on approach
RRR, nl S1/S2
CTAB
Abd soft, nondistended. Mild tenderness to palpation. Incision
clean, dry, intact with steri strips.
Ext no edema/tenderness

 

###RESPONSE: BP {Blood pressure finding}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, NAD {No abnormality detected}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, CTAB {Normal breath sounds}, Abd {Examination of abdomen}, soft {Abdomen soft}, nondistended {Normal abdominal contour}, tenderness {Tenderness}, palpation {Palpation}, Incision {Surgical incision wound}, clean, dry, intact {Wound healing well}, edema {Edema}, tenderness {Tenderness}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 01:15PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 
LEUK-NEG
___ 12:08PM   ALT(SGPT)-25 AST(SGOT)-23 LD(LDH)-267* 
CK(CPK)-63 ALK PHOS-104 TOT BILI-0.3
___ 12:08PM   WBC-6.6# RBC-3.72* HGB-11.7* HCT-34.1* MCV-92 
MCH-31.4 MCHC-34.3 RDW-12.9
 

###RESPONSE: PROTEIN {Measurement of protein in urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, PHOS {Phosphate, total measurement}, TOT BILI {Bilirubin, total measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Upon arrival to the ED, Ms ___ vital signs were 
T 98.4  HR 64  BP 158/89  RR 14  O2 100%RA. She received a bolus 
of 4g of magnesium and 10mg of IV hydralazine. She then reported 
no visual changes and a very mild headache and denied RUQ pain. 
Abdominal/incisional pain well controlled with Tylenol and 
Motrin. No other associated symptoms. A head CT showed no 
intracranial process. Her U/A was negative for protein, mod 
blood, rare bacteria. Her pre-Eclampsia labs were negative 
except Uric Acid which was 5.9. 

She was readmitted to Labor and Delivery and continued on a 
magnesium drip for 12 hours given concern for Pre-eclampsia. Her 
blood pressures were well controlled in the 120s/70s without 
additional antihypertensives. Repeat Pre-eclampsia labs were 
negative and she was transferred to the postpartum floor after 
12 hours of Magnesium. She was monitored for an additional day 
on the postpartum floor to ensure that her blood pressures were 
well controlled and that she remained free of pre-eclampsia 
symtoms.

She was discharged home on hospital day 2 with no 
antihypertensive medications and a plan for close blood pressure 
monitoring and an outpatient.

 

###RESPONSE: vital signs {Vital signs finding}, visual changes {Visual disturbance}, headache {Headache}, RUQ pain {Right upper quadrant pain}, pain well controlled {Demonstrates adequate pain control}, head CT {Computed tomography of head}, intracranial {Intracranial structure}, pre-Eclampsia {Pre-eclampsia}, Pre-eclampsia {Pre-eclampsia}, blood pressures {Finding of increased blood pressure}, Pre-eclampsia {Pre-eclampsia}, blood pressures {Finding of increased blood pressure}, pre-eclampsia {Pre-eclampsia}, blood pressure 
monitoring {Blood pressure monitoring}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Tylenol, Motrin
 
Discharge Medications:
Tylenol, Motrin
 

###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:
Postpartum Preeclampsia

 
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent

 

###RESPONSE: Postpartum Preeclampsia {Pre-eclampsia in puerperium}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Call for blood pressures >150 (top number) or >100 (bottom 
number)
Call for Headaches, visual changes or right sided upper 
abdominal pain
Call with any questions
 

###RESPONSE: blood pressures {Finding of increased blood pressure}, Headaches {Headache}, visual changes {Visual disturbance}, right sided upper 
abdominal pain {Right upper quadrant pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___.                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   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: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___
 
___ Complaint:
shortness of breath
 
Major Surgical or Invasive Procedure:
Pulmonary vein isolation abaltion

 

###RESPONSE: shortness of breath {Dyspnea}, Pulmonary vein {Structure of vein of pulmonary circulation}, abaltion {Destructive 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:
Patient is a ___ male with a history of DM, HL, CM, CAD 
s/p PCIs and atrial fibrillation. In ___ he was 
referred back to the ___ cath lab because of symptoms of 
shortness of breath and congestive heart failure. Cardiac 
catheterization on ___ did not reveal any significant  
obstructive CAD. RVEDP was noted at 33 mmHG with a mean wedge of 
 
32 mmHG. There was severe pulmonary artery hypertension. He was  

diuresed at that time. Stress testing in ___ had 
revealed a predominantly fixed inferior apical defect with an 
LVEF of 46% and somewhat dilated LV chamber.  

The patient presented for Afib ablation today. Patient underwent 
PVI with additional lines and failed cardioversion. He was given 
1mg ibutilide and developed QT prolongation to 800ms which 
transitioned to vfib. He was shocked and rhythm became sinus and 
then slow afib. He was admitted to the CCU for close monitoring. 
 

On review of systems, he denies SOB, CP, ___ pain, 
numbness/tingling, lightheadedness. Reports had been in USOH 
prior to this elective procedure.  

 

###RESPONSE: DM {Diabetes mellitus}, HL {Hyperlipidemia}, CAD {Coronary arteriosclerosis}, PCIs {Percutaneous coronary intervention}, atrial fibrillation {Atrial fibrillation}, shortness of breath {Dyspnea}, congestive heart failure {Congestive heart failure}, Cardiac 
catheterization {Cardiac catheterization}, CAD {Coronary arteriosclerosis}, pulmonary artery hypertension {Pulmonary hypertensive arterial disease}, diuresed {Diuretic therapy}, Stress {Electrocardiogram with exercise test}, inferior {Structure of myocardium of diaphragmatic region}, apical {Structure of apex of heart}, dilated LV chamber {Dilatation of left cardiac ventricle}, Afib {Atrial fibrillation}, ablation {Destructive procedure}, cardioversion {Cardioversion}, QT prolongation {Prolonged QT interval}, vfib {Ventricular fibrillation}, rhythm became sinus {Sinus rhythm}, afib {Atrial fibrillation}, monitoring {Monitoring procedure}, review of systems {Review of systems}, SOB {Dyspnea}, CP {Chest pain}, pain {Pain}, numbness/tingling {Numbness and tingling sensation of skin}, lightheadedness {Lightheadedness}, procedure {Procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
CAD, s/p LAD stenting and diagonal PTCA/stenting to LAD and D1  
Hyperlipidemia  
Diabetes  
Cardiomyopathy  
? GERD  
Removal of colon polyps  
___- Surgical repair of an AV fistula in the left posterior  
thigh/buttock  
Atrial fibrillation (now chronic), s/p multiple prior  
cardioversions  
___- Right hip replacement  
Arthritis of spine  
Congestive heart failure  

 

###RESPONSE: CAD {Coronary arteriosclerosis}, LAD stenting {Stent in anterior descending branch of left coronary artery}, PTCA {Percutaneous transluminal coronary angioplasty}, stenting {Insertion of arterial stent}, LAD {Structure of anterior descending branch of left coronary artery}, Hyperlipidemia {Hyperlipidemia}, Diabetes {Diabetes mellitus}, Cardiomyopathy {Cardiomyopathy}, GERD {Gastroesophageal reflux disease}, Removal of colon polyps {Colonic polypectomy}, Surgical repair of an AV fistula {Repair of arteriovenous fistula}, left {Structure of left thigh}, posterior {Structure of posterior surface of thigh}, thigh {Thigh structure}, buttock {Structure of left buttock}, Atrial fibrillation {Atrial fibrillation}, chronic {Chronic atrial fibrillation}, cardioversions {Cardioversion}, Right hip replacement {Prosthetic arthroplasty of right hip}, Arthritis of spine {Arthritis of spine}, Congestive heart failure {Congestive heart failure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
(-) FHx CAD 
 

###RESPONSE: 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:
GENERAL: Middle aged man, flat in bed. NAD  
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were 
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.  

NECK: Unable to appreciate JVP, thick neck.  
CARDIAC: Irregularly irregular, no MRG. Nl S1, S2.  
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp 
were unlabored, no accessory muscle use. CTAB, no crackles, 
wheezes or rhonchi.  
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not 
enlarged by palpation. No abdominial bruits.  
EXTREMITIES: B/l femoral vein sheaths in place. No palpable 
hematoma. Sl ooze. Sensation intact distally.  
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.  
PULSES:  
Right: DP 2+ ___ 2+  
Left: DP 2+ ___ 2+  

 

###RESPONSE: GENERAL {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva {Conjunctival structure}, pallor {Pallor of skin of face}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthalesma {Xanthelasma}, NECK {Physical examination procedure}, JVP {Finding of jugular venous pressure}, neck {Neck structure}, CARDIAC {Cardiovascular physical examination}, Irregularly irregular {Heart irregularly irregular}, no MRG {Heart sounds normal}, S2 {Normal second heart sound, S>2<}, 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}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, Abd {Examination of abdomen}, palpation {Palpation}, abdominial bruits {Abdominal bruit}, EXTREMITIES {Examination of limb}, B/l femoral vein sheaths {Bilateral femoral canals}, hematoma {Hematoma}, Sensation intact {Normal sensation}, SKIN {Examination of skin}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, Right: DP 2+ {Normal pulse in right dorsalis pedis artery}, Left: DP 2+ {Normal pulse in left dorsalis pedis artery}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
labs-

___ 07:05AM BLOOD WBC-11.1* RBC-5.12 Hgb-14.6 Hct-41.4 
MCV-81* MCH-28.6 MCHC-35.3* RDW-16.0* Plt ___
___ 03:19PM BLOOD WBC-12.7* RBC-4.45* Hgb-12.5* Hct-35.6* 
MCV-80* MCH-28.1 MCHC-35.1* RDW-16.2* Plt ___
___ 09:42PM BLOOD Hct-39.2*
___ 03:51AM BLOOD Hct-35.9*
___ 07:05AM BLOOD Neuts-73.0* Lymphs-17.9* Monos-4.8 
Eos-3.5 Baso-0.8
___ 07:05AM BLOOD ___
___ 03:51AM BLOOD ___
___ 07:05AM BLOOD Glucose-231* UreaN-50* Creat-1.4* Na-130* 
K-6.6* Cl-87* HCO3-33* AnGap-17
___ 03:51AM BLOOD Glucose-254* UreaN-36* Creat-1.1 Na-129* 
K-3.7 Cl-91* HCO3-31 AnGap-11
___ 03:19PM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0
___ 03:51AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.___ yo m with CAD and chronic afib admitted for cardioversion. 

# Atrial fibrillation: (see HPI for more details) Went for PVI 
with ablation, was unsuccessful. He was given 1mg ibutilide and 
developed QT prolongation to 800ms which transitioned to vfib. 
He was shocked and rhythm became sinus and then slow afib. At 
discharge he was still in slow afib. He was started on amio 
400mg BID x 1 week, 400mg Qday x 1 week, then 200mg. Also on CCB 
and dig home doses. Restarted on coumadin at discharge, but 
subtheraputic. Was started on lovenox bridge with 60mg BID. Will 
have INR checked in 2 days. Plan for out pt f/u with MRI to 
evaluate pulmonary veins and then out pt cardioversion with Dr. 
___. Will also have follow up with his regular 
cardiologist and PCP. 

# Coronary artery disease: Had known CAD, s/p PCI x ___, cath 
in ___ revealed no flow limiting disease. Was stable during 
admission.   
-Continue ASA, statin, BB, ACEI  
-Cardiac diet  

# chronic systolic HF: Last EF based on MR was 45% with mildly 
increased cavity size and mild global hypokinesis. Was stable 
during admission. Continued on home lasix, metazolone, 
spironolactone.  
  
# Hypotension: Pt has HTN at baseline. Post-procedure SBPs in 
___. Given one 500cc bolus of NS. HR in 60-70s at time. Pulsus 
10mmHg. Asymptomatic. Potentially vagal rxn. Hcts were stable 
and blood pressure improved before discharge, home meds were 
restarted.

# DM- was on sliding scale insulin, was restarted on Lantus, but 
the dose was increased to 24units in the morning. Glyburide was 
stopped due to possiblly causing arrythmias.  Instead he was 
started on Metformin 500mg BID.

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Hct {Hematocrit determination}, Hct {Hematocrit 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}, 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}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, CAD {Coronary arteriosclerosis}, chronic {Chronic disease}, cardioversion {Cardioversion}, Atrial fibrillation {Atrial fibrillation}, ablation {Destructive procedure}, QT prolongation {Prolonged QT interval}, vfib {Ventricular fibrillation}, rhythm became sinus {Normal sinus rhythm}, afib {Atrial fibrillation}, afib {Atrial fibrillation}, Restarted {Restart of medication}, coumadin {Anticoagulant therapy}, INR {Calculation of international normalized ratio}, MRI {Magnetic resonance imaging}, pulmonary veins {Structure of vein of pulmonary circulation}, cardioversion {Cardioversion}, PCP {Primary care management}, disease {Disease}, CAD {Coronary arteriosclerosis}, PCI {Percutaneous coronary intervention}, cath {Cardiac catheterization}, disease {Disease}, stable {Patient's condition stable}, Cardiac diet {Postoperative progressive diet}, chronic {Chronic disease}, cavity {Structure of cavity of left cardiac ventricle}, mild global hypokinesis {Mild hypokinesis of cardiac wall}, stable {Patient's condition stable}, lasix {Diuretic therapy}, Hypotension {Low blood pressure}, HTN {Hypertensive disorder, systemic arterial}, baseline {Baseline state}, procedure {Procedure}, Asymptomatic {Asymptomatic}, Hct {Hematocrit determination}, stable {Patient's condition stable}, improved {Patient's condition improved}, restarted {Restart of medication}, DM {Diabetes mellitus}, sliding scale insulin {Sliding scale insulin regime}, restarted {Restart of medication}, arrythmias {Cardiac arrhythmia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Carvedilol 12.5mg twice a day  
Digoxin .125mg daily every afternoon  
Diltiazem 120mg daily every morning  
Furosemide 80mg daily  
Glyburide 5mg two tablets twice a day  
Lantus insulin 20 units every morning  
Lisinopril daily (unknown dosing)  
Metolazone 2.5mg daily  
KCL daily (unknown dosing)  
Spironolactone 25mg daily every morning  
Coumadin 4mg alternating with 5mg, last dose ___  
Vitamin C 500mg daily  
Aspirin 325mg daily  
Vitamin B complex one daily  
MVI  

 
Discharge Medications:
1. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1)  Subcutaneous 
BID (2 times a day) for 7 days: take until instructed to stop by 
your INR clnic.
Disp:*14 syninges* Refills:*1*
2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times 
a day): 2 pills twice a day for 7 days, then two pills once a 
day for 3 weeks, then continue on one pill once a week.
Disp:*70 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 
4 hours) as needed for fever, pain.  
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).  
7. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
8. B-Complex with Vitamin C     Tablet Sig: One (1) Cap PO DAILY 
(Daily).  
9. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times 
a day). Tablet(s) 
10. Ascorbic Acid ___ mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
12. Insulin Glargine 100 unit/mL Solution Sig: ___ (24) 
units Subcutaneous once a day: in the morning.  
13. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) 
Capsule, Sustained Release PO DAILY (Daily).  
14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
15. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day: 
alternate 2 pills with 2.5 pills.
Disp:*75 Tablet(s)* Refills:*2*
16. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day.  

17. Outpatient Lab Work
please check on ___ INR, 
please fax result to PCP,
goal INR ___. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Atrial fibrillation, s/p ablation
CAD, s/p LAD stent and diagonal PTCA/stenting
Diabetes
GERD
Cardiomyopathy
Congestive heart failure, systolic, chronic

 
Discharge Condition:
Hemodynamically stable, afebrile

 

###RESPONSE: Atrial fibrillation {Atrial fibrillation}, ablation {Destructive procedure}, CAD {Coronary arteriosclerosis}, LAD stent {Stent in anterior descending branch of left coronary artery}, PTCA {Percutaneous transluminal coronary angioplasty}, stenting {Insertion of arterial stent}, Diabetes {Diabetes mellitus}, GERD {Gastroesophageal reflux disease}, Cardiomyopathy {Cardiomyopathy}, Congestive heart failure, systolic, chronic {Chronic systolic heart failure}, Hemodynamically stable {Hemodynamically stable}, afebrile {Temperature 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: Discharge Instructions:
You were admitted to ___ for a cardioversion. You had the 
cardioversion, but the cardiologist was not able to albate the 
cause of your a fib. Your heart rate became more irregular 
during the procedure and you had to be shocked. You were started 
on a medication called amiodarone for your afib and you will see 
Dr. ___ in one ___ weeks to have a cardioversion after 
your MRI. You will have a cardiac MRI to evaluate your heart's 
blood vessels, call ___ to schedule.

If you have chest pain, shortnes of breath, groin pain or 
swelling or other concerning symptoms please seek medical 
attention. 

Please follow activiy, wound, and medication guidelines as 
discussed.

Your new medication amiodarone will be 400mg twice a day for a 
week (starting on ___, then 400mg once a day until your 
appointment with ___ in 1 month. Then he will adjust the 
dose. 

Your insulin was increased to 24units in the morning and your 
glyburide was changed to metformin.

You are also being sent home on a heart monitor, please follow 
the instructions provided.

You were started on Lovenox injections to thin your blood as 
your coumadin levele are increased. Please take Coumadin as 
ordered and get INR on ___ with ___ further 
Coumadin dose. Take your lovenox until instructed to stop.
 

###RESPONSE: cardioversion {Cardioversion}, cardioversion {Cardioversion}, a fib {Atrial fibrillation}, heart rate {Finding of heart rate}, irregular {Irregular heart beat}, procedure {Procedure}, medication {Administration of drug or medicament}, afib {Atrial fibrillation}, cardioversion {Cardioversion}, MRI {Magnetic resonance imaging}, cardiac MRI {Magnetic resonance imaging of heart}, heart {Heart structure}, blood vessels {Blood vessel structure}, chest pain {Chest pain}, shortnes of breath {Dyspnea}, groin pain {Inguinal pain}, swelling {Swelling}, seek medical 
attention {Recommendation to seek attention}, activiy {Functional activity education}, wound {Wound}, medication {Patient medication education}, medication {Patient medication education}, heart monitor {Cardiac monitoring}, instructions {Recommendation to}, injections {Injection}, coumadin {Anticoagulant therapy}, Coumadin {Anticoagulant therapy}, INR {Calculation of international normalized ratio}, Coumadin {Anticoagulant therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: CARDIOTHORACIC
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
Chest pain
 
Major Surgical or Invasive Procedure:
___ CABG x2(LIMA-LAD,SVG-OM) 

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, Chest pain {Chest pain}, CABG x2 {Coronary artery bypass grafts x 2}, LIMA {Structure of left internal thoracic artery}, LAD {Structure of anterior descending branch of left coronary artery}, SVG {Aortocoronary artery bypass graft with saphenous vein graft}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 hyperlipidemia and GERD/hiatal hernia 
reports about one year of feeling fatigued/low energy. He has 
also experienced intermittent episodes of chest burning that is 
felt across the entire chest, occurring   with exertion, 
resolving with rest. These episodes are unpredictable and do not
consistently occur, happening about ___ times per month. He also 
feels slightly more short of breath with exercise as compared to 
prior years. A stress echo in ___ showed possible ischemia 
involving the distal inferoseptum and possibly distal inferior 
wall. He has been treated with imdur, aspirin and a statin and 
is now being referred for coronary angiography.

 

###RESPONSE: hyperlipidemia {Hyperlipidemia}, GERD {Gastroesophageal reflux disease}, hiatal hernia {Hiatal hernia}, fatigued {Fatigue}, chest burning {Burning chest pain}, chest {Thoracic structure}, exertion {Chest pain on exertion}, short of breath with exercise {Dyspnea on exertion}, stress echo {Stress echocardiography}, ischemia {Ischemia}, inferior 
wall {Structure of myocardium of diaphragmatic region}, aspirin {Administration of aspirin}, coronary angiography {Angiography of coronary artery}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1. Hypercholesterolemia
2. GERD, hiatal hernia
3. H. Pylori s/p treatment
4. Asthma as a child
5. Insomnia
6. Prior bone fractures

 

###RESPONSE: Hypercholesterolemia {Hypercholesterolemia}, GERD {Gastroesophageal reflux disease}, hiatal hernia {Hiatal hernia}, H. Pylori {Infection caused by Helicobacter pylori}, Asthma {Asthma}, Insomnia {Insomnia}, fractures {Fracture}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Half-brother has had PCI in his ___, s/p AVR and CABG in his 
___. Grandfather was thought to have had a heart attack in his 
___.

 

###RESPONSE: PCI {Percutaneous coronary intervention}, AVR {Replacement of aortic valve}, CABG {Coronary artery bypass grafting}, heart attack {Myocardial infarction}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Discharge PE:
Physical Exam

Pulse:73 Resp:20  O2 sat:93/RA
B/P: 101/65
Height:6'1""     Weight:95.3 kg preop, 99.1kg postop

General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Sternum: stable, healing well, C/D/I
Heart: RRR [x]  Irregular []  Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds 
+
[x]
Extremities: Warm [x], well-perfused [x]  Edema: 1+BLE [x], LLE 
healing well
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
DP           Right: 2+   Left:2+
___           Right: 2+   Left:2+
Radial       Right: 2+   Left:2+

 

###RESPONSE: Physical Exam {Physical examination procedure}, Resp {Examination of respiratory system}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, General {General examination of patient}, NAD {No abnormality detected}, Skin {Examination of skin}, HEENT {Physical examination procedure}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Full ROM {Normal range of cervical spine movement}, Chest {Examination of respiratory system}, Lungs {Examination of respiratory system}, Sternum {Bone structure of sternum}, stable {Patient's condition stable}, healing well {Wound healing well}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, Irregular {Irregular heart beat}, Murmur {Murmur}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-distended {Normal abdominal contour}, non-tender {Abdominal tenderness}, bowel sounds 
+ {Normal bowel sounds}, Extremities {Examination of limb}, Warm {Warm skin}, well-perfused {Normal tissue perfusion}, Edema {Edema}, BLE {Edema of bilateral lower legs}, LLE {Structure of left lower limb}, healing well {Wound healing well}, Varicosities {Venous varices}, Neuro {Neurological examination}, Grossly intact {Normal nervous system function}, DP {Structure of dorsalis pedis artery}, Radial {Structure of radial artery}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ ECHO
PRE BYPASS The left atrium is dilated. No spontaneous echo 
contrast or thrombus is seen in the body of the left atrium/left 
atrial appendage or the body of the right atrium/right atrial 
appendage. No atrial septal defect is seen by 2D or color 
Doppler. Regional left ventricular wall motion is normal. 
Overall left ventricular systolic function is normal (LVEF>55%). 
The right ventricle displays normal free wall contractility. The 
aortic root is mildly dilated at the sinus level. The ascending 
aorta is mildly dilated. There are simple atheroma in the aortic 
arch. The descending thoracic aorta is mildly dilated. There are 
simple atheroma in the descending thoracic aorta. The aortic 
valve leaflets (3) are mildly thickened but aortic stenosis is 
not present. Trace aortic regurgitation is seen. The mitral 
valve leaflets are mildly thickened. Mild (1+) mitral 
regurgitation is seen. There is no pericardial effusion. Dr. 
___ was notified in person of the results in the 
operating room at the time of the study. 

POST BYPASS There is normal biventricular systolic function. 
Valvular function is unchanged from the pre-bypass exam. The 
thoracic aorta is intact after decannulation

CXR ___:
IMPRESSION:   
As compared to the previous radiograph, there is unchanged 
evidence of minimal bilateral atelectatic changes at the lung 
bases. No new parenchymal opacities. The lateral radiograph 
reveals a minimal right pleural effusion.  No other relevant 
change.  Normal alignment of sternal wires. Unchanged position 
of the right internal jugular vein catheter. 

LABS:
___ 04:14AM BLOOD WBC-7.1 RBC-3.86* Hgb-11.8* Hct-36.0* 
MCV-93 MCH-30.6 MCHC-32.8 RDW-11.9 Plt ___
___ 03:35AM BLOOD WBC-9.3 RBC-4.12* Hgb-12.7* Hct-38.6* 
MCV-94 MCH-30.7 MCHC-32.8 RDW-12.2 Plt ___
___ 02:20AM BLOOD ___ PTT-25.5 ___
___ 04:14AM BLOOD Glucose-104* UreaN-14 Creat-0.9 Na-137 
K-4.6 Cl-101 HCO3-32 AnGap-9
___ 03:35AM BLOOD Glucose-110* UreaN-15 Creat-1.0 Na-138 
K-4.1 Cl-102 HCO3-32 AnGap-8
___ 03:35AM BLOOD Mg-2.1
 

###RESPONSE: ECHO {Echocardiography}, BYPASS {Construction of shunt}, left atrium {Left atrial structure}, dilated {Dilatation}, echo {Echocardiography}, thrombus {Thrombus}, left atrium {Left atrial structure}, left 
atrial appendage {Entire left auricular appendage}, right atrium {Right atrial structure}, right atrial 
appendage {Structure of right auricular appendage}, atrial septal defect {Atrial septal defect}, color 
Doppler {Color Doppler ultrasound}, left ventricular {Left cardiac ventricular structure}, wall {Cardiac wall structure}, left ventricular systolic function is normal {Normal left ventricular systolic function and wall motion}, right ventricle {Right cardiac ventricular structure}, wall {Cardiac wall structure}, aortic root is mildly dilated {Aortic root dilatation}, sinus {Structure of sinus of Valsalva}, ascending 
aorta {Ascending aorta structure}, dilated {Dilatation}, atheroma {Atheroma}, aortic 
arch {Aortic arch structure}, descending thoracic aorta {Structure of descending thoracic aorta}, dilated {Dilatation}, atheroma {Atheroma}, descending thoracic aorta {Structure of descending thoracic aorta}, aortic 
valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral 
valve leaflets are mildly thickened {Thickened mitral leaflet}, Mild (1+) mitral 
regurgitation {Mild mitral valve regurgitation}, pericardial effusion {Pericardial effusion}, BYPASS {Construction of shunt}, biventricular {Cardiac ventricular structure}, Valvular {Structure of heart valve tissue}, bypass {Construction of shunt}, exam {Physical examination procedure}, thoracic aorta {Thoracic aorta structure}, decannulation {Vascular cannula removal}, radiograph {Plain radiography}, atelectatic {Atelectasis}, lung 
bases {Structure of base of lung}, opacities {Abnormally opaque structure}, radiograph {Plain radiography}, right {Structure of right pleural cavity}, pleural effusion {Pleural effusion}, sternal {Bone structure of sternum}, Unchanged position {Intravenous catheter in situ}, right internal jugular vein {Structure of right internal jugular vein}, 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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Mr. ___ was admitted to the ___ on ___ for surgical 
management of his coronary artery disease. He was taken to the 
operating room on the same day where he underwent coronary 
artery bypass grafting to two vessels. Please see the operative 
note for details. Postoperatively he was taken to the intensive 
care unit for monitoring. Over the next several hours, he awoke 
neurologically intact and was extubated. On postoperative day 
one, he was transferred to the step down unit for further 
recovery. His epicardial wires and chest tubes were removed per 
protocol. He was gently diuresed towards his preoperative 
weight. The physical therapy service was consulted for 
assistance in his postoperative strength and recovery. He 
continued to make steady progress and was discharged home on 
postoperative day four.
 

###RESPONSE: coronary artery disease {Coronary arteriosclerosis}, coronary 
artery bypass grafting to two vessels {Coronary artery bypass grafts x 2}, operative {Surgical procedure}, was taken to the intensive 
care unit {Patient transfer to intensive care unit}, monitoring {Monitoring response to treatment}, neurologically intact {Normal nervous system function}, extubated {Removal of endotracheal tube}, chest tubes were removed {Intercostal drain removal}, diuresed {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: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO DAILY 
2. Isosorbide Mononitrate (Extended Release) 60 mg PO BID 
3. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY 
4. Lorazepam 1 mg PO DAILY 
5. Simvastatin 40 mg PO DAILY 
6. Aspirin 325 mg PO DAILY 

 
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY 
2. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY 
3. Simvastatin 40 mg PO DAILY 
4. Docusate Sodium 100 mg PO BID 
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice 
a day Disp #*60 Capsule Refills:*0
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain 
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3 
hours as needed Disp #*50 Tablet Refills:*0
6. Lorazepam 1 mg PO DAILY 
7. Furosemide 20 mg PO DAILY Duration: 7 Days 
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet 
Refills:*0
8. Metoprolol Tartrate 12.5 mg PO BID 
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth 
twice a day Disp #*30 Tablet Refills:*0

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
1. Hypercholesterolemia
2. GERD, hiatal hernia
3. H. Pylori s/p treatment
4. Asthma as a child
5. Insomnia
6. Prior bone fractures

 
Discharge Condition:
Alert and oriented x3 nonfocal 
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions: 
Sternal - healing well, no erythema or drainage 
Leg Right/Left - healing well, no erythema or drainage. Edema 1+

 

###RESPONSE: Home With Service {Home health aide service management}, Hypercholesterolemia {Hypercholesterolemia}, GERD {Gastroesophageal reflux disease}, hiatal hernia {Hiatal hernia}, H. Pylori {Infection caused by Helicobacter pylori}, Asthma {Asthma}, Insomnia {Insomnia}, fractures {Fracture}, Alert {Mentally alert}, oriented x3 {Oriented to person, time and place}, Ambulating {Fully mobile}, steady gait {Gait normal}, Incisional {Surgical incision wound}, pain {Wound pain}, oral analgesics {Administration of analgesic}, Incisions {Surgical incision wound}, Sternal {Wound of structure of sternal region}, healing well {Wound healing well}, erythema {Erythema}, drainage {Discharge}, Leg Right {Structure of right lower limb}, Left {Structure of left lower limb}, healing well {Wound healing well}, erythema {Erythema}, drainage {Discharge}, Edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
1) Please shower daily including washing incisions gently with 
mild soap, no baths or swimming until cleared by surgeon. Look 
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions. 
3) Each morning you should weigh yourself and then in the 
evening take your temperature, these should be written down on 
the chart provided.
4) No driving for approximately one month and while taking 
narcotics. Driving will be discussed at follow up appointment 
with surgeon when you will likely be cleared to drive. 
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns ___

*Females: Please wear bra to reduce pulling on incision, avoid 
rubbing on lower edge
**Please call cardiac surgery office with any questions or 
concerns ___. Answering service will contact on call 
person during off hours**

 

###RESPONSE: incisions {Surgical incision wound}, incisions {Surgical incision wound}, redness {Redness of skin over lesion}, drainage {Discharge}, incisions {Surgical incision wound}, incision {Surgical incision wound}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___              Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
wound dehiscence
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, wound dehiscence {Wound dehiscence}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ M s/p splenectomy readmitted for wound dehiscence
 

###RESPONSE: splenectomy {Splenectomy}, wound dehiscence {Wound dehiscence}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
DM 
HTN
 

###RESPONSE: DM {Diabetes mellitus}, HTN {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
sister with ITP 
 

###RESPONSE: ITP {Chronic idiopathic thrombocytopenic purpura}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Gen: NAD
Abd: S/NT/ND, wound dehiscence at laterally edge of wound with 
dehiscence of anterior but not posterior sheath, no erythema, no 
signs of infection
Ext: WNL

 

###RESPONSE: Gen {General examination of patient}, NAD {No abnormality detected}, Abd {Examination of abdomen}, NT {Abdominal tenderness}, ND {Swollen abdomen}, wound dehiscence {Wound dehiscence}, wound {Gunshot wound}, dehiscence {Dehiscence}, erythema {Erythema}, Ext {Examination of limb}, WNL {No abnormality detected}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 04:00PM   WBC-19.8* RBC-3.60* HGB-10.1* HCT-32.4* 
MCV-90 MCH-28.1 MCHC-31.2 RDW-15.8*
___ 04:00PM   PLT COUNT-359
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
The patient was admitted, and a vac dressing was placed on the 
wound. VAC therapy was continued with good results, but the 
patient was kept in house until the first scheduled change of 
the VAC dressing. This was performed without difficulty and the 
patient is now discharged home with ___ for VAC changes. 
 

###RESPONSE: wound {Wound}, VAC therapy {Vacuum assisted skin closure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
lasix 80am/40pm, metformin 500''', humalog ssi, NPH 56/50, 
dexamethasone 8'', claritin prn  

 
Discharge Medications:
1. Metformin 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a 
day).  
2. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO QAM (once a 
day (in the morning)).  
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a 
day (in the evening)).  
4. Ascorbic Acid ___ mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
5. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed.  
6. Dexamethasone 4 mg Tablet Sig: Two (2) Tablet PO Q12H (every 
12 hours).  
7. Medication
Please resume all other home medications as before.

 

###RESPONSE: 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: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
wound dehiscence

 
Discharge Condition:
Good

 

###RESPONSE: Home With Service {Home health aide service management}, wound dehiscence {Wound dehiscence}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted for placement of a VAC dressing on your wound. 
Please call Dr. ___ or return to the E.R. for any of 
the following:
*new nausea/vomiting
*inability to eat
*fever > 101.4
*chest pain
*shortness of breath
*inability to have bowel movements or pass gas
*new redness around wound
*any other questions or concerns
 

###RESPONSE: placement {Application of dressing}, wound {Wound}, nausea/vomiting {Nausea and vomiting}, fever {Fever}, chest pain {Chest pain}, shortness of breath {Dyspnea}, inability to have bowel movements {Does not defecate}, pass gas {Unable to break wind}, redness {Redness of skin over lesion}, wound {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: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
Dyspnea 
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: Penicillins {Allergy to penicillin}, 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 of AVR + single vessel CABG (___), pAF s/p 
cardioversion, on sotalol, HTN, HLD p/w 1 day of worsening 
dyspnea in the setting of gradual worsening over the past few 
weeks. Her symptoms started around ___ and were associated 
with diaphoresis, nausea, and pallor. She denied any chest 
pain/pressure.  She presented to ___ where her EKG showed 
sinus rhythm and she was given ASA 300mg rectally.  Her initial 
TropT was elevated at 0.15.  She had a CXR which showed 
pulmonary vascular congestion without frank pulmonary edema.  
Her lungs were noted to have diffuse wheezes which were felt to 
be most likely ___ pulmonary edema.  She was placed on BiPAP for 
increased work of breathing and was transferred to ___ for 
further management and potential ICU level of care.

On arrival to the ___ ED, her EKG was unchanged from her prior 
one at ___.  Her labs were notable for a WBC of 17 and Cr 
rising from 1.3 to 1.4.  Her CKMB was normal at 6, and her 
initial Troponin was 0.21 which declined to 0.16.  She was 
initially on CPAP due to increased work of breathing with her 
two VBGs being 7.37/48 and 7.4/42.  ___ was weaned to 5LNC 
after being given 20mg of IV lasix.  She made 700cc of UOP over 
the next 6 hours but developed increased WOB and was re-trialed 
on BiPAP.  She was redosed with 20mg of IV lasix.  She was 
hemodynamically stable throughout.  She is transferred to the 
CCU for further management.     

REVIEW OF SYSTEMS:  
Cardiac review of systems is notable for absence of chest pain, 
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, 
ankle edema, palpitations, syncope or presyncope.  

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. 
Denies recent fevers, chills or rigors. 
Denies exertional buttock or calf pain. All of the other review 
of systems were negative.  
 

###RESPONSE: AVR {Replacement of aortic valve}, single vessel {Single coronary vessel disease}, CABG {Coronary artery bypass grafting}, pAF {Paroxysmal atrial fibrillation}, cardioversion {Cardioversion}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, dyspnea {Dyspnea}, diaphoresis {Excessive sweating}, nausea {Nausea}, pallor {Pallor of skin of face}, chest 
pain {Chest pain}, pressure {Tight chest}, EKG {Electrocardiographic procedure}, sinus rhythm {Sinus rhythm}, TropT was elevated {Troponin I above reference range}, CXR {Plain chest X-ray}, pulmonary vascular {Structure of pulmonary blood vessel}, congestion {Congestion}, pulmonary edema {Pulmonary edema}, lungs {Lung structure}, wheezes {Wheezing}, pulmonary edema {Pulmonary edema}, BiPAP {Bilevel positive airway pressure titration}, EKG {Electrocardiographic procedure}, WBC {White blood cell count}, Troponin {Troponin measurement}, on CPAP {Dependence on continuous positive airway pressure ventilation}, IV {Administration of drug or medicament via intravenous route}, lasix {Diuretic therapy}, BiPAP {Bilevel positive airway pressure titration}, IV {Administration of drug or medicament via intravenous route}, lasix {Diuretic therapy}, hemodynamically stable {Hemodynamically stable}, REVIEW OF SYSTEMS {Review of systems}, Cardiac {Heart disease}, review of systems {Review of systems}, chest pain {Chest pain}, dyspnea on exertion {Dyspnea on exertion}, paroxysmal nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, ankle edema {Ankle edema}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope}, stroke {Cerebrovascular accident}, TIA {Transient ischemic attack}, deep venous thrombosis {Deep venous thrombosis}, pulmonary embolism {Pulmonary embolism}, bleeding {Bleeding}, myalgias {Muscle pain}, joint pains {Joint pain}, cough {Cough}, hemoptysis {Hemoptysis}, black stools {Dark stools}, red stools {Red stools}, fevers {Fever}, chills {Chill}, rigors {Rigor}, buttock {Pain in buttock}, calf pain {Pain in calf}, review 
of systems {Review of systems}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
(+) HTN (+) HLD (-) DM
b/l cataracts s/p surgery
s/p cholecystectomy, hysterectomy
 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, DM {Diabetes mellitus}, cataracts {Cataract}, cholecystectomy {Cholecystectomy}, hysterectomy {Hysterectomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father died of suspected MI @ ___. Mother died @ ___.
 

###RESPONSE: died {Dead}, MI {Myocardial infarction}, 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 EXAM:
Gen: Elderly woman with increased work of breathing, saturating 
well on BiPAP
HEENT: NCAT EOMI MMM 
NECK: +JVP to mid neck
CV: S1/S2, RRR ___ systolic murmur heard best at ___ IS MCL with 
radiation to axilla
LUNGS: expiratory wheezing, bibasilar crackles
ABD: +BS soft NT/ND
EXT: no c/c/e
PULSES: 2+ pulses b/l
SKIN: warm and dry
NEURO: AAOx1-2

DISCHARGE EXAM:
Gen: No spontaneous respirations or chest wall movement noted
HEENT: Pupils fixed and dilated. Absent corneal reflexes.
CV: No heart sound appreciable on auscultation.
Lungs: No breath sounds on auscultation.

Patient pronounced dead at 16:51PM on ___.
 

###RESPONSE: Gen {General examination of patient}, BiPAP {Bilevel positive airway pressure titration}, HEENT {Physical examination procedure}, NC {Normal head}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, JVP {Finding of jugular venous pressure}, neck {Neck structure}, CV {Cardiovascular physical examination}, S2 {Normal second heart sound, S>2<}, RRR {Normal heart rate}, murmur {Murmur}, axilla {Axillary region structure}, LUNGS {Examination of respiratory system}, wheezing {Wheezing}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, ABD {Examination of abdomen}, BS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, PULSES {Normal pulse}, 2+ pulses {Peripheral pulses normal}, SKIN {Examination of skin}, warm {Warm skin}, dry {Xeroderma}, NEURO {Neurological examination}, Gen {General examination of patient}, spontaneous respirations {Spontaneous respiration}, chest wall {Chest wall structure}, Pupils fixed {Fixed dilatation of pupil}, dilated {Dilated pupil}, Absent corneal reflexes {Corneal reflex absent}, CV {Cardiovascular physical examination}, No heart sound {Heart sound inaudible}, auscultation {Auscultation}, Lungs {Lung structure}, No breath sounds {Absent breath sounds}, auscultation {Auscultation}, Patient pronounced dead {Patient status determination, deceased}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 04:10AM BLOOD WBC-17.5* RBC-3.91* Hgb-12.8 Hct-35.6* 
MCV-91 MCH-32.6* MCHC-35.8* RDW-13.6 Plt ___
___ 04:10AM BLOOD Neuts-84.5* Lymphs-8.2* Monos-6.4 Eos-0.7 
Baso-0.2
___ 04:29AM BLOOD ___ PTT-25.0 ___
___ 04:29AM BLOOD Glucose-125* UreaN-38* Creat-1.3* Na-141 
K-4.9 Cl-104 HCO3-22 AnGap-20
___ 04:29AM BLOOD CK-MB-6
___ 04:29AM BLOOD cTropnT-0.21*
___ 04:29AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.0
___ 04:38AM BLOOD ___ pO2-48* pCO2-48* pH-7.37 
calTCO2-29 Base XS-1
___ 04:38AM BLOOD O2 Sat-81

PERTINENT LABS:
___ 09:07AM BLOOD WBC-16.4* RBC-3.91* Hgb-12.0 Hct-37.5 
MCV-96 MCH-30.8 MCHC-32.0 RDW-14.2 Plt ___
___ 09:07AM BLOOD ___ PTT-21.2* ___
___ 09:07AM BLOOD Glucose-120* UreaN-128* Creat-5.0*# 
Na-139 K-6.1* Cl-104 HCO3-17* AnGap-24*
___ 11:40AM BLOOD cTropnT-0.16* ___
___ 09:07AM BLOOD Calcium-8.6 Phos-11.4*# Mg-2.4
___ 11:40PM BLOOD Lactate-2.2*
___ 03:30PM BLOOD Lactate-1.9

DISCHARGE LABS:   NONE, PATIENT MADE CMO AND EXPIRED

MICRO:
___ BLOOD CULTURE:  PENDING
___ URINE CULTURE:   NO GROWTH.

IMAGING: 
___  ECG
Normal sinus rhythm. Left ventricular hypertrophy. 
Intraventricular 
conduction delay. No previous tracing available for comparison.  


___  CHEST (PORTABLE AP)
FINDINGS:  The patient is rotated to the left. The patient is 
status post median sternotomy. There is moderate pulmonary 
edema. More confluent opacity at the right lung base may relate 
to vascular congestion however a consolidation due to pneumonia 
is not excluded. No large pleural effusion is seen. There is no 
evidence of pneumothorax. The cardiac silhouette is enlarged. 
The aorta is calcified and tortuous. 

___  Portable TTE 
Conclusions   
The left atrium is mildly dilated. No atrial septal defect is 
seen by 2D or color Doppler. There is mild symmetric left 
ventricular hypertrophy with normal cavity size and 
regional/global systolic function (LVEF>55%). Diastolic function 
could not be assessed. There is a mild resting left ventricular 
outflow tract obstruction. The right ventricular free wall is 
hypertrophied. The right ventricular cavity is mildly dilated 
with mild global free wall hypokinesis. A bioprosthetic aortic 
valve prosthesis is present. The transaortic gradient is higher 
than expected for this type of prosthesis. A paravalvular aortic 
valve leak is probably present. Mild (1+) aortic regurgitation 
is seen. The mitral valve leaflets are mildly thickened. There 
is mild functional mitral stenosis (mean gradient 7 mmHg) due to 
mitral annular calcification. Mild (1+) mitral regurgitation is 
seen. [Due to acoustic shadowing, the severity of mitral 
regurgitation may be significantly UNDERestimated.] The 
tricuspid valve leaflets are mildly thickened. Moderate [2+] 
tricuspid regurgitation is seen. The tricuspid regurgitation jet 
is eccentric and may be underestimated. [Due to acoustic 
shadowing, the severity of tricuspid regurgitation may be 
significantly UNDERestimated.] There is moderate pulmonary 
artery systolic hypertension. There is no pericardial effusion. 

IMPRESSION: Mild symmetric left ventricular hypertrophy with 
near-hyperdynamic left ventricular systolic function. The right 
ventricle is dilated and hypokinetic with moderate tricuspid 
regurgitation and moderate pulmonary hypertension. Bioprosthetic 
AVR with high gradients - likely a combination of a relatively 
small valve and hyperdynamic function. The leaflets as seen on 
images #21 and #22 seem to move well although there is 
significant calcification seen at ___ o'clock on the short axis 
views. It is not clear if this is outside the valve or not. At 
least mild mitral regurgitation. Mild calcific mitral stenosis. 
Biatrial dilation.   

___  CHEST (PORTABLE AP)
IMPRESSION:  Interval worsening of pulmonary edema, without 
effusions. 

___  BILAT LOWER EXT VEINS
IMPRESSION: No evidence of deep venous thrombosis in the right 
or left lower extremity veins. 

___  ECG
Sinus rhythm. Prolonged Q-T interval. Left ventricular 
hypertrophy. No major change from the previous tracing. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, 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}, pH {pH measurement}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, K {Blood potassium 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}, ECG {Electrocardiographic procedure}, Normal sinus rhythm {Normal sinus rhythm}, Left ventricular hypertrophy {Left ventricular hypertrophy}, CHEST (PORTABLE AP {Plain x-ray of chest anteroposterior view}, median sternotomy {Median sternotomy}, pulmonary 
edema {Pulmonary edema}, opacity {Abnormally opaque structure}, right lung base {Structure of base of right lung}, vascular {Blood vessel structure}, congestion {Congestion}, consolidation {Consolidation}, pneumonia {Pneumonia}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, cardiac {Heart structure}, enlarged {Enlargement}, aorta {Aortic structure}, calcified {Pathologic calcification, calcified structure}, TTE {Transthoracic echocardiography}, left atrium {Left atrial structure}, dilated {Dilatation}, atrial septal defect {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, mild symmetric left 
ventricular hypertrophy {Mild left ventricular hypertrophy}, normal cavity {Normal size cardiac chamber}, regional/global systolic function {Normal left ventricular systolic function and wall motion}, left ventricular 
outflow tract obstruction {Left ventricular outflow tract obstruction}, right ventricular {Right cardiac ventricular structure}, wall {Cardiac wall structure}, right ventricular cavity is mildly dilated {Dilatation of right cardiac ventricle}, wall {Cardiac wall structure}, hypokinesis {Behavior showing reduced motor activity}, aortic 
valve {Aortic valve structure}, aortic 
valve leak {Aortic valve regurgitation}, Mild (1+) aortic regurgitation {Mild mitral valve regurgitation}, mitral valve leaflets are mildly thickened {Thickened mitral leaflet}, mild functional mitral stenosis {Mild mitral valve stenosis}, mitral annular calcification {Mitral valve annular calcification}, Mild (1+) mitral regurgitation {Mild mitral valve regurgitation}, mitral 
regurgitation {Mitral valve regurgitation}, tricuspid valve leaflets are mildly thickened {Tricuspid leaflet thickened}, Moderate [2+] 
tricuspid regurgitation {Moderate tricuspid valve regurgitation}, tricuspid regurgitation {Tricuspid valve regurgitation}, tricuspid regurgitation {Tricuspid valve regurgitation}, pulmonary 
artery systolic hypertension {Pulmonary hypertensive arterial disease}, pericardial effusion {Pericardial effusion}, Mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, right 
ventricle is dilated {Dilatation of right cardiac ventricle}, hypokinetic {Hypokinetic right ventricular wall}, moderate tricuspid 
regurgitation {Moderate tricuspid valve regurgitation}, moderate pulmonary hypertension {Moderate pulmonary hypertension}, Bioprosthetic 
AVR {Repair of aortic valve with tissue graft}, leaflets {Structure of cardiac valve leaflet}, calcification {Pathologic calcification, calcified structure}, mild mitral regurgitation {Mild mitral valve regurgitation}, Mild calcific mitral stenosis {Mild mitral valve regurgitation}, Biatrial dilation {Atrial dilatation}, CHEST (PORTABLE AP {Plain x-ray of chest anteroposterior view}, pulmonary edema {Pulmonary edema}, effusions {Pleural effusion}, LOWER EXT VEINS {Structure of vein of lower limb}, deep venous thrombosis {Deep venous thrombosis}, right {Structure of vein of right lower limb}, left lower extremity veins {Structure of vein of left lower limb}, ECG {Electrocardiographic procedure}, Sinus rhythm {Sinus rhythm}, Prolonged Q-T interval {Prolonged QT interval}, Left ventricular 
hypertrophy {Left ventricular hypertrophy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ y/o F w/ hx of AVR, CABG in ___, PAF on sotalol, HTN, HLD w/ 
recent echo showing preserved ejection fraction with acute on 
subacute worsening dyspnea in the setting of leukocytosis and 
CXR findings c/w PNA, found to have volume overload on exam with 
increased work of breathing initially requiring BiPAP but later 
made comfort care only after unsuccessful attempts at diuresis 
and development of acute renal failure.

ACTIVE ISSUES:
#ACUTE DECOMPENSATED DIASTOLIC HEART FAILURE: LVEF >55%, mild 
symmetric LVH, MAC, +MR. ___ consistent with heart 
failure exacerbation in the setting of PNA. She initially 
responded to IV lasix boluses but quickly developed acute renal 
failure and persistent oxygen requirement. PE was considered in 
the differential given +D-dimer and increased WOB but LENIs were 
negative for DVT and symptomatology was not consistent. Patient 
and family was approached regarding elective intubation and 
right heart cath but declined as this was felt to be too 
invasive. After a meeting with the patient and her family 
(including HCP), patient was made DNR/DNI. Medical team and 
family agreed to try high dose IV Lasix and if this was 
unsuccessful, patient would be made comfort care only. 
Unfortunately, high dose IV diuresis was unsuccessful and 
patient was made comfort care only on ___. Palliative care was 
consulted to assist with comfort measures. Patient expired on 
___ at 16:51PM with family at bedside.

#PNA: Patient presented with leukocytosis characterized by a 
left shift. This in combination with her CXR which was 
suggestive of a RLL opacification, was concerning for PNA. This 
PNA also likely contributed if not caused her CHF exacerbation. 
She was treated with CTX and azithromycin. Antibiotics were 
withdrawn once patient was made comfort care only.

CHRONIC ISSUES:
#Atrial fibrillation: Patient remained in atrial fibrillation 
throughout admission. She was continued on her home sotalol on 
admission but this was withdrawn once patient was made CMO.

#HTN: Normotensive on admission. Home BP meds were held on 
admission especially in the setting of diuresis. 

#HLD: Stable, she was continued on her home pravastatin which 
was discontinued once she was made CMO.

TRANSITIONAL ISSUES:
NONE
 

###RESPONSE: AVR {Replacement of aortic valve}, CABG {Coronary artery bypass grafting}, PAF {Paroxysmal atrial fibrillation}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, echo {Echocardiography}, dyspnea {Dyspnea}, leukocytosis {Leukocytosis}, CXR {Plain chest X-ray}, PNA {Pneumonia}, volume overload {Hypervolemia}, BiPAP {Bilevel positive airway pressure titration}, comfort care {Comfort measures}, diuresis {Diuresis}, acute renal failure {Acute kidney injury}, DECOMPENSATED DIASTOLIC HEART FAILURE {Decompensated cardiac failure}, mild 
symmetric LVH {Mild left ventricular hypertrophy}, MAC {Mitral valve annular calcification}, MR {Mitral valve regurgitation}, heart 
failure {Heart failure}, PNA {Pneumonia}, IV {Administration of drug or medicament via intravenous route}, lasix {Diuretic therapy}, acute renal 
failure {Acute kidney injury}, PE {Pulmonary embolism}, DVT {Deep venous thrombosis}, intubation {Intubation}, right heart cath {Catheterization of right heart}, DNR {Not for resuscitation}, IV {Administration of drug or medicament via intravenous route}, comfort care {Comfort measures}, IV {Administration of drug or medicament via intravenous route}, diuresis {Diuresis}, comfort care {Comfort measures}, Palliative care {Palliative care}, comfort measures {Comfort measures}, PNA {Pneumonia}, leukocytosis {Leukocytosis}, left shift {Left shifted white blood cells}, CXR {Plain chest X-ray}, RLL {Structure of lower lobe of right lung}, opacification {Abnormally opaque structure}, PNA {Pneumonia}, PNA {Pneumonia}, CHF exacerbation {Exacerbation of congestive heart failure}, Antibiotics {Antibiotic therapy}, comfort care {Comfort measures}, Atrial fibrillation {Atrial fibrillation}, atrial fibrillation {Atrial fibrillation}, HTN {Hypertensive disorder, systemic arterial}, Normotensive {Normal blood pressure}, diuresis {Diuresis}, HLD {Hyperlipidemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list may be inaccurate and requires 
futher investigation.
1. Acetaminophen 650 mg PO Q8H:PRN pain 
2. ALPRAZolam 0.5 mg PO QHS insomnia 
3. Losartan Potassium 25 mg PO DAILY 
4. Potassium Chloride 20 mEq PO DAILY 
5. Pravastatin 40 mg PO QPM 
6. Sotalol 80 mg PO BID 
7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing 

 
Discharge Medications:
PATIENT EXPIRED
 

###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:
Expired
 
Discharge Diagnosis:
PATIENT EXPIRED
 
Discharge Condition:
PATIENT EXPIRED
 

###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 Instructions:
PATIENT EXPIRED
 

###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: 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:
confusion, abnormal labs

 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, confusion {Clouded consciousness}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Patient is a ___ w/pmh chronic mild hypoNa likely ___ SIADH, 
HTN, COPD and chronic etoh use disorder who presents with 
confusion in the setting of worsening hypoNa. 

History obtained from patient as well as her son and daughter 
who were at bedside. Patient has a long history of chronic 
asymptomatic hyponatremia (Na 130-132) thought to be due to 
SIADH and chronic tea and toast potomania (""nibbles"" and drinks 
about 2 gallons of wine a week). Na was as low as 129 in ___ 
due to increased ETOH intake and very poor PO intake. After PCP 
counseling and change in her diet (more salty soups), Na was 
improved to low 130s. Per daughter in law, patient has been 
increasing her ETOH intake recently with very little PO intake. 
Family has noted increased confusion and forgetfulness over the 
past 2 weeks. Denied any speech slurring, weakness, numbness, 
recent falls.

Patient was taken to urgent care today for above sxs and noted 
to have Na 125 from baseline around 130. She was sent to ___ 
ED for further eval. Of note yesterday patient was also taken to 
___ UC yesterday for a rash on her face. She was given Keflex 
and prednisone for possible shingles. She reports the rash was 
initially itchy but never painful. Currently it feels well and 
does not bother her. 

In the ED, initial VS were: 98.9 88 123/54 16 96% RA 
  
 ED physical exam was recorded as:
Awake and alert but forgetful at times, moving all ext, CN 
II-XII
CTAB, RRR and abd NTND soft
Ext wwp, 2+ pulses
No signs of trauma
rash on right side of face

ED labs were notable for: 
Na 125
WBC 10.6
H/H 10.8/32.1
Urine sodium 42, Uosm 241

Imaging showed:
CXR:   
No acute cardiopulmonary process seen. 

Transfer VS were: 90 126/62 18 97% RA 
 
 When seen on the floor, she is alert and oriented times 3. She 
is not sure why she is in the hospital. She denies any pain 
anywhere, dysuria, abd pain, n/v, diarrhea, fever, chills. 
Reports chronic cough. Requesting sleep aid and nicotine patch.
  
REVIEW OF SYSTEMS: 
 A ten point ROS was conducted and was negative except as above 
in the HPI.

 

###RESPONSE: chronic {Chronic disease}, hypoNa {Hyponatremia}, SIADH {Syndrome of inappropriate vasopressin secretion}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, chronic etoh use disorder {Persistent alcohol abuse}, confusion {Clouded consciousness}, worsening {Patient's condition worsened}, hypoNa {Hyponatremia}, chronic {Chronic disease}, asymptomatic {Asymptomatic}, hyponatremia {Hyponatremia}, SIADH {Syndrome of inappropriate vasopressin secretion}, chronic {Chronic disease}, potomania {Hypo-osmolality and or hyponatremia}, drinks {Current drinker of alcohol}, increased ETOH intake {Problem drinker}, poor PO intake {Decrease in appetite}, counseling {Counseling}, diet {Dietary regime}, improved {Patient's condition improved}, ETOH {Alcohol abuse}, confusion {Clouded consciousness}, forgetfulness {Forgetful}, slurring {Slurred speech}, weakness {Asthenia}, numbness {Numbness}, falls {Falls}, baseline {Baseline state}, eval {Evaluation procedure}, rash on her face {Eruption of skin of face}, shingles {Herpes zoster}, rash {Eruption of skin}, itchy {Itching}, painful {Pain}, feels well {Well in self}, Awake {Awake}, alert {Mentally alert}, forgetful {Forgetful}, CN 
II-XII {Examination of cranial nerve}, CTAB {Normal breath sounds}, RRR {Normal heart rate}, NTND {Abdominal tenderness}, soft {Abdomen soft}, 2+ pulses {Peripheral pulses normal}, signs {Sign}, trauma {Traumatic injury}, rash {Eruption of skin}, right side of face {Structure of right half of face}, labs {Laboratory test}, CXR {Plain chest X-ray}, No acute {No abnormality detected}, alert {Mentally alert}, oriented times 3 {Oriented to person, time and place}, pain {Pain}, dysuria {Dysuria}, abd pain {Abdominal pain}, diarrhea {Diarrhea}, fever {Fever}, chills {Chill}, chronic cough {Chronic cough}, REVIEW OF SYSTEMS {Review of systems}, ROS {Review of systems}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Purpura [D69.2] 
Alcohol dependence [F10.20] 
Emphysematous COPD [J43.9] 
Tobacco dependence [F17.200] 
HYPERTENSION - ESSENTIAL, UNSPEC [I10] 
Lisinopril
H/O solitary pulmonary nodule [___] 
Hyponatremia [___.1] c/w SIADH
RLL consolidation of chest CT -resolved. ( ___
B12 deficiency, borderline [E53.8] 
Asymptomatic PVD (peripheral vascular disease) [___.9] 
SCREENING FOR COLON CANCER [___.11] 
LICHEN SCLEROSUS ET ATROPHICUS 

 

###RESPONSE: Purpura {Purpuric disorder}, Alcohol dependence {Alcohol dependence}, Emphysematous COPD {Pulmonary emphysema}, Tobacco dependence {Tobacco dependence syndrome}, HYPERTENSION - ESSENTIAL {Essential hypertension}, solitary pulmonary nodule {Solitary nodule of lung}, Hyponatremia {Hyponatremia}, SIADH {Syndrome of inappropriate vasopressin secretion}, RLL {Structure of lower lobe of right lung}, consolidation {Lung consolidation}, chest CT {Computed tomography of chest}, resolved {Problem resolved}, Asymptomatic {Asymptomatic}, PVD (peripheral vascular disease {Peripheral vascular disease}, SCREENING FOR COLON CANCER {Screening for malignant neoplasm of colon}, LICHEN SCLEROSUS {Lichen sclerosus}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
No family history
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
On Admission: 
Gen: NAD, A&O x3, lying in bed
Eyes: EOMI, sclerae anicteric  
HEENT: MMM, OP clear. Erythematous patch on right facial and 
cervical area, with no tenderness to palpation, no induration. 
Small dry crusted areas on the overlying skin.
Cardiovasc: RRR, no MRG, full pulses, no edema  
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect

On Discharge:
VS: 97.8 134/59 66 18 91% RA
GEN: Well appearing in NAD, sitting up in bed
HEENT/Neck: Anicteric sclera, MMM, OP clear, neck supple.  
HEART: RRR no m/r/g
LUNGS: CTAB no wheezes, rales, or crackles.  Symmetric expansion
ABD: soft NT/ND +BS no rebound or guarding, dry cough throughout
exam, which patient states is her ""smoker's cough.""
EXT: warm well perfused, no pitting edema
NEURO: alert and oriented x3.  Fluent speech.  CN II-XII intact. 

No focal deficits on strength testing.
 

###RESPONSE: Gen {General examination of patient}, NAD {No abnormality detected}, O x3 {Oriented to person, time and place}, lying in bed {Lying in bed}, EOMI {Normal ocular motility}, sclerae anicteric {White sclera}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, Erythematous {Erythema}, facial and 
cervical {Face and/or neck structure}, tenderness {Tenderness}, palpation {Palpation}, induration {Induration of skin}, crusted areas {Crust on skin}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, pulses {Normal pulse}, edema {Edema}, Resp {Examination of respiratory system}, normal effort {Visible respiratory effort}, accessory muscle {Accessory skeletal muscle}, lungs {Lung structure}, CTA {Normal breath sounds}, GI {Examination of digestive system}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, MSK {Musculoskeletal system physical examination}, kyphosis {Kyphosis deformity of spine}, palpable {Palpation}, synovitis {Synovitis}, Skin {Examination of skin}, rash {Eruption of skin}, jaundice {Jaundice}, Neuro {Neurological examination}, Ox3 {Oriented to person, time and place}, facial droop {Weakness of face muscles}, Psych {Psychological assessment}, affect {Mood finding}, GEN {General examination of patient}, Well appearing {Well cared for appearance}, NAD {Distress}, HEENT {Physical examination procedure}, Neck {Physical examination procedure}, Anicteric sclera {White sclera}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, neck supple {Normal movement of neck}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, LUNGS {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, crackles {Respiratory crackles}, Symmetric expansion {Chest expansion normal}, ABD {Examination of abdomen}, soft {Abdomen soft}, +BS {Normal bowel sounds}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, dry cough {Dry cough}, exam {Examination of abdomen}, smoker's cough {Smokers' cough}, EXT {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, pitting edema {Pitting edema}, NEURO {Neurological examination}, alert {Mentally alert}, oriented x3 {Oriented to person, time and place}, Fluent speech {Finding of fluency of speech}, CN II-XII intact {Normal central nervous system}, No focal deficits {Normal nervous system function}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
On Admission:
___ 05:20PM URINE  OSMOLAL-241
___ 05:20PM URINE  HOURS-RANDOM CREAT-29 SODIUM-42
___ 01:40PM   GLUCOSE-106* UREA N-14 CREAT-0.7 SODIUM-125* 
POTASSIUM-4.7 CHLORIDE-89* TOTAL CO2-26 ANION GAP-15
___ 01:40PM   CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-1.8
___ 01:40PM   OSMOLAL-283
___ 01:40PM   WBC-10.6* RBC-3.47* HGB-10.8* HCT-32.1* 
MCV-93 MCH-31.1 MCHC-33.6 RDW-14.2 RDWSD-48.2*
___ 01:40PM   NEUTS-74.4* LYMPHS-14.6* MONOS-9.4 EOS-0.4* 
BASOS-0.4 IM ___ AbsNeut-7.90* AbsLymp-1.55 AbsMono-1.00* 
AbsEos-0.04 AbsBaso-0.04
___ 01:40PM   PLT COUNT-300

CXR: No acute cardiopulmonary process seen.

CT chest (___):
1.  4 mm noncalcified pulmonary nodule is stable since ___.  
Followup per ___ recommendations.
2.  COPD.

On Discharge:
___ 06:50AM BLOOD WBC-5.7 RBC-3.14* Hgb-9.8* Hct-30.0* 
MCV-96 MCH-31.2 MCHC-32.7 RDW-14.4 RDWSD-49.9* Plt ___
___ 07:15AM BLOOD Glucose-91 UreaN-12 Creat-0.6 Na-129* 
K-4.0 Cl-93* HCO3-26 AnGap-14
___ 07:15AM BLOOD Mg-1.6
___ 06:20AM BLOOD VitB12-548 Folate-2.9
___ 01:40PM BLOOD Osmolal-283
___ 06:20AM BLOOD TSH-2.9
 

###RESPONSE: URINE  OSMOLAL {Osmolality measurement, urine}, URINE {Evaluation of urine specimen}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, GLUCOSE {Glucose measurement, urine}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, CALCIUM {Blood calcium measurement}, PHOSPHATE {Phosphate, total measurement}, MAGNESIUM {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PLT COUNT {Platelet count}, CXR {Plain chest X-ray}, No acute {No abnormality detected}, pulmonary nodule {Nodule of lung}, stable {Symptom not changed}, COPD {Chronic obstructive lung disease}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Mg {Blood magnesium measurement}, TSH {Thyroid stimulating hormone 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:
Patient is a ___ year old woman with history of mild chronic 
hypoNa attributed to SIADH, HTN, COPD and etoh use disorder who 
presents with confusion and worsening hypoNa. 

#Acute metabolic encephalopathy:
#Hyponatremia:
Patient's confusion and forgetfulness is likely due to acute on 
chronic hyponatremia ___ poor solute intake (""tea and toast"", or 
""wine and toast"") as well as possible mild SIADH (elevated UNa 
and UOsm). It is unclear why she would have SIADH, no 
intrapulmonary process on CXR.  She has a lung nodule which has 
been stable on serial imaging. DDx also includes toxic metabolic 
encephalopathy from chronic alcohol use vs alcohol withdrawal 
(although currently not exhibiting any signs). Unlikely to be 
infection (given clear CXR and UA), head trauma (no recent 
history of head strike) medication side effects (not on any 
culprit meds).  Na improved to recent baseline with free water 
restriction and salt tabs.  She was encouraged to increase her 
solute intake.  TSH, B12, folate wnl. B1 pending on discharge.

Given her encephalopathy, ___ and OT were consulted and found 
significant deficits concerning for her safety.  Her MMSE was 
___ suggestive of mild-moderate cognitive impairment.  Her 
family echoed these concerns about safety at home and she is now 
discharged to rehab. She should have cognitive neurology follow 
up as an outpatient. 

#Facial Rash: 
Mild cellulitis vs dermatitis with faint erythema, induration.  
Does not appear to be shingles given lack of a dermatomal 
distribution and no vescicular lesions.  In the outpatient 
setting was given Keflex and steroid.  Her Keflex should be 
continued through ___ to complete a ___TOH use disorder
#Fall safety risk: 
Per daughter in law, patient has longstanding history of ETOH 
use disorder (about 2 gallons a wine per week), with prior 
history of falls (twice last year). She was able to ambulate 
independently at home, however now needs help with paying bills. 
Family is concerned about patient's ability to take care of 
herself at home and have entertained the possibility of 
placement.  See above for evaluation.  She did not trigger on 
CIWA

#HTN: Continued Lisinopril 40 mg PO and amLODIPine 10 mg PO 
DAILY 

Chronic issues: COPD stable
- Continued ASA
- Continued vitamin B12 and D

# Code status: DNR/DNI (confirmed with pt/family)

Transitional:
- Patient will need to be scheduled for follow up with cognitive 
neurology
- Continue Keflex through ___

 

###RESPONSE: chronic 
hypoNa {Chronic hyponatremia}, SIADH {Syndrome of inappropriate vasopressin secretion}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, etoh use disorder {Alcohol abuse}, confusion {Clouded consciousness}, hypoNa {Hyponatremia}, Hyponatremia {Hyponatremia}, confusion {Clouded consciousness}, forgetfulness {Forgetful}, chronic hyponatremia {Chronic hyponatremia}, mild {Symptom mild}, SIADH {Syndrome of inappropriate vasopressin secretion}, SIADH {Syndrome of inappropriate vasopressin secretion}, CXR {Plain chest X-ray}, lung nodule {Nodule of lung}, stable {Symptom not changed}, imaging {Imaging}, toxic metabolic 
encephalopathy {Toxic metabolic encephalopathy}, chronic alcohol use {Persistent alcohol abuse}, alcohol withdrawal {Alcohol withdrawal syndrome}, signs {Sign}, infection {Infectious disease}, clear {No abnormality detected}, CXR {Plain chest X-ray}, head trauma {Injury of head}, head strike {Injury of head}, medication side effects {Medication side effects present}, improved {Patient's condition improved}, baseline {Baseline state}, water 
restriction {Fluid restriction}, TSH {Thyroid stimulating hormone measurement}, B12 {B12/folate level}, encephalopathy {Disorder of brain}, concerning for her safety {Safeguarding concern}, MMSE {Assessment using mini-mental state examination}, moderate cognitive impairment {Moderate cognitive impairment}, concerns about safety {Safeguarding concern}, neurology follow 
up {Follow-up neurological assessment}, Facial Rash {Eruption of skin of face}, Mild {Symptom mild}, cellulitis {Cellulitis}, dermatitis {Inflammatory dermatosis}, erythema {Erythema}, induration {Induration}, shingles {Herpes zoster}, vescicular lesions {Vesicular eruption}, steroid {Steroid therapy}, TOH use disorder {Alcohol abuse}, Fall safety risk {At increased risk for falls}, ETOH 
use disorder {Alcohol abuse}, falls {Falls}, able to ambulate {Able to walk}, evaluation {Evaluation procedure}, HTN {Hypertensive disorder, systemic arterial}, Chronic issues {Chronic disease}, COPD {Chronic obstructive lung disease}, stable {Patient condition unchanged}, DNR {Not for resuscitation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Lisinopril 40 mg PO DAILY 
2. amLODIPine 10 mg PO DAILY 
3. Vitamin D 1000 UNIT PO DAILY 
4. Cyanocobalamin 1000 mcg PO 3X/WEEK (___) 
5. Aspirin 81 mg PO DAILY 

 
Discharge Medications:
1.  Cephalexin 500 mg PO Q6H  
2.  Docusate Sodium 100 mg PO BID 
do not take if you are having loose stools  
3.  FoLIC Acid 1 mg PO DAILY  
4.  Multivitamins 1 TAB PO DAILY  
5.  Nicotine Patch 7 mg TD DAILY  
6.  Polyethylene Glycol 17 g PO DAILY:PRN constipation  
7.  Senna 8.6 mg PO BID:PRN constipation  
8.  Sodium Chloride 1 gm PO BID  
9.  Thiamine 100 mg PO DAILY  
10.  TraZODone 25 mg PO QHS:PRN insomnia  
11.  amLODIPine 10 mg PO DAILY  
12.  Aspirin 81 mg PO DAILY  
13.  Cyanocobalamin 1000 mcg PO 3X/WEEK (___)  
14.  Lisinopril 40 mg PO DAILY  
15.  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:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Acute metabolic encephalopathy
Hyponatremia, SIADH
Mild cognitive impairment

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: metabolic encephalopathy {Metabolic encephalopathy}, Hyponatremia {Hyponatremia}, SIADH {Syndrome of inappropriate vasopressin secretion}, Mild cognitive impairment {Mild neurocognitive disorder}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}, walker {Uses zimmer frame}, cane {Uses single walking stick}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Patient admitted with increased confusion at home and worsened 
hyponatremia.  Improved with fluid restriction.  Found to have 
cognitive impairment and safety concerns at home.  Rehab 
recommended as well as follow up with a neurologist.  Please 
encourage alcohol cessation, encourage salt intake, and water 
restriction to 1.5-2L per day
 

###RESPONSE: confusion {Clouded consciousness}, hyponatremia {Hyponatremia}, Improved {Patient's condition improved}, fluid restriction {Fluid restriction}, cognitive impairment {Impaired cognition}, safety concerns {Safeguarding concern}, follow up {Follow-up arranged}, alcohol {Current drinker of alcohol}, water 
restriction {Fluid restriction}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
morphine / Dilaudid
 
Attending: ___.
 
Chief Complaint:
L distal femur nonunion 
 
Major Surgical or Invasive Procedure:
L distal femur nonunion ORIF with plate ___, ___

 

###RESPONSE: morphine {Allergy to morphine}, L distal femur {Bone structure of distal left femur}, L distal femur {Bone structure of distal left femur}, nonunion {Nonunion of fracture}, ORIF {Open reduction of fracture of femur with internal fixation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 follow-up visit for ___ chief complaint is
left distal femur fracture history ___ is here today for
follow-up with regards to his distal femur fracture he recently
had a CT scan and is here today to discuss the findings.

Past medical history no changes since we last saw him.

Review of systems no fevers or chills.

 

###RESPONSE: distal femur fracture {Fracture of distal end of femur}, distal femur fracture {Fracture of distal end of femur}, CT scan {Computed tomography of left lower limb}, Review of systems {Review of systems}, fevers {Fever}, chills {Chill}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
HTN
 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
NC
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
On discharge 

General: well-appearing, breathing comfortably
CV: pink and well perfused
Abd: soft, non-tender, non-distended

LLE: Incision well approximated. Dressing clean and dry. Fires 
FHL, ___, TA, GCS. SILT ___ n distributions. Toes WWP 
distally.

 

###RESPONSE: General {General examination of patient}, well-appearing {Well cared for appearance}, breathing comfortably {Breathing easily}, CV {Cardiovascular physical examination}, well perfused {Normal tissue perfusion}, Abd {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, LLE {Structure of left lower limb}, Incision {Surgical incision wound}, Dressing {Application of dressing}, SILT {Light touch sensation present}, Toes {Structure of all toes}, WWP {Normal tissue perfusion}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:30AM BLOOD WBC-15.4* RBC-3.41* Hgb-9.8* Hct-30.6* 
MCV-90 MCH-28.7 MCHC-32.0 RDW-13.5 RDWSD-44.4 Plt ___
___ 06:30AM BLOOD Glucose-322* UreaN-11 Creat-1.0 Na-134* 
K-4.0 Cl-96 HCO3-24 AnGap-14
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
The patient is well known to the service and has been undergoing 
evaluation for left distal femur. He presented from home on 
___ for scheduled left distal femur nonunion ORIF, which 
the patient tolerated well. For full details of the procedure 
please see the separately dictated operative report.

After the procedure the patient was taken from the OR to the 
PACU, but was hypotensive requiring temporary pressors while in 
the PACU. He was weaned off pressors prior to arrival on floor 
(POD0) and SBP remained at 100 with HR around 100. Home 
Metoprolol was held given hypotensive on POD1 with SBP to ___. 
He was treated with IVF and pressures normalized. Additionally, 
___ Diabetes service was consulted for newly found 
hyperglycemia.

He was initially given IV fluids and IV pain medications, but 
progressed to a regular diet and oral medications on POD1. The 
patient was given ___ antibiotics per routine. He is 
on Apixaban at home and was switched to Enoxaparin ___. He 
was restarted on home Apixaban on POD1. The patient's other home 
medications were also continued throughout this hospitalization. 
His intraoperative cultures did not grow any bacteria. The 
___ hospital course was otherwise unremarkable.

At the time of discharge the patient's pain was well controlled 
with oral medications, incisions were clean/dry/intact, and the 
patient was voiding/moving bowels spontaneously. The patient is 
weight bearing as tolerated in left lower extremity, and will be 
discharged on home Apixaban for DVT prophylaxis. The patient 
will follow up with Dr. ___ routine. A thorough 
discussion was had with the patient regarding the diagnosis and 
expected post-discharge course including reasons to call the 
office or return to the hospital, and all questions were 
answered. The patient was also given written instructions 
concerning precautionary instructions and the appropriate 
follow-up care. The patient expressed readiness for discharge.

 

###RESPONSE: evaluation {Evaluation procedure}, left distal femur {Bone structure of distal left femur}, left distal femur {Bone structure of distal left femur}, nonunion {Nonunion of fracture}, ORIF {Open reduction of fracture of femur with internal fixation}, procedure {Surgical procedure}, procedure {Surgical procedure}, PACU {Postanesthesia care}, hypotensive {Low blood pressure}, pressors {Hypotensive therapy}, PACU {Postanesthesia care}, pressors {Hypotensive therapy}, hypotensive {Hypotensive therapy}, IVF {Administration of intravenous fluids}, pressures normalized {Normal blood pressure}, Diabetes service was consulted {Referral to diabetes service}, hyperglycemia {Hyperglycemia}, given IV fluids {Administration of intravenous fluids}, pain medications {Administration of analgesic}, regular diet {Normal diet}, oral medications {Administration of drug or medicament via oral route}, antibiotics {Antibiotic therapy}, cultures {Microbial culture}, unremarkable {No abnormality detected}, pain was well controlled {Demonstrates adequate pain control}, oral medications {Administration of drug or medicament via oral route}, incisions {Surgical incision wound}, clean/dry/intact {Wound healing well}, voiding {Micturition finding}, moving bowels {Finding of defecation}, weight bearing {Weight-bearing}, left lower extremity {Structure of left lower limb}, DVT prophylaxis {Prevention of deep vein thrombosis}, follow up {Follow-up arranged}, discussion {Discussion}, instructions {Education}, instructions {Education}, follow-up care {Postoperative procedure education}, readiness for discharge {Ready for discharge}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Apixaban 5 mg PO BID  
Atorvastatin 40 mg PO QPM  
Digoxin 0.125 mg PO DAILY  
Gabapentin 300 mg PO TID  
Metoprolol Succinate XL 100 mg PO DAILY Please HOLD for SBP < 
100 or HR < 
Pantoprazole 40 mg PO Q12H  

 
Discharge Medications:
1.  Acetaminophen 650 mg PO Q6H  
2.  Bisacodyl 10 mg PO/PR DAILY:PRN Constipation  
3.  Calcium Carbonate 500 mg PO BID  
4.  Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN Cough/Sore 
Throat  
5.  Docusate Sodium 100 mg PO BID  
6.  Milk of Magnesia 30 ml PO BID:PRN Constipation  
7.  Multivitamins 1 TAB PO DAILY  
8.  OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain 
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours 
PRN Disp #*50 Tablet Refills:*0 
9.  Senna 8.6 mg PO BID  
10.  Vitamin D 400 UNIT PO DAILY  
11.  Apixaban 5 mg PO BID  
12.  Atorvastatin 40 mg PO QPM  
13.  Digoxin 0.125 mg PO DAILY  
14.  Gabapentin 300 mg PO TID  
15.  Metoprolol Succinate XL 100 mg PO DAILY 
Please HOLD for SBP < 100 or HR < 55.  
16.  Pantoprazole 40 mg PO Q12H  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
L distal femur nonunion 

 
Discharge Condition:
AVSS
NAD
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

LLE: Incision well approximated. Dressing clean and dry. Fires 
FHL, ___, TA, GCS. SILT ___ n distributions. Toes WWP 
distally.

 

###RESPONSE: nonunion {Nonunion of fracture}, AVSS {Normal vital signs}, NAD {No abnormality detected}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - requires assistance or aid {Finding of walking aid use}, LLE {Structure of left lower limb}, Incision {Surgical incision wound}, well approximated {Wound healing well}, Dressing {Application of dressing}, SILT {Light touch sensation present}, Toes {Structure of all toes}, WWP {Normal tissue perfusion}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal 
to feel tired or ""washed out"" after surgery, and this feeling 
should improve over the first few days to week. 
- Resume your regular activities as tolerated, but please follow 
your weight bearing precautions strictly at all times.

ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated in left lower extremity 

MEDICATIONS:
- Please take all medications as prescribed by your physicians 
at discharge.
- Continue all home medications unless specifically instructed 
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate 
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should 
drink eight 8oz glasses of water daily and take a stool softener 
(colace) to prevent this side effect.

PAIN MEDICATIONS INSTRUCTIONS:
1)  Take Tylenol ___ every 6 hours around the clock.
2)  Add your prescribed narcotics as needed for increased pain. 
Start weaning the narcotic medication once you get home. 

This is an example on how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days, 
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.  
Then continue with Tylenol for pain.

3)  Do not stop the Tylenol until you are off of the narcotic 
medication. 

ANTICOAGULATION:
- Please continue taking your home Eliquis

WOUND CARE:
- Your incision is covered with a dry dressing. Please change 
the dressing daily. If there is no drainage, you may leave your 
incision open to the air. If you are continuing to have 
drainage, you may place a dry dressing over the incision as 
needed.
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken 
out at your 2-week follow up appointment.

THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
Activity:   Activity:  Activity as tolerated
 Right lower extremity:  Full weight bearing
 Left lower extremity:  Full weight bearing
Encourage turn, cough and deep breathe q2h when awake

Treatments Frequency:
Any staples or superficial sutures you have are to remain in 
place for at least 2 weeks postoperatively.  Incision may be 
left open to air unless actively draining.  If draining, you may 
apply a gauze dressing secured with paper tape.  You may shower 
and allow water to run over the wound, but please refrain from 
bathing for at least 4 weeks postoperatively.

Call your surgeon's office with any questions.  
 

###RESPONSE: INSTRUCTIONS {Education}, SURGERY {Surgical procedure}, surgery {Surgical procedure}, tired {Tired}, washed out {Exhaustion}, after surgery {Postoperative state}, weight bearing {Weight-bearing}, precautions {Safety precautions}, Weight bearing {Weight-bearing}, left lower extremity {Structure of left lower limb}, Do not drink alcohol {Education about alcohol consumption}, pain relievers {Administration of analgesic}, pain relievers {Administration of analgesic}, constipation {Constipation}, take a stool softener {Administration of laxative}, Add your prescribed narcotics as needed {Narcotics education}, increased pain {Increased pain}, Start weaning the narcotic medication once you get home {Narcotics education}, pain {Pain}, Do not stop the Tylenol until you are off of the narcotic 
medication {Narcotics education}, incision {Surgical incision wound}, dressing {Application of dressing}, change 
the dressing {Change of dressing}, drainage {Discharge}, incision {Surgical incision wound}, drainage {Discharge}, dressing {Application of dressing}, incision {Surgical incision wound}, Activity as tolerated {Education about increasing activity tolerance}, Right lower extremity {Structure of right lower limb}, Full weight bearing {Full weight-bearing gait training}, Left lower extremity {Structure of left lower limb}, Full weight bearing {Full weight-bearing gait training}, cough and deep breathe {Deep breathing and coughing exercises}, awake {Awake}, Incision {Surgical incision wound}, draining {Wound discharge}, draining {Wound discharge}, apply a gauze dressing {Application of dressing}, wound {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: 
Penicillins / Amoxicillin
 
Attending: ___.
 
Chief Complaint:
COPD exacerbation
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Penicillins {Allergy to penicillin}, Amoxicillin {Allergy to amoxicillin}, COPD exacerbation {Acute exacerbation of chronic obstructive airways 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: History of Present Illness:
___ w/ COPD p/w shortness of breath. Her symptoms started ___ 
when she felt congested and had a little cough and bad chills. 
Then with progressive SOB, cough, yellow sputum, subjective 
fever. She reports being febrile to 99 at home. Today at ___ O2 
sat 92% and was sent in after 2 nebs. Feels as though a 
bronchial infection is occurring, but not pneumonia (she has had 
both in the past). This is similar to her prior COPD 
exacerbations, of which she has ___ per year, however this is 
her first hospitalization for COPD exacerbation. No sick 
contacts. 

In the ED, initial VS were 98.3 102 114/71 20 94%. Labs were 
remarkable for UA with 45 WBCs/few bacteria, K 3.6, Cr 0.6, mWBC 
8.4, HCT 41. CXR showed evidence of COPD and L apical nodule. 
Received albuterol/ipratropium nebs, 50mg prednisone, 500mg 
azithromycin and was transferred to medicine for further 
management. Transfer VS were 99.0 95 ___ 94% RA.

On arrival to the floor, patient reports that she is no longer 
experiencing fever and chills. Not currently SOB although she 
feels some chest tightness.  She has a slight sore throat 
although this is improved from this AM. Patient is very 
friendly, speaking in full sentences, not on supplemental 
oxygen.

 

###RESPONSE: COPD {Chronic obstructive lung disease}, shortness of breath {Dyspnea}, cough {Cough}, chills {Chill}, SOB {Dyspnea}, cough {Cough}, yellow sputum {Yellow sputum}, fever {Fever}, febrile {Fever}, O2 
sat {Oxygen saturation measurement}, bronchial infection {Infectious disorder of bronchus}, pneumonia {Pneumonia}, COPD 
exacerbations {Acute exacerbation of chronic obstructive airways disease}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, VS {Vital signs finding}, UA {Urinalysis}, CXR {Plain chest X-ray}, COPD {Chronic obstructive lung disease}, L apical {Structure of apex of left lung}, nodule {Nodule of lung}, VS {Vital signs finding}, RA {Breathing room air}, fever {Fever}, chills {Chill}, SOB {Dyspnea}, chest tightness {Tight chest}, sore throat {Sore throat}, 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: Past Medical History:
COPD
MI
Positive PPD
Hyperlipidemia 
Arthritis in bilateral hands 
Coronary artery disease s/p angioplasty with stent 
Bronchiectasis
 

###RESPONSE: COPD {Chronic obstructive lung disease}, MI {Myocardial infarction}, Positive PPD {Mantoux: positive}, Hyperlipidemia {Hyperlipidemia}, Arthritis in bilateral hands {Arthritis of finger of bilateral hand}, Coronary artery disease {Coronary arteriosclerosis}, angioplasty {Angioplasty of blood vessel}, stent {Insertion of arterial stent}, Bronchiectasis {Bronchiectasis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father:  Cancer 
___ Grandmother:  ___ - Type II
 

###RESPONSE: Cancer {Malignant neoplasm}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 98.5  119/66  97  22  92% RA
General: Patient is sitting comfortably in bed, friendly and 
alert, no acute distress
HEENT: MMM
Neck: Supple, non-tender, no lymphadenopathy appreciated  
CV: Clear s1 and s2, irregular rhythm, no murmurs
Lungs: Lungs with decreased breath sounds bilaterally, regular 
respiratory rate and effort
Abdomen: Soft, non distended, nontender, bowel sounds present
GU: Deferred 
Ext: Warn and well perfused, no edema
Neuro: Patient with tremor of hands and head
Skin: No rashes 

DISCHARGE PHYSICAL EXAM 
VS - 97.9  118/79  91  18  98% RA
General: Patient is sitting comfortably in bed, friendly and 
alert, no acute distress
HEENT: MMM
Neck: Supple, non-tender, no lymphadenopathy appreciated  
CV: Regular rate and rhythm, clear s1 and s2, no murmurs
Lungs: Lungs with decreased breath sounds bilaterally, regular 
respiratory rate and effort, prolonged expiratory phase 
Abdomen: Soft, non distended, nontender, bowel sounds present
GU: Deferred 
Ext: Warn and well perfused, no edema
Neuro: Patient with tremor of b/l hands and head
Skin: No rashes 

 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, sitting {Sitting position}, alert {Mentally alert}, distress {Distress}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, non-tender {Abdominal tenderness}, lymphadenopathy {Lymphadenopathy}, CV {Cardiovascular physical examination}, Clear {Normal breath sounds}, s1 and s2 {Heart sounds normal}, irregular rhythm {Irregular heart beat}, murmurs {Murmur}, Lungs {Examination of respiratory system}, Lungs {Examination of respiratory system}, decreased breath sounds {Decreased breath sounds}, regular 
respiratory rate {Respiratory rate normal}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, distended {Swollen abdomen}, nontender {Abdominal tenderness}, bowel sounds present {Normal bowel sounds}, GU {Examination of genitourinary system}, Ext {Examination of limb}, well perfused {Normal tissue perfusion}, edema {Edema}, Neuro {Neurological examination}, tremor {Tremor}, hands {Hand structure}, head {Head structure}, Skin {Examination of skin}, rashes {Eruption of skin}, PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, sitting {Sitting position}, alert {Mentally alert}, distress {Distress}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, non-tender {Abdominal tenderness}, lymphadenopathy {Lymphadenopathy}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, s1 and s2 {Heart sounds normal}, murmurs {Murmur}, Lungs {Examination of respiratory system}, Lungs {Examination of respiratory system}, decreased breath sounds {Decreased breath sounds}, regular 
respiratory rate {Respiratory rate normal}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, distended {Swollen abdomen}, nontender {Abdominal tenderness}, bowel sounds present {Normal bowel sounds}, GU {Examination of genitourinary system}, Ext {Examination of limb}, well perfused {Normal tissue perfusion}, edema {Edema}, Neuro {Neurological examination}, tremor {Tremor}, hands {Hand structure}, head {Head structure}, Skin {Examination of skin}, rashes {Eruption of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 02:36PM BLOOD WBC-8.4 RBC-4.53 Hgb-13.9 Hct-41.0 MCV-91 
MCH-30.7 MCHC-33.9 RDW-12.2 Plt ___
___ 02:36PM BLOOD Neuts-79.1* Lymphs-11.3* Monos-7.5 
Eos-1.4 Baso-0.7
___ 02:36PM BLOOD Plt ___
___ 02:36PM BLOOD Glucose-159* UreaN-17 Creat-0.6 Na-142 
K-3.6 Cl-100 HCO3-32 AnGap-14

IMAGING:
CXR ___
PA and lateral views of the chest.  The lungs are hyperinflated. 
 There is asymmetric left apical pulmonary opacity worrisome for 
underlying nodule.  Surgical chain sutures seen in the right mid 
lung.  There is also subtle increased opacity projecting over 
the right breast shadow, anteriorly on the lateral view.  The 
cardiomediastinal silhouette is within normal limits.  No acute 
osseous abnormality is identified. 
  
IMPRESSION:   
Findings compatible with COPD.  Subtle asymmetric right basilar 
opacity potentially in the middle lobe which could represent 
atelectasis or scarring however infection cannot be totally 
excluded. 
  
Findings worrisome for left apical pulmonary nodule for which 
dedicated nonurgent chest CT is suggested.  

DISCHARGE LABS:
___ 07:55AM BLOOD WBC-8.2 RBC-4.80 Hgb-14.7 Hct-43.1 MCV-90 
MCH-30.6 MCHC-34.1 RDW-12.2 Plt ___
___ 07:55AM BLOOD Plt ___
___ 07:55AM BLOOD Glucose-113* UreaN-14 Creat-0.6 Na-144 
K-4.0 Cl-101 HCO3-30 AnGap-17

MICROBIOLOGY:
___ URINE CULTURES: no growth (final)
___ BLOOD CULTURES: no growth (final)

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, 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}, CXR {Plain chest X-ray}, lungs {Lung structure}, hyperinflated {Chest over-expanded}, left apical pulmonary {Structure of apex of left lung}, opacity {Abnormally opaque structure}, nodule {Nodule}, lung {Lung structure}, opacity {Abnormally opaque structure}, right breast {Right breast structure}, shadow {Shadow}, lateral {Diagnostic radiography of chest, lateral}, osseous {Bone structure}, COPD {Chronic obstructive lung disease}, right basilar {Structure of base of right lung}, opacity {Abnormally opaque structure}, middle lobe {Structure of middle lobe of right lung}, atelectasis {Atelectasis}, scarring {Healing scar}, infection {Infectious disease}, left apical {Structure of apex of left lung}, pulmonary nodule {Nodule of lung}, chest CT {Computed tomography of chest}, 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}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ year old woman with a history of COPD, bronchiectasis, CAD 
s/p MI with stent, among other medical issues who presented with 
shortness of breath and increased cough and sputum production 
consistent with her prior COPD flares.

ACTIVE DIAGNOSES:

# COPD exacerbation: Patient presented with symptoms similar to 
her prior COPD exacerbations. Cannot exclude infectious etiology 
however white count non-elevated, CXR consistent w/COPD. 
Throughout the admission the patient has not needed supplemental 
O2. She was treated with steroids, azithromycin, and PRN nebs. 
Azithromycin was transitioned to doxycycline prior to discharge. 
She remained stable with no worsening of symptoms. At time of 
discharge, she is able to ambulate safely with a O2 sat in mid 
90's. As her symptoms were not progressing and she was 
saturating well on room air, we discharged her to follow-up with 
PCP for further care. Of note, she asked us to provide her with 
home nebulizer machine. We did not feel that was necessary. We 
provided her with prescription for MDI plus spacer and urged her 
to speak with her PCP if she believes she would benefit from 
home nebulizer machine. 

# Nausea: Patient complained of some morning nausea, with no 
clear etiology. She noted that she would feel better after 
eating or having her morning coffee. She received IV zofran PRN 
for the nausea. No emesis on this admission. It had resolved by 
time of discharge.

CHRONIC DIAGNOSES: 

# CAD: Her home medications of metoprolol succinate and aspirin 
162 daily were continued continued on this stay. She did not 
have any chest pain or symptoms suggestive of cardiac origin for 
her shortness of breath or nausea.

# Lung nodule: Patient has known lung nodules which have been 
documented on prior CT scan. Nodule found incidentally on CXR, 
and per report of location seems that it may be consistent with 
location of previously known nodules. We recommended that this 
be followed up on an outpatient basis. Radiology recommended a 
non-urgent CT, however they may not have been aware that pt 
already has known lung lesions being followed by serial CTs. As 
above, patient has a significant smoking history.

# Tremor: Pt with resting tremor in b/l hands and head, she has 
not noticed it before. Husband has noticed and says it is not 
new. Patient was surprised when it was brought up, however it 
may be exacerbated by nebs and not as prominent at baseline. 
Most likely essential tremor, however we recommend outpatient 
follow-up by PCP for further evaluation.  

TRANSITIONAL ISSUES:

# We recommend continued outpatient follow-up of lung lesions

# Tremor is likely benign, however may need to be evaluated 
further
 

###RESPONSE: COPD {Chronic obstructive lung disease}, bronchiectasis {Bronchiectasis}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, stent {Insertion of arterial stent}, shortness of breath {Dyspnea}, cough {Cough}, sputum production {Productive cough}, COPD {Chronic obstructive lung disease}, COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, COPD exacerbations {Acute exacerbation of chronic obstructive airways disease}, infectious {Infectious disease}, CXR {Plain chest X-ray}, COPD {Chronic obstructive lung disease}, stable {Patient's condition stable}, able to ambulate {Able to walk}, O2 sat {Oxygen saturation measurement}, on room air {Breathing room air}, nebulizer {Nebulizer therapy}, nebulizer {Nebulizer therapy}, Nausea {Nausea}, IV {Administration of drug or medicament via intravenous route}, nausea {Nausea}, emesis {Vomiting}, CAD {Coronary arteriosclerosis}, medications {Prescription of drug}, chest pain {Chest pain}, cardiac {Heart structure}, shortness of breath {Dyspnea}, nausea {Nausea}, Lung nodule {Nodule of lung}, lung nodules {Nodule of lung}, CT scan {Computed tomography}, Nodule {Nodule}, CXR {Plain chest X-ray}, nodules {Nodule}, followed up on an outpatient basis {Outpatient care management}, CT {Computed tomography}, lung lesions {Lesion of lung}, CTs {Computed tomography}, smoking {Smoker}, Tremor {Tremor}, resting tremor {Resting tremor}, hands {Hand structure}, head {Head structure}, essential tremor {Essential tremor}, outpatient 
follow-up {Outpatient care management}, evaluation {Evaluation procedure}, outpatient follow-up {Outpatient care management}, lung lesions {Lesion of lung}, Tremor {Tremor}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 
2. Lorazepam 1 mg PO HS:PRN Insomnia 
3. ipratropium-albuterol ___ mcg/actuation Inhalation 4 times 
daily PRN SOB/wheezing 
4. Metoprolol Succinate XL 25 mg PO DAILY 
5. Atorvastatin 40 mg PO DAILY 
6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation 
Inhalation 2 puffs twice daily 
7. Aspirin 162 mg PO DAILY 
8. Nitroglycerin SL 0.3 mg SL PRN chest pain 

 
Discharge Medications:
1. PredniSONE 40 mg PO DAILY Duration: 3 Days 
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*6 
Tablet Refills:*0
2. Aspirin 162 mg PO DAILY 
3. Atorvastatin 40 mg PO DAILY 
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 
5. Lorazepam 1 mg PO HS:PRN Insomnia 
6. Metoprolol Succinate XL 25 mg PO DAILY 
7. ipratropium-albuterol ___ mcg/actuation Inhalation 4 times 
daily PRN SOB/wheezing 
8. Nitroglycerin SL 0.3 mg SL PRN chest pain 
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation 
Inhalation 2 puffs twice daily 
10. Doxycycline Hyclate 100 mg PO Q12H Duration: 3 Days 
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every 
twelve (12) hours Disp #*6 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:
COPD exacerbation

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: COPD exacerbation {Acute exacerbation of chronic obstructive airways disease}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,

It was a pleasure taking care of you at ___. You were admitted 
to the hospital for evaluation and management of your COPD 
exacerbation, after you presented to your Primary Care Physician 
with increased shortness of breath and productive cough.  While 
here, you were given antibiotics, steroids, and nebulizer 
treatments and monitored overnight. You have not needed any 
supplemental oxygen, and are walking around without significant 
shortness of breath. 

As your oxygen levels have been adequate and your symptoms have 
not worsened, you are being discharged to continue your recovery 
at home. We are discharging you with 3 days of antibiotics and 
steroids to continue at home. 

Thank you for allowing us to participate in your care.
 

###RESPONSE: COPD 
exacerbation {Acute exacerbation of chronic obstructive airways disease}, shortness of breath {Dyspnea}, productive cough {Productive cough}, antibiotics {Antibiotic therapy}, steroids {Steroid therapy}, nebulizer 
treatments {Nebulizer therapy}, shortness of breath {Dyspnea}, antibiotics {Antibiotic therapy}, steroids {Steroid therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___.                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
Chest pain
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Chest pain {Chest pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ h/o HCV cirrhosis s/p OLT ___ who presents with chest 
discomfort and ___. Patient states that yesterday (___) he 
developed sharp pleuritic type chest pain that was worse with 
deep inspiration. He has never had pain like this before. Pain 
did not travel. It persisted for at least one day and prompted 
him to present to outside hospital. There an EKG was negative 
for acute ischemia and initial troponin was reported as 
indeterminate near his baseline. Due to elevated creatinine, 
patient was unable to undergo CTA and was transferred here. 
Patient with history of liver transplant ___ years ago and 
infected hardware in the left knee that has been removed several 
months ago while he waits for a new knee repair. Currently 
anticoagulated with Coumadin for history of PE and atrial 
fibrillation. Patient states he does not remember what his prior 
PE felt like. In the ED his CP resolved. On arrival to the floor 
he complained only of right Knee pain for which he receives high 
doses of narcotics at his rehab. He reports pain is ___ 
currently compared to ___ yesterday, but he will not beable to 
sleep with this level of pain.  

In the ED, initial vitals were:  
98.2 67 123/68 19 99% 2L Nasal Cannula  
- Labs were significant for  
CBC  
5.5 9.7 199  
28.6  
N:70.5 L:22.1 M:7.1 E:0 Bas:0.___.0 PTT: 37.1 INR: 3.4  
Trop-T: 0.13  
Chem 7  
131 94 72  
------------<125  
4.4 26 2.2  
ALT: 25 AP: 129 Tbili: 0.8 Alb: 3.0  
AST: 12  
- Imaging revealed  
OSH CXR was without consolidation  
ECG was Afib with RBBB stable from ___  
 
-The patient was given  
0.5 mg IV dilaudid x 1  
Vitals prior to transfer were:  
97.8 66 136/68 18 98% RA  
Upon arrival to the floor,  
T 97.8 BP 92/50 p 61 R 18 98% On RA  

REVIEW OF SYSTEMS:  
(+) Per HPI Of not he has not urinated in 12 hours  
(-) Chest paint resolved in ED Denies fever, chills, night 
sweats, recent weight loss or gain. Denies headache, sinus 
tenderness, rhinorrhea or congestion. Denies cough, shortness of 
breath. Denies chest pain or tightness, palpitations. Denies 
nausea, vomiting, diarrhea, constipation or abdominal pain. No 
recent change in bowel habits. No dysuria. 
 

###RESPONSE: HCV cirrhosis {Cirrhosis of liver due to chronic hepatitis C}, OLT {Orthotopic transplantation of whole liver}, chest 
discomfort {Chest discomfort}, sharp {Sharp pain}, pleuritic {Pleuritic pain}, chest pain {Chest pain}, worse {Increased pain}, pain {Pain}, Pain 
did not travel {Radiating chest pain}, EKG {Electrocardiographic procedure}, acute ischemia {Acute myocardial ischemia}, troponin {Troponin measurement}, baseline {Baseline state}, elevated creatinine {Serum creatinine above reference range}, CTA {Computed tomography angiography with contrast}, liver transplant {Transplantation of liver}, left knee {Structure of left knee region}, removed {Removal}, knee repair {Arthroplasty of knee}, anticoagulated with Coumadin {Anticoagulant therapy}, PE {Pulmonary embolism}, atrial 
fibrillation {Atrial fibrillation}, PE {Pulmonary embolism}, resolved {Problem resolved}, right Knee {Structure of right knee region}, narcotics {Narcotherapy}, pain {Pain}, pain {Pain}, vitals {Vital signs finding}, Nasal Cannula {Oxygen administration by nasal cannula}, Labs {Laboratory test}, CBC {Complete blood count}, INR {Calculation of international normalized ratio}, Trop {Troponin measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, Imaging {Imaging}, CXR {Plain chest X-ray}, consolidation {Consolidation}, ECG {Electrocardiographic procedure}, Afib {Atrial fibrillation}, RBBB {Electrocardiographic right bundle branch block}, stable {Patient's condition stable}, IV {Intravenous therapy}, RA {Breathing room air}, RA {Breathing room air}, REVIEW OF SYSTEMS {Review of systems}, urinated {Micturition finding}, Chest paint {Chest pain}, resolved {Problem resolved}, fever {Fever}, chills {Chill}, night 
sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, headache {Headache}, sinus 
tenderness {Tenderness over frontal sinus}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, Denies cough {Does not cough}, shortness of 
breath {Dyspnea}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, change in bowel habits {Altered bowel function}, dysuria {Dysuria}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1. Hep C Cirrhosis s/p transplant at ___ on ___  
-- Discharged from ___, presented to ___ 8 weeks post op for  
prolonged hosp stay complicated by encephalopathy (due to  
cyclosporine and tacrolimus), transient ischemic attack,  
neutropenia, thrombocytopenia, mild acute rejection, acute  
kidney injury, hypertension (cyclosporine related), recurrent c.
difficile infection, and lower extremity edema  
-- ___: portal vein thrombus with found incidental PE. U/S  
of ___ negative for DVT. No anticoag at that time d/t bleeding  
risk.  
-- ___: Pt admitted to OSH with left ___ DV (fem-pop).  
Preceded by episode of imobility from hospitalization for  
pneumonia. Pt started on coumadin since this time with INR goal 
___.  
-- ___: left DVT in the setting of seemingly on  
therapeutic anticoagulation with coumadin  
-- BM suppression posttransplant: ___ BM Aspirate dyspoiesis 
with myeloid and erythroid lineages along with megakaryocytic 
hyperplasia  
-- Posttransplant skin cancer: scalp lesion/squamous cell  
carcinoma, R distal dorsal arm/squamous cell carcinoma, L  
chest/basal cell carcinoma (s/p MOHs)  
-- pseudogout, knee aspiration, s/p steroid injection  
-- ___ edema, started lasix ___  
2. H/O Esophageal varices, PVT prior to transplant: Most recent 
BI records with ___ EGD without varicies  
3. AVNRT s/p ablation in ___  
4. Atrial fibrillation: failed CV immed post-tx, on coumadin  
5. Melanoma status post excision in 1980s  
6. Septic meningitis in ___  
7. Osteoarthritis in the knees status post arthroscopy and left 
knee replacement c/b septic joint on abx in ___.  
8. Aphthous stomatitis  
9. Asthma  
10. GERD  
11. High tibial osteotomy  
12. s/p bilaterally cataract extraction  
13. s/p Appendectomy  
14. C. diff several times (4x) in ___ prior to transplant  
15. History of CMV viremia.  
16. History of acute rejection of a liver transplant.  
 

###RESPONSE: Hep C Cirrhosis {Cirrhosis of liver due to chronic hepatitis C}, transplant {Transplantation of liver}, post op {Postoperative state}, encephalopathy {Disorder of brain}, transient ischemic attack {Transient ischemic attack}, neutropenia {Neutropenia}, thrombocytopenia {Thrombocytopenic disorder}, mild acute rejection {Acute rejection of liver transplant}, acute  
kidney injury {Acute kidney injury}, hypertension {Hypertensive disorder, systemic arterial}, recurrent c.
difficile infection {Recurrent infection caused by Clostridioides difficile}, lower extremity edema {Edema of lower extremity}, portal vein thrombus {Portal vein thrombosis}, PE {Pulmonary embolism}, S {Ultrasonography}, negative {No pathologic diagnosis}, DVT {Deep venous thrombosis}, bleeding  
risk {At increased risk of hemorrhage}, imobility {Musculoskeletal immobility}, pneumonia {Pneumonia}, INR {Calculation of international normalized ratio}, DVT {Deep venous thrombosis}, anticoagulation {Anticoagulant therapy}, BM suppression {Myelosuppression}, BM Aspirate {Bone marrow aspiration procedure}, dyspoiesis {Dyserythropoiesis}, megakaryocytic 
hyperplasia {Megakaryocytic hyperplasia of bone marrow}, skin cancer {Malignant neoplasm of skin}, scalp lesion {Lesion of scalp}, squamous cell  
carcinoma {Squamous cell carcinoma}, R {Right upper arm structure}, dorsal arm {Structure of posterior surface of upper arm}, squamous cell carcinoma {Squamous cell carcinoma of skin}, L  
chest {Structure of left half of chest wall}, basal cell carcinoma {Basal cell carcinoma}, MOHs {Mohs surgery}, pseudogout {Chondrocalcinosis due to pyrophosphate crystals}, knee aspiration {Aspiration of knee joint}, steroid injection {Injection of steroid}, edema {Edema}, lasix {Diuretic therapy}, Esophageal varices {Esophageal varices}, PVT {Portal vein thrombosis}, transplant {Transplantation}, EGD {Esophagogastroduodenoscopy}, varicies {Venous varices}, AVNRT {Re-entrant atrioventricular node tachycardia}, ablation {Destructive procedure}, Atrial fibrillation {Atrial fibrillation}, failed CV {Heart failure}, Melanoma {Malignant melanoma of skin}, excision {Excision of melanoma}, Septic meningitis {Infective meningitis}, Osteoarthritis in the knees {Osteoarthritis of knee}, arthroscopy {Arthroscopy of knee joint}, left 
knee replacement {Total replacement of left knee joint}, septic joint {Arthritis of knee}, Aphthous stomatitis {Aphthous ulcer of mouth}, Asthma {Asthma}, GERD {Gastroesophageal reflux disease}, tibial osteotomy {Osteotomy of tibia}, bilaterally cataract extraction {Extraction of cataract of bilateral eyes}, Appendectomy {Excision of appendix}, transplant {Transplant of kidney}, CMV viremia {Cytomegalovirus viremia}, acute rejection of a liver transplant {Acute rejection of liver transplant}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
The patient's father had bilateral lower extremity amputations 
but had no clots prior to the surgery. There is no history of 
VTE in the family. There is no history of miscarriages in the 
family either. 

 

###RESPONSE: bilateral lower extremity amputations {Amputation of bilateral lower limbs}, clots {Blood clot}, surgery {Surgical procedure}, VTE {Thromboembolism of vein}, miscarriages {Miscarriage}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION EXAM:  
================
Vitals: T 97.8 BP 92/50 p 61 R 18 98% On RA  
General: Alert, oriented, mildly distraught regarding right knee 
pain  
HEENT: Sclera anicteric, dry oropharynx, EOMI  
Neck: Supple  
CV: Regular rate and rhythm, ___ SEM at apex  
Lungs: Clear to auscultation bilaterally, no wheezes, rales, 
rhonchi  
Abdomen: obese, soft,  
Ext: Cool, pitting edema to sacrum bilaterally, R knee non ttp 
but tender to flexion/extension and varous/valgus stress  
Neuro: A+Ox3 ___ motor exam limited ___ pain  

DISCHARGE EXAM:
================
Vitals: T 97.5, HR 81, BP 179/95, RR 22, SaO2 99% RA
General: Alert, oriented, NAD, chronically ill-appearing 
HEENT: Sclera anicteric, oropharynx wnl, MMM, EOMI  
Neck: Supple, no JVD 
CV: Irregular rhythm, normal rate, no murmurs
Lungs: Limited exam, clear to auscultation anteriorly
Abdomen: +BS, obese, soft, nontender, nondistended  
Ext: WWP, ___ pitting edema bilaterally, compression dressings 
in place. L knee in brace.
Neuro: Oriented to self, place, and year (not day or month), no 
asterixis, ___ motor exam limited ___ pain, sensation to light 
touch intact
 

###RESPONSE: Vitals {Vital signs finding}, BP {Blood pressure finding}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, right knee {Structure of right knee region}, pain {Pain}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, oropharynx {Oropharyngeal structure}, EOMI {Normal ocular motility}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, SEM {Ejection murmur}, apex {Structure of apex of heart}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Abdomen {Examination of abdomen}, obese {Obese abdomen}, soft {Abdomen soft}, Ext {Examination of limb}, Cool {Cool skin}, edema {Edema}, sacrum {Structure of sacral vertebral column}, R knee {Structure of right knee region}, ttp {Tenderness}, tender {Abdominal tenderness}, flexion {Flexion test}, extension {Abnormal extension}, varous/valgus stress {Adduction test of knee}, Neuro {Neurological examination}, Ox3 {Oriented to person, time and place}, motor exam {Motor testing}, pain {Pain}, Vitals {Vital signs finding}, SaO2 {Finding of oxygen saturation}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, NAD {No abnormality detected}, ill-appearing {Looks ill}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, oropharynx {Oropharyngeal structure}, MMM {Moist oral mucosa}, EOMI {Normal ocular motility}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVD {Jugular venous engorgement}, CV {Cardiovascular physical examination}, Irregular rhythm {Irregular heart beat}, normal rate {Normal heart rate}, murmurs {Heart murmur}, Lungs {Examination of respiratory system}, exam {Lung finding}, clear to auscultation {Normal breath sounds}, Abdomen {Examination of abdomen}, +BS {Normal bowel sounds}, obese {Obese abdomen}, soft {Abdomen soft}, nontender {Abdominal tenderness}, nondistended {Normal abdominal contour}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, pitting edema {Pitting edema}, L knee {Structure of left knee region}, Neuro {Neurological examination}, Oriented to self, place, and year {Oriented to person, time and place}, asterixis {Asterixis}, motor exam {Motor testing}, pain {Pain}, sensation to light 
touch intact {Light touch sensation 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 LABS:
================
___ 12:20AM BLOOD WBC-5.5 RBC-3.23* Hgb-9.7* Hct-28.6* 
MCV-89 MCH-30.2 MCHC-34.1 RDW-16.3* Plt ___
___ 12:20AM BLOOD Neuts-70.5* ___ Monos-7.1 Eos-0 
Baso-0.2
___ 12:20AM BLOOD ___ PTT-37.1* ___
___ 12:20AM BLOOD Plt ___
___ 12:20AM BLOOD Glucose-125* UreaN-72* Creat-2.2* Na-131* 
K-4.4 Cl-94* HCO3-26 AnGap-15
___ 12:20AM BLOOD ALT-25 AST-12 AlkPhos-129 TotBili-0.8
___ 12:20AM BLOOD CK-MB-1 cTropnT-0.13*
___ 05:40AM BLOOD CK-MB-1 cTropnT-0.14*
___ 09:45AM BLOOD CK-MB-2 cTropnT-0.15*
___ 12:20AM BLOOD Albumin-3.0*
___ 05:40AM BLOOD Albumin-3.0* Calcium-9.1 Phos-4.1 Mg-1.6
___ 05:40AM BLOOD Osmolal-300
___ 05:40AM BLOOD Cyclspr-80*
___ 02:46PM URINE Color-LtAmb Appear-SlHazy Sp ___
___ 02:46PM URINE Blood-NEG Nitrite-NEG Protein-30 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 02:46PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 02:46PM URINE CastHy-8*
___ 02:46PM URINE Mucous-OCC
___ 02:46PM URINE Hours-RANDOM Creat-139 Na-15 K-63 Cl-<10
___ 02:46PM URINE Osmolal-369

OTHER PERTINENT LABS:
======================
___ 05:45AM BLOOD Cyclspr-157
___ 08:00AM BLOOD Cyclspr-114
___ 05:35AM BLOOD Cyclspr-140
___ 08:55AM BLOOD Cyclspr-339
___ 04:47AM BLOOD Cyclspr-77*
___ 05:40AM BLOOD Cyclspr-86*
___ 05:24AM BLOOD Cyclspr-81*
___ 06:40AM BLOOD Cyclspr-82*

DISCHARGE LABS:
================
___ 05:40AM BLOOD WBC-4.5 RBC-3.08* Hgb-9.1* Hct-27.4* 
MCV-89 MCH-29.5 MCHC-33.1 RDW-15.6* Plt ___
___ 05:40AM BLOOD ___ PTT-36.1 ___
___ 05:40AM BLOOD Glucose-121* UreaN-57* Creat-2.1* Na-130* 
K-4.3 Cl-91* HCO3-33* AnGap-10
___ 05:40AM BLOOD ALT-12 AST-9 AlkPhos-133* TotBili-0.8
___ 05:40AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.7

MICROBIOLOGY:
==============
___ 11:48 pm URINE      Source: Catheter. 

**FINAL REPORT ___

URINE CULTURE (Final ___: 
PROTEUS MIRABILIS.    >100,000 ORGANISMS/ML.. 
PRESUMPTIVE IDENTIFICATION. 

SENSITIVITIES: MIC expressed in MCG/ML
                      
_________________________________________________________
                             PROTEUS MIRABILIS
                             |   
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--     8 S
CEFAZOLIN-------------    16 R
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----  =>16 R

___ 2:46 pm URINE      Source: Catheter. 

URINE CULTURE (Final ___:    NO GROWTH. 
Blood Culture, Routine (Final ___:    NO GROWTH. 

IMAGING:
=========
TTE (___):
The left atrium is elongated. The right atrium is moderately 
dilated. No atrial septal defect is seen by 2D or color Doppler. 
There is mild symmetric left ventricular hypertrophy with normal 
cavity size and regional/global systolic function (LVEF>55%). 
There is no ventricular septal defect. Right ventricular chamber 
size and free wall motion are normal. 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. Mild (1+) mitral 
regurgitation is seen. The tricuspid valve leaflets are mildly 
thickened. There is mild pulmonary artery systolic hypertension. 
There is a small pericardial effusion. There are no 
echocardiographic signs of tamponade. 
Compared with the prior study (images reviewed) of ___, 
the degree of MR seen has decreased. AS is not appreciated.  

CXR (___):
There is a right-sided PICC line terminating in the mid SVC.  
Patient rotation contributes to exaggeration of the cardiac 
size, which is likely normal. Segmental atelectasis is noted, 
particular in the right lung, although there does appear to be 
new pulmonary edema superimposed on this. There may be small 
tiny effusions. There is no pneumothorax. 

Renal U/S (___):
IMPRESSION:  
1. No evidence of hydronephrosis. 
2. Extremely limited Doppler evaluation due to technically 
limited study, 
demonstrating both kidneys to be vascularized.  No further 
Dopp;er analysis could be obtained. 
 

###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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, Albumin {Albumin measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Nitrite {Nitrite measurement}, Protein {Measurement of protein in urine}, Glucose {Glucose measurement, urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, URINE {Urinalysis}, RBC {Red blood cell count}, WBC {White blood cell count}, Bacteri {Bacteriuria}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, URINE {Urinalysis}, 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}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, URINE {Urine culture}, URINE CULTURE {Urine culture}, SENSITIVITIES {Antimicrobial susceptibility test}, URINE {Urine culture}, URINE CULTURE {Urine culture}, Blood Culture {Blood culture}, left atrium is elongated {Left atrial enlargement}, right atrium is moderately 
dilated {Right atrial dilatation}, atrial septal defect {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, normal 
cavity {Normal size cardiac chamber}, regional/global systolic function {Normal left ventricular systolic function and wall motion}, ventricular septal defect {Ventricular septal defect}, Right ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Normal 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 cardiac valve leaflet}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, Mild (1+) aortic regurgitation {Mild mitral valve regurgitation}, mitral 
valve leaflets are mildly thickened {Thickened mitral leaflet}, Mild (1+) mitral 
regurgitation {Mild mitral valve regurgitation}, tricuspid valve leaflets {Structure of leaflet of tricuspid valve}, pulmonary artery systolic hypertension {Pulmonary hypertensive arterial disease}, pericardial effusion {Pericardial effusion}, echocardiographic {Echocardiography}, signs {Sign}, tamponade {Cardiac tamponade}, MR {Mitral valve regurgitation}, PICC line {Peripherally inserted central venous catheter in situ}, SVC {Superior vena cava structure}, cardiac {Heart structure}, normal {Normal appearance}, atelectasis {Atelectasis}, right lung {Right lung structure}, pulmonary edema {Pulmonary edema}, effusions {Pleural effusion}, pneumothorax {Pneumothorax}, No evidence {No abnormality detected}, hydronephrosis {Hydronephrosis}, evaluation {Evaluation procedure}, both kidneys {Both kidneys}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Mr. ___ is a ___ gentleman with HCV cirrhosis ___ years 
s/p OLD and h/o DVT and PE (on Coumadin) who was transferred 
from an OSH with chest pain, which resolved on admission, but 
found to have supratherapeutic INR and ___.

# Acute on chronic kidney disease:  Cr up to 2.2 on admission 
from baseline of 1.4-1.5.  Cr rose to 2.7 after albumin/IVF 
boluses.  Muddy brown casts were seen on urine sediment.  Per 
renal, multiple hypotensive episodes and bradycardia likely 
resulted in ATN.  Patient's creatinine slowly improved after 
starting diuretics.  Cr on discharge was 2.1.  Kidney function 
is expected to recover with time.

# Anasarca:  Patient was grossly anasarcic after being volume 
resuscitated with albumin for hypotension.  TTE was largely 
unchanged.  Patient was diuresed with 40-80 mg IV Lasix/day and 
his edema improved.  He was discharged on torsemide 40 mg po 
daily.

# Hepatitis C cirrhosis s/p OLT:  Transplanted in ___, on 
cyclosporine 75 mg q12h.  MMF was stopped in clinic in 
___ and LFTs remained normal.  HCV VL 342,000 IU/mL on 
___.  Last biopsy was performed at previous admission 
revealed Grade ___ inflammation, no acute cellular rejection, no 
steatosis or ballooning, and stage ___ fibrosis.   Atovaquone 
was continued for prophylaxis.  Cyclosporine was decreased to 50 
mg q12h and levels were monitored.

# Supratherapeutic INR:  Patient's Coumadin was held on 
admission for supratherapeutic INR.  He received vitamin K for 
INR 5.2 and INR then became subtherapeutic.  Warfarin was 
restarted with a heparin gtt until INR became therapeutic.  INR 
became supratherapeutic again and Coumadin dose was adjusted.  
INR on discharge was 3.6.  He was discharged on Coumadin 1 mg 
daily.

# Hypertension:  Patient was initially hypotensive and losartan 
and diuretics were held.  He received an albumin bolus with 
improvement in his blood pressure.  He then became hypertensive 
during the latter part of his hospitalization (SBP up to 
170/180s).  Losartan continued to be held given ___.  Patient 
was started on amlodipine 5 mg daily, which can be uptitrated as 
needed.

# Prior left knee infection s/p hardware removal in ___:  
Patient has chronic pain related to his previous knee 
infection/hardware removal.  He also has shallow venous stasis 
ulcers on bilateral lower extremities.  Patient's orthopedic 
surgeon plans to replace his knee hardware once his ulcers have 
healed and his leg swelling has resolved.  Patient's pain was 
well-controlled on home Oxycontin and po Dilaudid.  He became 
confused after receiving IV Dilaudid, so this was avoided.   

# Catheter-associated UTI:  Initial urine culture was negative.  
Repeat urine culture after catheter was placed grew >100,000 
Klebsiella sensitive to ceftriaxone.  Foley was exchanged and 
patient completed a 7 day course of ceftriaxone.  Foley was 
removed prior to discharge.

# Chest Pain:  Patient had chest pain at OSH, which resolved on 
admission here.  No ischemic changes on EKG and three sets of 
cardiac enzymes were negative.  Considered PE, especially given 
h/o prior PE, but patient had been therapeutic on Coumadin.  CTA 
was deferred given ___.

# Atrial fibrillation/pauses:  Not on agents for rate or rhythm 
control.  During last admission (___), patient was 
bradycardic at night with ___ second pauses seen on telemetry. 
 Patient continued to have pauses with HR ___, though rates 
improved to ___ without intervention.  It is unclear if these 
pauses are contributing to hypotensive episodes.  Patient is 
followed by Dr. ___ have further outpatient EP 
evaluation if warranted. 
 
# Hyponatremia:  Na persistently low (as low as 130s), which is 
chronic per review of prior discharge summaries.  Hyponatremia 
neither responded to nor worsened with albumin or diuretics.

TRANSITIONAL ISSUES:
=====================
[ ] Please check labs (CBC, CMP, LFTs, cyclosporine level, INR, 
and PTT) on ___. Send labs to the ___ at ___ 
___.
[ ] INR 3.6 on discharge. Please hold Coumadin on ___. 
Restart Coumadin at 1 mg daily on ___. Recheck INR on 
___. Goal INR 2.0-3.0
[ ] Patient was started on torsemide 40 mg daily for leg edema. 
This should be decreased/discontinued if kidney function 
worsens.
[ ] Losartan held given ___. Amlodipine 5 mg daily started for 
hypertension. Uptitrate to 10 mg daily as needed for blood 
pressure.
[ ] Cyclosporine dose decreased from 75 mg q12h to 50 mg q12h.
[ ] Patient is followed by Dr. ___. Consider further 
evaluation of bradycardia/pauses if indicated (note: bradycardia 
improved, pauses persisted)
[ ] Patient will have follow-up scheduled with orthopedics and 
neurology (for pre-op clearance, per ortho). Ortho plans to 
replace his left knee after venous stasis ulcers have healed and 
after lower extremity swelling has resolved.
[ ] PICC kept in place given need for frequent lab draws. 
# Code: Full (confirmed) 
# Emergency contact/HCP: ___ (wife) ___
 

###RESPONSE: HCV cirrhosis {Cirrhosis of liver due to chronic hepatitis C}, OLD {Orthotopic liver transplant}, DVT {Deep venous thrombosis}, PE {Pulmonary embolism}, chest pain {Chest pain}, resolved {Problem resolved}, INR {Calculation of international normalized ratio}, Acute on chronic kidney disease {Acute-on-chronic renal failure}, Cr {Finding of creatinine level}, baseline {Baseline state}, Cr {Finding of creatinine level}, albumin {Administration of albumin}, IVF {Administration of intravenous fluids}, casts {Cast}, hypotensive episodes {Hypotensive episode}, bradycardia {Bradycardia}, ATN {Acute tubular necrosis}, creatinine {Creatinine measurement}, improved {Patient's condition improved}, diuretics {Diuretic therapy},  Cr {Finding of creatinine level}, Kidney function {Renal function monitoring}, Anasarca {Anasarca}, anasarcic {Anasarca}, resuscitated {Resuscitation}, albumin {Administration of albumin}, hypotension {Low blood pressure}, TTE {Transthoracic echocardiography}, diuresed {Diuretic therapy}, edema {Edema}, improved {Patient's condition improved}, Hepatitis C cirrhosis {Cirrhosis of liver due to chronic hepatitis C}, OLT {Orthotopic transplantation of whole liver}, Transplanted {Transplantation of liver}, LFTs {Hepatic function panel}, HCV {Viral hepatitis type C}, VL {Viral load}, biopsy {Biopsy}, inflammation {Inflammatory disorder}, acute cellular rejection {Acute cellular graft rejection}, steatosis {Steatosis}, fibrosis {Fibrosis}, prophylaxis {Preventive procedure}, monitored {Monitoring procedure}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, Warfarin {Warfarin therapy}, restarted {Restart of medication}, heparin {Heparin therapy}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, Hypertension {Hypertensive disorder, systemic arterial}, hypotensive {Low blood pressure}, diuretics {Diuretic therapy}, albumin {Administration of albumin}, improvement {Patient's condition improved}, blood pressure {Blood pressure finding}, hypertensive {Hypertensive disorder, systemic arterial}, SBP {Increased systolic arterial pressure}, left knee {Structure of left knee region}, infection {Infectious disease}, hardware removal {Removal of device}, chronic pain {Chronic pain}, knee {Structure of left knee region}, infection {Infectious disease}, hardware removal {Removal of device}, venous stasis 
ulcers on bilateral lower extremities {Venous ulcer of lower limb}, knee {Structure of left knee region}, ulcers {Ulcer}, leg swelling {Leg swelling symptom}, resolved {Problem resolved}, pain was 
well-controlled {Demonstrates adequate pain control}, confused {Clouded consciousness}, IV {Intravenous therapy}, Catheter-associated UTI {Urinary tract infection associated with catheter}, urine culture was negative {Urine culture - no growth}, urine culture {Urine culture}, catheter was placed {Catheterization}, Foley {Catheterization of urinary bladder}, exchanged {Replacement procedure}, Foley was 
removed {Removal of urinary bladder catheter}, Chest Pain {Chest pain}, chest pain {Chest pain}, resolved {Problem resolved}, No ischemic changes {Electrocardiogram: no myocardial ischemia}, EKG {Electrocardiographic procedure}, cardiac enzymes were negative {Cardiac enzymes within reference range}, PE {Pulmonary embolism}, PE {Pulmonary embolism}, CTA {Computed tomography angiography with contrast}, Atrial fibrillation {Atrial fibrillation}, rate {Finding of heart rate}, rhythm {Normal sinus rhythm}, bradycardic {Bradycardia}, pauses {Heart block}, telemetry {Cardiac telemetry}, pauses {Heart block}, HR {Finding of heart rate}, rates {Finding of heart rate}, improved {Patient's condition improved}, hypotensive episodes {Hypotensive episode}, EP {Cardiac electrophysiology}, evaluation {Evaluation procedure}, Hyponatremia {Hyponatremia}, chronic {Chronic disease}, Hyponatremia {Hyponatremia}, worsened {Patient's condition worsened}, albumin {Administration of albumin}, diuretics {Diuretic therapy}, CBC {Complete blood count}, LFTs {Hepatic function panel}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, hold {Recommendation to stop drug treatment}, Restart {Restart of medication}, INR {Calculation of international normalized ratio}, INR {Calculation of international normalized ratio}, leg edema {Edema of lower leg}, discontinued {Recommendation to stop drug treatment}, kidney function 
worsens {Decreased renal function}, hypertension {Hypertensive disorder, systemic arterial}, evaluation {Evaluation procedure}, bradycardia {Bradycardia}, pauses {Heart block}, bradycardia {Bradycardia}, improved {Patient's condition improved}, pauses {Heart block}, follow-up {Follow-up arranged}, left knee {Structure of left knee region}, venous stasis ulcers {Venous ulcer of lower limb}, lower extremity swelling {Swelling of lower limb}, resolved {Problem resolved}, PICC {Peripherally inserted central venous catheter in situ}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Acetaminophen 650 mg PO Q6H:PRN pain 
2. Atovaquone Suspension 1500 mg PO DAILY 
3. Bisacodyl ___AILY:PRN constipation 
4. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H 
5. Fluoxetine 20 mg PO DAILY 
6. Gabapentin 200 mg PO TID 
7. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain 
8. Losartan Potassium 25 mg PO DAILY 
9. Omeprazole 40 mg PO BID 
10. Ranitidine 75 mg PO BID:PRN heartburn 
11. Senna 17.2 mg PO QHS 
12. Vitamin D ___ UNIT PO DAILY 
13. Warfarin 2.5 mg PO DAILY16 
14. Lactulose 30 mL PO TID 
15. Ondansetron 4 mg PO Q8H:PRN nausea 
16. Acidophilus (L.acidoph & 
___ acidophilus) 175 mg oral 
BID  
17. Ferrous Sulfate 325 mg PO DAILY 
18. Polyethylene Glycol 17 g PO EVERY OTHER DAY 
19. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 
20. Furosemide 40 mg PO DAILY 

 
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain 
2. Atovaquone Suspension 1500 mg PO DAILY 
3. Bisacodyl ___AILY:PRN constipation 
4. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 
5. Ferrous Sulfate 325 mg PO DAILY 
6. Fluoxetine 20 mg PO DAILY 
7. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain 
RX *hydromorphone 4 mg 1 tablet(s) by mouth q6h prn Disp #*10 
Tablet Refills:*0
8. Lactulose 30 mL PO QID 
9. Omeprazole 40 mg PO BID 
10. Ondansetron 4 mg PO Q8H:PRN nausea 
11. Polyethylene Glycol 17 g PO EVERY OTHER DAY 
12. Ranitidine 75 mg PO BID:PRN heartburn 
13. Senna 17.2 mg PO QHS 
14. Vitamin D ___ UNIT PO DAILY 
15. Warfarin 1 mg PO DAILY16 
16. Amlodipine 5 mg PO DAILY 
17. Torsemide 40 mg PO DAILY 
18. Lidocaine 5% Patch 1 PTCH TD QAM 
19. Acidophilus (L.acidoph & 
___ acidophilus) 175 mg oral 
BID  
20. OxyCONTIN (oxyCODONE) 10 mg oral Q12H 
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every 
twelve (12) hours Disp #*10 Tablet Refills:*0

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
Acute on chronic kidney disease

SECONDARY DIAGNOSES:
=====================
Hypertension
Catheter-associated urinary tract infection

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or 
wheelchair.

 

###RESPONSE: Acute on chronic kidney disease {Acute-on-chronic renal failure}, Hypertension {Hypertensive disorder, systemic arterial}, Catheter-associated urinary tract infection {Urinary tract infection associated with catheter}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Out of Bed with assistance {Difficulty getting off a bed}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 during your stay at ___.  You 
were admitted because your kidney function was abnormal.  This 
was likely due to damage to your kidneys from intermittently 
having low blood pressure.  Your kidney function slowly 
recovered and will hopefully continue to improve.  You were 
given medications to remove fluid from your legs.  After your 
leg swelling resolves and your leg ulcers heal, the orthopedic 
surgeons will replace your knee.  Your blood pressure became 
high, so you were started on a new medication to help with this.

It is very important that you continue to take your medications 
as prescribed and keep your follow-up appointments.

We wish you good health!

Sincerely,
Your ___ Team
 

###RESPONSE: kidney function {Renal function monitoring}, damage {Damage}, kidneys {Kidney structure}, low blood pressure {Low blood pressure}, kidney function {Renal function monitoring}, medications {Patient medication education}, legs {Lower limb structure}, leg swelling {Leg swelling symptom}, resolves {Problem resolved}, leg ulcers {Ulcer of lower extremity}, replace your knee {Arthroplasty of knee}, blood pressure became 
high {Hypertensive disorder, systemic arterial}, new medication {New medication commenced}, take your medications 
as prescribed {Patient medication education}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   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:
needs heparin bridge
 
Major Surgical or Invasive Procedure:
___ right premolar extraction

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, right {Structure of right half of lower jaw region}, premolar {Structure of premolar tooth}, extraction {Tooth extraction}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ is a ___ ___ lady with AFib, MV 
stenosis s/p mechanical MV replacement ___ on Warfarin (INR 
goal 2.5-3.5), severe tricuspid regurgitation, chronic 
right-sided heart failure (EF 50%), with congestive hepatopathy 
and ascites, severe pulmonary hypertension, and CAD s/p CABG 
___ who has had ongoing tooth pain and requires a dental 
procedure so she is admitted for Heparin bridge in anticipation 
of the procedure.

She has been having tooth pain for weeks.  Pain is located in 
right pre-molar. She denies fevers and has not been on any 
antibiotics.  She went to the dentist as an outpatient who 
stated that she will need dental extraction (right pre-molar 
tooth) but was unable to perform this in the setting of 
mechanical valve.  She told this with her HCA PCP ___ 
___ who discussed with her Cardiologist (___) who 
recommended IV heparin bridging prior to dental procedure.  She 
is a direct admit to the Medicine floor.
 
On arrival to the floor, she feels at her baseline with pain of 
right pre-molar tooth.

Review of sytems:  
Denies fever, chills, night sweats, headache, vision changes, 
rhinorrhea, congestion, sore throat, cough, chest pain, 
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, 
melena, hematochezia, dysuria, hematuria.  
 

###RESPONSE: AFib {Atrial fibrillation}, MV 
stenosis {Mitral valve stenosis}, mechanical MV replacement {Mechanical prosthetic mitral valve replacement}, severe tricuspid regurgitation {Severe tricuspid valve regurgitation}, chronic 
right-sided heart failure {Chronic right-sided heart failure}, hepatopathy {Disorder of liver}, ascites {Ascites}, severe pulmonary hypertension {Severe pulmonary hypertension}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, tooth pain {Toothache}, dental 
procedure {Dental surgical procedure}, procedure {Procedure}, tooth {Structure of dentition}, pain {Pain}, Pain {Pain}, right {Structure of right half of lower jaw region}, pre-molar {Structure of premolar tooth}, fevers {Fever}, antibiotics {Antibiotic therapy}, dental extraction {Tooth extraction}, right {Structure of right half of lower jaw region}, pre-molar 
tooth {Structure of premolar tooth}, dental procedure {Dental surgical procedure}, pain {Pain}, right {Structure of right half of lower jaw region}, pre-molar tooth {Structure of premolar tooth}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, headache {Headache}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, sore throat {Sore throat}, cough {Cough}, 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:
1. CARDIAC RISK FACTORS: 
      Diabetes
2. CARDIAC HISTORY:  
   1.) Severe right heart failure: As of ___, 
well-compensated NYHA ___, secondary to rheumatic fever as a 
child. Complicated by congestive hepatopathy and cirrhosis.
   2.) Severe pulmonary hypertension
   3.) ""Wide open,"" severe tricuspid regurgitation since MVR 
___.
Status post-mitral valve
   4.) Mechanical mitral valve repair ___ (and ___ per Pt) for 

mitral stenosis (from rheumatic fever), on warfarin chronically
   5.) Preserved EF
   6.) CAD s/p CABG ___
   7.) Atrial fibrillation, on warfarin. Bilaterally enlarged 
atria.
-CABG: ___
-PERCUTANEOUS CORONARY INTERVENTIONS:  
-PACING/ICD:  
OTHER PAST MEDICAL HISTORY:  
1. Crystal-proven gout. 
2. Osteoarthritis of the knees.
3.  Osteoarthritis of the hands.
4.  Right rotator tendinopathy, resolved.
5.  Cirrhosis, secondary to chronic passive liver congestion: 
with ascites
6.  Diabetes mellitus: Insulin-dependent, type II, complicated 
by neuropathy
7.  Anxiety
8.  Varicose veins (extensive).
9.  GERD

 

###RESPONSE: CARDIAC RISK FACTORS {Assessment for risk of cardiovascular disease}, Diabetes {Diabetes mellitus}, CARDIAC {Heart structure}, right heart failure {Right ventricular failure}, rheumatic fever {Rheumatic fever}, hepatopathy {Disorder of liver}, cirrhosis {Cirrhosis of liver}, Severe pulmonary hypertension {Severe pulmonary hypertension}, severe tricuspid regurgitation {Severe tricuspid valve regurgitation}, MVR {Replacement of mitral valve}, mitral valve {Mitral valve structure}, Mechanical mitral valve repair {Mechanical prosthetic mitral valve replacement}, mitral stenosis {Mitral valve stenosis}, rheumatic fever {Rheumatic fever}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, Atrial fibrillation {Atrial fibrillation}, Bilaterally enlarged 
atria {Bilateral enlargement of atria}, CABG {Coronary artery bypass grafting}, PERCUTANEOUS CORONARY INTERVENTIONS {Percutaneous coronary intervention}, gout {Inflammatory disorder due to increased blood urate level}, Osteoarthritis of the knees {Osteoarthritis of knee}, Osteoarthritis of the hands {Degenerative joint disease of hand}, Right rotator tendinopathy {Tendinitis of right rotator cuff}, Cirrhosis {Cirrhosis of liver}, liver congestion {Cardiac cirrhosis}, ascites {Ascites}, Diabetes mellitus {Diabetes mellitus type 2}, neuropathy {Neuropathy}, Anxiety {Anxiety}, Varicose veins {Venous varices}, GERD {Gastroesophageal reflux 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:
No family history of early MI, arrhythmia, cardiomyopathies, or 
sudden cardiac death; otherwise non-contributory.  
 

###RESPONSE: MI {Myocardial infarction}, arrhythmia {Cardiac arrhythmia}, cardiomyopathies {Cardiomyopathy}, sudden cardiac death {Sudden cardiac death}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION EXAM
Vitals - 98.2, 135/77, 68, 98%RA
General- Alert, oriented, no acute distress  
HEENT- Sclera anicteric, dentures of lower teeth on, pain of 
right pre-molar, no erythema/exudate appreciated  
Neck- supple, JVP not elevated, no LAD  
Lungs- Clear to auscultation bilaterally, no wheezes, rales, 
ronchi  
CV- Irregular, diastolic murmur RUSB
Abdomen- soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding, no organomegaly  
GU- no foley  
___- significant vericose veins b/l ___, 2+ pulses, no clubbing, 
cyanosis or edema
Neuro- CNs2-12 intact, motor function grossly normal  

DISCHARGE EXAM
Vitals - 97.___.2 129/54(120s-130s/50s), 70, 98%RA
GEN - Alert, oriented, no acute distress  
HEENT - Right lower pre molar extracted, sutures observed, no 
active signs of bleeding. Pain well controlled. No 
erythema/exudate appreciated, no jaw pain, no difficulty 
opening/closing mouth  
NECK - supple, JVP elevated 5cm, no LAD  
LUNGS - Clear to auscultation bilaterally, no wheezes, or 
crackles  
CV - Irregular, diastolic murmur RUSB/LSB
ABD - unchanged. soft, non-tender, non-distended, bowel sounds 
present, no rebound tenderness or guarding, no organomegaly  
GU- no foley  
___ - unchanged. significant vericose veins b/l ___, 2+ pulses, 
no clubbing, cyanosis or edema
Neuro- CNs2-12 intact, motor function grossly normal. lucid.  
ambulating on own.
 

###RESPONSE: Vitals {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, teeth {Structure of dentition}, pain {Pain}, right {Structure of right half of lower jaw region}, pre-molar {Structure of premolar tooth}, erythema {Erythema}, exudate {Exudate}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, ronchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, Irregular {Irregular heart beat}, murmur {Murmur}, Abdomen- soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, vericose veins {Venous varices}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, CNs2-12 intact {Normal nervous system function}, motor function grossly normal {Normal motor response to command}, Vitals {Vital signs finding}, RA {Breathing room air}, GEN {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Right lower {Structure of right half of lower jaw region}, signs {Sign}, bleeding {Bleeding}, Pain well controlled {Demonstrates adequate pain control}, erythema {Erythema}, exudate {Exudate}, pain {Pain}, closing mouth {Difficulty closing mouth}, supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, LAD {Lymphadenopathy}, LUNGS {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, crackles {Respiratory crackles}, CV {Cardiovascular physical examination}, Irregular {Irregular heart beat}, murmur {Murmur}, ABD {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds 
present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, vericose veins {Venous varices}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Neuro {Neurological examination}, CNs2-12 intact {Normal nervous system function}, motor function grossly normal {Normal motor response to command}, lucid {Lucid}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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
___ 10:02PM BLOOD WBC-7.0 RBC-3.57* Hgb-11.4* Hct-33.4* 
MCV-94# MCH-31.9 MCHC-34.0 RDW-14.8 Plt ___
___ 11:47AM BLOOD ___
___ 06:00AM BLOOD Glucose-153* UreaN-50* Creat-1.5* Na-133 
K-4.2 Cl-91* HCO3-33* AnGap-13
___ 06:00AM BLOOD Calcium-9.7 Phos-3.4 Mg-2.3

DISCHARGE LABS
___ 07:15AM BLOOD WBC-6.7 RBC-3.78* Hgb-12.0 Hct-34.8* 
MCV-92 MCH-31.7 MCHC-34.4 RDW-14.6 Plt ___
___ 07:15AM BLOOD ___ PTT-91.1* ___
___ 06:48AM BLOOD Glucose-138* UreaN-46* Creat-1.4* Na-132* 
K-4.4 Cl-88* HCO3-32 AnGap-16
___ 06:48AM BLOOD Calcium-9.8 Phos-4.2 Mg-2.4

INR TREND
___ 11:47AM BLOOD ___
___ 06:00AM BLOOD ___ PTT-150* ___
___ 07:00AM BLOOD ___ PTT-61.8* ___
___ 06:00AM BLOOD ___ PTT-58.5* ___
___ 12:43AM BLOOD ___ PTT-77.4* ___
___ 06:48AM BLOOD ___ PTT-90.5* ___
___ 07:15AM BLOOD ___ PTT-91.1* ___

___ (PANOREX FOR DENTAL) - unread

Pathology ReportTissue: Tooth # 28.Procedure Date of ___
Report not finalized.
Assigned Pathologist ___.
Please contact the pathology department, ___ ___
PATHOLOGY # ___
Tooth # 28.
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, 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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, 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}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, Tooth {Structure of dentition}, Tooth {Structure of dentition}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Sra. ___ is a ___ ___ lady with AFib, MV 
stenosis s/p mechanical MV replacement ___ on Warfarin (INR 
goal 2.5-3.5), severe tricuspid regurgitation, chronic 
right-sided heart failure (EF 50%), with congestive hepatopathy 
and ascites, severe pulmonary hypertension, and CAD s/p CABG 
___ who had ongoing tooth pain as an outpatient.  She was 
directly admitted to Medicine for Heparin bridge while her INR 
was allowed to drift downwards in order to undergo tooth 
extraction.  She underwent uncomplicated single extraction of 
tooth #28 on ___ and then remained in house on a Heparin drip 
until her INR was therapeutic again, and then she was discharged 
home.

## DENTAL INFECTION & PAIN: resolved s/p extraction.
No signs or symptoms of severe infection.  OMFS performed 
uncomplicated single extraction of tooth #28 on ___, with 
pre-operative Unasyn.  No bleeding complications.  The procedure 
was done in the OR but only under local anesthesia.  Sutures 
will dissolve.  She will follow up with her dentist or OMFS, as 
she prefers.

## MECHANICAL MV REPLACEMENT: on Warfarin, goal INR 2.5-3.5.
As soon as she was directly admitted to the Medicine floor, she 
was placed on Heparin gtt and her Warfarin was held.  She was 
therapeutic for the duration of her admission, except for 
stopping the drip 6 hrs pre-procedure.  It was able to be 
re-started immediately post-operatively, and she was restarted 
on her Warfarin post-operatively as well.  Heparin gtt was 
stopped and she was discharged when her INR was >2.5.  Home 
Warfarin dose was not changed; she will f/u tomorrow at ___ 
___ clinic for INR check.
- 5mg given ___ mg given ___ (INR in am = 1.9)
- 7.5 mg give ___ (INR in am = 2.3)
- Discharged ___ (INR in am = 3.0), please take 5 mg at home

## CHF: stable issue, euvolemic.
Her tricuspid regurgitation is severe and moderate pulmonary 
hypertension; she was euvolemic on exam.  She was continued on 
her home meds (torsemide, metoprolol, hctz, spironolactone).

## HYPONa: asymptomatic, stable.
Na 133 on admission.  Euvolemic on exam. Baseline Na appears to 
be 133-140.  She remains on HCTZ, Torsemide, Spironolactone 
which could be contributing.  Na was stable at 132 on the day of 
discharge.

## DM 2: stable.
She was continued on her home Lantus 60mg QHS.  She initially 
declined the proposed sliding scale (she felt that she would 
drop too low since she was NPO for the procedure) and was 
subsequently hyperglycemic in the 200's-300's.  When her family 
brought in her home sliding scale, it was entered and she 
complied, with much better blood glucose control.  She did not 
have any hypoglycemia during this admission.

## GOUT/OA: stable.
She was continued on Febuxostat and low-dose Prednisone.

## TRANSITIONAL ISSUES
Emergency Contact:   ______
Studies/labs pending at discharge:  
--Panorex was viewed/interpreted by ___ so no Radiology read 
pending
--Extracted tooth pathology
 

###RESPONSE: AFib {Atrial fibrillation}, MV 
stenosis {Mitral valve stenosis}, mechanical MV replacement {Mechanical prosthetic mitral valve replacement}, severe tricuspid regurgitation {Severe tricuspid valve regurgitation}, chronic 
right-sided heart failure {Chronic right-sided heart failure}, congestive hepatopathy {Cardiac cirrhosis}, ascites {Ascites}, severe pulmonary hypertension {Severe pulmonary hypertension}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, tooth pain {Toothache}, tooth 
extraction {Tooth extraction}, single extraction of 
tooth {Extraction of single tooth}, DENTAL INFECTION {Infection of tooth}, PAIN {Pain}, extraction {Tooth extraction}, signs {Sign}, infection {Infectious disease}, single extraction of tooth {Extraction of single tooth}, bleeding {Bleeding}, procedure {Procedure}, under local anesthesia {Under local anesthesia}, MECHANICAL MV REPLACEMENT {Mechanical prosthetic mitral valve replacement}, CHF {Congestive heart failure}, stable {Patient's condition stable}, tricuspid regurgitation {Tricuspid valve regurgitation}, moderate pulmonary 
hypertension {Moderate pulmonary hypertension}, HYPONa {Hyponatremia}, asymptomatic {Asymptomatic}, Baseline {Baseline state}, DM 2 {Diabetes mellitus type 2}, stable {Patient's condition stable}, procedure {Procedure}, blood glucose {Glucose measurement, blood}, hypoglycemia {Hypoglycemia}, GOUT {Inflammatory disorder due to increased blood urate level}, OA {Osteoarthritis}, stable {Patient's condition stable}, Extracted tooth {Tooth extraction}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
1. Febuxostat 80 mg PO DAILY 
2. Gabapentin 600 mg PO TID 
3. Hydrochlorothiazide 12.5 mg PO DAILY  
4. Metoprolol Succinate XL 25 mg PO DAILY  
5. Potassium Chloride 10 mEq PO BID  
6. PredniSONE 5 mg PO DAILY 
7. Spironolactone 50 mg PO DAILY  
8. Torsemide 150 mg PO DAILY 
9. Warfarin ___ mg PO DAILY (AS DIRECTED BY ___ 
___ CLINIC) 
10. Glargine 60 Units Bedtime
Insulin SC Sliding Scale using HUMALOG Insulin
 
Discharge Medications:
1. Febuxostat 80 mg PO DAILY 
2. Gabapentin 600 mg PO TID 
3. Hydrochlorothiazide 12.5 mg PO DAILY  
4. Metoprolol Succinate XL 25 mg PO DAILY  
5. Potassium Chloride 10 mEq PO BID  
6. PredniSONE 5 mg PO DAILY 
7. Spironolactone 50 mg PO DAILY  
8. Torsemide 150 mg PO DAILY 
9. Warfarin ___ mg PO DAILY (AS DIRECTED BY ___ 
___ CLINIC) 
10. Glargine 60 Units Bedtime
Insulin SC Sliding Scale using HUMALOG Insulin
 

###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:
- Tooth extraction
- INR maintenance and Heparin Bridge

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Tooth extraction {Tooth extraction}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear. Ms. ___,

Thank you for choosing ___.  You were 
admitted for extraction of your right premolar tooth and 
management of your Warfarin/INR during this procedure.  Your 
Home INR(International Normalized Ratio) goal is 2.5 - 3.5 given 
your mechanical mitral valve.  Your Warfarin was stopped the day 
before the procedure, and Heparin was started to maintain 
anticoagulation.  The oral and maxillofacial surgeons (___) 
performed the extraction in an operating room while Heparin was 
off.  The operation was successful and there was minimal 
bleeding.  Sutures were left in the location of the former 
tooth, and these sutures will dissolve on their own.  The ___ 
team suggests you follow up with them, or your home Dentist.  
The ___ phone number is ___ if you wish to follow up 
with them.

After the procedure your Heparin was continued and Warfarin was 
restarted to reach your INR goal of 2.5.  On the day of 
discharge your INR = 3.0. 

POST PROCEDURE RECOMMENDATIONS:
- Pain control with Tylenol
- Soft diet
- Maintain meticulous oral hygiene
- Rinse your mouth with Over the counter product called 
""Peridex"" twice/day
- No straws, vigorous rinsing, spitting

MEDICATIONS:
WARFARIN:
- 5mg given ___ mg given ___ (INR in am = 1.9)
- 7.5 mg give ___ (INR in am = 2.3)
- Discharged ___ (INR in am = 3.0), please take 5 mg at home

Continue other medications normally
 

###RESPONSE: extraction {Extraction}, premolar tooth {Structure of premolar tooth}, procedure {Procedure}, mechanical mitral valve {Metal mitral valve prosthesis in situ}, procedure {Procedure}, anticoagulation {Anticoagulant therapy}, extraction {Extraction}, bleeding {Bleeding}, tooth {Structure of dentition}, procedure {Procedure}, Pain control {Pain control}, Soft diet {Soft diet}, oral hygiene {Mouth care}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___
 
Chief Complaint:
Change in mental status and fever
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: Change in mental status {Altered mental status}, fever {Fever}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ yo M with recent diagnosis of gastric CA s/p total 
gastrectomy of the Roux-en-Y reconstruction and feeding 
jejunostomy with known anastamosis site ulcer and h/o aspiration 
admitted with change in mental status and fever. Patient has 
been feeling poorly since he was discharged home from the 
hospital about 3 weeks ago. The patient has been following up 
closely with his PCP who added ___ fentanyl patch and zofran to 
help with pain and nausea. The patient went home and had 2 very 
good days. On the third day he was a bit out of it but stable 
and then on the fourth day he fell out of his chair and was 
disoriented. He presented to the ED ___ and was treated for a 
change in MS felt likely ___ oversedation with opiates. A CXR 
was sent which showed atelectasis but no infiltrate. He was 
taken off the oxycodone and fentanyl patch and sent home. 
 On the day of admission his wife noted his temp to be 102 and 
thought his MS had not improved very much so she called his pcp. 
In office temp was 96, patient was noted to have increased cough 
and sputum.  His PCP sent him here for workup of mental status 
change and fever. 
 On presentation he did not complain of pain just a diffuse 
malaise. He reports a cough and wretching with nausea that is 
responsive to zofran. He does not report SOB, chest pain, 
abdominal pain, or calf pain. He reports feeling hot off and on 
at homebut normally temp runs ___ except for the one at ___ 
yesterday. He reports feeling a bit dehydrated but not dizzy or 
light-headed. N one at home is sick and he has not traveled 
anywhere recently.

 

###RESPONSE: gastric CA {Malignant tumor of stomach}, total 
gastrectomy {Total gastrectomy}, Roux-en-Y reconstruction {Total gastrectomy and anastomosis of esophagus to transposed jejunum}, feeding 
jejunostomy {Feeding enterostomy of jejunum}, anastamosis site ulcer {Ulcer of anastomosis}, aspiration {Pulmonary aspiration}, change in mental status {Altered mental status}, fever {Fever}, pain {Pain}, nausea {Nausea}, stable {Patient's condition stable}, disoriented {Disorientated}, MS {Altered mental status}, CXR {Plain chest X-ray}, atelectasis {Atelectasis}, infiltrate {Infiltration}, temp {Body temperature finding}, MS {Altered mental status}, improved {Patient's condition improved}, temp {Body temperature finding}, cough {Cough}, sputum {Sputum finding}, workup {Evaluation procedure}, mental status {Neurological mental status determination}, fever {Fever}, pain {Pain}, malaise {Malaise}, cough {Cough}, nausea {Nausea}, SOB {Dyspnea}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, calf pain {Pain in calf}, temp {Body temperature finding}, dehydrated {Dehydration}, dizzy {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: Past Medical History:
Per OMR:
HTN
Osteoarthritis of L knee and R shoulder - s/p TKR ___
Tonsillectomy
Appendectomy 
Bilateral cataract excision.
 

###RESPONSE: Osteoarthritis of L knee {Osteoarthritis of left knee joint}, R shoulder {Osteoarthritis of joint of right shoulder region}, TKR {Total knee replacement}, Tonsillectomy {Tonsillectomy}, Appendectomy {Excision of appendix}, Bilateral cataract excision {Extraction of cataract of bilateral eyes}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Family history is notable for a son who died of lung cancer.
 

###RESPONSE: died {Dead}, lung cancer {Malignant tumor of lung}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VITALS: t 95.6 BP 141/61 HR 80 RR 16 O2sat 95% RA
GEN: Cachectic elderly M in NAD
HEENT: NC/AT No scleral icterus. MMM
NECK: No JVD. No LAD
LUNGS: Crackles ___ way up
HEART: RRR S1/S2 No M/R/G
ABD: Incision site without erythema, dehiscence, or discharge. 
Well-healed. Feeding tube in place with dressing 
clean/dry/intact and just replaced today by PCP. +BS. NT/ND. NO 
HSM 
EXTREM: No cyanosis, clubbing, edema
NEURO: Alert. Oriented X 3. CN ___ in tact. 

 

###RESPONSE: VITALS {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2sat {Oxygen saturation measurement}, RA {Breathing room air}, GEN {General examination of patient}, Cachectic {Cachexia}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, scleral icterus {Scleral icterus}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, LUNGS {Examination of respiratory system}, Crackles {Respiratory crackles}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, No M/R/G {Heart sounds normal}, ABD {Examination of abdomen}, Incision site {Surgical incision wound}, erythema {Erythema}, dehiscence {Dehiscence}, Well-healed {Wound healed}, +BS {Normal bowel sounds}, NT {Abdominal tenderness}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, EXTREM {Examination of limb}, cyanosis {Cyanosis}, clubbing {Clubbing}, edema {Edema}, NEURO {Neurological examination}, Alert {Mentally alert}, Oriented X 3 {Oriented to person, time and place}, CN {Cranial nerve structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 12:30PM   WBC-13.0* RBC-3.72* HGB-11.2* HCT-33.8* 
MCV-91 MCH-30.2 MCHC-33.2 RDW-15.5
___ 12:30PM   NEUTS-87.0* LYMPHS-6.2* MONOS-6.5 EOS-0.3 
BASOS-0.1
___ 12:30PM   PLT COUNT-268
___ 12:30PM   UREA N-17 CREAT-0.7 SODIUM-135 POTASSIUM-4.4 
CHLORIDE-93* TOTAL CO2-33* ANION GAP-13
___ 03:35PM   ___ PTT-32.4 ___
___ 03:35PM   ALBUMIN-3.4 CALCIUM-9.0 PHOSPHATE-3.2 
MAGNESIUM-1.9
___ 03:35PM   ALT(SGPT)-18 AST(SGOT)-19 LD(LDH)-166 ALK 
PHOS-71 TOT BILI-0.___XR: Pneumonia in the superior segment of the left lower lobe. 
Results 
communicated with Dr. ___ at 2:20 p.m. 

CT HEAD: No acute intracranial abnormality.

Assessment/Plan:
___ yo M with recent diagnosis of gastric CA s/p total 
gastrectomy of the Roux-en-Y reconstruction and feeding 
jejunostomy admitted with fever and inc cough productive of 
yellow sputum ___ PNA.
.
#. PNA: Patient with likely aspiration PNA. Clindmycin 300mg Q8H 
and then switched to levofloxacin which would cover both the PNA 
and the UTI. Blood cultures were pending at time of discharge 
and will be followed up by Dr. ___.
.
#. UTI: Urine culture showed E.Coli. Sensitivities are pending 
at time of discharge. He will be treated with Levofloxacin for 5 
days with your last dose on ___.
.
#. Aspiration: Speech and swallow saw him and said nectar thick 
liquids and pureed foods are ok but no medications PO. Refused 
video swallow to eval for silent aspiration as cause of PNA. 
Will go home on nectar thick liquids and pureed foods and have 
repeat swallow exam as outpatient when can tolerate barium.
.
#. Pain: Controlled with tylenol standing, fentanyl patch, and 
dilaudid PRN for pain while in house. 
.
#.Nausea: Exacerbated by constipation and increased rate of tube 
feedings. Responds well to Zofran and compazine. Will go home 
with scripts for this. Tube feeding goal rate was decreased to 
70mL/hour to help him tolerate this and still get sufficient 
caloric intake daily.
.
#. Anemia: Patient was noted to have a low hematocrit. Iron 
studies suggest anemia of chronic disease. Patient will follow 
up with his pcp regarding treatment and monitoring of this.
.
#. HTN: Patient had HTN while admitted. Started on previous dose 
of metoprolol 12.5mg BID with good effect. Will continue as 
outpatient.
.
#. FEN:Nutrtion recommened replete with fiber at 70mL/hour for 
24hours daily. He will follow up for further recommendations 
with the nutrition clinic at ___ as an outpatient. 
.
#. Prophylaxis: SC Heparin and PNeumoboots
.
#. Communication: With patient and dtr
.
#. Dispo: Full Code .
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, PTT {Partial thromboplastin time, activated}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, TOT BILI {Bilirubin, total measurement}, Pneumonia {Pneumonia}, left lower lobe {Structure of lower lobe of left lung}, intracranial {Intracranial structure}, abnormality {No abnormality detected}, gastric CA {Malignant tumor of stomach}, total 
gastrectomy {Total gastrectomy}, Roux-en-Y reconstruction {Total gastrectomy and anastomosis of esophagus to transposed jejunum}, feeding 
jejunostomy {Feeding enterostomy of jejunum}, fever {Fever}, cough productive of 
yellow sputum {Productive cough-yellow sputum}, PNA {Pneumonia}, PNA {Pneumonia}, aspiration PNA {Aspiration pneumonia}, PNA {Pneumonia}, UTI {Urinary tract infectious disease}, Blood cultures {Blood culture}, UTI {Urinary tract infectious disease}, Urine culture {Urine culture}, E.Coli {Infection caused by Escherichia coli}, Sensitivities {Antimicrobial susceptibility test}, Aspiration {Aspiration}, nectar thick 
liquids {Dietary liquid consistency - nectar thick liquid}, video swallow {Videofluoroscopy swallow}, aspiration {Pulmonary aspiration}, PNA {Pneumonia}, nectar thick liquids {Dietary liquid consistency - nectar thick liquid}, swallow exam {Fiberoptic endoscopic evaluation of swallowing}, Pain {Pain}, pain {Pain}, Nausea {Nausea}, constipation {Constipation}, tube 
feedings {Tube feeding of patient}, Tube feeding {Tube feeding of patient}, Anemia {Anemia}, low hematocrit {Hematocrit below reference range}, anemia of chronic disease {Anemia of chronic disorder}, HTN {Hypertensive disorder, systemic arterial}, HTN {Hypertensive disorder, systemic arterial}, FEN {Nutrition management}, Prophylaxis {Preventive procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Alternagel 1 tsp QID
Dilaudid-5 1 mg Q6H PRN
Atenolol 25mg PGT daily
Zofran 4mg Q6H
Lorazepam 0.5mg Per NG BID

 
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 
times a day): Please take through the feeding tube.
Disp:*30 Tablet(s)* Refills:*2*
2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 
hours) as needed for pain: Please take through the feeding tube.
Disp:*30 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H 
(Every 8 Hours): Please take through the feeding tube.  
4. Lidocaine HCl 4 % Solution Sig: ___ MLs Mucous membrane Q6H 
(every 6 hours).
Disp:*500 mL* Refills:*2*
5. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr 
Transdermal Q72H (every 72 hours).
Disp:*5 Patch 72 hr(s)* Refills:*2*
6. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q4H 
(every 4 hours): Please do not take if you are having diarrhea.
___ mL* Refills:*2*
7. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) g 
PO DAILY (Daily) as needed: Please do not take if you are having 
diarrhea.
Disp:*500 grams* Refills:*0*
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at 
bedtime) as needed for for sleep.  
9. Prochlorperazine Edisylate 5 mg/5 mL Syrup Sig: Ten (10) mg 
PO every six (6) hours as needed for nausea.
Disp:*60 ml* Refills:*1*
10. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 
times a day) as needed for cough.  
11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, 
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.  
12. Jevity Plus     Liquid Sig: Seventy (70) ml/hr PO once a 
day: Please increase tube feedings to 70mL/hour continuously for 
24hours daily.
Disp:*30 cans* Refills:*2*
13. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H 
(every 24 hours): Last dose on ___.
Disp:*5 Tablet(s)* Refills:*0*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Aspiration PNA
Constipation

 
Discharge Condition:
The patient was afebrile, normotensive, not tachycaric, and 
having normal bowel movements when he was discharged.

 

###RESPONSE: Aspiration PNA {Aspiration pneumonia}, Constipation {Constipation}, afebrile {Fever}, normotensive {Normal blood pressure}, tachycaric {Tachycardia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 have been admitted with pneumonia. you have been treated 
with antibiotics for this infection. You should continue the 
antibiotics at home as outlined below.
 You have also had constipation leading to nausea while you were 
here. You should go home on stool softeners and laxatives as 
outlined below. For the nausea you should take the anti-nausea 
medicines you have at home.
 You were also started on a low dose patch for your pain. You 
should continue this patch and take dilaudid for breakthrough 
pain only.
 You have been given a swallowing evaluation that shows that you 
are stil having a little bit of difficult swallowing. You should 
only eat nectar thick liquids and soft solids. Pills should be 
taken through your feeding tube. 
 You had high blood pressures while you were hospitalized. You 
were re-started on your metoprolol and your blood pressures were 
more controlled. You should continue this as an outpatient.

Medication changes:
CHANGE Fentanyl Patch 25mg every 72 hours to Fentanyl Patch 
12.5mg every 72 hours
START: Clindamycin 300mg through feeding tube every 6 hours. 
Last dose on ___
START: Compazine 5mg through feeding tube every 6 hours as 
needed for nausea
START: Lactulose 60mL through feeding tube four times daily
START: Polyethylene glycol 17g through feeding tube daily.
START: Benzonatate 100mg through feeding tube every 8 hours as 
needed for cough.
START: Metoprolol 12.5mg via the feeding tube 2 times daily.

You should call your PCP or come back to the ED if you have 
fevers, shortness of breath, chest pain, severe abdominal pain, 
severe nausea/vomiting, bright red blood in your stools or 
tarry-looking stools. 
 

###RESPONSE: pneumonia {Pneumonia}, treated 
with antibiotics {Antibiotic therapy}, antibiotics {Antibiotic therapy}, constipation {Constipation}, nausea {Nausea}, stool softeners {Administration of laxative}, nausea {Nausea}, pain {Pain}, breakthrough 
pain {Breakthrough pain}, nectar thick liquids {Dietary liquid consistency - nectar thick liquid}, high blood pressures {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: 
Lipitor / Simvastatin / Megestrol
 
Attending: ___.
 
Chief Complaint:
abdominal distension
 
Major Surgical or Invasive Procedure:
Paracentesis

 

###RESPONSE: Lipitor {Allergy to atorvastatin}, Simvastatin {Allergy to simvastatin}, Megestrol {Allergy to megestrol}, abdominal distension {Swollen abdomen}, Paracentesis {Centesis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 ___ year old man with h/o gastric ca, s/p 
gastrectomy in ___, s/p 4 cycles ECX, cycle 1 CapOx in ___, 
now with diffuse omental caking and malignant ascites, who is 
being admitted with worsening abdominal distension, with plan 
for ___ guided paracentesis.  
  
The patient had a therapeutic paracentesis last week with some 
improvement in abdominal fullness. However, he has noted 
increasing abdominal fullness over the past few days, associated 
with abdominal pain typically in the evenings. He was seen in 
the ED yesterday and discharged home with plan for ___ 
paracentesis today. Otherwise, the patient is feeling ok. His 
wife notes that he has had increasing nausea, not relieved with 
Zofran, but Ativan helped yesterday. He also has mild shortness 
of breath with exertion, but is still able to make it up 3 
flights of stairs to their apartment.
    
ROS: No fevers, chills, chest pain, cough, headache, dysuria. No 
BM in a week, not taking in much PO; on TPN at home.
 

###RESPONSE: gastric ca {Malignant tumor of stomach}, gastrectomy {Excision of stomach structure}, omental {Omentum structure}, malignant ascites {Malignant ascites}, abdominal distension {Swollen abdomen}, paracentesis {Centesis}, paracentesis {Centesis}, abdominal fullness {Abdominal distension symptom}, abdominal fullness {Abdominal distension symptom}, abdominal pain {Abdominal pain}, paracentesis {Centesis}, nausea {Nausea}, mild {Symptom mild}, shortness 
of breath with exertion {Dyspnea on exertion}, fevers {Fever}, chills {Chill}, chest pain {Chest pain}, cough {Cough}, headache {Headache}, dysuria {Dysuria}, on TPN {Total parenteral nutrition}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
- p/w dysphagia  
- EGD demonstrated a mass in the cardia of the stomach and  
biopsy was consistent with poorly differentiated adenocarcinoma  

with focal signet ring features.  
- by EUS, he was staged as T3 with no evidence of invasion into 
the thoracic aorta pericardium or pleura  
- PET CT scan demonstrated a focus of avidity in the region of a 
gastroesophageal junction, likely corresponding to the known 
carcinoma and no evidence of distant metastatic disease was 
identified.  
- ___, underwent total gastrectomy - Pathology from that 
procedure revealed a 6 x 6 x 1.5cm adenocarcinoma, diffuse type, 
poorly differentiated with invasion into the serosa/visceral 
peritoneum.  
- ___ lymph nodes were positive out of 18 examined lymph nodes. 
The proximal margin was involved by invasive carcinoma and he 
did have lymphatic invasion.  
- diagnosed with stage IIIC gastric cancer.  
- Started on ___ with adjuvant ECX - received 4 cycles - 
last treatment given on ___.  
- Metastatic disease noted in ___ and C1D1 
Oxaliplatin/capecitabine started on ___
  
Other 
###RESPONSE: dysphagia {Dysphagia}, EGD {Esophagogastroduodenoscopy}, mass {Mass}, cardia {Cardia structure}, stomach {Stomach structure}, biopsy {Biopsy}, adenocarcinoma {Adenocarcinoma}, no evidence of invasion {No tumor invasion}, thoracic aorta {Thoracic aorta structure}, pericardium {Pericardial structure}, pleura {Pleural membrane structure}, PET {Positron emission tomography}, CT scan {Computed tomography of abdomen}, gastroesophageal junction {Cardioesophageal junction structure}, carcinoma {Carcinoma}, metastatic disease {Metastatic malignant neoplasm}, total gastrectomy {Total gastrectomy}, procedure {Procedure}, adenocarcinoma, diffuse type {Carcinoma, diffuse type}, serosa {Serous membrane structure}, lymph nodes {Structure of lymph node}, lymph nodes {Structure of lymph node}, carcinoma {Carcinoma}, lymphatic {Structure of lymphatic vessel}, gastric cancer {Malignant tumor of stomach}, Metastatic disease {Metastatic malignant neoplasm}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:  
HLD  
Chronic pruritis, unknown etiology  
Tonsillectomy and Adenoidectomy  
Hydrocele repair  
Ex-lap ___  
Open chole  
Meniscus surgery in ___  
Cataract surgery in ___  
Removal of a large colonic polyp on ___
 

###RESPONSE: HLD {Hyperlipidemia}, Chronic {Chronic disease}, Tonsillectomy and Adenoidectomy {Tonsillectomy and adenoidectomy}, Hydrocele repair {Repair of hydrocele}, Meniscus surgery {Operation on meniscus of the knee}, Cataract surgery {Cataract surgery}, Removal {Removal}, colonic polyp {Polyp of colon}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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 died at age ___ from a brain hemorrhage and then had a 
kidney removed. Father had high blood pressure and died at ___ of 
a stroke. Sister had cancer and died at ___. A sister had a 
stroke and died at ___. He has another sister with no medical 
problems and a brother had early stage lung cancer who is alive 
at age ___.  
 

###RESPONSE: died {Dead}, brain {Brain structure}, hemorrhage {Hemorrhage}, kidney {Kidney structure}, high blood pressure {Hypertensive disorder, systemic arterial}, died {Dead}, stroke {Cerebrovascular accident}, cancer {Malignant neoplasm}, died {Dead}, stroke {Cerebrovascular accident}, died {Dead}, problems {Problem}, lung cancer {Malignant tumor of lung}, alive {Alive}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION EXAM:
VS: T 96.5 BP 118/78 HR 95 RR 18 O2sat 97%RA 
GEN: AOx3, NAD, cachectic appearing  
HEENT: MMM. no LAD. no JVD. neck supple. 
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.  
Pulm: No dullness to percussion, CTAB no crackles or wheezes  
Abd: BS+, soft, diffusely tender in abdomen, mildly distended 
with +fluid wave, no rebound/guarding, no HSM 
Extremities: wwp, no edema. DPs, PTs 2+.  
Neuro: AOx3, no focal deficits 
  
DISCHARGE EXAM:
Less fullness on abdominal exam, otherwise unchanged
 

###RESPONSE: VS {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, GEN {General examination of patient}, AOx3 {Oriented to person, time and place}, NAD {No abnormality detected}, cachectic {Cachexia}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, supple {Normal movement of neck}, RR {Finding of rate of respiration}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, Pulm {Examination of respiratory system}, dullness to percussion {Dullness to percussion over Traube's space}, CTAB {Normal breath sounds}, crackles {Respiratory crackles}, wheezes {Wheezing}, Abd {Examination of abdomen}, BS+ {Normal bowel sounds}, soft {Abdomen soft}, tender {Abdominal tenderness}, distended {Swollen abdomen}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, HSM {Hepatosplenomegaly}, Extremities {Examination of limb}, wwp {Normal tissue perfusion}, edema {Edema}, Neuro {Neurological examination}, AOx3 {Oriented to person, time and place}, no focal deficits {Normal nervous system function}, abdominal exam {Examination of abdomen}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 09:45AM BLOOD WBC-13.7* RBC-3.91* Hgb-11.6* Hct-33.1* 
MCV-85 MCH-29.7 MCHC-35.1* RDW-15.2 Plt ___
___ 09:45AM BLOOD Neuts-82.3* Lymphs-9.7* Monos-6.0 Eos-1.8 
Baso-0.3
___ 09:45AM BLOOD ___ PTT-25.7 ___
___ 09:45AM BLOOD Glucose-177* UreaN-30* Creat-0.7 Na-132* 
K-5.7* Cl-100 HCO3-24 AnGap-14
___ 01:09PM BLOOD K-4.4
  
STUDIES:
___ U/S guided paracentesis:
1. Small volume ascites.  
2. Given the patient's pressure symptoms, 1.1 liters of fluid 
was drained via a right flank approach.  

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, 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}, K {Blood potassium measurement}, U/S guided paracentesis {Puncture and aspiration of abdomen using ultrasonographic guidance}, ascites {Ascites}, fluid 
was drained {Drainage of abdomen}, flank {Flank structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Mr. ___ is a ___ year old man with h/o gastric ca, s/p 
gastrectomy in ___, s/p 4 cycles ECX, cycle 1 CapOx in ___, 
now with diffuse omental caking and malignant ascites, admitted 
for U/S-guided therapeutic paracentesis for abdominal 
distension.  
    
#. Abdominal distension: Initially thought to be due to 
increasing ascites. However, only 1L removed from paracentesis 
with little improvement in symptoms. Abdominal fullness likely 
also related to constipation, as the patient did not have a 
bowel movement for almost 10 days prior to admission. He was 
given a dose of Lactulose, as well as an enema, and had a 
successful bowel movement prior to discharge. He was started on 
Lactulose, Colace, and Senna.
 

 

###RESPONSE: gastric ca {Malignant tumor of stomach}, gastrectomy {Excision of stomach structure}, omental {Omentum structure}, malignant ascites {Malignant ascites}, U/S-guided therapeutic paracentesis {Puncture and aspiration of abdomen using ultrasonographic guidance}, abdominal 
distension {Swollen abdomen}, Abdominal distension {Swollen abdomen}, ascites {Ascites}, paracentesis {Centesis}, Abdominal fullness {Abdominal distension symptom}, constipation {Constipation}, did not have a 
bowel movement {Constipation}, enema {Giving patient an enema}, bowel movement {Does defecate}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Vitamin B12 1000mcg IM qmonth  
Lidocaine-Prilocaine cream for port access  
Lorazepam 0.5mg PO q6h prn  
Zofran 8mg PO q8h prn  
Oxycontin 10mg PO BID
Oxycodone ___ PO q4-6h prn  
Maalox ___ PO prn  
Terbinafine 1% cream BID to rash  
Lidoderm TD daily
 
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 
hours) as needed for nausea, anxiety.
Disp:*30 Tablet(s)* Refills:*0*
2. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO 
three times a day as needed for constipation.
Disp:*500 mL* Refills:*0*
3. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO 
every six (6) hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
4. insulin regular human 100 unit/mL Solution Sig: sliding scale 
 Injection four times a day: ___ 151-200: 2units
___ 201-250: 4units
___ 251-300: 6units
___ 301-350: 8units
___ 351-400: 10units.  
5. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) 
Tablet Extended Release 12 hr PO Q12H (every 12 hours).  
6. oxycodone 5 mg/5 mL Solution Sig: ___ mg PO Q6H (every 6 
hours) as needed for pain.  
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 
Fifteen (15) ML PO QID (4 times a day) as needed for 
indigestion.  
8. terbinafine 1 % Cream Sig: One (1) Appl Topical BID (2 times 
a day).  
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day) as needed for constipation.  
11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: 
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary Diagnosis: Malignant ascites, constipation, nausea
Secondary Diagnosis: Gastric cancer

 
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}, Malignant ascites {Malignant ascites}, constipation {Constipation}, nausea {Nausea}, Gastric cancer {Malignant tumor of stomach}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___,
  
You were admitted to the hospital for a therapeutic 
paracentesis. You had a liter of fluid removed by the 
radiologists. You were also found to be constipated - you should 
take stool softeners and Lactulose as needed for constipation.
  
The following changes were made to your medications:
#. START Lactulose as needed for constipation
#. START Compazine as needed for nausea
  
It was a pleasure meeting you and taking part in your care.
 

###RESPONSE: paracentesis {Centesis}, fluid removed {Drainage of abdomen}, constipated {Constipation}, take stool softeners {Administration of laxative}, constipation {Constipation}, constipation {Constipation}, nausea {Nausea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: NEUROSURGERY
 

###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: 
latex
 
Attending: ___
 
Chief Complaint:
Traumatic brain injury

 
Major Surgical or Invasive Procedure:
___ - Left craniectomy and right EVD placement 
___ - Right chest tube placement
___ - Left chest tube placement
___ - Right EVD removal
___ - Right EVD placement
___ - Tracheostomy
___ - PEG tube placement
___ - Intermaxillary fixation
___ - Removal of chest tubes
___ - Right EVD replacement
___ - Left cranioplasty
___ - Right EVD removal

 

###RESPONSE: latex {Allergy to Hevea brasiliensis latex protein}, Traumatic brain injury {Traumatic brain injury}, Left {Structure of left half of head}, craniectomy {Craniectomy}, right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, placement {Implantation procedure}, Right {Right thorax structure}, chest tube placement {Insertion of pleural tube drain}, Left {Left thorax structure}, chest tube placement {Insertion of pleural tube drain}, Right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, removal {Removal}, Right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, placement {Implantation procedure}, Tracheostomy {Exteriorization of trachea}, PEG tube placement {Percutaneous endoscopic insertion of gastrostomy tube}, Intermaxillary fixation {Intermaxillary fixation of mandible and maxilla}, Removal of chest tubes {Intercostal drain removal}, Right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, replacement {Replacement procedure}, Left {Structure of left half of head}, cranioplasty {Repair of bone of skull}, Right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, removal {Removal}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ is a ___ year old male who presented to the 
Emergency Department on ___ as a transfer from an outside 
facility status post fall approximately 25 feet from a 
scaffolding. CT of the head at the outside facility revealed 
multiple areas of acute extra-axial, subarachnoid, 
intraparenchymal, and intraventricular hemorrhage with cerebral 
compression as well as multiple skull and facial fractures. 
Patient was transferred to ___ 
for further evaluation and management.  
 

###RESPONSE: fall {Falls}, CT {Computed tomography}, head {Head structure}, extra-axial {Cerebral hemorrhage}, subarachnoid {Subarachnoid intracranial hemorrhage}, intraparenchymal {Intraparenchymal hemorrhage of brain}, intraventricular hemorrhage {Ventricular hemorrhage}, cerebral 
compression {Compression of brain}, multiple skull {Multiple fractures of skull}, facial fractures {Fracture of multiple bones of face}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- asthma
- opioid abuse
 

###RESPONSE: asthma {Asthma}, opioid abuse {Opioid abuse}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Noncontributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
On Admission:
-------------
General:

___ Coma Scale At The Scene: 4

___ Coma Scale Upon Neurosurgical Evaluation: 6T

Airway: [x]Intubated [ ]Not intubated

Eye Opening: 
[x]1 Does not open eyes

Verbal:
[x]1 Makes no sounds

Motor:
___ Flexion/withdrawal to painful stimuli 


###RESPONSE: General {General examination of patient}, Coma Scale At The Scene: 4 {Glasgow coma scale, 4}, Neuro {Neurological examination}, Airway {Airway structure}, Intubated {Intubation}, intubated {Intubation}, Eye Opening: {Finding of response to visual stimuli}, open eyes {Finding of response to visual stimuli}, Flexion {Flexion test}, withdrawal {Withdrawn}, pain {Pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:

General: Well nourished male. Intubated, sedated, unresponsive.
Head, Eyes, Ears, Nose Throat: Open left temporal skull fracture 
without obvious brain matter visible, however there is 
disruption of the galea. 
Extremities: Warm and well perfused.

Neurologic:

Mental Status: Intubated, sedated, unresponsive.
Orientation: Unable to assess, patient intubated, sedated, 
unresponsive.
Language: Unable to assess, patient intubated, sedated, 
unresponsive.

If Intubated:
[ ]Cough [ ]Gag [x]Over breathing the ventilator

Cranial Nerves:
I: Not tested.
II: Right pupil 3mm and minimally reactive to light. Left pupil 
5mm and nonreactive to light.
III, IV, VI: Unable to assess, patient intubated, sedated, 
unresponsive.
V, VII: Unable to assess, patient intubated, sedated, 
unresponsive.
VIII: Unable to assess, patient intubated, sedated, 
unresponsive.
IX, X: Unable to assess, patient intubated, sedated, 
unresponsive.
XI: Unable to assess, patient intubated, sedated, unresponsive.
XII: Unable to assess, patient intubated, sedated, unresponsive.

Motor: Off sedation. Right upper extremity withdraws to noxious. 
Minimal to no movement of the right lower extremity. Moves left 
upper and lower extremities spontaneously.

On Discharge:
-------------
General:

Vital Signs: T 99.4F, HR 99, BP 143/63, RR 17, O2Sat 99% 
tracheostomy mask

Exam:

Opens Eyes: [ ]Spontaneous [x]To voice - Right eye opens, left
does not [ ]To noxious
Orientation: [ ]Person [ ]Place [ ]Time [x]None
Follows Commands: [ ]Simple [ ]Complex [x]None
Pupils: Right pupil round, reactive to light. Left pupil round,
nonreactive to light.

Motor: Right upper extremity briskly withdraws to noxious. Right
lower extremity moves spontaneously, briskly withdraws to
noxious. Left upper and lower extremities move spontaneously and
purposefully, grossly full strength.

Surgical Incision: 
[x]Clean, dry, intact 
[x]Sutures 
[x]Staples
 

###RESPONSE: Physical Exam {Physical examination procedure}, General {General examination of patient}, Well nourished {Well nourished}, Intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, Head {Head structure}, Eyes {Structure of eye proper}, Ears {Ear structure}, Nose {Nasal structure}, Throat {Structure of anterior portion of neck}, skull fracture {Fracture of skull}, brain {Brain structure}, disruption {Disruption}, galea {Structure of galea aponeurotica}, Extremities {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, Mental Status {Neurological mental status determination}, Intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, Orientation {Finding related to orientation}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, Cough {Cough}, II {Optic nerve structure}, Right pupil {Structure of pupil of right eye}, reactive to light {Finding of pupil reaction to light}, Left pupil {Structure of pupil of left eye}, nonreactive to light {Finding of pupil reaction to light}, III {Oculomotor nerve structure}, IV {Trochlear nerve structure}, VI {Abducens nerve structure}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, V {Trigeminal nerve structure}, VII {Facial nerve structure}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, VIII {Vestibulocochlear nerve structure}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, IX {Glossopharyngeal nerve structure}, X {Vagus nerve structure}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, XI {Accessory nerve structure}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, XII {Hypoglossal nerve structure}, intubated {Intubation}, sedated {Sedated}, unresponsive {Unresponsive}, Motor {Motor testing}, sedation {Administration of sedative}, Right upper extremity {Structure of right upper limb}, withdraws to noxious {Responds to pain}, right lower extremity {Structure of right lower limb}, Moves {Does move}, left 
upper {Structure of left upper limb}, lower extremities {Lower limb structure}, Vital Signs {Vital signs finding}, T {Body temperature finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, O2Sat {Oxygen saturation measurement}, tracheostomy {Exteriorization of trachea}, Eyes {Ophthalmic examination and evaluation}, Right eye {Right eye structure}, left {Left eye structure}, Orientation {Finding related to orientation}, Place {Oriented to place}, Time {Oriented to time}, Pupils {Pupil finding}, Right {Structure of pupil of right eye}, pupil round {Pupil round}, reactive to light {Finding of pupil reaction to light}, Left {Structure of pupil of left eye}, pupil round {Pupil round}, nonreactive to light {Finding of pupil reaction to light}, Motor {Motor testing}, Right upper extremity {Structure of right upper limb}, withdraws to noxious {Responds to pain}, Right
lower extremity {Structure of right lower limb}, moves {Does move}, withdraws to
noxious {Responds to pain}, Left upper {Structure of left upper limb}, move {Does move}, Surgical Incision {Surgical incision wound}, Clean, dry, intact {Wound healing well}, Sutures {Removal of suture}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Please see OMR for relevant laboratory and imaging results.

 

###RESPONSE: imaging {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: Brief Hospital Course:
___ year old male with a traumatic brain injury. Patient's 
injuries included multiple areas of acute extra-axial, 
subarachnoid, intraparenchymal, and intraventricular hemorrhage 
with cerebral compression, multiple skull and facial fractures, 
left clavicular fracture, multiple rib fractures, pulmonary 
contusion, and hemothorax.

#Traumatic Brain Injury
Patient was taken to the operating room on ___ for a left 
craniectomy and right EVD placement. Please see operative report 
by Dr. ___ further details. Patient was transferred 
back to the Trauma Intensive Care Unit. The patient's neurologic 
exam waxed and waned throughout his hospitalization. Patient had 
a progressive return of spontaneous movement on the left side 
without significant progression on the right. Right EVD placed 
in the operating room was subsequently removed on ___. CT 
of the head on ___ showed external hydrocephalus, and the 
right EVD was replaced. CT of the head on ___ showed 
improvement in the patient's external hydrocephalus. Patient 
returned to the operating room on ___ for a left 
cranioplasty. Please see operative report by Dr. ___ 
further details. A subgaleal drain was left in place and 
subsequently removed on postoperative day two. The right EVD was 
raised over the course of several days after the left 
cranioplasty, intracranial pressures remained within expected 
limits. The right EVD was clamped on ___, and the patient's 
intracranial pressures remained stable. CT of the head on 
___ was stable and the right EVD was removed. The patient 
was started on sodium tablets during this hospitalization for 
management of sodium, which continue to be weaned as tolerated. 
The patient was transferred to the floor on ___. On 
___ the patient's neurologic exam was stable. He was 
afebrile with stable vital signs, tolerating activity with 
assistance, tolerating his continuous tube feedings, voiding 
without difficulty, and his pain was well controlled on enteral 
pain medications. Patient was discharged to ___ 
___ on ___ in stable condition.

#Multiple Skull and Facial Fractures
Plastic Surgery was consulted, and the patient underwent 
intermaxillary fixation.

#Left Clavicular Fracture
Left clavicular fracture was nonoperable.

#Respiratory
Patient had progressive hypoxia on admission and had bilateral 
chest tubes placed on ___. All chest tubes were 
subsequently removed. Patient underwent tracheostomy on ___ 
due to prolonged intubation and was subsequently weaned to a 
tracheostomy mask. The patient had multiple bronchoscopies 
during this hospitalization and was treated for a ventilator 
associated pneumonia with cefepime and vancomycin. The patient 
was noted to be tachypneic to the high ___ and low ___. A CTA of 
the chest showed no evidence of pulmonary embolism. A chest 
x-ray was ordered, which showed bilateral pulmonary effusions, 
which were stable compared to prior imaging. The patient's 
respiratory status continued to improve throughout his 
hospitalization.

#Nutrition
Patient underwent PEG tube placement on ___ due to 
prolonged intubation. Nutrition was consulted for tube feeding 
recommendations. The patient tolerated advancement of his 
continuous tube feedings to goal. 

#Right Upper Extremity Thomboses
Patient was found to have a nonocclusive right brachial, basilic 
thrombus as well as an occlusive right cephalic thrombus. 
Vascular Surgery consulted for question of a superior vena cava 
filter, however they recommended conservative treatment. 

#Loose Stools
Patient had an increase in diarrhea during this hospitalization 
and was diagnosed with Clostridium difficile colitis. A rectal 
tube was placed. Vancomycin was started and patient completed 
the course on ___. Repeat stool sample was negative for 
Clostridium difficile on ___. Patient continued to have 
loose stools. Nutrition was consulted and recommended adding 
banana flakes.

#Buttock Rash
Antifungal cream was started for a rash on the patient's 
buttocks.

#Elevated Phosphorus
Nutrition was consulted and recommended adding Tums for elevated 
phosphorus. 

#Anemia
Patient's hemoglobin and hematocrit were monitored closely. They 
were both low, but remained stable. 

#Elevated PTT
The patient's PTT was consistently elevated and subcutaneous 
heparin was held. 

#Disposition
Physical Therapy and Occupational Therapy were both consulted, 
and both recommended discharge to rehabilitation.
 

###RESPONSE: traumatic brain injury {Traumatic brain injury}, injuries {Traumatic or non-traumatic injury}, extra-axial {Cerebral hemorrhage}, subarachnoid {Subarachnoid intracranial hemorrhage}, intraparenchymal {Intraparenchymal hemorrhage of brain}, intraventricular hemorrhage {Ventricular hemorrhage}, cerebral compression {Compression of brain}, multiple skull {Multiple fractures of skull}, facial fractures {Fracture of multiple bones of face}, left clavicular {Bone structure of left clavicle}, fracture {Fracture}, multiple rib fractures {Fracture of multiple ribs}, pulmonary 
contusion {Contusion of lung}, hemothorax {Hemothorax}, Traumatic Brain Injury {Traumatic brain injury}, left {Structure of left half of head}, craniectomy {Craniectomy}, right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, placement {Implantation procedure}, Trauma {Traumatic injury}, neurologic 
exam {Neurological examination}, left {Structure of left half of body}, right {Structure of right half of body}, Right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, placed {Implantation procedure}, removed {Removal}, CT {Computed tomography}, head {Head structure}, external hydrocephalus {External hydrocephalus}, right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, replaced {Replacement procedure}, CT {Computed tomography}, head {Head structure}, improvement {Patient's condition improved}, external hydrocephalus {External hydrocephalus}, left {Structure of left half of head}, cranioplasty {Repair of bone of skull}, removed {Removal}, right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, left {Structure of left half of head}, cranioplasty {Repair of bone of skull}, intracranial pressures {Finding of intracranial pressure}, right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, clamped {Application of clamp}, intracranial pressures {Finding of intracranial pressure}, stable {Patient's condition stable}, CT {Computed tomography}, head {Head structure}, stable {Patient's condition stable}, right {Right cerebral hemisphere structure}, EVD {External drainage procedure from ventricle of brain}, removed {Removal}, neurologic exam {Neurological examination}, stable {Normal vital signs}, afebrile {Fever}, stable vital signs {Normal vital signs}, activity {Finding of functional performance and activity}, tube feedings {Tube feeding of patient}, voiding 
without difficulty {Normal micturition}, pain was well controlled {Demonstrates adequate pain control}, pain medications {Administration of analgesic}, stable condition {Patient's condition stable}, Multiple Skull {Multiple fractures of skull}, Facial Fractures {Fracture of multiple bones of face}, intermaxillary fixation {Intermaxillary fixation of mandible and maxilla}, Left Clavicular {Bone structure of left clavicle}, Fracture {Fracture}, Left clavicular {Bone structure of left clavicle}, fracture {Fracture}, Respiratory {Examination of respiratory system}, hypoxia {Hypoxia}, chest tubes placed {Insertion of pleural tube drain}, chest tubes {Insertion of pleural tube drain}, removed {Removal}, tracheostomy {Exteriorization of trachea}, intubation {Intubation}, tracheostomy {Exteriorization of trachea}, bronchoscopies {Bronchoscopy}, ventilator 
associated pneumonia {Ventilator-acquired pneumonia}, tachypneic {Tachypnea}, CTA {Computed tomography angiography with contrast}, chest {Plain chest X-ray}, no evidence {No abnormality detected}, pulmonary embolism {Pulmonary embolism}, chest 
x-ray {Plain chest X-ray}, bilateral pulmonary {Both lungs}, effusions {Pleural effusion}, stable {Patient's condition stable}, imaging {Imaging}, respiratory {Structure of respiratory system}, Nutrition {Nutritional finding}, PEG tube placement {Percutaneous endoscopic insertion of gastrostomy tube}, intubation {Intubation}, Nutrition {Nutritional finding}, tube feeding {Tube feeding of patient}, tube feedings {Tube feeding of patient}, Right Upper Extremity {Structure of right upper limb}, Thomboses {Thrombus}, nonocclusive {Partial obstruction}, right brachial {Structure of right brachial vein}, basilic {Structure of basilic vein}, thrombus {Thrombus}, occlusive {Complete obstruction}, right cephalic {Structure of right cephalic vein}, thrombus {Thrombus}, Vascular Surgery {Vascular surgery procedure}, superior vena cava {Superior vena cava structure}, Loose Stools {Loose stool}, diarrhea {Diarrhea}, Clostridium difficile colitis {Clostridium difficile colitis}, rectal 
tube was placed {Insertion of tube into rectum}, stool sample {Collection of stool specimen}, loose stools {Loose stool}, Nutrition {Nutritional finding}, Buttock {Buttock structure}, Rash {Eruption of skin}, rash {Eruption of skin}, buttocks {Buttock structure}, Elevated Phosphorus {Increased phosphorus diet}, Nutrition {Nutritional finding}, elevated 
phosphorus {Increased phosphorus diet}, Anemia {Anemia}, hemoglobin {Hemoglobin finding}, hematocrit {Hematocrit determination}, stable {Patient's condition stable}, Elevated PTT {Partial thromboplastin time increased}, PTT was consistently elevated {Partial thromboplastin time increased}, heparin {Heparin therapy}, Physical Therapy {Physical therapy procedure}, Occupational Therapy {Occupational therapy}, rehabilitation {Rehabilitation therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
This Preadmission Medication List may be inaccurate and requires 
further investigation.
1. buprenorphine-naloxone (8mg-2mg) one tablet sublingual twice 
daily 
 
Discharge Medications:
1. Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN Pain - Mild 
Please do not take more than 3000mg in 24 hours.  
2. Calcium Carbonate 500 mg PO QID  
3. Famotidine 20 mg PO BID  
4. Ketoconazole 2%  1 Appl TP BID Duration: 28 Doses  
5. Labetalol 200 mg PO BID 
Hold for HR < 55 or SBP < 90.  
6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - 
Moderate  
7. Ramelteon 8 mg PO QHS 
Should be given 30 minutes before bedtime.  
8. Sarna Lotion 1 Appl TP QID:PRN Dry skin  
9. Sodium Chloride 1 gm PO BID 
Goal normonatremia, wean as tolerated.  
10. Tamsulosin 0.4 mg PO QHS  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
- traumatic brain injury with multiple areas of acute 
extra-axial, subarachnoid, intraparenchymal, and 
intraventricular hemorrhage with cerebral compression
- multiple skull and facial fractures
- external hydrocephalus 
- left clavicular fracture
- multiple rib fractures
- pulmonary contusion
- hemothorax
- nonocclusive right brachial, basilic thrombus
- occlusive right cephalic thrombus
- Clostridium difficile colitis 

 
Discharge Condition:
Mental Status: Confused, always.
Level of Consciousness: Lethargic, but arousable.
Activity Status: Out of bed with assistance to chair or 
wheelchair.

 

###RESPONSE: traumatic brain injury {Traumatic brain injury}, extra-axial {Cerebral hemorrhage}, subarachnoid {Subarachnoid intracranial hemorrhage}, intraparenchymal {Intraparenchymal hemorrhage of brain}, intraventricular hemorrhage {Ventricular hemorrhage}, cerebral compression {Compression of brain}, multiple skull {Multiple fractures of skull}, facial fractures {Fracture of multiple bones of face}, external hydrocephalus {External hydrocephalus}, left clavicular {Fracture of multiple bones of face}, fracture {Fracture}, multiple rib fractures {Fracture of multiple ribs}, pulmonary contusion {Contusion of lung}, hemothorax {Hemothorax}, nonocclusive {Partial obstruction}, right brachial {Structure of right brachial vein}, basilic {Structure of basilic vein}, thrombus {Thrombus}, occlusive {Complete obstruction}, right cephalic {Structure of right cephalic vein}, thrombus {Thrombus}, Clostridium difficile colitis {Clostridium difficile colitis}, Mental Status {Neurological mental status determination}, Confused {Clouded consciousness}, Level of Consciousness {Assessment of consciousness level}, Lethargic {Lethargy}, Activity Status {Physical functional dependency}, Out of bed with assistance {Difficulty getting off a bed}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Surgery:
• You underwent a surgery called a craniectomy. A portion of 
your skull was removed to allow your brain to swell. 
• You also underwent surgery to have your skull bone (or an 
artificial bone) placed back on. 
• Please keep your sutures and staples along your incision dry 
until they are removed.
• It is best to keep your incision open to air but it is ok to 
cover it when outside. 
• Call your surgeon if there are any signs of infection like 
fever, redness, or drainage. 

Activity:
• We recommend that you avoid heavy lifting, running, climbing, 
or other strenuous exercise until your follow-up appointment.
• You make take leisurely walks and slowly increase your 
activity at your own pace once you are symptom free at rest. 
___ try to do too much all at once.
• No driving while taking any narcotic or sedating medication. 
• If you experienced a seizure while admitted, you are NOT 
allowed to drive by law. 
• No contact sports until cleared by your neurosurgeon. You 
should avoid contact sports for six months. 

Medications:
• Please do NOT take any blood thinning medication (aspirin, 
Coumadin, ibuprofen, Plavix) until cleared by the neurosurgeon. 
• You may use acetaminophen (Tylenol) for minor discomfort if 
you are not otherwise restricted from taking this medication.

What You ___ Experience:
• You may have difficulty paying attention, concentrating, and 
remembering new information.
• Emotional and/or behavioral difficulties are common. 
• Feeling more tired and restlessness, irritability, and mood 
swings are also common.
• You may also experience some postoperative swelling around 
your face and eyes. This is normal after surgery and most 
noticeable on the second and third day of surgery. You may apply 
ice or a cool or warm washcloth to your eyes to help with the 
swelling. The swelling will be its worst in the morning after 
laying flat from sleeping but should decrease when up. 
• You may experience soreness with chewing. This is normal from 
the surgery and will improve with time. Softer foods may be 
easier during this time. 
• Constipation is common. Be sure to drink plenty of fluids and 
eat a high fiber diet. If you are taking narcotics (prescription 
pain medications), try an over the counter stool softener.

Headaches:
• Headache is one of the most common symptoms after a traumatic 
brain injury. 
• Most headaches are not dangerous but you should call your 
doctor if the headache gets worse, if you have increased 
sleepiness, if you develop arm or leg weakness, and/or if you 
have nausea or vomiting with a headache. 
• Mild pain medications may be helpful with these headaches but 
avoid taking pain medications on a daily basis unless prescribed 
by your doctor. 
• There are other things that can be done to help with your 
headaches, including avoiding caffeine, getting enough sleep, 
daily exercise, relaxation/meditation, massage, acupuncture, and 
ice or heat packs. 

More Information About Traumatic Brain Injuries:
• You were given information about headaches after a traumatic 
brain injury and the impact that a traumatic brain injury can 
have on your family.
• If you would like to read more about other topics such as 
fatigue, balance, cognitive problems, sleeping, seizures, 
driving, emotional problems, depression, sexuality after a 
traumatic brain injury, and/or return to school or work, please 
ask our staff for this information or visit 
___.

When To Call Your Doctor At ___:
• Severe pain, redness, swelling, or drainage from the incision 
site. 
• Fever greater than 101.5 degrees Fahrenheit
• Nausea and/or vomiting
• Extreme sleepiness and not being able to stay awake
• Severe headaches not relieved by pain relievers
• Seizures
• Any new problems with your vision or ability to speak
• Weakness or changes in sensation in your face, arms, or legs

Call ___ And Go To The Nearest Emergency Department If You 
Experience Any Of The Following:
• Sudden numbness or weakness in the face, arms, or legs
• Sudden confusion or trouble speaking or understanding
• Sudden trouble walking, dizziness, or loss of balance or 
coordination
• Sudden severe headaches with no known reason
 

###RESPONSE: Surgery {Surgical procedure}, surgery {Surgical procedure}, craniectomy {Craniectomy}, skull {Bone structure of cranium}, removed {Removal}, brain {Brain structure}, swell {Swelling}, surgery {Surgical procedure}, skull {Bone structure of cranium}, sutures {Removal of suture}, incision {Incision}, removed {Removal of dressing}, incision {Incision}, signs of infection {Monitoring for signs and symptoms of infection}, fever {Fever}, redness {Redness of skin over lesion}, drainage {Discharge}, lifting {Does lift}, running {Does run}, climbing {Does climb}, strenuous exercise {Physical activity target strenuous exercise}, walks {Does walk}, activity {Functional activity education}, seizure {Seizure}, tired {Tired}, restlessness {Restlessness}, irritability {Feeling irritable}, mood 
swings {Mood swings}, swelling {Swelling}, face {Face structure}, eyes {Structure of eye proper}, after surgery {Postoperative state}, surgery {Surgical procedure}, eyes {Structure of eye proper}, swelling {Swelling}, swelling {Swelling}, sleeping {Asleep}, soreness {Soreness}, surgery {Surgical procedure}, Constipation {Constipation}, high fiber diet {High residue diet}, narcotics {Narcotherapy}, pain medications {Administration of analgesic}, stool softener {Administration of laxative}, Headache {Headache}, traumatic 
brain injury {Traumatic brain injury}, headaches {Headache}, headache {Headache}, sleepiness {Drowsy}, arm {Monoparesis - arm}, leg weakness {Monoparesis of lower limb}, nausea {Nausea}, vomiting {Vomiting}, headache {Headache}, Mild {Symptom mild}, pain medications {Administration of analgesic}, headaches {Headache}, pain medications {Administration of analgesic}, headaches {Headache}, exercise {Exercises}, relaxation {Relaxation training therapy}, meditation {Transcendental meditation therapy}, massage {Massage physiotherapy}, acupuncture {Acupuncture}, ice {Cold pack treatment}, heat packs {Thermotherapy with hot packs}, headaches {Headache}, traumatic 
brain injury {Traumatic brain injury}, traumatic brain injury {Traumatic brain injury}, fatigue {Fatigue}, cognitive problems {Impaired cognition}, sleeping {Asleep}, seizures {Seizure}, emotional problems {Emotional problems}, depression {Depressive disorder}, sexuality {Finding related to sexual state}, traumatic brain injury {Traumatic brain injury}, Severe pain {Severe pain}, redness {Redness of skin over lesion}, swelling {Swelling}, drainage {Discharge}, incision 
site {Surgical incision wound}, Fever {Fever}, Nausea {Nausea}, vomiting {Vomiting}, sleepiness {Drowsy}, awake {Awake}, headaches {Headache}, pain relievers {Administration of analgesic}, Seizures {Seizure}, problems with your vision {Abnormal vision}, ability to speak {Difficulty using language}, Weakness {Asthenia}, changes in sensation {Altered sensation of skin}, face {Face structure}, arms {Upper limb structure}, legs {Lower limb structure}, numbness {Numbness}, weakness {Asthenia}, face {Face structure}, arms {Upper limb structure}, legs {Lower limb structure}, confusion {Clouded consciousness}, walking {Does walk}, dizziness {Dizziness}, loss of balance {Unable to balance}, coordination {Finding related to coordination / incoordination}, headaches {Headache}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: 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: 
Gatifloxacin / Penicillins / Ciprofloxacin / Bactrim
 
Attending: ___.
 
Chief Complaint:
Nausea and vomiting
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Gatifloxacin {Allergy to fluoroquinolone}, Penicillins {Allergy to penicillin}, Ciprofloxacin {Allergy to ciprofloxacin}, Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, Nausea and vomiting {Nausea and vomiting}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ with a history of diabetes (thought to be type I) and 
chronic ___ erythema who presents with nausea vomiting without 
abdominal pain for the past day. Pateint reports she began 
vomiting this am and in total has had 4 episodes of non bloody 
vomiting in addition to loose stools and dysuria. She denies 
associated chest pain, fevers, chills or shortness of breath. 
She has not been able to tolerate oral intake at home. She 
additionally notes an associated HA with photophobia starting 
this am. Of note the patient also has a history of frequent 
UTIs. She has been checking blood sugars at home and states they 
have been in the 150s throughout the day.  
Initial VS in the ED:97.2 79 ___ 93% Exam notable for 
bilateral ___ edema and eryhtema with chronic skin changes 
consistent with venous stasis. Labs notable for BG of 455, AG of 
16 and trop negative x 2. VBG was 7.42/34/70. UA showed ketones 
of 10 in addition to > 182 WBC, 17 RBC, moderate bacteria and 
moderate nitrites. Head CT was negative for acute process. 
Patient was given vanco for cellulitis, ctx for UTI. She was 
started on IVF (received 3 L total). She was given 8 units IB 
insulin and BG fell to 25. She was therefore given D50 with 
increase to 417. In terms of blood pressure control she was 
given her home losartan 50 mg with improvment in BP to systolics 
of 160. VS prior to transfer: 77 167/62 16 99%.  

 

###RESPONSE: diabetes {Diabetes mellitus}, erythema {Erythema}, nausea vomiting {Nausea and vomiting}, abdominal pain {Abdominal pain}, vomiting {Vomiting}, bloody 
vomiting {Hematemesis}, loose stools {Loose stool}, dysuria {Dysuria}, chest pain {Chest pain}, fevers {Fever}, chills {Chill}, shortness of breath {Dyspnea}, able to tolerate oral intake {Tolerating oral fluid}, HA {Headache}, photophobia {Photophobia}, frequent 
UTIs {Recurrent urinary tract infection}, blood sugars {Glucose measurement, blood}, VS {Vital signs finding}, Exam {Physical examination procedure}, edema {Edema}, eryhtema {Erythema}, skin changes {Skin appearance abnormal}, venous stasis {Venous stasis}, Labs {Laboratory test}, UA {Urinalysis}, moderate bacteria {Bacteriuria}, Head CT {Computed tomography of head}, cellulitis {Cellulitis}, UTI {Urinary tract infectious disease}, IVF {Administration of intravenous fluids}, VS {Vital signs finding}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1. DM2: insulin-dependent may be Type 1  
-followed by ___  
-c/b recurrent ulcers, urosepsis  
-Charcot deformity  
2. s/p amputation of L ___ & ___ toe  
3. chronic ulcer of R pretibia  
4. hx of MRSA foot ___  
5. HTN  
6. PVD  
7. hypercholesterolemia  
8. Anemia, ? ACD, baseline low ___  
9. Hematemesis in ___ thought to be ___ small ___, 
EGD ulcer in GE junction  

 

###RESPONSE: DM2 {Diabetes mellitus type 2}, Type 1 {Diabetes mellitus type 1}, ulcers {Ulcer}, urosepsis {Sepsis due to urinary tract infection}, Charcot deformity {Charcot's arthropathy}, amputation of L ___ & ___ toe {Amputated toe of left foot}, chronic ulcer of R pretibia {Chronic ulcer of skin of lower leg}, MRSA {Methicillin resistant Staphylococcus aureus infection}, foot {Structure of left foot}, HTN {Hypertensive disorder, systemic arterial}, PVD {Peripheral vascular disease}, hypercholesterolemia {Hypercholesterolemia}, Anemia {Anemia}, Hematemesis {Hematemesis}, EGD ulcer {Gastrointestinal ulcer}, GE junction {Cardioesophageal junction structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 DM2, died of diabetes related coma  
Father has DM2, still alive  
Several family members on paternal side with DM2  
No FH of CAD, MI, or cancer.
 

###RESPONSE: DM2 {Diabetes mellitus type 2}, died {Dead}, diabetes related coma {Coma due to diabetes mellitus}, DM2 {Diabetes mellitus type 2}, alive {Alive}, DM2 {Diabetes mellitus type 2}, CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, cancer {Malignant neoplasm of colon}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Admission 
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:  
Vitals: T: 98.2 BP: 191/110 P: 89 R:20 O2: 96% RA  
General: Alert, oriented, appears mildly uncomfortable  
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear  

Neck: supple, JVP not elevated, no LAD  
Lungs: Clear to auscultation bilaterally  
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, 
gallops  
Abdomen: soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding  
Ext: Warm, erythma of the shins bilaterally, bilateral peeling 
scaling, several toes amputated.  
Neuro: CN II-XII, strength ___, sensation in tact to light touch 
 

Discharge Physical Exam:
T 97.6 BP 170/65 (150-194/65-91) HR 86 RR 20 O2 sat 98% FSG @ 
0600 160 (61-267)
GEN: Alert, oriented, no acute distress  
HEENT: NCAT MMM EOMI sclera anicteric, OP clear, poor dentition  

NECK: supple, no JVD, no LAD  
PULM: Good aeration, CTAB no wheezes, rales, ronchi  
CV: RRR normal S1/S2, no mrg  
ABD: soft obese NT ND normoactive bowel sounds, no r/g, no 
suprapubic tenderness, no CVA tenderness  
EXT: Erythema in lower extremities bilaterally with peeling 
skin, no purulent drainage. Left toes amputated. No edema, 
thready DP pulses.
NEURO: CNs2-12 intact, motor function grossly normal, sensation 
grossly intact 

 

###RESPONSE: Physical Exam {Physical examination procedure}, Vitals {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, P {Finding of pulse rate}, R {Finding of rate of respiration}, O2 {Oxygen saturation measurement}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, dry mucous membranes {Mucous membrane dryness}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, Ext {Examination of limb}, Warm {Warm skin}, erythma {Erythema}, shins {Shin structure}, peeling {Peeling of skin}, scaling {Scaly skin}, toes amputated {Amputation of toe}, Neuro {Neurological examination}, CN II-XII {Normal central nervous system}, sensation in tact to light touch {Normal sensation}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, GEN {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, NCAT {Normal head}, MMM {Moist oral mucosa}, EOMI {Normal ocular motility}, sclera anicteric {White sclera}, OP clear {Pharynx normal}, poor dentition {Impaired dentition}, 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/S2 {Heart sounds normal}, no mrg {Heart sounds normal}, ABD {Examination of abdomen}, soft {Abdomen soft}, obese {Obese}, NT {Abdominal tenderness}, ND {Normal abdominal contour}, normoactive bowel sounds {Normal bowel sounds}, suprapubic tenderness {Suprapubic pain}, CVA tenderness {Renal angle tenderness}, EXT {Examination of limb}, Erythema {Erythema}, lower extremities {Lower limb structure}, peeling 
skin {Peeling of skin}, purulent drainage {Purulent discharge from wound}, Left toes amputated {Amputated toe of left foot}, edema {Edema}, DP pulses {Dorsalis pulse present}, NEURO {Neurological examination}, CNs2-12 intact {Normal nervous system function}, motor function grossly normal {Normal motor response to command}, sensation 
grossly intact {Normal sensation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Admission:
___ 06:00PM BLOOD WBC-10.3 RBC-4.99# Hgb-15.5# Hct-47.3# 
MCV-95 MCH-31.1 MCHC-32.9 RDW-13.6 Plt ___
___ 06:00PM BLOOD Neuts-91.0* Lymphs-5.9* Monos-2.6 Eos-0.1 
Baso-0.4
___ 06:00PM BLOOD ___ PTT-22.7* ___
___ 06:00PM BLOOD Glucose-445* UreaN-31* Creat-1.4* Na-136 
K-4.9 Cl-99 HCO3-20* AnGap-22*
___ 06:00PM BLOOD ALT-12 AST-25 AlkPhos-113* TotBili-0.6
___ 06:00PM BLOOD Albumin-4.2
___ 10:52PM BLOOD Osmolal-313*
___ 06:14PM BLOOD pO2-70* pCO2-34* pH-7.42 calTCO2-23 Base 
XS--1 Comment-GREEN TOP
___ 06:14PM BLOOD Lactate-3.2*

Discharge:
___ 07:55AM BLOOD WBC-7.7# RBC-4.17* Hgb-12.8 Hct-39.6 
MCV-95 MCH-30.7 MCHC-32.3 RDW-13.7 Plt ___
___ 07:55AM BLOOD ___ PTT-26.7 ___
___ 07:55AM BLOOD Glucose-168* UreaN-24* Creat-1.3* Na-138 
K-4.7 Cl-107 HCO3-22 AnGap-14
___ 07:55AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.0
___ 11:44AM BLOOD Lactate-2.4*
___ 11:44AM BLOOD ___ pO2-90 pCO2-54* pH-7.27* 
calTCO2-26 Base XS--2 Comment-GREEN TOP
___ 10:52PM BLOOD CK-MB-5 cTropnT-<0.01
___ 06:00PM BLOOD cTropnT-<0.01

Microbiology:
___ and ___ Blood Cultures: Pending
___ Urine Culture: Negative
___ Urinalysis: Large leukocytes, positive nitrite, >182 WBC, 
17 RBC, moderate bacteria

Imaging:
___ CCR: Limited, with mild cardiomegaly and no definite signs 
of 
pneumonia or overt CHF. 
___ CT Head: No acute intracranial process.  Sinus disease in 
the right 
sphenoid sinus. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, pH {pH measurement}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, 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}, pH {pH measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, Blood Cultures {Blood culture}, Urine Culture {Urine culture}, Urinalysis {Urinalysis}, Large leukocytes {Leukocytes in urine}, positive nitrite {Nitrite detected in urine}, moderate bacteria {Bacteriuria}, cardiomegaly {Cardiomegaly}, pneumonia {Pneumonia}, CHF {Congestive heart failure}, CT Head {Computed tomography of head}, intracranial {Intracranial structure}, Sinus disease {Disorder of nasal sinus}, right 
sphenoid sinus {Right sphenoid sinus structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Brief Course:
___ yo female with hx of likely type I diabetes presents with 
nausea and vomiting, found to have elevated blood glucose to 455 
and anion gap in the setting of UTI. Patient's blood sugars were 
controlled and her anion gap resolved with subcutaneous insulin 
and IV fluids. She was treated for her UTI with IV ceftriaxone 
and discharged on oral cefuroxime.
 
Active Issues:
# DKA: Patient presented with elevated blood glucose, increased 
anion gap, and ketones in urine reflective of some degree of 
DKA. UTI is most likely precipitant. Patient recieved 8 units of 
IV insulin and was transitioned to subcutaneous insulin regimen 
which was taylored per ___ recommendations. Her electrolytes 
were monitored and repleated as necessary and her anion gap 
closed. She received IV fluids and was able to tolerated po. 
Patient's blood glucose stabilized and she was discharged on her 
home insulin regimen.
 
# Hypertensive emergency: Patient presented with elevated blood 
pressures to 200 systolic. She had a headache on admission 
concerning for some level of end organ ischemia, which resolved 
with blood pressure control. Patient maintained good urine 
output with stable creatinine. Head CT negative. Trop negative x 
2, EKG without evidence of ischemic changes. Patient was 
continued on her home antihypertensive medication and required 2 
prn doses of 12.5 mg captopril.
  
# UTI: Patient with grossly positive UA and leukocytosis, 
although urine culture was negative. Patient has history of UTI 
with culture growing pan sensitive proteus and ecoli. She was 
initially treated with IV ceftriaxone then transitioned to oral 
cefuroxime for total 10 day course, given her multiple 
medication allergies and history of frequent UTIs.

# Lower extremity erythema: Per patient lower extremity edema 
currently at baseline. No obvious signs of cellulitis. Likely 
combination of venous stasis dermatitis and arterial 
insufficiency. Patient will fo home with ___ for wound care and 
dressing changes.
  
Inactive Issue: 
# CKD: Creatinine was below baseline (1.5-1.8). 

Transitional Issues:
1. Code Status: FULL
2. Communication: Patient
3. Medication changes: 
-START Cefuroxime for UTI
4. Follow up: PCP
5. Pending studies: Blood cultures
 

###RESPONSE: type I diabetes {Diabetes mellitus type 1}, nausea and vomiting {Nausea and vomiting}, elevated blood glucose {Glucose level above reference range}, UTI {Urinary tract infectious disease}, blood sugars {Glucose measurement, blood}, subcutaneous insulin {Subcutaneous injection of insulin}, IV fluids {Administration of intravenous fluids}, UTI {Urinary tract infectious disease}, DKA {Ketoacidosis due to diabetes mellitus}, elevated blood glucose {Glucose level above reference range}, increased 
anion gap {Increased anion gap}, ketones in urine {Ketonuria}, DKA {Ketoacidosis due to diabetes mellitus}, UTI {Urinary tract infectious disease}, subcutaneous insulin {Subcutaneous injection of insulin}, regimen {Therapeutic regimen}, electrolytes 
were monitored {Electrolyte monitoring}, anion gap 
closed {Reduced anion gap}, IV fluids {Administration of intravenous fluids}, able to tolerated po {Tolerating oral fluid}, blood glucose stabilized {Blood glucose within reference range}, insulin regimen {Insulin regime}, Hypertensive emergency {Hypertensive emergency}, elevated blood 
pressures {Finding of increased blood pressure}, headache {Headache}, ischemia {Ischemia}, urine 
output {Finding of measures of urine output}, stable creatinine {Creatinine clearance-glomerular filtration within reference range}, Head CT {Computed tomography of head}, Trop {Troponin measurement}, EKG {Electrocardiographic procedure}, without evidence of ischemic changes {Electrocardiogram: no myocardial ischemia}, antihypertensive medication {Antihypertensive therapy}, UTI {Urinary tract infectious disease}, UA {Urinalysis}, leukocytosis {Leukocytosis}, urine culture was negative {Urine culture - no growth}, UTI {Urinary tract infectious disease}, culture {Microbial culture}, medication allergies {Allergy to drug}, frequent UTIs {Recurrent urinary tract infection}, Lower extremity {Lower limb structure}, erythema {Erythema}, lower extremity edema {Edema of lower extremity}, cellulitis {Cellulitis}, venous stasis dermatitis {Stasis dermatitis of lower limb due to chronic peripheral venous hypertension}, arterial 
insufficiency {Arterial insufficiency}, wound care {Wound care}, dressing changes {Change of dressing}, CKD {Chronic kidney disease}, Creatinine was below baseline {Creatine kinase below reference range}, UTI {Urinary tract infectious disease}, Blood cultures {Blood culture}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Preadmissions medications listed are incomplete and require 
futher investigation.  Information was obtained from 
PatientwebOMR.
1. Vitamin D 50,000 UNIT PO MONTHLY 
2. Nortriptyline 150 mg PO HS 
3. Rosuvastatin Calcium 20 mg PO DAILY 
4. Losartan Potassium 50 mg PO DAILY 
5. Pantoprazole 40 mg PO Q24H 
6. Hydrochlorothiazide 25 mg PO DAILY 
7. Detemir 70 Units Bedtime

 
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY 
2. Losartan Potassium 50 mg PO DAILY 
3. Nortriptyline 150 mg PO HS 
4. Pantoprazole 40 mg PO Q24H 
5. Rosuvastatin Calcium 20 mg PO DAILY 
6. Vitamin D 50,000 UNIT PO MONTHLY 
7. cefUROXime axetil *NF* 500 mg Oral BID Duration: 8 Days 
RX *cefuroxime axetil 500 mg 1 tablet(s) by mouth twice a day 
Disp #*16 Tablet Refills:*0
8. Detemir 70 Units Bedtime

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary:  Diabetic ketoacidosis
          UTI
          Dehydration
          CKD
 
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}, Diabetic ketoacidosis {Ketoacidosis due to diabetes mellitus}, UTI {Urinary tract infectious disease}, Dehydration {Dehydration}, CKD {Chronic kidney disease}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}, walker {Uses zimmer frame}, cane {Uses single walking stick}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,

It was a pleasure taking care of you at ___. You were admitted 
for nausea and vomiting, and your blood sugars were found to be 
very high and you were in DKA. We were able to control your 
blood sugar level with insulin and your nausea and vomiting 
improved.

You were also suspected to have a urinary tract infection which 
we treating with antibiotics.

Please make the following changes to your medications:
START Cefuroxime for your UTI
 

###RESPONSE: nausea and vomiting {Nausea and vomiting}, blood sugars {Glucose measurement, blood}, DKA {Ketoacidosis due to diabetes mellitus}, nausea and vomiting {Nausea and vomiting}, improved {Patient's condition improved}, urinary tract infection {Urinary tract infectious disease}, antibiotics {Antibiotic therapy}, UTI {Urinary tract infectious disease}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: CARDIOTHORACIC
 

###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: 
Enbrel / Methotrexate / Ampicillin
 
Attending: ___
 
Chief Complaint:
chest and arm pain
 
Major Surgical or Invasive Procedure:
___ CABG x6(LIMA-LAD,SVG-OM2-D2-D1,SVG-OM1,SVG-PDA)

 

###RESPONSE: Methotrexate {Allergy to methotrexate}, Ampicillin {Allergy to ampicillin}, chest {Chest pain}, arm pain {Pain in upper limb}, CABG {Coronary artery bypass grafting}, LIMA {Structure of left internal thoracic artery}, LAD {Structure of anterior descending branch of left coronary artery}, SVG {Aortocoronary artery bypass graft with saphenous vein graft}, OM2 {Structure of second obtuse marginal branch of circumflex branch of left coronary artery}, D2 {Structure of second diagonal branch of anterior descending branch of left coronary artery}, D1 {Structure of first diagonal branch of anterior descending branch of left coronary artery}, SVG {Aortocoronary artery bypass graft with saphenous vein graft}, OM1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, SVG {Aortocoronary artery bypass graft with saphenous vein graft}, PDA {Structure of posterior descending coronary artery}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ year old female who presented to ___ yesterday 
with substernal chest pain radiating to her left arm that woke 
her from sleep. She reports these symptoms have been occurring 
intermittently over the last one month. At
___ she ruled out for MI per enzymes. Stress test 
showed small LV apex ischemia and mild inferior wall basal 
hypokinesis, EF 57%. She was transferred to ___ for cardiac 
catheterization and further evaluation. She was found to have 
three vessel disease upon cardiac catheterization and is now
being referred to cardiac surgery for revascularization. 

 

###RESPONSE: substernal chest pain {Retrosternal pain}, radiating to her left arm {Pain radiating to left arm}, MI {Myocardial infarction}, Stress test {Electrocardiogram with exercise test}, LV apex {Structure of apex of left ventricle}, ischemia {Ischemia}, inferior wall {Structure of myocardium of inferior surface of left ventricle}, hypokinesis {Behavior showing reduced motor activity}, cardiac 
catheterization {Cardiac catheterization}, evaluation {Evaluation procedure}, three vessel disease {Triple vessel disease of the heart}, cardiac catheterization {Cardiac catheterization}, revascularization {Heart revascularization}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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
Dyslipidemia
Tobacco abuse (currently smoking 1 PPD)
Peripheral artery disease
Hypothyroid
Anxiety
Depression
Osteoporosis
Rheumatoid arthritis
Psoriasis
Lupus (remote)
C-diff (___)
Past Surgical History:
Choleysectomy
Bilateral Cataract

 

###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, Dyslipidemia {Dyslipidemia}, Tobacco abuse {Tobacco dependence syndrome}, smoking {Smoker}, Peripheral artery disease {Peripheral arterial disease}, Hypothyroid {Hypothyroidism}, Anxiety
Depression {Mixed anxiety and depressive disorder}, Osteoporosis {Osteoporosis}, Rheumatoid arthritis {Rheumatoid arthritis}, Psoriasis {Psoriasis}, Lupus {Lupus erythematosus}, Choleysectomy {Cholecystectomy}, Bilateral Cataract {Bilateral cataracts}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Premature coronary artery disease- non contributory

 

###RESPONSE: coronary artery disease {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:
Pulse:67 Resp:18  O2 sat:99/RA
B/P  Right:158/103    Left:155/88
Height:5'5""     Weight:64.3 kgs

General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck:  Supple [x] Full ROM [x] MMM
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur -none
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm x[], well-perfused [x]  Edema none
 rash bilat upper and lower legs, red/dry/puritic w/ecoriated
ankles and feet
Varicosities: None [x]
Neuro: Grossly intact [x] A&O x3, MAE, nonfocal exam
Pulses:
Femoral      Right: 2+ Left: 2+
DP           Right: dop  Left: dop
___           Right: dop  Left: dop
Radial       Right: cath  Left: 2+

Carotid Bruit  none

 

###RESPONSE: Pulse {Finding of pulse rate}, Resp {Examination of respiratory system}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, B/P {Blood pressure finding}, Right {Right upper arm structure}, Left {Left upper arm structure}, Weight {Weight finding}, General {General examination of patient}, NAD {No abnormality detected}, Skin {Examination of skin}, Dry {Xeroderma}, intact {Intact skin}, HEENT {Physical examination procedure}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Full ROM {Normal range of cervical spine movement}, MMM {Moist oral mucosa}, Chest {Examination of respiratory system}, Lungs {Examination of respiratory system}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, Irregular {Irregular heart beat}, Murmur {Heart murmur}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-distended {Normal abdominal contour}, non-tender {Abdominal tenderness}, +BS {Normal bowel sounds}, Extremities {Examination of limb}, Warm {Warm skin}, well-perfused {Normal tissue perfusion}, Edema {Edema}, rash {Eruption of skin}, upper {Upper limb structure}, lower legs {Lower limb structure}, dry {Xeroderma}, puritic {Pruritic disorder of skin}, ecoriated {Excoriation of skin}, ankles {Ankle region structure}, feet {Foot structure}, Varicosities {Venous varices}, Neuro {Neurological examination}, Grossly intact {Normal nervous system function}, A {Mentally alert}, O x3 {Oriented to person, time and place}, MAE {Does move all four limbs}, Femoral {Structure of femoral artery}, DP {Structure of dorsalis pedis artery}, Radial {Structure of radial artery}, Right {Structure of right radial artery}, cath {Cardiac catheterization}, Left: 2 {Normal radial pulse}, Carotid Bruit {Carotid bruit}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
ECHO ___
Prebypass:
The left atrium is normal in size. No thrombus is seen in the 
left atrial appendage. There is mild symmetric left ventricular 
hypertrophy. There is mild global left ventricular systolic 
dysfunction with estimated Ejection Fraction 50-55%. Right 
ventricular chamber size and free wall motion are normal. There 
are simple atheroma in the ascending aorta. There are complex 
(>4mm) atheroma in the aortic arch, maximum dimension 0.8 cm. 
There are simple atheroma in the descending thoracic aorta. The 
aortic valve leaflets (3) appear structurally normal with good 
leaflet excursion and no aortic stenosis or aortic 
regurgitation. The mitral valve appears structurally normal with 
trivial mitral regurgitation. There is no pericardial effusion. 
Dr. ___ was notified in person of the results on 
___ at 1400. 
Postbypass:
The patient is AV paced on epinephrine, phenylephrine, 
norepinephrine & vasopressin infusions. There is moderate mitral 
regurgitation. There is mild tricuspid regurgitation. The 
remaining valves are unchanged. Biventricular function is 
maintained on multiple agents. There is biatrial enlargement and 
bowing of the interatrial septum L->R. The aorta is intact.
Prior to chest closure, biventricular function remains intact on 
only norepinephrine & vasopressin infusions. The tricuspid 
regurgitation is trace to mild. The mitral regurgitation is now 
mild to moderate.  

___ 04:44AM BLOOD WBC-9.5 RBC-2.90* Hgb-8.8* Hct-25.3* 
MCV-87 MCH-30.4 MCHC-34.7 RDW-13.2 Plt ___
___ 04:29AM BLOOD WBC-10.6 RBC-2.97* Hgb-8.8* Hct-26.1* 
MCV-88 MCH-29.7 MCHC-33.8 RDW-13.2 Plt ___
___ 02:53PM BLOOD WBC-11.4* RBC-3.35* Hgb-9.8* Hct-29.4* 
MCV-88 MCH-29.3 MCHC-33.4 RDW-13.2 Plt ___
___ 04:44AM BLOOD Glucose-88 UreaN-16 Creat-0.7 Na-130* 
K-4.2 Cl-95* HCO3-25 AnGap-14
___ 04:29AM BLOOD Glucose-90 UreaN-14 Creat-0.6 Na-126* 
K-4.6 Cl-95* HCO3-27 AnGap-9
___ 02:53PM BLOOD Glucose-121* UreaN-10 Creat-0.6 Na-127* 
K-4.4 Cl-94* HCO3-25 AnGap-12
___ 10:58AM BLOOD Glucose-102* Na-129* K-3.9 Cl-96
 

###RESPONSE: ECHO {Echocardiography}, left atrium {Left atrial structure}, normal in size {Normal size}, thrombus {Thrombus}, left atrial appendage {Structure of left auricular appendage}, mild symmetric left ventricular 
hypertrophy {Mild left ventricular hypertrophy}, left ventricular systolic 
dysfunction {Left ventricular systolic dysfunction}, Right 
ventricular chamber {Right cardiac ventricular structure}, wall motion are normal {Normal ventricular wall motion}, atheroma {Atheroma}, ascending aorta {Ascending aorta structure}, atheroma {Atheroma}, aortic arch {Aortic arch structure}, atheroma {Atheroma}, descending thoracic aorta {Structure of descending thoracic aorta}, aortic valve leaflets {Structure of cardiac valve leaflet}, structurally normal {Aortic valve normal}, leaflet {Structure of cardiac valve leaflet}, aortic stenosis {Aortic valve stenosis}, aortic 
regurgitation {Aortic valve regurgitation}, mitral valve appears structurally normal {Mitral valve normal}, trivial mitral regurgitation {Mild mitral valve regurgitation}, pericardial effusion {Pericardial effusion}, moderate mitral 
regurgitation {Moderate mitral valve regurgitation}, mild tricuspid regurgitation {Mild tricuspid valve regurgitation}, Biventricular {Cardiac ventricular structure}, biatrial {Atrial structure}, enlargement {Enlargement}, interatrial septum {Interatrial septum structure}, aorta {Aortic structure}, chest {Thoracic structure}, closure {Reparative closure}, biventricular {Cardiac ventricular structure}, infusions {Infusion}, tricuspid 
regurgitation is trace to mild {Mild tricuspid valve regurgitation}, mitral regurgitation is now 
mild {Mild mitral valve regurgitation}, moderate {Moderate mitral valve regurgitation}, 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}, 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}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
The patient was admitted to the hospital and brought to the 
operating room on ___ where the patient underwent urgent 
coronary artery bypass graft times six.  Left internal mammary 
artery to left anterior descending artery and saphenous vein 
grafts to posterior descending artery, obtuse marginal 1 and 2, 
and diagonal 1 and 2, and Endoscopic harvesting of the long 
saphenous vein.  See operative note for full deatils. Overall 
the patient tolerated the procedure well and post-operatively 
was transferred to the CVICU in stable condition for recovery 
and invasive monitoring. Post-operative day one found the 
patient extubated, alert and oriented and breathing comfortably. 
Initially she had no underlying rhythm and remained DDD paced. 
The electrophysiology service was consulted.  Lopressor was 
initiated once the patient regained her rhythm and she was 
tolerating beta blockers with a rate in the 80's.  The patient 
was neurologically intact and hemodynamically stable on no 
inotropic or vasopressor support. She was gently diuresed toward 
the preoperative weight.  The patient was transferred to the 
telemetry floor for further recovery.  Mediastinal chest tubes 
were removed and the pleural chest tube stayed in an additional 
day due to an air leak.  After the pleural chest tube was on 
waterseal for greater than ___ hours with a small stable 
left pneumothorax, pleural chest tube was pulled. Follow up 
chest radiograph showed small stable left pneumothorax. Pacing 
wires were discontinued without complication on post-operative 
day four. The patient was evaluated by the physical therapy 
service for assistance with strength and mobility.  By the time 
of discharge on post-operative day six the patient was 
ambulating freely, the wound was healing and pain was controlled 
with oral analgesics.  The patient was discharged to ___ 
Rehab in good condition with appropriate follow up instructions.
 

###RESPONSE: coronary artery bypass graft {Coronary artery bypass grafting}, Left internal mammary 
artery {Structure of left internal thoracic artery}, left anterior descending artery {Structure of anterior descending branch of left coronary artery}, saphenous vein 
grafts {Arterial bypass using vein graft}, posterior descending artery {Structure of posterior descending branch of right coronary artery}, obtuse marginal 1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, 2 {Structure of second obtuse marginal branch of circumflex branch of left coronary artery}, diagonal 1 {Structure of first diagonal branch of anterior descending branch of left coronary artery}, 2 {Structure of second diagonal branch of anterior descending branch of left coronary artery}, long 
saphenous vein {Great saphenous vein structure}, stable condition {Patient's condition stable}, Post-operative {Postoperative state}, extubated {Removal of endotracheal tube}, alert {Mentally alert}, oriented {Oriented to person}, breathing comfortably {Breathing easily}, neurologically intact {Normal nervous system function}, hemodynamically stable {Hemodynamically stable}, vasopressor support {Vasopressor therapy}, diuresed {Diuretic therapy}, telemetry {Cardiac telemetry}, Mediastinal chest tubes 
were removed {Removal of tube from mediastinum}, left pneumothorax {Left pneumothorax}, pleural chest tube was pulled {Intercostal drain removal}, chest radiograph {Plain chest X-ray}, left pneumothorax {Left pneumothorax}, ambulating {Fully mobile}, wound was healing {Wound healing well}, pain was controlled 
with oral analgesics {Demonstrates adequate pain control}, instructions {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:
Preadmission medications listed are correct and complete.  
Information was obtained from webOMR.
1. Atenolol 150 mg PO DAILY 
2. Enalapril Maleate 20 mg PO BID 
3. Hydrochlorothiazide 25 mg PO DAILY 
4. Levothyroxine Sodium 100 mcg PO DAILY 
5. Rosuvastatin Calcium 20 mg PO DAILY 
6. Diazepam 5 mg PO Q12H:PRN anxiety 
7. Carbamazepine 400 mg PO DAILY 
8. Nortriptyline 200 mg PO HS 
9. Aspirin 81 mg PO DAILY 
10. Calcium Carbonate 500 mg PO QID:PRN reflux 
11. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN prn 

 
Discharge Medications:
1. Albuterol-Ipratropium ___ PUFF IH Q6H 
2. Aspirin 81 mg PO DAILY 
3. Carbamazepine 400 mg PO DAILY 
4. Enalapril Maleate 10 mg PO BID 
Hold for sbp<100 
5. Levothyroxine Sodium 100 mcg PO DAILY 
6. Nortriptyline 200 mg PO HS 
7. Rosuvastatin Calcium 20 mg PO DAILY 
8. Clopidogrel 75 mg PO DAILY 
poor grafts 
9. Fluticasone Propionate 110mcg 2 PUFF IH BID 
10. Metoprolol Tartrate 12.5 mg PO BID 
Hold for HR < 55 or SBP < 90 and call medical provider. 
11. Ranitidine 150 mg PO BID 
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 
RX *tramadol 50 mg one tablet(s) by mouth every six hours Disp 
#*40 Tablet Refills:*0
13. Calcium Carbonate 500 mg PO QID:PRN reflux 
14. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN prn 
15. Insulin SC 
      Sliding Scale

Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
16. Diazepam 5 mg PO Q12H:PRN anxiety 
17. Furosemide 40 mg PO DAILY Duration: 1 Weeks 
18. Potassium Chloride 40 mEq PO DAILY Duration: 1 Weeks 
Hold for K >4.5 

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
coronary artery disease, Hypertension, Dyslipidemia, 
Tobacco(currently 1 PPD), Peripheral artery disease, 
Hypothyroid, Anxiety, Depression, Osteoporosis,  
Rheumatoid arthritis, Psoriasis, Lupus(remote), ___, 
Choleysectomy, Bilateral Cataract  

 
Discharge Condition:
Alert and oriented x3 nonfocal 
Ambulating with steady gait 
Incisional pain managed with Ultram
Incisions: 
Sternal - healing well, no erythema or drainage 
Leg Left - healing well, no erythema or drainage. 
Trace Edema bilaterally
 

 

###RESPONSE: coronary artery disease {Coronary arteriosclerosis}, Hypertension {Hypertensive disorder, systemic arterial}, Dyslipidemia {Dyslipidemia}, Tobacco {Tobacco dependence syndrome}, Peripheral artery disease {Peripheral arterial disease}, Hypothyroid {Hypothyroidism}, Osteoporosis {Osteoporosis}, Rheumatoid arthritis {Rheumatoid arthritis}, Psoriasis {Psoriasis}, Lupus {Lupus erythematosus}, Choleysectomy {Cholecystectomy}, Bilateral Cataract {Bilateral cataracts}, Alert {Mentally alert}, oriented x3 {Oriented to person, time and place}, Ambulating {Fully mobile}, steady gait {Gait normal}, Incisional {Surgical incision wound}, pain {Pain}, Incisions {Surgical incision wound}, Sternal {Wound of structure of sternal region}, healing well {Wound healing well}, erythema {Erythema}, drainage {Wound discharge}, Leg Left {Structure of left lower leg}, healing well {Wound healing well}, erythema {Erythema}, drainage {Wound discharge}, Edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Please shower daily including washing incisions gently with mild 
soap, no baths or swimming until cleared by surgeon. Look at 
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions 
Each morning you should weigh yourself and then in the evening 
take your temperature, these should be written down on the chart 

No driving for approximately one month and while taking 
narcotics, will be discussed at follow up appointment with 
surgeon when you will be able to drive 
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid 
rubbing on lower edge
**Please call cardiac surgery office with any questions or 
concerns ___. Answering service will contact on call 
person during off hours**

 

###RESPONSE: incisions {Surgical incision wound}, incisions {Surgical incision wound}, redness {Redness of skin over lesion}, drainage {Wound discharge}, incisions {Surgical incision wound}, incision {Surgical incision wound}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Abdominal pain
 
Major Surgical or Invasive Procedure:
ERCP: single stone in CBD removed + sphincterotomy.

 

###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, Abdominal pain {Abdominal pain}, ERCP {Endoscopic retrograde cholangiopancreatography}, stone in CBD {Common bile duct calculus}, removed + sphincterotomy {Endoscopic sphincterotomy of sphincter of Oddi and removal of calculus}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
HPI:This is a ___ yo male who was transfered from ___ today where he was admitted on  ___ for abdominal
discomfort, vomiting and substernal chest pain. The patient has 
a
history of ischemic cardiomyopathy (EF:20%), Coronary artery
disease and atrial fibrillation. He spiked a fever on the day of
admission, blood cultures were obtained and  yielded 
pansensitive
E.coli. Repeated liver funtion tests showed an increase of total
bilirubin (2.7 > 5.4) LFT's ( AST 52>343, ALT 33> 269). A RUQ
ultrasound  didn't yield any evicence of gallstones, no intra or
extrahepatic dilation. HIDA scan was performed on ___ and
showed non-opacification of the gallbladder, consitant with 
acute
cholecystitis. He was transferred to the ___ today for further
evaluation and treatment.
 

###RESPONSE: abdominal
discomfort {Abdominal discomfort}, vomiting {Vomiting}, substernal chest pain {Retrosternal pain}, ischemic cardiomyopathy {Generalized ischemic myocardial dysfunction}, Coronary artery
disease {Coronary arteriosclerosis}, atrial fibrillation {Atrial fibrillation}, fever {Fever}, blood cultures {Blood culture}, liver funtion tests {Hepatic function panel}, total
bilirubin {Bilirubin, total measurement}, RUQ {Structure of right upper quadrant of abdomen}, ultrasound {Ultrasonography of abdomen}, gallstones {Gallbladder calculus}, intra {Intrahepatic biliary tract structure}, dilation {Dilatation}, HIDA scan {Radionuclide imaging of liver and/or biliary tract using radioactive isotope}, gallbladder {Gallbladder structure}, acute
cholecystitis {Acute cholecystitis}, evaluation {Evaluation procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Cardiomyopathy with EF of 20%, Atrial fibrillation,
hypertension, hyperlipidemia, h/o ventricular tachycardia, 
status
post ICD placement, CAD, compensated congested heart failure,
status post aortobi-iliac stent graft placement in ___, h/o
renal lesion, presumed cacinoma, treated conservatively in the
past, h/o prostate cancer
 

###RESPONSE: Cardiomyopathy {Cardiomyopathy}, Atrial fibrillation {Atrial fibrillation}, hypertension {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, ventricular tachycardia {Ventricular tachycardia}, ICD placement {Automatic defibrillator procedure}, CAD {Coronary arteriosclerosis}, congested heart failure {Congestive heart failure}, stent graft placement {Insertion of arterial stent}, renal {Kidney structure}, lesion {Lesion}, cacinoma {Carcinoma}, prostate cancer {Carcinoma of prostate}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Noncontributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VS: 97.2 HR 81 BP 94/68 RR 18 Sat 100% RA 
General: awake and alert
HEENT: no cervical or supraclavicular adenopathy noted, 
Skin:dry
CV: regular rhythm, II/VI SEM
Lungs: CTA bilaterally
Abdomen: soft, +BS, non-tender, no rebound/guarding
Extremities: warm,no edema
 

###RESPONSE: Physical Exam {Physical examination procedure}, VS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, RA {Breathing room air}, General {General examination of patient}, awake {Awake}, alert {Mentally alert}, HEENT {Physical examination procedure}, cervical {Cervical lymphadenopathy}, supraclavicular adenopathy {Supraclavicular lymphadenopathy}, Skin {Examination of skin}, dry {Xeroderma}, CV {Cardiovascular physical examination}, regular rhythm {Normal sinus rhythm}, SEM {Ejection murmur}, Lungs {Examination of respiratory system}, CTA {Normal breath sounds}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, +BS {Normal bowel sounds}, non-tender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, Extremities {Examination of limb}, warm {Warm skin}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 04:40AM BLOOD WBC-6.2 RBC-4.20* Hgb-13.1* Hct-40.3 
MCV-96 MCH-31.2 MCHC-32.5 RDW-13.7 Plt ___
___ 06:35AM BLOOD ___ PTT-34.3 ___
___ 06:50AM BLOOD Glucose-124* UreaN-35* Creat-1.6* Na-137 
K-4.1 Cl-98 HCO3-27 AnGap-16
___ 06:50AM BLOOD ALT-47* AST-23 AlkPhos-271* TotBili-2.7*
___ 06:50AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.5

ERCP ___
Impression: Cannulation of the biliary duct was successful and 
deep with a sphincterotome using a free-hand technique. 
Periampullary diverticulum. 
A single 1 cm round stone that was causing partial obstruction 
was seen at the middle third of the common bile duct.  A 
successful biliary sphincterotomy was performed in the 12 
o'clock position using a sphincterotome over an existing 
guidewire.  A biliary balloon sphincteroplasty was performed. A 
12mm balloon was introduced for dilation successfully.  The 
stone was extracted successfully using a balloon catheter. 
Occlusion cholangiogram revealed no residual filling defects. 
The cystic duct was dilated and widely patent. Partial 
pancreatogram was normal.   
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, ERCP {Endoscopic retrograde cholangiopancreatography}, Cannulation {Cannulation}, biliary duct {Bile duct structure}, Periampullary diverticulum {Diverticulum of peri-ampullary tissue of hepatopancreatic ampulla}, stone {Calculus}, partial obstruction {Partial obstruction}, common bile duct {Common bile duct structure}, biliary sphincterotomy {Endoscopic incision of sphincter of Oddi}, dilation {Dilatation}, stone was extracted {Extraction of calculus of biliary tract}, Occlusion {Complete obstruction}, cholangiogram {Cholangiogram}, filling defects {Filling defect}, cystic duct {Cystic duct structure}, dilated {Dilatation}, pancreatogram {Pancreatic contrast 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:
The patient was admitted to the General Surgical Service for 
evaluation and treatment. On ___ the patient underwent ERCP 
and were able to extract a CBD stone and performed a 
sphincterotomy and sphincteroplasty which went well without 
complication (reader referred to the Operative Note for 
details). The patient arrived on the floor NPO, on IV fluids and 
antibiotics. The patient was hemodynamically stable.

Neuro: The patient did not have any complaints of pain on 
arrival to the floor.

CV: The patient remained stable from a cardiovascular 
standpoint; vital signs were routinely monitored.

Pulmonary: The patient remained stable from a pulmonary 
standpoint; vital signs were routinely monitored. Good pulmonary 
toilet, early ambulation and incentive spirrometry were 
encouraged throughout hospitalization.

GI/GU/FEN: Post-operatively, the patient was made NPO with IV 
fluids. Diet was advanced when appropriate, which was well 
tolerated. Patient's intake and output were closely monitored, 
and IV fluid was adjusted when necessary. 

ID: The patient's white blood count and fever curves were 
closely watched for signs of infection. He did have a urine 
culture that showed enterococcus ___. ID was curbsided 
and they did not recommend antibiotics for treatment. Repeat UA 
x 2 was negative. They suspect that it is colinization of the 
UT. He was also on Zosyn for the ERCP. 

Endocrine: The patient's blood sugar was monitored throughout 
his stay.

Hematology: The patient's complete blood count was examined 
routinely; no transfusions were required.

Prophylaxis: The patient received subcutaneous heparin and 
venodyne boots were used during this stay; was encouraged to get 
up and ambulate as early as possible.

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 received discharge teaching and 
follow-up instructions with understanding verbalized and 
agreement with the discharge plan.

 

###RESPONSE: General Surgical Service {Admission to surgical department}, evaluation {Evaluation procedure}, ERCP {Endoscopic retrograde cholangiopancreatography}, CBD {Common bile duct structure}, stone {Extraction of calculus of biliary tract}, sphincterotomy {Endoscopic incision of sphincter of Oddi}, Operative {Surgical procedure}, NPO {Nil by mouth}, IV fluid {Administration of intravenous fluids}, antibiotics {Antibiotic therapy}, hemodynamically stable {Hemodynamically stable}, Neuro {Neurological examination}, pain {Pain}, CV {Cardiovascular physical examination}, stable {Patient's condition stable}, cardiovascular {Cardiovascular physical examination}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, Pulmonary {Examination of respiratory system}, stable {Patient's condition stable}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, pulmonary 
toilet {Airway toilet}, incentive spirrometry {Incentive spirometry}, GI {Examination of digestive system}, GU {Examination of genitourinary system}, NPO {Nil by mouth}, IV 
fluids {Administration of intravenous fluids}, Diet {Dietary finding}, intake and output {Measuring intake and output}, IV fluid {Administration of intravenous fluids}, white blood count {White blood cell count}, fever {Fever}, signs of infection {Monitoring for signs and symptoms of infection}, urine 
culture {Urine culture}, antibiotics {Antibiotic therapy}, UA {Urinalysis}, UT {Structure of urinary tract proper}, ERCP {Endoscopic retrograde cholangiopancreatography}, blood sugar {Glucose measurement, blood}, complete blood count {Complete blood count}, transfusions {Transfusion}, Prophylaxis {Preventive procedure}, 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}, follow-up {Follow-up arranged}, instructions {Patient education}, 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:
(updated per documented OSH record ___
Coumadin 4mg PO daily (on hold)
Coreg 12.5mg po BID
Amiodarone 200mg PO BID
Trazodone 50 mg po QHS
Nitro-patch 0.4mg/Hr TD overnight only
Lasix 80 mg po dialy
Spironolactone 12.5mg PO daily
Digoxin 0.125 po daily
Zocor 20mg PO QHS
Colace 100mg PO BID
Milk of Magnesia prn
Zofran prn
Morphine 2 to 4 mg q3h prn

 
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times 
a day).  
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at 
bedtime).  
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times 
a day).  
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
6. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 
 
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) 
as needed for insomnia.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Choledocholithiasis

 
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}, Choledocholithiasis {Gallbladder and bile duct calculi}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - 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:
Please call your doctor or nurse practitioner or return to the 
Emergency Department for any of the following:

*You experience new chest pain, pressure, squeezing or 
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your 
medications.
*You are getting dehydrated due to continued vomiting, diarrhea, 
or other reasons. Signs of dehydration include dry mouth, rapid 
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a 
bowel movement.
*You experience burning when you urinate, have blood in your 
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone 
within 24 hours. Call or return immediately if your pain is 
getting worse or changes location or moving to your chest or 
back.
*You have shaking chills, or fever greater than 101.5 degrees 
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern 
you.

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.

 

###RESPONSE: chest pain {Chest pain}, pressure {Tight chest}, squeezing {Squeezing chest pain}, tightness {Tight chest}, cough {Cough}, shortness of breath {Dyspnea}, wheeze {Wheezing}, vomiting {Vomiting}, medications {Medication education}, dehydrated {Dehydration}, vomiting {Vomiting}, diarrhea {Diarrhea}, Signs {Sign}, dehydration {Dehydration}, dry mouth {Xerostomia}, rapid 
heartbeat {Tachycardia}, dizzy {Dizziness}, faint {Feeling faint}, standing {Orthostatic body position}, blood or dark/black material when you vomit {Vomit contains blood}, bowel movement {Hematochezia}, burning {Burning sensation}, urinate {Micturition finding}, blood in your 
urine {Blood in urine}, discharge {Discharge}, pain {Pain}, pain {Pain}, chest {Thoracic structure}, back {Structure of back of trunk}, shaking {Tremor}, chills {Chill}, fever {Fever}, medications {Medication education}, medication {Medication education}, medications {Medication education}, Avoid lifting 
weights {Functional activity education}, follow-up {Follow-up arranged}, activity 
restrictions {Functional activity education}, while taking pain 
medications {Patient medication education}, follow-up {Follow-up arranged}, PCP {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: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
ulcerative colitis
 
Major Surgical or Invasive Procedure:
___ ileostomy takedown
 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, ulcerative colitis {Ulcerative colitis}, ileostomy takedown {Closure of ileostomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
A ___ man who previously underwent
abdominal colectomy, laparoscopic proctectomy, and diverting
loop ileostomy, J pouch on ___.  The pouch study was normal. 
 Risks
and benefits included, but not limited to, infection,
bleeding, leak, need for more procedures were discussed.  The
patient understood and agreed.
 

###RESPONSE: colectomy {Excision of colon}, laparoscopic {Laparoscopic procedure}, proctectomy {Resection of rectum}, loop ileostomy {Creation of loop ileostomy}, J pouch {J pouch}, normal {No abnormality detected}, infection {Infectious disease}, bleeding {Bleeding}, leak {Anastomosis, leaking}, procedures {Procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
PMH:
Ulcerative Colitis

PSH:
Lap colectomy w/ end ileostomy (___)
 

###RESPONSE: Ulcerative Colitis {Ulcerative colitis}, Lap colectomy w/ end ileostomy {Laparoscopic total colectomy and ileostomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
M: CAD, HLD
Maternal GM: RA
DM in father's side of family

 

###RESPONSE: CAD {Coronary arteriosclerosis}, HLD {Hyperlipidemia}, RA {Rheumatoid arthritis}, DM {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:
NAD
CV: RRR
Resp: nl breathing effort
GI: inc c/d/i, ND, NT, soft
 

###RESPONSE: NAD {No abnormality detected}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, Resp {Examination of respiratory system}, nl breathing {Normal respiratory function}, GI {Examination of digestive system}, ND {Swollen abdomen}, NT {Abdominal tenderness}, soft {Abdomen soft}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:

###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 Template:  
Mr ___ presented to ___ holding at ___ on ___ for 
a ileostomy takedown. He tolerated the procedure well without 
complications (Please see operative note for further details). 
After a brief and uneventful stay in the PACU, the patient was 
transferred to the floor for further post-operative management.  

On ___, the patient was discharged to home. At discharge, 
he was tolerating a regular diet, passing flatus, stooling, 
voiding, and ambulating independently. He will follow-up in the 
clinic in ___ weeks. This information was communicated to the 
patient directly prior to discharge.  
Include in Brief Hospital Course for Every Patient and check of 
boxes that apply:  
Post-Surgical Complications During Inpatient Admission:  
[x] None  
Social Issues Causing a Delay in Discharge:  
[x] No social factors contributing in delay of discharge.  

 

###RESPONSE: ileostomy takedown {Closure of ileostomy}, procedure {Surgical procedure}, operative {Surgical procedure}, PACU {Postanesthesia care}, post-operative management {Postoperative care}, regular diet {Normal diet}, passing flatus {Passing flatus}, stooling {Able to defecate}, voiding {Normal micturition}, ambulating independently {Independent walking}, follow-up {Follow-up arranged}, clinic {Outpatient care management}, Post-Surgical Complications {Postoperative complication}, social factors {Social factor}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
None
 
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain 
do not take more than 3000mg of Tylenol or drink alcohol  
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) 
hours Disp #*50 Tablet Refills:*0
2. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN pain 
do not drink alcohol or drive a car while taking 
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours 
Disp #*30 Tablet Refills:*0
3. Tamsulosin 0.4 mg PO QHS 
please take for 5 more days at home 
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*5 
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:
Ileostomy Takedown

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Ileostomy Takedown {Closure of ileostomy}, 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 - 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 hospital after an ileostomy takedown. 
You have recovered from this procedure well and you are now 
ready to return home. You have tolerated a regular diet, passing 
 
gas and your pain is controlled with pain medications by mouth. 
You may return home to finish your recovery.  
 
Please monitor your bowel function closely. You may or may not 
have had a bowel movement prior to your discharge which is 
acceptable, however it is important that you have a bowel 
movement in the next ___ days. After anesthesia it is not 
uncommon for patient’s to have some decrease in bowel function 
but your should not have prolonged constipation. Some loose 
stool and passing of small amounts of dark, old appearing blood 
are expected however, if you notice that you are passing bright 
red blood with bowel your please seek medical attention. If you 
are passing loose stool without improvement please call the 
office or go to the emergency room if the symptoms are severe. 
If you are taking narcotic pain medications there is a risk that 
you will have some constipation. Please take an over the counter 
stool softener such as Colace, and if the symptoms does not 
improve call the office. It is also not uncommon after an 
ileostomy takedown to have frequent loose stools until you are 
taking more regular food however this should improve.  
The muscles of the sphincters have not been used in quite some 
time and you may experience urgency or small amounts of 
incontinence however this should improve. If you do not show 
improvement in these symptoms within ___ days please call the 
office for advice. Occasionally, patients will need to take a 
medication to slow their bowel movements as their bodies adjust 
to the new normal without an ileostomy, you should consult with 
our office for advice. If you have any of the following symptoms 
please call the office for advice or go to the emergency room if 
 
severe: increasing abdominal distension, increasing abdominal 
pain, nausea, vomiting, inability to tolerate food or liquids, 
prolonged loose stool, or constipation.  
 
You have a small wound where the old ileostomy once was. This 
should be covered with a dry sterile gauze dressing. The wound 
no longer requires packing with gauze packing strip. Please  
monitor the incision for signs and symptoms of infection 
including: increasing redness at the incision, opening of the 
incision, increased pain at the incision line, draining of 
white/green/yellow/foul smelling drainage, or if you develop a 
fever. Please call the office if you develop these symptoms or 
go to the emergency room if the symptoms are severe. You may  
shower, let the warm water run over the wound line and pat the 
area dry with a towel, do not rub. Please apply a new gauze 
dressing after showering.  
 
No heavy lifting for at least 6 weeks after surgery unless 
instructed otherwise by your surgical team. You may gradually 
increase your activity as tolerated but clear heavy exercise 
with your surgical team.
 
You will be prescribed a small amount of the pain medication 
oxycodone. Please take this medication exactly as prescribed. 
You may take Tylenol as recommended for pain. Please do not take 
more than 3000mg of Tylenol daily. Do not drink alcohol while 
taking narcotic pain medication or Tylenol. Please do not drive 
a car while taking narcotic pain medication.  
 
Thank you for allowing us to participate in your care! Our hope 
is that you will have a quick return to your life and usual 
activities. Good luck! 
 

 

###RESPONSE: ileostomy takedown {Closure of ileostomy}, recovered from this procedure well {Good recovery following surgery}, ready to return {Ready for discharge}, regular diet {Normal diet}, passing 
 
gas {Passing flatus}, pain {Pain}, pain medications {Administration of analgesic}, by mouth {Administration of drug or medicament via oral route}, monitor your bowel function {Monitoring bowel motility}, bowel movement {Able to defecate}, bowel 
movement {Able to defecate}, anesthesia {Administration of anesthesia}, decrease in bowel function {Altered bowel function}, constipation {Constipation}, loose 
stool {Loose stool}, dark {Dark stools}, old appearing blood {Melena}, bright 
red blood {Hematochezia}, bowel {Intestinal structure}, seek medical attention {Recommendation to seek attention}, loose stool {Loose stool}, improvement {Patient's condition improved}, emergency {Emergency treatment}, taking narcotic pain medications {Narcotics education}, constipation {Constipation}, take an over the counter 
stool softener {Administration of laxative}, ileostomy takedown {Closure of ileostomy}, loose stools {Loose stool}, e regular food {Normal diet}, muscles of the sphincters {Structure of sphincter ani muscle}, urgency {Urgent desire for stool}, small {Symptom mild}, incontinence {Incontinence of feces}, improvement {Patient's condition improved}, medication {Administration of drug or medicament}, bowel movements {Altered bowel function}, ileostomy {Ileostomy - stoma}, emergency {Emergency treatment}, abdominal distension {Swollen abdomen}, abdominal 
pain {Abdominal pain}, nausea, vomiting {Nausea and vomiting}, inability to tolerate food or liquids {Nausea and vomiting}, loose stool {Loose stool}, constipation {Constipation}, wound {Wound}, ileostomy {Ileostomy operation}, sterile gauze dressing {Application of dressing, sterile}, wound {Wound}, packing {Packing of wound}, packing {Packing of wound}, 
monitor {Monitoring for signs and symptoms of infection}, incision {Surgical incision wound}, signs {Sign}, infection {Local infection of wound}, redness {Redness of skin over lesion}, incision {Surgical incision wound}, incision {Surgical incision wound}, increased pain {Increased pain}, incision {Surgical incision wound}, draining {Wound discharge}, drainage {Wound discharge}, fever {Fever}, emergency {Emergency treatment}, shower {Functional activity education}, wound {Wound}, dressing {Application of dressing}, No heavy lifting {Functional activity education}, after surgery {Postoperative state}, activity as tolerated {Education about increasing activity tolerance}, t clear heavy exercise {Functional activity education}, Please take this medication exactly as prescribed {Patient medication education}, pain {Pain}, do not take {Patient medication education}, Do not drink alcohol {Education about alcohol consumption}, while 
taking narcotic pain medication {Narcotics education}, Please do not drive 
a car {Patient medication education}, while taking narcotic pain medication {Narcotics education}, activities {Finding of functional performance and activity}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:  ___            ___ No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: UROLOGY
 

###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:
Metastatic colon cancer to left ureter
 
Major Surgical or Invasive Procedure:
Left nephroureterectomy

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Metastatic colon cancer {Metastatic carcinoma to colon}, left ureter {Metastatic malignant neoplasm to ureter}, Left {Left kidney structure}, nephroureterectomy {Nephroureterectomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Dear Doctors:

I had the pleasure of seeing our mutual patient, Ms. ___, today at the ___ in
followup.  I performed cystoscopy on her today after a urine
cytology demonstrated malignant cells consistent with colon
cancer.  I had previously counseled her and seen her regarding
her positive PET scan, which demonstrated a potential tumor in
the left ureter.  However, she has a history of a completely
obstructed left upper tract.  Therefore, I did not expect to see
a positive urine cytology if she was indeed completely 
obstructed
and the only disease was in her ureter.  I, therefore, brought
her back for a cystoscopy to evaluate her bladder to make sure
that there were no additional tumors in her bladder.

I performed flexible cystoscopy today, which is dictated
separately.  It turns out that she does have a tumor in her
bladder, near her left ureteral orifice.  This was pedunculated
in nature, and had appearance similar to transitional cell
carcinoma, although I could not make a diagnosis visually.  I 
did
take a small biopsy of it for histologic diagnosis and 
cauterized
the biopsy defect.

This is a surprising finding, but it is a good thing that we
evaluated the bladder, for we were planning left
nephroureterectomy, and this would have been an unexpected
finding.  Depending on what the histology shows, this will have
different implications for her prognosis and for the future
treatment plan.

For example, if this is colon cancer, then a left
nephroureterectomy with a larger bladder cuff, encompassing this
tumor could be a reasonable treatment, as there is no other
obvious site of disease.  If this is TCC, then this is a
different story and I would not be able to fully explain her
elevated CEA.  She would likely still need removal of this
bladder tumor as well as left kidney and ureter, but her
prognosis would likely be different, and we would have to look
for other sites of disease.  I will bring her back in two weeks
for a revisit and discussion of the biopsy results, and we will
have a conversation then about what this implies and what we can
do for her going forward.  Dr. ___ was present in clinic
today, so I did show him the results of the cystoscopy visually,
and we are in agreement in regards to the plan going forward.

Thank you very much again for allowing me to participate in her
care, and please feel free to contact me with any questions or
concerns that you may have.

Sincerely,

___ MD, ___
 

###RESPONSE: cystoscopy {Transurethral cystoscopy}, urine
cytology {Urine cytology}, malignant cells {Tumor cells, malignant}, colon
cancer {Malignant neoplasm of colon}, PET scan {Positron emission tomography}, tumor {Tumor finding}, left ureter {Structure of left ureter}, obstructed {Obstruction}, upper tract {Structure of upper urinary system}, positive {Detected by cytology}, urine cytology {Urine cytology}, obstructed {Obstruction}, disease {Disease}, ureter {Ureteric structure}, cystoscopy {Transurethral cystoscopy}, bladder {Urinary bladder structure}, tumors in her bladder {Neoplasm of bladder}, flexible cystoscopy {Flexible cystoscopy}, tumor in her
bladder {Neoplasm of bladder}, left ureteral orifice {Structure of left ureteral orifice}, transitional cell
carcinoma {Transitional cell carcinoma}, biopsy {Biopsy}, biopsy {Biopsy}, bladder {Urinary bladder structure}, left {Left kidney structure}, nephroureterectomy {Nephroureterectomy}, colon cancer {Malignant neoplasm of colon}, left {Left kidney structure}, nephroureterectomy {Nephroureterectomy}, TCC {Transitional cell carcinoma of bladder}, elevated CEA {Carcinoembryonic antigen above reference range}, removal {Removal}, bladder tumor {Neoplasm of bladder}, left kidney {Laceration of left kidney}, ureter {Ureteric structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- Stage I (pT1 pN0 cM0) sigmoid colon adenocarcinoma in ___  
- Stage IIA (pT3 pN0 cM0) rectosigmoid colon adenoCA ___  
intact IHC for MLH1, MSH2, MSH6, and PMS2; microsatellite stable 
(MSS) by PCR; KRAS wild-type, BRAF wild-type  
-obesity  
-asthma  
- HTN  
- lipomatosis  
- depression  
SurgHx:  
___ surgical history, in addition to the two colectomies, by 
her report includes a cesarean section and possible bilateral 
salpingo-oophorectomies. She also states that she underwent a 
benign breast biopsy in the 1980s. I could find no record of the 
pelvic surgery or any breast surgery by operative note or 
pathology.  
 

###RESPONSE: sigmoid colon adenocarcinoma {Adenocarcinoma of sigmoid colon}, rectosigmoid colon {Rectosigmoid structure}, adenoCA {Malignant adenomatous neoplasm}, obesity {Obesity}, asthma {Asthma}, HTN {Hypertensive disorder, systemic arterial}, lipomatosis {Lipomatosis}, depression {Depressive disorder}, colectomies {Excision of colon}, cesarean section {Cesarean section}, bilateral 
salpingo-oophorectomies {Excision of bilateral fallopian tubes and ovaries}, breast biopsy {Biopsy of breast}, pelvic {Structure of pelvis}, surgery {Surgical procedure}, breast {Breast structure}, surgery {Surgical 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: 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:
___ family history is significant for her father who had a 
laryngeal cancer, but was a heavy smoker. She has two children 
who are well. There are no other family members with colon 
cancer, sarcoma or any other malignancy that she was aware of. 
 

###RESPONSE: laryngeal cancer {Malignant tumor of larynx}, smoker {Smoker}, colon 
cancer {Malignant neoplasm of colon}, sarcoma {Sarcoma}, malignancy {Malignant neoplasm}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
NAD
WWP
No respiratory distress
Abdomen S, appropriately TTP, ND, incision c/d/i with staples
No focal deficits
 

###RESPONSE: NAD {No abnormality detected}, WWP {Normal tissue perfusion}, distress {Distress}, Abdomen {Examination of abdomen}, TTP {Tenderness}, ND {Swollen abdomen}, incision {Surgical incision wound}, No focal deficits {Normal nervous system function}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 07:10AM BLOOD WBC-4.7 RBC-2.78* Hgb-8.3* Hct-24.8* 
MCV-89 MCH-29.8 MCHC-33.4 RDW-13.0 Plt ___
___ 07:10AM BLOOD Glucose-88 UreaN-11 Creat-1.5* Na-138 
K-4.6 Cl-100 HCO3-29 AnGap-14
___ 07:10AM BLOOD Calcium-8.8 Phos-5.0*# Mg-2.1
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, 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}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Patient was admitted to Urology after undergoing laparoscopic 
left nephrectomy, open distal ureterectomy, transurethral 
resection of bladder cuff, retroperitoneal lymph node 
dissection. The surgery was complicated by an iatrogenic 
incision into the vagina, which was repaired. Please see 
dictated operative note for details.
The patient received perioperative antibiotic prophylaxis. The 
patient was transferred to the floor from the PACU in stable 
condition. On POD0-1, pain was well controlled on PCA, hydrated 
for urine output >30cc/hour, and provided with pneumoboots and 
incentive spirometry for prophylaxis. On POD1, the patient 
ambulated, restarted on home medications, basic metabolic panel 
and complete blood count were checked. The patient was a little 
nauseated for the first couple days post-operatively and she was 
kept on sips. A KUB was performed, which did not show any 
evidence of an ileus. The patient was started on anti-emetics 
and an aggressive bowel regimen. She started to have bowel 
movements on POD4 and her diet was slowly advanced. She was also 
transitioned from a PCA to oral analgesics. On POD6, JP 
creatinine was sent and showed no evidence of a urine leak. Her 
JP was subsequently removed. The patient was discharged in 
stable condition, eating well, ambulating independently, and 
with pain control on oral analgesics. On exam, incision was 
clean, dry, and intact, with no evidence of hematoma collection 
or infection. The patient will go home with a foley catheter for 
another ___ weeks and she will follow-up in clinic for a void 
trial.

 

###RESPONSE: laparoscopic {Laparoscopic procedure}, left nephrectomy {Excision of left kidney}, ureterectomy {Ureter excision}, transurethral 
resection of bladder {Transurethral bladder excision}, retroperitoneal lymph node 
dissection {Excision of retroperitoneal lymph node group}, incision {Surgical incision wound}, vagina {Vaginal structure}, repaired {Surgical repair}, antibiotic prophylaxis {Administration of prophylactic antibiotic}, stable 
condition {Patient's condition stable}, pain was well controlled {Demonstrates adequate pain control}, PCA {Patient controlled analgesia}, incentive spirometry {Incentive spirometry}, prophylaxis {Preventive procedure}, ambulated {Ambulation training}, restarted {Restart of medication}, complete blood count {Complete blood count}, nauseated {Nausea}, post-operatively {Postoperative state}, KUB {Radiography of kidney-ureter-bladder}, ileus {Intestinal obstruction co-occurrent and due to decreased peristalsis}, bowel regimen {Bowel care}, bowel 
movements {Does defecate}, PCA {Patient controlled analgesia}, oral analgesics {Administration of analgesic}, creatinine {Creatinine measurement}, no evidence {No abnormality detected}, urine leak {Urinary incontinence}, stable condition {Patient's condition stable}, ambulating independently {Independent walking}, pain control on oral analgesics {Demonstrates adequate pain control with oral analgesics}, incision {Surgical incision wound}, clean, dry, and intact {Wound healing well}, no evidence {No abnormality detected}, hematoma {Hematoma}, infection {Infectious disease}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ipratropium-Albuterol Inhalation Spray 2 INH IH Q6H:PRN 
wheezing, SOB 
2. Diltiazem Extended-Release 120 mg PO DAILY 
3. Docusate Sodium 100 mg PO BID 
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 
5. Multivitamins 1 TAB PO DAILY 
6. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN pain 
7. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH BID 
8. Ciprofloxacin HCl 500 mg PO Q12H 
9. albuterol sulfate 90 mcg/actuation inhalation BID wheezing, 
SOB 
10. Vitamin D 50,000 UNIT PO DAILY 

 
Discharge Medications:
1. Diltiazem Extended-Release 120 mg PO DAILY 
2. Docusate Sodium 100 mg PO BID 
3. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH BID 
4. Acetaminophen 1000 mg PO Q6H 
5. Enoxaparin Sodium 30 mg SC Q24H 
Start: Today - ___, First Dose: Next Routine Administration 
Time 
6. OxycoDONE (Immediate Release)  2.5 mg PO Q4H:PRN pain 
7. albuterol sulfate 90 mcg/actuation inhalation BID wheezing, 
SOB 
8. Ipratropium-Albuterol Inhalation Spray 2 INH IH Q6H:PRN 
wheezing, SOB 
9. Multivitamins 1 TAB PO DAILY 
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 
11. Vitamin D 50,000 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:
Metastatic colon cancer

 
Discharge Condition:
Alert and oriented
Ambulating
Stable

 

###RESPONSE: Home With Service {Home health aide service management}, Metastatic colon cancer {Metastatic carcinoma to colon}, Alert {Mentally alert}, oriented {Orientated}, Ambulating {Fully mobile}, Stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
-Please also refer to the provided written instructions on 
post-operative care, instructions and expectations made 
available from Dr. ___.

-Resume your pre-admission/home medications except as noted. 
ALWAYS call to inform, review and discuss any medication changes 
and your post-operative course with your primary care doctor.

-___ reduce the strain/pressure on your abdomen and incision 
sites; remember to “log roll” onto your side and then use your 
hands to push yourself upright while taking advantage of the 
momentum of putting your legs/feet to the ground.

--There may be bandage strips called “steristrips” which have 
been applied to reinforce wound closure.  Allow these bandage 
strips to fall off on their own over time but PLEASE REMOVE ANY 
REMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may 
get the steristrips wet.

-Please AVOID aspirin or aspirin containing products and 
supplements that may have “blood-thinning” effects (like Fish 
Oil, Vitamin E, etc.) unless you have otherwise been advised.

-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken 
even though you may also be taking Tylenol/Acetaminophen. You 
may alternate these medications for pain control.  For pain 
control, try TYLENOL FIRST, then ibuprofen, and then take the 
narcotic pain medication as prescribed if additional pain relief 
is needed.

-Ibuprofen should always be taken with food. Please discontinue 
taking and notify your
doctor should you develop blood in your stool (dark, tarry 
stools)

-Call your Urologist's office to schedule/confirm your follow-up 
appointment in ___ weeks AND if you have any questions.

-Do not eat constipating foods for ___ weeks, drink plenty of 
fluids to keep hydrated

-No vigorous physical activity or sports for 4 weeks or until 
otherwise advised. Light household chores/activity and leisurely 
walking/activity is OK and should be continued. Do NOT be a 
“couch potato”

-Tylenol should be your first-line pain medication. A narcotic 
pain medication has been
prescribed for breakthrough pain ___. REPLACE the Tylenol with 
this narcotic pain medication if additional pain control is 
needed..

-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL 
sources, note that narcotic pain medication also contains 
Tylenol

-Do not lift anything heavier than a phone book (10 pounds) or 
drive until you are seen by your Urologist in follow-up

-You may shower normally but do NOT immerse your incisions or 
bathe

-Do not drive or drink alcohol while taking narcotics and do not 
operate dangerous machinery

-Colace has been prescribed to avoid post surgical constipation 
and constipation related to narcotic pain medication. 
Discontinue if loose stool or diarrhea develops. Colace is a
stool-softener, NOT a laxative

-If you have fevers > 101.5 F, vomiting, or increased redness, 
swelling, or discharge from your incision, call your doctor or 
go to the nearest emergency room.

-Your Foley should be secured to the catheter secure on your 
thigh at ALL times until your follow up with the surgeon.

-Follow up in ___ weeks for wound check and Foley removal. DO 
NOT 
allow anyone that is outside of the urology team remove your 
Foley for any reason.

-Wear Large Foley bag for majority of time; the leg bag is only 
for short-term when leaving the house, etc.

 

###RESPONSE: strain {Muscle strain}, pressure {Pressure}, abdomen {Skin structure of anterior abdominal wall}, incision 
sites {Surgical incision wound}, wound closure {Wound healed}, pain control {Pain control}, pain 
control {Pain control}, narcotic {Narcotherapy}, pain relief {Pain relief}, blood in your stool {Hematochezia}, dark {Dark stools}, tarry 
stools {Melena}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, breakthrough pain {Breakthrough pain}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, pain control {Pain control}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, constipation {Constipation}, constipation {Constipation}, narcotic {Narcotherapy}, pain medication {Administration of analgesic}, loose stool {Loose stool}, diarrhea {Diarrhea}, stool-softener {Administration of laxative}, fevers {Fever}, vomiting {Vomiting}, redness {Redness of skin over lesion}, swelling {Swelling}, incision {Surgical incision wound}, Foley {Urinary catheter in situ}, thigh {Thigh structure}, wound check {Wound assessment}, Foley removal {Removal of urinary bladder catheter}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
 etoh withdrawal  

 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, etoh withdrawal {Alcohol withdrawal syndrome}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ y/o, primarily ___ speaking (but conversational in 
___ presents with HA and shaking after stopping drinking. 
Pt reports drinking 1 large bottle of cognac daily x `1 week. He 
attests to being sober for 3 months prior to this binge. Last 
drink was ___ afternoon. The HA is frontal and intense but 
similar to prior HA. no Vision or hearing changes. Pt also 
reports N/V and diffuse abd pain starting today. No 
hematemeisis. Pain is discribed as intense. He says it is 
different than his typical pancreatitis pain, but he can not 
discribe in what way. Pain improves with vomitting. No diarrhea 
or constipation. Pt reports feeling tremulous. Subjective 
fevers. Pt endorses h/o etoh withdrawal seizures. He endorses 
depression but denies SI/HI now or ever.  
.  
In the ED, initial VS: 98.0, 78, 150/89, 17, 100%RA. Pt received 
10mg PO valium and 4mg IV zofran in ED. CIWA of ___. Pt was 
tachy in ED and diaphoretic. Also complained of belly discomfort 
and vomitted. Labs and abd exam benign. MS oriented. VS prior to 
transfer 125/78, 93, 17, 95% RA.  
.  
Upon arrival to the floor the pt was seen inducing vomitting 
multiple times and complained of a headache. He complains of a 
HA.  
.  
Pt was admitted ___ with etoh withdrawal and abd pain but 
left AMA the same day.  
.  
ROS: Denies, chills, night sweats, vision changes, rhinorrhea, 
congestion, sore throat, cough, shortness of breath, chest pain, 
, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, 
hematuria.  

 

###RESPONSE: HA {Headache}, shaking {Tremor}, drinking {Current drinker of alcohol}, drinking {Current drinker of alcohol}, binge {Drinking binge}, drink {Drinking episode}, HA is frontal {Frontal headache}, HA {Headache}, Vision {Visual disturbance}, hearing changes {Hearing change}, N/V {Nausea and vomiting}, diffuse {Diffuse pain}, abd pain {Abdominal pain}, hematemeisis {Hematemesis}, Pain {Pain}, pancreatitis {Pancreatitis}, pain {Pain}, Pain {Pain}, vomitting {Vomiting}, diarrhea {Diarrhea}, constipation {Constipation}, fevers {Fever}, etoh withdrawal seizures {Alcohol withdrawal-induced convulsion}, depression {Depressive disorder}, SI/HI {Suicidal intent}, tachy {Tachycardia}, diaphoretic {Excessive sweating}, discomfort {Discomfort}, Labs {Laboratory test}, abd exam {Examination of abdomen}, oriented {Orientated}, inducing vomitting {Self-induced vomiting}, headache {Headache}, HA {Headache}, etoh withdrawal {Alcohol withdrawal syndrome}, abd pain {Abdominal pain}, ROS {Review of systems}, chills {Chill}, night sweats {Night sweats}, vision changes {Visual disturbance}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, sore throat {Sore throat}, cough {Cough}, shortness of breath {Dyspnea}, chest pain {Chest pain}, diarrhea {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:
1.  Recurrent pancreatitis complicated by necrosis in ___ secondary to alcohol abuse.
2.  Hypertension.
3.  History of a seizure disorder; status post a motor vehicle 
accident in ___ (negative magnetic resonance 
imaging and electroencephalogram).
4.  Status post left knee surgery.
5.  History of alcohol abuse with episodes of withdrawal.

 

###RESPONSE: Recurrent pancreatitis {Recurrent pancreatitis}, necrosis {Necrosis}, alcohol abuse {Alcohol abuse}, Hypertension {Hypertensive disorder, systemic arterial}, seizure disorder {Seizure disorder}, motor vehicle 
accident {Motor vehicle accident victim}, negative {No abnormality detected}, magnetic resonance 
imaging {Magnetic resonance imaging}, electroencephalogram {Electroencephalogram}, left knee {Structure of left knee region}, surgery {Surgical procedure}, alcohol abuse {Alcohol abuse}, withdrawal {Alcohol withdrawal syndrome}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father had kidney cancer
 

###RESPONSE: kidney cancer {Malignant tumor 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: Physical Exam:
GENERAL - well-appearing man in NAD, comfortable, appropriate  
HEENT - NC/AT, PERRLA, EOMI, sclerae erythematous, MMM, OP clear 
 
NECK - supple, no JVD,  
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored 
 
HEART - RRR, no MRG, nl S1-S2  
ABDOMEN - soft/ND, mild epigastric tenderness. No rebound or 
guarding. no masses or HSM,  
EXTREMITIES - WWP, no c/c/e, 2+ DPs  
SKIN - no rashes or lesions  
LYMPH - no cervical LAD  
NEURO - awake, A&Ox3, CNs II-XII grossly intact, not tremulous. 
muscle strength ___ throughout, sensation grossly intact 
throughout, DTRs 2+ and symmetric, cerebellar exam intact, 
steady gait. Normal visual fields  
 

 

###RESPONSE: GENERAL {General examination of patient}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, comfortable {Comfortable appearance}, HEENT {Physical examination procedure}, NC {Normal head}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, sclerae {Scleral structure}, erythema {Erythema}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, NECK {Physical examination procedure}, supple {Normal movement of neck}, JVD {Jugular venous engorgement}, LUNGS {Examination of respiratory system}, CTA {Normal breath sounds}, rh/wh {Wheeze - rhonchi}, good air movement {Breath normal}, resp unlabored {Labored breathing}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, S2 {Normal second heart sound, S>2<}, ABDOMEN {Examination of abdomen}, soft {Abdomen soft}, ND {Swollen abdomen}, mild {Symptom mild}, tenderness {Tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, no c/c/e {No abnormality detected}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, LYMPH {Lymphatic system physical examination}, LAD {Lymphadenopathy}, NEURO {Neurological examination}, awake {Awake}, Ox3 {Oriented to person, time and place}, grossly intact {Normal nervous system function}, tremulous {Tremor}, muscle strength {Muscle weakness}, sensation grossly intact {Normal sensation}, DTRs 2 {Normal tendon reflex}, steady gait {Gait normal}, Normal visual fields {Normal visual field}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 07:20AM BLOOD WBC-7.2 RBC-4.89 Hgb-14.6 Hct-40.8 MCV-83 
MCH-29.8 MCHC-35.8* RDW-13.4 Plt ___
___ 07:50PM BLOOD WBC-5.6 RBC-5.12 Hgb-15.7 Hct-42.4 MCV-83 
MCH-30.6 MCHC-37.0* RDW-13.2 Plt ___
___ 07:50PM BLOOD Neuts-50.4 Lymphs-42.3* Monos-5.1 Eos-1.0 
Baso-1.2
___ 07:20AM BLOOD Glucose-98 UreaN-9 Creat-0.9 Na-138 K-3.8 
Cl-100 HCO3-24 AnGap-18
___ 07:50PM BLOOD Glucose-125* UreaN-11 Creat-1.1 Na-135 
K-3.5 Cl-94* HCO3-24 AnGap-21*
___ 07:50PM BLOOD ALT-27 AST-30 AlkPhos-42 TotBili-0.9
___ 07:20AM BLOOD Albumin-4.3 Mg-1.9
___ 07:50PM BLOOD Lipase-31
___ 07:50PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG 
Barbitr-NEG Tricycl-NEG
___ 08:09AM BLOOD Lactate-2.4*
.

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
HOSPITAL COURSE
This is a ___ year old gentleman  with a history of multiple 
admissions for alcohol withdrawal who presented with 
tachycardia, vomitting, diaphoresis consistent with Etoh 
withdrawal.  He was treated with diazepam overnight and left 
against medical advice the following morning 
.  
ACTIVE ISSUES
# ETOH WITHDRAWAL: History of chronic ETOH use complicated by 
pancreatitis in the past with recent admission in ___ for 
management of withdrawal symptoms.  The patient's CIWA scale was 
24 on admission which improved significantly with 10mg diazepam. 
He only scored positive on the CIWA scale twice. The patient 
reports a history of withdrawal seizures however on 
clarification appears to be more consistent with tremors. 
History of prior seizure after motor vehicle accident ___ years 
ago. No evidence of pancreatitis on lab work. Alchohol cessation 
was discussed with the patient who wanted treatment only for 
withdrawal not abstinence.  A social work consult was requested. 
 He was given thiamine folate and a multivitamin intravenously.  
At mid-day following admission the patient was dressed and found 
at the elevators preparing to leave.  The danger of alcohol 
withdrawal and risk of seizures and even death was discussed.  
The patient understood the importance of seeking medical 
attention if his withdrawal returned.
.  
# ELEVATED AG: AG 17 on admission improved to 14 the following 
morning. Likely in setting of etoh and with ketones in UA.  
Lactate only marginally elevated at 2.4.
.  
# HEADACHE: Headache per review of prior discharge summaries is 
a typical withdrawal symptoms for this patient. Improved 
headache with treatment of withdrawal symptoms overnight with 
valium. 
.  
# N/V, ABDOMINAL PAIN: Abdominal pain in this patient concerning 
for pancreatitis given multiple admissions in past for alcohol 
induced pancreatitis.  No evidence of pancreatitis on admission. 
 Patient report frequent emesis is causing abdominal pain.
He tolerated a solid diet prior to leaving AMA.
.  
# HISTORY OF DEPRESSION: The patient has a history of depression 
with psychiatric evaluations in the past for suicidal ideation.  
He did not present expressing suicidal ideation however 
completely off all psychiatric medications and more frequent 
admissions for alcohol withdrawal. The patient did not stay long 
enough to meet with social work. Prior to leaving, the 
importance of following up with his psychiatrist was stressed.
.
TRANSITIONAL ISSUES:
The patient left against medical advice. Follow-up with his 
primary care physician and psychiatrist was urged.  He does not 
take any medications regularly.
 

###RESPONSE: alcohol withdrawal {Alcohol withdrawal syndrome}, tachycardia {Tachycardia}, vomitting {Vomiting}, diaphoresis {Excessive sweating}, Etoh 
withdrawal {Alcohol withdrawal syndrome}, left 
against medical advice {Left against medical advice}, ETOH WITHDRAWAL {Alcohol withdrawal syndrome}, ETOH {Alcohol abuse}, pancreatitis {Pancreatitis}, management of withdrawal symptoms {Management of withdrawal symptom}, CIWA scale {Assessment using alcohol withdrawal scale}, improved {Patient's condition improved}, CIWA scale {Assessment using alcohol withdrawal scale}, withdrawal seizures {Alcohol withdrawal-induced convulsion}, tremors {Tremor}, seizure {Seizure}, motor vehicle accident {Motor vehicle accident victim}, No evidence {No abnormality detected}, pancreatitis {Pancreatitis}, withdrawal {Alcohol withdrawal syndrome}, alcohol 
withdrawal {Alcohol withdrawal syndrome}, seizures {Seizure}, death {Dead}, withdrawal {Alcohol withdrawal syndrome}, ELEVATED AG {Increased anion gap}, improved {Patient's condition improved}, etoh {Alcohol abuse}, Lactate {Lactic acid measurement}, HEADACHE {Headache}, Headache {Headache}, withdrawal symptoms {Withdrawal symptom}, Improved {Patient's condition improved}, headache {Headache}, withdrawal symptoms {Withdrawal symptom}, ABDOMINAL PAIN {Abdominal pain}, Abdominal pain {Abdominal pain}, pancreatitis {Pancreatitis}, alcohol 
induced pancreatitis {Inflammation of pancreas caused by alcohol}, No evidence {No abnormality detected}, pancreatitis {Pancreatitis}, emesis {Vomiting}, abdominal pain {Abdominal pain}, solid diet {Normal diet}, leaving AMA {Patient self-discharge against medical advice}, DEPRESSION {Depressive disorder}, depression {Depressive disorder}, psychiatric evaluations {Evaluation of psychiatric state of patient}, suicidal ideation {Suicidal thoughts}, suicidal ideation {Suicidal thoughts}, psychiatric {Psychiatry procedure or service}, medications {Administration of drug or medicament}, alcohol withdrawal {Alcohol withdrawal syndrome}, social {Social therapy}, psychiatrist {Psychiatric follow-up}, left against medical advice {Left against medical advice}, primary care {Primary care management}, psychiatrist {Psychiatric follow-up}, medications {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: Medications on Admission:
not regularly taking any medications  
occasionally takes atenolol for HTN when he ""feels his BP is 
bad"".  

 
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours) as needed for pain/fever.  

 

###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:
Alcohol withdrawal

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Alcohol withdrawal {Alcohol withdrawal syndrome}, 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 left the hospital against medical advice.  We discussed the 
risks of leaving including further alcohol withdrawal leading to 
possible seizures and even death.  You were aware of these risks 
and decided to leave.  Please follow up with your primary care 
physician and psychiatrist.  No changes were made to your 
medications.
 

###RESPONSE: alcohol withdrawal {Alcohol withdrawal syndrome}, seizures {Seizure}, death {Dead}, primary care {Primary care management}, psychiatrist {Psychiatric follow-up}, changes were made to your 
medications {Change of medication}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   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:
Occluded suprapubic catheter, urinary tract infection
 
Major Surgical or Invasive Procedure:
Exchange of suprapubic catheter 

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Occluded suprapubic catheter {Obstruction of suprapubic catheter}, urinary tract infection {Urinary tract infectious disease}, Exchange of suprapubic catheter {Change of cystostomy tube}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ with rectal cancer, stage IV with extensive pelvic nodal 
involvement, receiving palliative CAPOX, s/p palliative 
resection of his lower rectum and anus with diverting colostomy 
and suprapubic tube for urethral injury who presented to ___ 
with urinary retention since last night. The patient reports 
that no urine has come through catheter since yesterday evening. 
Suprapubic tube was just replaced on ___. Pt also having 
decreased ostomy output since this AM. Normally empties ___ per 
day. He also has significant abdominal discomfort.  
- In the ED, initial VS were 9 98.6 117 149/69 99% RA.  
- Exam was notable for purulent discharge surrounding SP tube, 
extreme discomfort & abdominal tenderness.  
- Labs were notable for lactate 2.6, cr 0.6, na 131, k 4.6, wbc 
10.3, hct 40, plt 202, UA was grossly +ve.  
- Imaging was notable for AXR which showed a non obstructive 
bowel gas pattern.  
- Consulted services included urology who recommended no need 
for further studies if Cr, lytes WNL. At 21:00, ED flushed 
foley, removed and manually drained bladder. Replaced with new 
___ foley. Urine with purulent material draininage. Pt's pain 
was much improved  
with this.  
- Patient was given IV ceftriaxone.  
- Patient was admitted to OMED for management of complicated 
UTI.  
- VS prior to ED transfer were 2 98.1 72 120/65 20 100% RA.  
On presentation to floor, patient was pain free, after having 
catheter excahnged. no anusea, said emptied colostomy bag prior 
to coming to ED. No fevers, chills, nausea or vomitting.
 

###RESPONSE: rectal cancer {Malignant tumor of rectum}, stage IV {Clinical stage IV}, pelvic nodal {Pelvic lymphadenopathy}, CAPOX {Chemotherapy}, resection {Excision}, rectum {Rectum structure}, anus {Anal structure}, diverting colostomy {Construction of diverting colostomy}, suprapubic tube {Procedure involving suprapubic catheter}, urethral injury {Injury of urethra}, urinary retention {Retention of urine}, urine {Urinalysis}, Suprapubic tube {Procedure involving suprapubic catheter}, abdominal discomfort {Abdominal discomfort}, VS {Vital signs finding}, RA {Breathing room air}, Exam {Physical examination procedure}, purulent discharge {Purulent discharge}, SP tube {Procedure involving suprapubic catheter}, discomfort {Discomfort}, abdominal tenderness {Abdominal tenderness}, wbc {White blood cell count}, hct {Hematocrit determination}, UA {Urinalysis}, Imaging {Imaging}, AXR {Diagnostic radiography of abdomen}, obstructive {Obstruction}, bowel gas pattern {Finding of gastrointestinal tract gas}, foley, removed {Removal of urinary bladder catheter}, drained bladder {Drainage of bladder}, Replaced with new 
___ foley {Replacement of urinary catheter}, Urine {Urinalysis}, purulent {Purulent}, draininage {Drainage procedure}, pain {Pain}, improved {Patient's condition improved}, IV {Administration of drug or medicament via intravenous route}, UTI {Urinary tract infectious disease}, VS {Vital signs finding}, RA {Breathing room air}, pain free {No present pain}, catheter excahnged {Replacement of catheter}, anusea {Nausea}, colostomy {Colostomy}, fevers {Fever}, chills {Chill}, nausea {Nausea}, vomitting {Vomiting}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: hyperlipidemia, cataracts, lymphadenopathy 
(supraclavicular, mediastinal, RP, pelvic sidewall, iliac, 
cervical)

Past oncologic history:
Presumed rectal cancer stage IV
- ___ Began having anal irritation and pain with blood
streaked stools and changing bowel habits. 
- ___ Presented to his PCP, who found inguinal adenopathy. 
- ___ Evaluated in the Hematologic Malignancies Clinic by
Dr. ___. 
- ___ PET CT showed, ""Widespread FDG-avid cervical,
supraclavicular, mediastinal, retroperitoneal, pelvic sidewall,
iliac, and inguinal lymphadenopathy, consistent with lymphoma.""
- ___iopsy revealed adenocarcinoma
consistent with a colorectal or appendiceal origin, positive for
CK7, CK20 and CDX-2.

PSH: cataract surgery, excision of right groin node ___, 
Dr ___
 

###RESPONSE: hyperlipidemia {Hyperlipidemia}, cataracts {Cataract}, lymphadenopathy {Lymphadenopathy}, supraclavicular {Supraclavicular lymphadenopathy}, mediastinal {Mediastinal lymphadenopathy}, RP {Retroperitoneal lymphadenopathy}, pelvic sidewall {Pelvic lymphadenopathy}, iliac {Iliac lymphadenopathy}, cervical {Cervical lymphadenopathy}, rectal cancer {Malignant tumor of rectum}, stage IV {Clinical stage IV}, pain {Abdominal pain}, blood
streaked stools {Hematochezia}, changing bowel habits {Altered bowel function}, adenopathy {Lymphadenopathy}, Hematologic Malignancies {Malignant tumor of lymphoid, hemopoietic AND/OR related tissue}, PET CT {Positron emission tomography}, FDG-avid {Positron emission tomography with computed tomography using fluorodeoxyglucose (18-F)}, cervical {Cervical lymphadenopathy}, supraclavicular {Supraclavicular lymphadenopathy}, mediastinal {Mediastinal lymphadenopathy}, retroperitoneal {Retroperitoneal lymphadenopathy}, pelvic {Pelvic lymphadenopathy}, iliac {Iliac lymphadenopathy}, inguinal lymphadenopathy {Inguinal lymphadenopathy}, lymphoma {Malignant lymphoma}, adenocarcinoma {Adenocarcinoma}, colorectal {Structure of colon and/or rectum}, appendiceal {Appendix structure}, cataract surgery {Cataract surgery}, excision {Excision}, right groin {Right inguinal region structure}, node {Inguinal lymph node structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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, healthy.
Father, treated for colon cancer in the past.
No other malignancies in the family which he is aware. 
 

###RESPONSE: colon cancer {Malignant neoplasm of colon}, malignancies {Malignant neoplasm}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
EXAM ON ADMISSION
General: NAD  
VITAL SIGNS: 98 132/70 85 18 98 ra  
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or  
axillary adenopathy, no thyromegaly  
CV: RR, NL S1S2 no S3S4 MRG  
PULM: CTAB  
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly, colostomy 
bag in palce with minimal formed brown stool, suprapubic 
catheter in place, purulent material noted around site of entry  

LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal 
adenopathy  
SKIN: No rashes or skin breakdown  
NEURO: Cranial nerves II-XII are within normal limits excluding  

visual acuity which was not assessed, no nystagmus; strength is  

___ of the proximal and distal upper and lower extremities  

EXAM ON DISCHARGE

 

###RESPONSE: General {General examination of patient}, NAD {No abnormality detected}, VITAL SIGNS {Vital signs finding}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, OP {Oropharyngeal structure}, lesions {Lesion}, cervical {Cervical lymphadenopathy}, supraclavicular {Supraclavicular lymphadenopathy}, axillary {Axillary lymph node structure}, adenopathy {Lymphadenopathy}, thyromegaly {Goiter}, CV {Cardiovascular physical examination}, RR {Finding of rate of respiration}, S2 {Normal second heart sound, S>2<}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, ABD {Examination of abdomen}, BS {Normal bowel sounds}, soft {Abdomen soft}, ND {Swollen abdomen}, masses {Abdominal mass}, hepatosplenomegaly {Hepatosplenomegaly}, colostomy {Colostomy}, stool {Stool finding}, suprapubic 
catheter in place {Suprapubic urinary catheter in situ}, purulent {Purulent}, LIMBS {Examination of limb}, edema {Edema}, clubbing {Clubbing}, tremors {Tremor}, asterixis {Asterixis}, inguinal 
adenopathy {Inguinal lymphadenopathy}, SKIN {Examination of skin}, rashes {Eruption of skin}, skin breakdown {Broken skin}, NEURO {Neurological examination}, Cranial nerves II {Optic nerve structure}, XII {Hypoglossal nerve structure}, visual acuity {Visual acuity finding}, nystagmus {Nystagmus}, upper {Upper limb structure}, lower extremities {Lower limb structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS
___ 09:20PM BLOOD WBC-10.3# RBC-4.14* Hgb-13.3* Hct-40.0 
MCV-97 MCH-32.3* MCHC-33.4 RDW-20.1* Plt ___
___ 09:20PM BLOOD Neuts-86.4* Lymphs-6.7* Monos-6.4 Eos-0.3 
Baso-0.1
___ 09:20PM BLOOD Glucose-136* UreaN-16 Creat-0.6 Na-131* 
K-7.0* Cl-97 HCO3-25 AnGap-16
___ 09:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:00PM URINE Blood-MOD Nitrite-POS Protein-30 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 09:00PM URINE RBC-117* WBC-132* Bacteri-MOD Yeast-NONE 
Epi-0

INTERVAL STUDIES
___ KUB
Nonobstructive bowel gas pattern

DISCHARGE LABS
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, 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}, URINE {Urinalysis}, Color {Color finding}, URINE Blood {Blood in urine}, Protein {Measurement of protein in urine}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, URINE {Urinalysis}, RBC {Red blood cell count}, WBC {White blood cell count}, Bacteri {Bacteriuria}, KUB {Radiography of kidney-ureter-bladder}, Nonobstructive {Obstruction}, bowel gas pattern {Finding of gastrointestinal tract gas}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ is a ___ year old man with stage IV rectal cancer with 
extensive pelvic nodal involvement, who is receiving palliative 
CAPOX, admitted to ___ with UTI.  

# Complicated UTI: patient presented with blocked suprapubic 
catheter, which was exchanged and is now draining well. His pain 
is better but found to have grossly positive UA consistent with 
UTI. He was never febrile. No prior culture data at ___. 
Creatinine stable at 0.5-0.6 range. Started on CTX, pending 
culture data for tailored antibiotics. Urine culture was 
polymicrobial, so he was switched to cefpodoxime to complete 10 
days on discharge. 

# Rectal Cancer: Patient stable on regimen of CAPOX. Currently 
C6D8  
- touch base with Dr. ___, as ___ need to continue 
capecitabine 1500 mg PO Q12H until C6D14 (ordered by oncology 
attending).
  
# CAD: stable - continued home ASA 81 mg.

 

###RESPONSE: stage IV {Clinical stage IV}, rectal cancer {Malignant tumor of rectum}, pelvic nodal {Pelvic lymphadenopathy}, CAPOX {Chemotherapy}, UTI {Urinary tract infectious disease}, UTI {Urinary tract infectious disease}, blocked suprapubic 
catheter {Obstruction of suprapubic catheter}, exchanged {Change of cystostomy tube}, pain {Abdominal pain}, UA {Urinalysis}, UTI {Urinary tract infectious disease}, febrile {Fever}, culture {Microbial culture}, Creatinine {Creatinine measurement}, CTX {Contraction of uterus during labor}, culture {Microbial culture}, antibiotics {Antibiotic therapy}, Urine culture {Urine culture}, Rectal Cancer {Malignant tumor of rectum}, stable {Patient's condition stable}, regimen {Therapeutic regimen}, CAPOX {Chemotherapy}, CAD {Coronary arteriosclerosis}, stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY 
2. Docusate Sodium 100 mg PO BID 
3. Capecitabine 1500 mg PO Q12 

 
Discharge Medications:
1. Aspirin 81 mg PO DAILY 
2. Docusate Sodium 100 mg PO BID 
3. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 9 Days 
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp 
#*36 Tablet Refills:*0
4. Capecitabine 1500 mg PO Q12 

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary diagnoses: occluded suprapubic catheter, UTI
Secondary diagnoses: stage IV rectal cancer, hyperlipidemia,  
cataracts, lymphadenopathy (supraclavicular, mediastinal, RP, 
pelvic sidewall, iliac, cervical); pelvic lymphadenopathy 
causing lower extremity swelling  

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: occluded suprapubic catheter {Obstruction of suprapubic catheter}, UTI {Urinary tract infectious disease}, stage IV {Clinical stage IV}, rectal cancer {Malignant tumor of rectum}, hyperlipidemia {Hyperlipidemia}, cataracts {Cataract}, lymphadenopathy {Lymphadenopathy}, supraclavicular {Supraclavicular lymphadenopathy}, mediastinal {Mediastinal lymphadenopathy}, RP {Retroperitoneal lymphadenopathy}, pelvic {Pelvic lymphadenopathy}, iliac {Iliac lymphadenopathy}, cervical {Cervical lymphadenopathy}, pelvic lymphadenopathy {Pelvic lymphadenopathy}, lower extremity swelling {Swelling of lower limb}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - 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 a clogged suprapubic 
catheter and a urinary tract infection. Your catheter was 
exchanged and you were treated for your urinary tract infection 
with IV antibiotics while in house. Lab data returned and showed 
which antibiotics your infection is susceptible to. We switched 
you to oral antibiotics to complete at home. 

We wish you a very speedy recovery! It was a pleasure caring for 
you.
- Your team at ___
 

###RESPONSE: clogged suprapubic 
catheter {Obstruction of suprapubic catheter}, urinary tract infection {Urinary tract infectious disease}, catheter was 
exchanged {Change of cystostomy tube}, urinary tract infection {Urinary tract infectious disease}, IV antibiotics {Intravenous antibiotic therapy}, antibiotics {Antibiotic therapy}, infection {Infectious disease}, oral antibiotics {Oral antibiotic therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: NEUROSURGERY
 

###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:
pituitary adenoma
 
Major Surgical or Invasive Procedure:
___ Transphenoidal resection of tumor

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, pituitary adenoma {Pituitary adenoma}, Transphenoidal resection of tumor {Transsphenoidal total excision of neoplasm of pituitary gland}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mr. ___ is a ___ year old male with a hitory of a prior 
transphenoidal resection on ___ at ___ by Dr. ___. 
His cystic pituitary mass was originally found incidentally in 
___, after he had imaging for a complaint of tinnitus.  He now 
presents for a re-resection of the pituitary lesion. The initial 
pathology from ___ was adenoma. 
 

###RESPONSE: transphenoidal resection {Transsphenoidal total excision of neoplasm of pituitary gland}, pituitary mass {Mass of pituitary}, tinnitus {Tinnitus}, resection of the pituitary lesion {Transsphenoidal total excision of neoplasm of pituitary gland}, pathology {Abnormal histology findings}, adenoma {Benign pituitary adenoma}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
transsphenoidal resection ___, polyp s/p lap,
and hypothyroidism
 

###RESPONSE: transsphenoidal resection {Transsphenoidal total excision of neoplasm of pituitary gland}, polyp {Polyp}, hypothyroidism {Hypothyroidism}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
NC
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Exam on Admission
Neural intact. Visual fields full.

On Discharge:
A&Ox3
PERRL 
visual fields intact
No pronator drift
No leaking from nose when sitting up and leaning forward
Motor: ___ throughout

 

###RESPONSE: Neural {Neurological examination}, Visual fields full {Normal visual field}, Ox3 {Oriented to person, time and place}, PERRL {Pupils equal and reacting to light}, visual fields intact {Normal visual field}, pronator drift {Downward drift of outstretched supinated arm}, leaking {Discharge}, nose {Nasal structure}, sitting {Sitting position}, Motor {Motor testing}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
CT HEAD W/O CONTRAST ___ 
Status post transsphenoidal resection of pituitary lesion with 
expected 
postoperative changes. No evidence of pneumocephalus or 
intracranial 
hemorrhage. 

 

###RESPONSE: AST {Aspartate aminotransferase measurement}, Status post {Postoperative state}, transsphenoidal resection of pituitary lesion {Transsphenoidal total excision of neoplasm of pituitary gland}, postoperative {Postoperative state}, No evidence {No abnormality detected}, pneumocephalus {Pneumocephalus}, intracranial 
hemorrhage {Intracranial hemorrhage}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 taken to the operating room on the day of 
admission on ___ and underwent a transphenoidal resection of a 
pituitary lesion. He tolerated the procedure well and was 
extubated in the operating room. He was transferred to the Neuro 
ICU post-operatively. Nasal packing was left in place 
post-operatively and he was started on antibiotics for the 
duration of the packing placement. He underwent a post-operative 
non-contrast head CT which showed post-operative changes. His 
diet as advanced as tolerated. His visual fields, as well as 
urine and serum labs were routinely monitored.
On ___ Mr ___ remained in the PACU. He was completely 
neurologically intact. Vitals remained stable and he was 
ambulatory out of bed to chair. Transfer orders pending and  
awaiting transfer to floor.

On ___, patient had two hours of increase urine output, urine 
specific gravity and serum Na which were normal. Endocrine 
evaluated the patient who recommended starting him on 40mg QAM 
and 20mg QPM hydrocortisone today and decreasing to 20mg QAM and 
10mg QPM tomorrow. They were not concerned with his output and 
recommended discharge home. On exam, no drainage from the nose 
or salty taste at the back of the throat. He was ambulating and 
eating appropriately. He was discharge home and will be contact 
for further follow up with endocrinology.

 

 

###RESPONSE: transphenoidal resection of a 
pituitary lesion {Transsphenoidal total excision of neoplasm of pituitary gland}, procedure {Surgical procedure}, extubated {Removal of endotracheal tube}, Neuro {Neurology service}, ICU {Patient transfer to intensive care unit}, post-operatively {Postoperative state}, Nasal packing {Packing of nasal cavity and nasopharynx}, post-operatively {Postoperative state}, antibiotics {Antibiotic therapy}, packing {Packing of wound}, post-operative {Postoperative state}, non-contrast head CT {Computed tomography of head without contrast}, post-operative {Postoperative state}, diet {Dietary finding}, visual fields {Visual field study}, urine {Evaluation of urine specimen}, serum labs {Blood test}, monitored {Monitoring procedure}, PACU {Postanesthesia care}, neurologically intact {Normal nervous system function}, Vitals remained stable {Normal vital signs}, increase urine output {Increased urine output}, urine 
specific gravity {Urine specific gravity within reference range}, serum Na which were normal {Serum sodium level within reference range}, drainage from the nose {Nasal discharge}, throat {Structure of anterior portion of neck}, ambulating {Fully mobile}, 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:
c
abergoline,fluocinonide,levothyroxine,simvastatin,Cialis,aspirin 
81, VITAMIN D2,multivitamin tablet

 
Discharge Medications:
1. Hydrocortisone 20 mg PO REFER TO OTHER INSTRUCTIONS 
please take 40mg QAM on ___ and 20mg QPM on ___, then 20mg QAM 
and 10mg QPM until follow up. 
RX *hydrocortisone 20 mg 1 tablet(s) by mouth refer to other 
instructions Disp #*60 Tablet Refills:*1
2. Levothyroxine Sodium 50 mcg PO DAILY 
3. Omeprazole 40 mg PO DAILY 
RX *omeprazole 40 mg 1 capsule(s) by mouth DAILY Disp #*60 
Capsule Refills:*1
4. OxycoDONE (Immediate Release)  ___ mg PO Q6H:PRN pain 
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours 
Disp #*50 Tablet Refills:*0
5. Simvastatin 10 mg PO QPM 
6. Vitamin D 1400 UNIT PO DAILY 
7. Docusate Sodium 100 mg PO BID 
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice 
a day Disp #*60 Capsule Refills:*1

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
pituitary adenoma

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: pituitary adenoma {Pituitary adenoma}, 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 - 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:
¨Take your pain medicine as prescribed.
¨Exercise should be limited to walking; no lifting, straining, 
or excessive bending.
¨Increase your intake of fluids and fiber, as narcotic pain 
medicine can cause constipation. We generally recommend taking 
an over the counter stool softener, such as Docusate (Colace) 
while taking narcotic pain medication.
¨Unless directed by your doctor, do not take any 
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and 
Ibuprofen etc. 
¨Clearance to drive and return to work will be addressed at 
your post-operative office visit.
¨Continue Sinus Precautions for an additional two weeks.  This 
means, no use of straws, forceful blowing of your nose, or use 
of your incentive spirometer. 
¨If you have been discharged on Prednisone, take it daily as 
prescribed.  
¨If you are required to take Prednisone, an oral steroid, make 
sure you are taking a medication to protect your stomach 
(Prilosec, Protonix, or Pepcid), as this medication can cause 
stomach irritation.  Prednisone should also be taken with a 
glass of milk or with a meal. 

CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE 
FOLLOWING

¨New onset of tremors or seizures.
¨Any confusion or change in mental status. 
¨Any numbness, tingling, weakness in your extremities.
¨Pain or headache that is continually increasing, or not 
relieved by pain medication.
¨Any signs of infection at the wound site: redness, swelling, 
tenderness, or drainage.
¨It is normal for feel nasal fullness for a few days after 
surgery, but if you begin to experience drainage or salty taste 
at the back of your throat, that resembles a “dripping” 
sensation, or persistent, clear fluid that drains from your nose 
that was not present when you were sent home, please call. 
¨Fever greater than or equal to 101° F.
¨If you notice your urine output to be increasing, and/or 
excessive, and you are unable to quench your thirst, please call 
your endocrinologist. 

 

###RESPONSE: Discharge Instructions {Final inpatient visit with instructions at discharge}, Take your pain medicine {Administration of analgesic}, Exercise {Exercises}, walking {Does walk}, Increase your intake of fluids {Fluid intake encouragement}, narcotic pain 
medicine can cause {Narcotics education}, constipation {Constipation}, stool softener {Administration of laxative}, while taking narcotic pain medication {Narcotics education}, Aspirin {Administration of aspirin}, post-operative office visit {Postoperative follow-up visit}, Sinus {Nasal sinus structure}, Precautions {Safety precautions}, nose {Nasal structure}, oral {Administration of drug or medicament via oral route}, steroid {Steroid therapy}, medication {Prescription of drug}, stomach {Stomach structure}, s medication can cause {Medication education}, stomach {Stomach structure}, tremors {Tremor}, seizures {Seizure}, confusion {Clouded consciousness}, mental status {Mental state finding}, numbness, tingling {Numbness and tingling sensation of skin}, weakness {Asthenia}, extremities {All extremities}, Pain {Pain}, headache {Headache}, pain medication {Administration of analgesic}, signs of infection {Monitoring for signs and symptoms of infection}, wound {Wound}, redness {Redness of skin over lesion}, swelling {Swelling}, tenderness {Tenderness}, drainage {Discharge}, nasal {Nasal structure}, after 
surgery {Postoperative state}, drainage {Nasal discharge}, throat {Structure of anterior portion of neck}, clear fluid that drains from your nose {Leakage of cerebrospinal fluid from nose following surgical procedure}, Fever {Fever}, urine output to be increasing {Increased urine output}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Urinary Tract Infection
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: Urinary Tract Infection {Urinary tract infectious disease}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ male with quadriplegia, recurrent prior UTIs, neurogenic 
bladder, and sacral decubitus presents with abd and back pain 
and persistent UTI symtpoms. In ___ had E. Coli UTI 
treated to ___ with Cefpodoxime. Was again admitted 
___ again for UTI symptoms without indication of 
infection.  A CT showed a decompressed bladder, bladder wall 
thickening and enhancement of unclear significance for which 
urology follow-up was recommended. He received Ceftriaxone then 
36hr Cefpodoxime. UCx (+) Enterococcus and another gram positive 
bacteria so treated with Bactrim.  He was given a 7 day course.  
On ___ he was empirically started on Ampicillin for another 
presumed UTI (had fevers).  Oxycodone ws increased and pyridium 
started ___ for complaints of bladder spasms, but this worsened 
with pain in back and over all body and abd. He was given 1mg 
Ativan and then sent in.

On ___ he was seen by Dr. ___ in Urology, where a KUB was 
done showing no renal calculi, though pneumatosis could not be 
ruled out.  Prior CT mentioned, ""There are scattered foci of air 
and soft tissue thickening in the anterior abdominal wall."" 

There has been concern that some of his behavior is 
stress/coping related, and I understand that the patient had a 
psych consult completed last week, after which Seroquel and 
Valium were increased and Wellbutrin was started.
 

###RESPONSE: quadriplegia {Quadriplegia}, recurrent prior UTIs {Recurrent urinary tract infection}, neurogenic 
bladder {Neurogenic bladder}, sacral decubitus {Chronic skin ulcer of sacrum}, abd {Abdominal pain}, back pain {Backache}, UTI {Urinary tract infectious disease}, E. Coli UTI {Urinary tract infection caused by Escherichia coli}, UTI {Urinary tract infectious disease}, infection {Infectious disease}, CT {Computed tomography}, bladder {Urinary bladder structure}, bladder wall {Structure of wall of urinary bladder}, thickening {Increased thickness}, UCx (+) Enterococcus and another gram positive {Urine culture - mixed growth}, Bactrim {Antibiotic therapy}, UTI {Urinary tract infectious disease}, fevers {Fever}, bladder spasms {Spasm of bladder}, worsened {Increased pain}, pain in back {Backache}, abd {Abdominal pain}, KUB {Radiography of kidney-ureter-bladder}, renal calculi {Kidney stone}, pneumatosis {Gas retention}, CT {Computed tomography}, soft tissue {Structure of soft tissue}, thickening {Increased thickness}, anterior abdominal wall {Anterior abdominal wall structure}, behavior {Behavior finding}, stress {Stress}, psych consult {Psychiatric procedure, interview AND/OR consultation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
- fall injury c/b cervical spine and rib fracture in ___, s/p 
multiple spine surgeries (c1-c4, c5-c7, L3-L5)
- complete quadriplegia s/p baclofen pump placement on ___ 
at ___
- neurogenic bladder s/p suprapubic indrwelling catheter 
(catheter placed in ___ ___
- multiple UTIs
- neurogenic bowel
- lower back stage II coccyx pressure ulcer
- muscle spasms
- type II diabetes
- anxiety (pyschiatrist ___. Worc. MA ___
- depression (pyschiatrist ___. Worc. MA ___
- hypercholesterolemia
- GERD
- h/o DVT/PE s/p IVC filter placement
- history of gastrostomy
- history of tracheostomy
- history of alcohol abuse
- history of drug (marijuana and cocaine) abuse

 

###RESPONSE: fall injury {Falling injury}, cervical spine {Structure of cervical vertebral column}, rib fracture {Fracture of rib}, spine surgeries {Operative procedure on spinal structure}, quadriplegia {Quadriplegia}, placement {Implantation procedure}, neurogenic bladder {Neurogenic bladder}, suprapubic indrwelling catheter {Suprapubic urinary catheter in situ}, placed {Implantation procedure}, UTIs {Recurrent urinary tract infection}, neurogenic bowel {Neurogenic bowel}, lower back {Lower back structure}, stage II coccyx pressure ulcer {Pressure injury of coccygeal region of back stage II}, muscle spasms {Spasm}, type II diabetes {Diabetes mellitus type 2}, anxiety {Anxiety}, depression {Depressive disorder}, hypercholesterolemia {Hypercholesterolemia}, GERD {Gastroesophageal reflux disease}, DVT {Deep venous thrombosis}, PE {Pulmonary embolism}, IVC filter placement {Insertion of inferior vena caval filter}, gastrostomy {Gastrostomy}, tracheostomy {Exteriorization of trachea}, alcohol abuse {Alcohol abuse}, drug {Drug abuse}, cocaine) abuse {Cocaine abuse}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Noncontributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
T 99.5, BP 111/66, HR 20, RR 20, SpO2 97%
In NAD.
OP clear, poor dentition, no lesions, no ___, neck supple
No JVD, no bruits
___ - none
LUNGS CTA bilat w/o rhonchi, rubs, wheezes
COR - RRR no MRG nl S2, S2.  Normal PMI
ABD - mild distended, nl active bowel signs, non-tender, LLQ 
mass under scar consistent with history of baclofen pump placed 
there.  No rebound/guarding
EXT - no clubbing, cyanosis, edema
SKIN - Stage II decubiti bilat upper medial gluteal area with 
surrounding StageI erythema, Stage II midline skin breakdown 
coccygeal
NERUO - Minimal proximal LUEx strength, more strength and 
sensation RUEXt.  Is paraplegic LExt.
 

###RESPONSE: BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, NAD {No abnormality detected}, OP clear {Pharynx normal}, dentition {Structure of dentition}, lesions {Lesion}, supple {Normal movement of neck}, JVD {Jugular venous engorgement}, bruits {Bruit}, LUNGS {Examination of respiratory system}, CTA {Normal breath sounds}, rhonchi {Wheeze - rhonchi}, rubs {Pericardial friction rub}, wheezes {Wheezing}, COR {Cardiovascular physical examination}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, S2 {Normal second heart sound, S>2<}, S2 {Normal second heart sound, S>2<}, Normal {No abnormality detected}, ABD {Examination of abdomen}, mild {Symptom mild}, distended {Swollen abdomen}, bowel {Intestinal structure}, non-tender {Abdominal tenderness}, LLQ 
mass {Mass of left lower quadrant of abdomen}, scar {Scar}, placed {Implantation procedure}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXT {Examination of limb}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, SKIN {Examination of skin}, Stage II decubiti {Pressure injury of sacral region of back stage II}, gluteal area {Buttock structure}, erythema {Erythema}, skin breakdown {Broken skin}, NERUO {Neurological examination}, LUEx {Structure of left upper limb}, sensation {Normal sensation}, RUEXt {Structure of right upper limb}, paraplegic {Paraplegia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 12:55PM   WBC-7.8 RBC-4.05* HGB-11.9* HCT-36.6* MCV-90 
MCH-29.4 MCHC-32.6 RDW-14.9
___ 12:55PM   NEUTS-52.8 ___ MONOS-4.1 EOS-4.1* 
BASOS-1.1
___ 12:22PM   LACTATE-3.6* K+-3.9
___ 12:10PM   GLUCOSE-249* UREA N-12 CREAT-0.4* SODIUM-138 
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-19
___ 12:10PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-25 
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 
LEUK-MOD
___ 12:10PM URINE  ___ BACTERIA-FEW 
YEAST-MOD ___

___ 12:00 am URINE     Site: CATHETER
                            **FINAL REPORT ___
   URINE CULTURE (Final ___: 
      ENTEROCOCCUS SP..    >100,000 ORGANISMS/ML.. 
                              SENSITIVITIES: MIC expressed in 
MCG/ML
_________________________________________________________
                             ENTEROCOCCUS SP.
                             |   
AMPICILLIN------------   <=2 S
NITROFURANTOIN--------    32 S
TETRACYCLINE----------   <=1 S
VANCOMYCIN------------     1 S

___ 2:00 am URINE      Source: Catheter. 
                            **FINAL REPORT ___
   URINE CULTURE (Final ___: 
      Culture workup discontinued. Further incubation showed 
contamination
      with mixed skin/genital flora. Clinical significance of 
isolate(s)
      uncertain. Interpret with caution. 
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML.. 
         ___. ___ (___) REQUESTED SUSCEPTIBILITY TEST FOR 
CEFPODOXIME ON
         ___. 
         Cefpodoxime = SENSITIVE, sensitivity testing performed 
by ___
         ___. 
                              SENSITIVITIES: MIC expressed in 
MCG/ML
_________________________________________________________
                             ESCHERICHIA COLI
                             |   
AMIKACIN--------------  =>64 R
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--    16 I
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------  =>16 R
TRIMETHOPRIM/SULFA----  =>16 R

CXR ___
AP CHEST 6:33 P.M. ___ 
  
HISTORY: Quadriplegic fever. Question pneumonia. 
  
IMPRESSION: AP chest compared to ___. 
  
A roughly crescentic opacity in the right lower lung, beneath 
the downward 
displaced minor fissure is probably scarring or atelectasis 
unchanged since at 
least ___. Lungs otherwise clear. Heart size normal. No 
pleural 
effusion or evidence of central adenopathy. 
  
The study and the report were reviewed by the staff radiologist. 


Time Taken Not Noted     Log-In Date/Time: ___ 2:05 pm
      URINE     Site: NOT SPECIFIED

                            **FINAL REPORT ___

   URINE CULTURE (Final ___: 
      YEAST.    10,000-100,000 ORGANISMS/ML.. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, PROTEIN {Measurement of protein in urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, URINE {Evaluation of urine specimen}, AST {Aspartate aminotransferase measurement}, URINE {Evaluation of urine specimen}, URINE CULTURE {Urine culture}, SENSITIVITIES {Antimicrobial susceptibility test}, URINE {Evaluation of urine specimen}, URINE CULTURE {Urine culture}, Culture {Microbial culture}, workup {Evaluation procedure}, sensitivity {Antimicrobial susceptibility test}, SENSITIVITIES {Antimicrobial susceptibility test}, CXR {Plain chest X-ray}, AP CHEST {Plain x-ray of chest anteroposterior view}, Quadriplegic {Quadriplegia}, fever {Fever}, pneumonia {Pneumonia}, AP chest {Plain x-ray of chest anteroposterior view}, opacity {Abnormally opaque structure}, right lower lung {Structure of base of right lung}, fissure {Fissure}, scarring {Scar}, atelectasis {Atelectasis}, Lungs {Lung structure}, clear {Normal breath sounds}, Heart {Heart structure}, normal {No abnormality detected}, pleural 
effusion {Pleural effusion}, adenopathy {Lymphadenopathy}, URINE CULTURE {Urine culture}, AST {Aspartate aminotransferase 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:
___ quadriplegic with recurrent UTIs, now with worsening 
dysuria while on Ampicillin which was started ___ for fevers 
for presumed UTI.  His UA is still positive nitrites and 
leukocyte esterase.
.
# Presumed UTI:  Given Vancomycin to cover enterococcus which he 
received in the ED.  He did not get anything for gram negative 
coverage. Ceftriaxone 2gm daily added to based on prior 
sensitivities.  UCX came back negative for bacteria, and showed 
___ of yeast, likely contaminant -- this was not treated 
here.  Will defer to PCP if he wants to treat this.  A CXR was 
negative for obvious pneumonia.
.
# Suprapubic/Abdominal Pain: DDx includes bladder spasm, but 
given recent KUB and Abd/pelvic CT reads referenced above, I 
reviewed recent radiology films with radiology ___ on 
call radiologist who indicated the CT showed mild enhancement of 
bladder which could be consistent with UTI, and non-specific air 
around stool in the bowel with constipation. Valium was recently 
increased prior to admission, and he was started on Pyridium 
(which he states never helps him). The latter is discontinue on 
discharge.  Pt given Oxycodone prn for improved pain control and 
continued on a bowel regimen as ordered.  His pain is LLQ and 
vague.  I discussed with his PCP about having him see the 
surgeons at ___ who put in his Baclofen pump at some point in 
near future.
.
# Sacral Decubitus Ulcer: Stage II - present on admission.  
___ wound RN to assess.  Continue treatments.
.
# DM2:  Normally on metformin, was continued.
.
#Depression/Anxiety:  continue Seroquel, Wellbutrin, Citalopram 
and valium.
.
CODE:  FULL per patient
.
CONTACT:  HCP = ___ ___

 

###RESPONSE: quadriplegic {Quadriplegia}, recurrent UTIs {Recurrent urinary tract infection}, dysuria {Dysuria}, Ampicillin {Antibiotic therapy}, fevers {Fever}, UTI {Urinary tract infectious disease}, UA {Urinalysis}, positive nitrites {Nitrite detected in urine}, UTI {Urinary tract infectious disease}, Vancomycin {Antibiotic therapy}, sensitivities {Antimicrobial susceptibility test}, UCX came back negative for bacteria {Urine culture - no growth}, PCP {Primary care management}, CXR {Plain chest X-ray}, negative {No abnormality detected}, pneumonia {Pneumonia}, Suprapubic {Suprapubic pain}, Abdominal Pain {Abdominal pain}, bladder spasm {Spasm of bladder}, KUB {Radiography of kidney-ureter-bladder}, Abd/pelvic CT {Computed tomography of abdomen and pelvis}, CT {Computed tomography}, bladder {Urinary bladder structure}, UTI {Urinary tract infectious disease}, bowel {Intestinal structure}, constipation {Constipation}, improved {Patient's condition improved}, pain control {Pain control}, bowel {Intestinal structure}, regimen {Therapeutic regimen}, pain {Pain}, LLQ {Structure of left lower quadrant of abdomen}, PCP {Primary care management}, Sacral Decubitus Ulcer: Stage II {Pressure injury of sacral region of back stage II}, wound {Wound}, DM2 {Diabetes mellitus type 2}, Depression {Depressive 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: Medications on Admission:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES 
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) 
Tablet, PO EVERY OTHER DAY 
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
4. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily). 

5. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).  

6. Ascorbic Acid ___ mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 

times a day).  
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.  
9. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO BID 
10. Baclofen 10 mg Tablet Sig: 2.5 Tablets PO TID 
11. Zofran 4 mg Tablet Sig: One (1) Tablet PO once a day as 
needed for nausea.  
12. Baclofen  Intrathecal
13. Metamucil Powder Sig: One (1) dose PO once a day as 
needed for constipation.  
14. Fragmin 5,000 unit/0.2 mL Syringe Sig: One (1) syringe 
Subcutaneous once a day.  
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn 
constipation.  
16. Miralax 17 gram/dose Powder Sig: One (1) dose PO once a day 
as needed for constipation.  
17. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H prn 
fever, pain.  
18. Oxycodone 5 mg Tablet Sig: Five (5) Tablet PO q8h:PRN pain
19. Buspirone 10 mg Tablet Sig: One (1) Tablet PO TID 
20. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY 
21. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS   
22. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H prn spasms.  

23. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS 
24. Sodium Chloride 0.65 % Aerosol, Spray Sig: ___ Sprays Nasal
BID  
25. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID prn 
bladder pain
26. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) 

Tablet PO BID (2 times a day) for 7 days.
27. MagOx 400 mg Tablet Sig: One (1) Tablet PO twice a day.  
28. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO at bedtime as 
needed for pain.  
29. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO q8h:PRN as needed 

for anxiety.
 
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed for fever.  
2. Senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day).  

3. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)  PO 
DAILY (Daily) as needed for constipation.  
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) 
Spray Nasal DAILY (Daily).  
5. Baclofen 10 mg Tablet Sig: 2.5 Tablets PO TID (3 times a 
day).  
6. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, 
Rapid Dissolve PO DAILY (Daily) as needed for nausea.  
7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every 
___.  
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal 
HS (at bedtime).  
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
10. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
11. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 
 
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times 
a day).  
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 
(2 times a day).  
14. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 
times a day).  
15. Buspirone 10 mg Tablet Sig: 1.5 Tablets PO TID (3 times a 
day).  
16. Diazepam 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) 
as needed for insomnia.  
17. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at 
bedtime).  
18. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
19. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 
hours) as needed for pain.  
20. Fragmin 5,000 unit/0.2 mL Syringe Sig: One (1) dose 
Subcutaneous once a day.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Abdominal Pain
Stage II sacral debuitus
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
 

###RESPONSE: Abdominal Pain {Abdominal pain}, Stage II sacral debuitus {Pressure injury of sacral region of back stage II}, 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}, Bedbound {Bed-ridden}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted with complaints of abdominal pain.  You were 
empirically given antibiotics for possible urinary tract 
infection but do not have a urinary tract infection by culture.  
You have discomfort in your lower left abdomen, you are 
tolerating all of your medications and a normal diet.  I 
recommend you follow-up with your PCP and discuss ___ possible 
visit with the surgeons who put in the baclofen pump (in the 
left abdomen).  Please exercise patience with your current 
condition and work with your facility's staff to help you as 
best as possible. 
 

###RESPONSE: abdominal pain {Abdominal pain}, antibiotics {Antibiotic therapy}, urinary tract 
infection {Urinary tract infectious disease}, urinary tract infection {Urinary tract infectious disease}, culture {Microbial culture}, discomfort {Discomfort}, lower left abdomen {Structure of left lower quadrant of abdomen}, medications {Patient medication education}, normal diet {Normal diet}, follow-up {Follow-up status}, PCP {Primary care management}, left abdomen {Structure of left side of abdomen}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
Headache
 
Major Surgical or Invasive Procedure:
Imaging-guided LP - ___

 

###RESPONSE: Penicillins {Allergy to penicillin}, Headache {Headache}, Imaging {Imaging}, LP {Lumbar puncture}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ is a ___ female with PMH of hypertension,
spinal stenosis, recent diagnosis of shingles, who presents with
severe headache.

Patient reports that the day of admission she woke up from sleep
around 3AM with a headache, which she describes as ""intense"" and
""all over"".  She states that this pain worsened throughout the
day.  It was associated with nausea and vomiting -reports
vomiting several times throughout the day, not able to keep
anything down.  She states that bright lights made somewhat
worse, but also that she does not normally like bright lights. 
No phonophobia, though she does note continued ear pain.  
Reports
no fevers or chills.  Did have some shooting pains at the back 
of
her neck, but no neck soreness or stiffness.  No dizziness or
lightheadedness, but not associated with falls.

On review of records, patient first presented to her PCPs office
on ___ with a rash on her face and neck.  She was diagnosed
at that time with shingles, and started on a 10-day course of
acyclovir.  She returned to urgent care on ___ with
weakness on the left side of her face.  She was diagnosed with
Bell's palsy secondary to her herpes zoster infection.  Was
started on prednisone 60 mg daily for a week.  Of note, patient
states that she was taking 60 mg 3 times a day rather than daily
(3 tabs, 3 times a day).  She return to clinic on ___, the
day of admission, with her headache as described above.  At this
time she was sent to the emergency department.

In the ED:

Initial vital signs were notable for: T 36.5, HR 63, BP 157/95,
RR 16, 98% RA 

Exam notable for:
Constitutional: Comfortable.
Head/eyes: NCAT, PERRLA, EOMI.
ENT/neck: neck supple, no rigidity or pain
Neuro: Slowed speech, but fluent, left sided facial droop that
has been ongoing for a week due to bell's palsy resulting from
shingles. strength and sensation intact in bl UE and ___. ftn in
tact. CN ___ otherwise intact with exception of CN VII on left
side.

Labs were notable for:

- CBC: WBC 11.7, hgb 13.0, plt 288 

- Lytes:

140 / 98 / 20     AGap=16 
-------------- 91 
3.4 \ 26 \ 0.8 

- LFTs: AST: 20 ALT: 19 AP: 81 Tbili: 0.5 Alb: 4.1 
- lipase 24
- lactate 1.8

Studies performed include:
- NCHCT with no evidence of acute intracranial hemorrhage.
- LP was attempted, but unable to obtain CSF sample 

Consults: ___ was consulted for an LP, which was not done at time
of admission 

Patient was given:  
___ 17:21 IVF  NS 1000 mL
___ 17:28 IV Metoclopramide 10 mg   
___ 17:28 IV DiphenhydrAMINE 25 mg  
___ 17:29 IV Acyclovir 600 mg 
___ 20:16 IV Morphine Sulfate 4 mg 

Vitals on transfer: T 98.5, HR 58, BP 158/82, RR 16, 96% RA 
 
Upon arrival to the floor, patient recounts history as above. 
She states that overall her headache is slightly better than it
was initially.

 

###RESPONSE: hypertension {Hypertensive disorder, systemic arterial}, spinal stenosis {Spinal stenosis}, shingles {Herpes zoster}, severe {Symptom severe}, headache {Headache}, headache {Headache}, pain {Pain}, nausea and vomiting {Nausea and vomiting}, vomiting {Vomiting}, worse {Increased pain}, phonophobia {Phonophobia}, ear pain {Pain of ear}, fevers {Fever}, chills {Chill}, shooting pains {Shooting pain}, back 
of
her neck {Cervical region back structure}, neck {Cervical region back structure}, soreness {Soreness}, stiffness {Stiffness}, dizziness {Dizziness}, lightheadedness {Lightheadedness}, falls {Falls}, rash {Eruption of skin}, face {Face structure}, neck {Neck structure}, shingles {Herpes zoster}, weakness {Weakness of face muscles}, left side of her face {Structure of left half of face}, Bell's palsy {Bell's palsy}, herpes zoster infection {Herpes zoster}, headache {Headache}, emergency {Emergency treatment management}, vital signs {Vital signs finding}, RA {Breathing room air}, Comfortable {Comfortable appearance}, Head/eyes {Physical examination procedure}, NCAT {Normal head}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, ENT/neck {Physical examination procedure}, neck supple {Normal movement of neck}, rigidity {Nuchal rigidity}, pain {Pain}, Neuro {Neurological examination}, Slowed speech {Bradylalia}, fluent {Does speak fluently}, left sided facial {Structure of left half of face}, bell's palsy {Bell's palsy}, shingles {Herpes zoster}, sensation intact {Normal sensation}, UE {Upper limb structure}, CN {Cranial nerve structure}, CN VII on left
side {Structure of left facial nerve}, CBC {Complete blood count}, WBC {White blood cell count}, LFTs {Hepatic function panel}, AST {Aspartate aminotransferase measurement}, ALT {Alanine aminotransferase measurement}, AP {Alkaline phosphatase measurement}, Tbili {Bilirubin, total measurement}, Alb {Albumin measurement}, lipase {Serum lipase measurement}, lactate {Lactic acid measurement}, NCHCT {Computed tomography of head without contrast}, no evidence {No abnormality detected}, intracranial hemorrhage {Intracranial hemorrhage}, LP {Lumbar puncture}, CSF {Cerebrospinal fluid collection}, LP {Lumbar puncture}, IVF {Administration of intravenous fluids}, Vitals {Vital signs finding}, RA {Breathing room air}, headache {Headache}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- hypertension 
- melanoma
- hyperlipidemia
- Gastric ulcer 
- Asthma 
- Spinal stenosis, lumbar region, with neurogenic claudication 
 

###RESPONSE: hypertension {Hypertensive disorder, systemic arterial}, melanoma {Malignant melanoma of skin}, hyperlipidemia {Hyperlipidemia}, Gastric ulcer {Gastric ulcer}, Asthma {Asthma}, Spinal stenosis, lumbar region {Spinal stenosis of lumbar region}, neurogenic claudication {Neurogenic claudication}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 ___ 
Father ___ 
Mother ___ CAD/PVD - Early (___); Gout; Hypertension 
 

###RESPONSE: CAD {Coronary arteriosclerosis}, PVD {Peripheral vascular disease}, Gout {Inflammatory disorder due to increased blood urate level}, Hypertension {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VITALS: T 98.4, HR 66, BP 171/90, RR 18, 93% RA 
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Neck supple with negative brudzinski's and kernig's signs.
Crusted over lesions on left side of face, including pinna of 
ear
and external canal. Very tender to light palpation
CV: Heart regular, no murmur, no S3, no S4.  No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally.  Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation.  Bowel
sounds present.  No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Lesions over left side of face as noted above
NEURO: Alert, oriented x3, PEERL, EOMI. Left-sided facial droop
with decreased sensation to forehead and nearly no sensation in
V2 and V3 distribution. Hearing grossly intact bilaterally.
Palate raises symmetrically, shoulder shrug normal, tongue
midline, strength ___ in upper and lower distal and proximal
muscle groups.  
PSYCH: pleasant, appropriate affect
 

###RESPONSE: VITALS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, RA {Breathing room air}, GENERAL {General examination of patient}, Alert {Mentally alert}, distress {Distress}, EYES {Ophthalmic examination and evaluation}, Anicteric {White sclera}, pupils equally round {Pupil size and shape normal}, ENT {Abdominal tenderness}, supple {Normal movement of neck}, negative {No abnormality detected}, brudzinski's {Brudzinski's sign}, kernig's signs {Kernig's sign}, lesions {Lesion}, left side of face {Structure of left half of face}, pinna of 
ear {Pinna structure}, external canal {External auditory canal structure}, tender {Abdominal tenderness}, palpation {Palpation}, CV {Cardiovascular physical examination}, Heart {Cardiovascular physical examination}, murmur {Murmur}, no S3 {Third heart sound, S>3<, inaudible}, no S4 {Fourth heart sound, S>4<, inaudible}, JVD {Jugular venous engorgement}, RESP {Examination of respiratory system}, Lungs {Examination of respiratory system}, good air movement {Breath normal}, Breathing {Examination of respiratory system}, labored {Labored breathing}, GI {Examination of digestive system}, soft {Abdomen soft}, non-distended {Normal abdominal contour}, non-tender {Abdominal tenderness}, palpation {Palpation}, Bowel
sounds present {Normal bowel sounds}, HSM {Hepatosplenomegaly}, GU {Examination of genitourinary system}, suprapubic {Hypogastric region structure}, tenderness {Tenderness}, palpation {Palpation}, MSK {Musculoskeletal system physical examination}, supple {Normal movement of neck}, all extremities {All extremities}, symmetric bilaterally in all limbs {Normal bilateral upper limbs and bilateral lower limbs}, SKIN {Examination of skin}, Lesions {Skin lesion}, left side of face {Structure of left half of face}, NEURO {Neurological examination}, Alert {Mentally alert}, oriented {Orientated}, PEERL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Left-sided facial {Structure of left half of face}, decreased sensation {Hypesthesia}, forehead {Forehead structure}, no sensation {Absence of sensation}, V2 {Entire maxilla}, V3 {Lower jaw region structure}, grossly intact {Normal nervous system function}, Palate {Palatal structure}, shoulder {Structure of right shoulder region}, normal {No abnormality detected}, tongue {Tongue structure}, upper and lower distal {Structure of distal palatal tooth surfaces}, muscle {Skeletal and/or smooth muscle structure}, PSYCH {Psychiatry procedure or service}, 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:
ADMISSION LABS:
___ 03:15PM BLOOD WBC-11.7* RBC-4.54 Hgb-13.0 Hct-41.5 
MCV-91 MCH-28.6 MCHC-31.3* RDW-12.6 RDWSD-41.7 Plt ___
___ 03:15PM BLOOD Glucose-91 UreaN-20 Creat-0.8 Na-140 
K-3.4* Cl-98 HCO3-26 AnGap-16
___ 07:18AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.9

LP RESULTS:
Tube 1: ___ 03:15PM CEREBROSPINAL FLUID (CSF) TNC-19* 
RBC-700* Polys-7 Bands-1 ___ Monos-4
Tube 4: ___ 03:15PM CEREBROSPINAL FLUID (CSF) TNC-22* 
RBC-174* Polys-6 Bands-3 ___ ___ 03:15PM CEREBROSPINAL FLUID (CSF) TotProt-36 Glucose-57

RELEVANT IMAGING:
___ NCHCT:
There is no evidence of acute, large territorial infarction, 
fracture, 
hemorrhage,edema,or mass effect.  There is mild prominence of 
the ventricles  and sulci suggestive of involutional changes.  
Periventricular white-matter hypodensities are nonspecific, 
likely sequela of chronic ischemic small vessel  disease. 
  
Hyperostosis frontalis interna is noted.  Partial opacification 
of the 
posterior ethmoid air cells.  Layering fluid within the 
bilateral sphenoid 
sinuses, left greater than right, with aerosolized component 
within the left sphenoid sinus.  The mastoid air cells are 
clear.  The visualized portion of the orbits are normal. 
  
IMPRESSION:  
1. No evidence of acute intracranial hemorrhage. 
2. Paranasal sinus disease. 

___ CTA head/neck:
FINDINGS:  
  
CT head shows no evidence of hemorrhage, or loss of gray-white 
matter 
differentiation. No midline shift or hydrocephalus seen.  
Aerosolized 
secretions and fluid level are seen in the sphenoid sinus. 
  
CT angiography of the neck shows normal appearance of the 
carotid and 
vertebral arteries without stenosis or occlusion or dissection. 
  
CT angiography of the head shows normal appearance of the 
arteries of the 
anterior and posterior circulation without stenosis or occlusion 
or aneurysm 
greater than 3 mm in size. 
  
IMPRESSION:  
No significant abnormalities on CT of the head without contrast. 
 No 
significant abnormalities on CT angiography of the head and 
neck.  Sphenoid sinus soft tissue changes. 

DISCHARGE RESULTS:
___ 06:50AM BLOOD WBC-7.4 RBC-3.83* Hgb-11.2 Hct-36.5 
MCV-95 MCH-29.2 MCHC-30.7* RDW-12.4 RDWSD-42.9 Plt ___
___ 07:00AM BLOOD Glucose-98 UreaN-13 Creat-1.0 Na-141 
K-4.4 Cl-103 HCO3-28 AnGap-10
___ 07:00AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.___ woman with PMH of hypertension, spinal stenosis, 
recent diagnosis of shingles with suspected Ramsay Hunt 
syndrome, who presented with severe headache. CT head and CTA 
head/neck showed no acute process. She underwent LP which showed 
22 WBCs, primarily lymphs, without xanthochromia. ID was 
consulted who felt this finding may represent VZV meningitis vs 
meningeal irritation from VZV, and recommended 10-day course of 
anti-viral therapy. She was treated initially with IV acyclovir, 
transitioned to valacyclovir to complete course, last day ___. 
She was also seen by neurology, who recommended initiation of 
amitriptyline for headache management, and treatment of 
neuropathic pain. Gabapentin was also uptitrated to 400mg TID. 
Lisinopril was uptitrated to 20mg from 10mg daily.

TRANSITIONAL ISSUES:
-Valtrex to finish ___
-Patient should receive shingles vaccine ___ weeks after 
resolution of symptoms
-Amitriptyline started for neuropathic pain and headache
-Gabapentin increased to 400mg TID for neuropathic pain
-Patient complaining of headaches brought on by chewing, thought 
to be related to shingles. If no improvement at f/u, would check 
ESR/CRP to evaluate for GCA
-Please refer to ___ neurology for f/u, per patient preference
-Lisinopril increased from 10mg to 20mg daily
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, 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}, RBC {Red blood cell count}, Monos {Monocyte count}, RBC {Red blood cell count}, Glucose {Glucose measurement, blood}, NCHCT {Computed tomography of head without contrast}, no evidence {No abnormality detected}, infarction {Infarct}, fracture {Fracture}, hemorrhage {Hemorrhage}, edema {Edema}, mass {Mass}, ventricles {Brain ventricle structure}, sulci {Structure of sulcus of brain}, involutional changes {Involution}, Periventricular white-matter {Structure of periventricular white matter}, chronic ischemic {Chronic cerebral ischemia}, small vessel {Structure of small blood vessel (organ)}, Hyperostosis frontalis interna {Hyperostosis interna frontalis}, opacification {Abnormally opaque structure}, posterior ethmoid air cells {Structure of posterior cells of ethmoid sinus}, fluid {Accumulation of fluid}, sphenoid 
sinuses {Sphenoid sinus structure}, left {Left sphenoid sinus structure}, right {Right sphenoid sinus structure}, left sphenoid sinus {Left sphenoid sinus structure}, mastoid air cells {Structure of mastoid cell}, are 
clear {No abnormality detected}, orbits {Structure of orbit proper}, normal {No abnormality detected}, No evidence {No abnormality detected}, intracranial hemorrhage {Intracranial hemorrhage}, Paranasal sinus disease {Disorder of nasal sinus}, CT head {Computed tomography of head}, no evidence {No abnormality detected}, hemorrhage {Hemorrhage}, midline shift {Midline shift of brain}, hydrocephalus {Hydrocephalus}, fluid {Accumulation of fluid}, sphenoid sinus {Sphenoid sinus structure}, CT angiography of the neck {Computed tomography angiography of vascular structure of neck with contrast}, normal appearance {Normal appearance}, carotid {Carotid artery structure}, vertebral arteries {Structure of vertebral artery}, stenosis {Stenosis}, occlusion {Complete obstruction}, dissection {Dissection of artery}, CT angiography of the head {Computed tomography angiography of head with contrast}, normal appearance {Normal appearance}, arteries {Arterial structure}, circulation {Structure of cardiovascular system}, stenosis {Stenosis}, occlusion {Complete obstruction}, aneurysm {Aneurysm}, No significant abnormalities {No abnormality detected}, CT of the head without contrast {Computed tomography of head without contrast}, No 
significant abnormalities {No abnormality detected}, CT angiography of the head and 
neck {Computed tomography angiography of head and neck with contrast}, Sphenoid sinus {Sphenoid sinus structure}, soft tissue {Structure of soft tissue}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, hypertension {Hypertensive disorder, systemic arterial}, spinal stenosis {Spinal stenosis}, shingles {Herpes zoster}, Ramsay Hunt 
syndrome {Herpes zoster auricularis}, severe {Symptom severe}, headache {Headache}, CT head {Computed tomography of head}, CTA 
head/neck {Computed tomography angiography of head and neck with contrast}, no acute {No abnormality detected}, LP {Lumbar puncture}, lymphs {Lymphocyte count}, VZV meningitis {Herpes zoster with meningitis}, meningeal irritation {Meningeal irritation}, anti-viral therapy {Antiviral therapy}, headache {Headache}, neuropathic pain {Neuropathic pain}, receive shingles vaccine {Administration of vaccine product containing only Human alphaherpesvirus 3 antigen for shingles}, neuropathic pain {Neuropathic pain}, headache {Headache}, neuropathic pain {Neuropathic pain}, headaches {Headache}, shingles {Herpes zoster}, no improvement {Patient condition unchanged}, 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: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY 
2. Omeprazole 20 mg PO BID 
3. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 
4. Pravastatin 40 mg PO DAILY 
5. Vitamin D ___ UNIT PO DAILY 
6. DICYCLOMine 20 mg PO TID 
7. Polyethylene Glycol 17 g PO BID 
8. TraZODone 50-100 mg PO QHS:PRN insomnia 
9. Senna 17.2 mg PO QHS 
10. Morphine SR (MS ___ 30 mg PO Q12H 
11. Gabapentin 300 mg PO TID 

 
Discharge Medications:
1.  Amitriptyline 10 mg PO QHS 
RX *amitriptyline 10 mg 1 tablet(s) by mouth at bedtime Disp 
#*30 Tablet Refills:*0 
2.  Artificial Tears 2 DROP BOTH EYES QID 
RX *dextran 70-hypromellose (PF) [Artificial Tears (PF)] 0.1 
%-0.3 % ___ drops ___ four times a day Disp #*1 Bottle Refills:*2 

3.  Capsaicin 0.025% 1 Appl TP TID 
RX *capsaicin 0.025 % Apply small amount to affected area three 
times a day Refills:*1 
4.  HydrOXYzine 25 mg PO QHS:PRN itchiness 
This medication will make you drowsy. Do not drive or operate 
machinery while using this medication. 
RX *hydroxyzine HCl 25 mg 1 tab by mouth at bedtime Disp #*20 
Tablet Refills:*0 
5.  ValACYclovir 1000 mg PO TID Duration: 4 Days 
RX *valacyclovir 1,000 mg 1 tab by mouth three times a day Disp 
#*13 Tablet Refills:*0 
6.  Gabapentin 400 mg PO TID 
RX *gabapentin 400 mg 1 capsule(s) by mouth three times a day 
Disp #*90 Capsule Refills:*0 
7.  Lisinopril 20 mg PO DAILY 
RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30 
Tablet Refills:*0 
8.  DICYCLOMine 20 mg PO TID  
9.  Morphine SR (MS ___ 30 mg PO Q12H  
10.  Omeprazole 20 mg PO BID  
11.  Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line  
12.  Polyethylene Glycol 17 g PO BID  
13.  Pravastatin 40 mg PO DAILY  
14.  Senna 17.2 mg PO QHS  
15.  TraZODone 50-100 mg PO QHS:PRN insomnia  
16.  Vitamin D ___ 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
 
Discharge Diagnosis:
Shingles with meningeal irritation

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Shingles with meningeal irritation {Herpes zoster with meningitis}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,

You came to the hospital with a headache. While you were here, 
you had a lumbar puncture which showed irritation due to 
shingles. You were started on anti-viral medication, as well as 
medications to help your headache. You should continue the 
anti-viral medication (valacyclovir, also called Valtrex) until 
___. You should also use artificial tears as needed for dry 
eyes, and use your eye patch at night until your eye is closing 
completely.

Please follow-up with your PCP as scheduled below. At this 
visit, you may request a referral to neurology for further 
follow-up.

It was a pleasure participating in your care.

Sincerely,
Your ___ Team
 

###RESPONSE: headache {Headache}, lumbar puncture {Lumbar puncture}, shingles {Herpes zoster}, anti-viral medication {Antiviral therapy}, medications {Patient medication education}, headache {Headache}, anti-viral medication {Antiviral therapy}, dry 
eyes {Dry eyes}, eye {Structure of eye proper}, eye {Structure of eye proper}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Syncope
Back pain
 
Major Surgical or Invasive Procedure:
Nil
 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Syncope {Syncope}, 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: History of Present Illness:
___ yo female with history of HL, hypothyroidism, anxiety and 
depression who presented after syncopal episode. She reports 
being in her USOH until she was walking up to the store this 
morning as per her routine. All of a sudden she felt her ""eyes 
went black"". She reports fainting and losing consciousness. She 
denies any other prior symptoms including dizziness, LH, visual 
changes, nausea, CP, SOB, or palpitations. She denies any 
urinary or fecal incontinence during the episode. She fell into 
a seated position, as if she ""plopped down"" and broke her fall 
with her right wrist. She then felt pain in both her right wrist 
and her left hip, and it was this pain that ""awoke her"". She 
denies hitting her head during the fall. No recent positional 
change prior to the syncopal event. She has previously 
experienced this same syncopal episode.  
.  
After her fall, she reports marked left hip pain. She denies any 
urinary or fecal incontinence since the fall. She denies 
numbness, tingling, weakness, or radiating pain in her legs
 

###RESPONSE: HL {Hyperlipidemia}, hypothyroidism {Hypothyroidism}, anxiety {Anxiety}, depression {Depressive disorder}, syncopal {Syncope}, yes 
went black {Syncope}, fainting {Syncope}, losing consciousness {Decreased level of consciousness}, dizziness {Dizziness}, LH {Labile essential hypertension}, visual 
changes {Sight deteriorating}, nausea {Nausea}, SOB {Dyspnea}, palpitations {Palpitations}, urinary {Urinary incontinence}, fecal incontinence {Incontinence of feces}, fell {Falls}, fall {Falls}, right wrist {Structure of right wrist region}, pain {Pain}, right wrist {Structure of right wrist region}, left hip {Left hip region structure}, pain {Pain}, fall {Falls}, syncopal {Syncope}, syncopal {Syncope}, fall {Falls}, left hip {Left hip region structure}, pain {Pain}, urinary {Urinary incontinence}, fecal incontinence {Incontinence of feces}, fall {Falls}, numbness, tingling {Numbness and tingling sensation of skin}, weakness {Asthenia}, radiating pain {Radiating pain}, legs {Lower limb structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Osteopenia  
Hypothyroidism  
Depression  
Anxiety  
HLD  
Cataracts s/p repair  

 

###RESPONSE: Osteopenia {Osteopenia}, Hypothyroidism {Hypothyroidism}, Depression {Depressive disorder}, Anxiety {Anxiety}, HLD {Hyperlipidemia}, Cataracts {Cataract}, repair {Cataract surgery}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother:faint spells, breast Ca in ___
 

###RESPONSE: faint {Syncope}, breast Ca {Malignant neoplasm of breast}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VS - 97.7 66 117/64 14 96% on RA 73.8kg  
GENERAL - Alert, interactive, well-appearing elderly female in 
pain, laying still in bed, unable to sit  
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear  
NECK - Supple, no JVD  
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG  
LUNGS - CTAB, no r/rh/wh, good air movement  
ABDOMEN - +BS, soft/NT/ND, no masses or HSM  
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses  
BACK - tender over thoracic spine T4-T8, no paraspinal muscle 
tenderness, no lumbosacral tenderness, pain over left SI joint 
and into left groin  
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength 
___ throughout, sensation grossly intact throughout  
.  

 

###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, Alert {Mentally alert}, interactive {Does communicate}, well-appearing {Well cared for appearance}, pain {Pain}, laying still in bed {Lying in bed}, unable to sit {Unable to sit}, HEENT {Physical examination procedure}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, sclerae anicteric {White sclera}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, JVD {Jugular venous engorgement}, HEART {Cardiovascular physical examination}, displaced {Apex beat displaced}, RRR {Normal heart rate}, nl S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, no MRG {Heart sounds normal}, LUNGS {Examination of respiratory system}, CTAB {Normal breath sounds}, ABDOMEN {Examination of abdomen}, +BS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, 2+ peripheral pulses {Peripheral pulses normal}, tender {Abdominal tenderness}, T4 {Bone structure of T4}, T8 {Bone structure of T8}, paraspinal {Structure of paravertebral region}, tenderness {Tenderness}, lumbosacral {Structure of lumbar and/or sacral region of back}, tenderness {Tenderness}, pain {Pain}, left SI joint {Structure of left sacroiliac joint}, left groin {Left inguinal region structure}, NEURO {Neurological examination}, awake {Awake}, Ox3 {Oriented to person, time and place}, grossly intact {Normal nervous system function}, muscle {Skeletal and/or smooth muscle structure}, sensation grossly intact {Normal sensation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 07:30PM   cTropnT-<0.01
___ 07:30PM   WBC-14.9* RBC-4.80 HGB-13.0 HCT-41.2 MCV-86 
MCH-27.2 MCHC-31.6 RDW-13.___ yo female with history of osteopenia, HL, and hypothyroidism 
admitted for syncope.  
.  
# Syncope: Although patient has had previous syncopal episodes 
in the past, she has always had prior warning of feeling hot and 
sweatty and had managed to sit down and prevent herself from 
passing out.  This episode was different.  She had no prior 
warning symptoms as before making this episode an unlikely 
vasovagal.  There was no positional changes prior to fall making 
orthostatic hypotension induced syncope unlikely.  She is also 
not on any current anti-hypertensives such as thiazides.  She 
was not exerting herself in terms of coughing/sneezing prior to 
episode making effort syncope unlikely. However, she was walking 
to the store and exerting herself minimally although she states 
this walk has never troubled her before.  No faecal/urinary 
incontinence or confusion post syncope also rules out a seizure. 
Although she denies any chest pain/palpitations/SOB/headache, 
and unremarkable cardiovascular exam, her recent ECG shows new 
atrial enlargement and slight intraventricular delay.  This 
warrants further cardiac workup to rule out transient arrhythmia 
inducing syncopal episodes.  

-ECG - no ST/T wave changes, troponin <0.01  
-monitor on telemetry  
-ECHO looking specifically at valvular function (evidence of 
aortic stenosis) which came back normal
-As per Dr. ___, patient going home with event 
recorder
-Out patient PCP and cardiology appointments  
.  
# Left hip pain: Xrays without evidence of fracture. Most likely 
contusion of left hip/sacrum.  
-tylenol standing  
-patient has been taking ibuprofen PRN for back pain, so discuss 
risks in terms of GI bleed and pre-renal failure
-small dose of oxycodone prn further pain  
-___ consult  
  
.  
# Back pain: History of osteopenia on BMD in ___. Compression 
fracture seen in lumbar spine L2 level but does not correlate to 
current symptoms. Compression fracture in the thoracic spine 
would not be an unreasonable explanation for her current 
symptoms given the mechanism of her fall.  
-thoracic spine films  
-___ as outpatient 
-Discuss commencement of Calcium and Vit D supplements as well 
as bisphosphonates even though patient has declined these in the 
past 
.  
# Leukocytosis: Most likely stress response. No signs or 
symptoms of infection.  
  
.  
# Hypothyroidism: continue levothyroxine  
.  
# HL: continue simvastatin  
.  
# Anxiety/depression: continue sertraline  
.  

 

###RESPONSE: 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}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, osteopenia {Osteopenia}, HL {Hyperlipidemia}, hypothyroidism {Hypothyroidism}, syncope {Syncope}, Syncope {Syncope}, syncopal {Syncope}, hot and 
sweatty {Feels hot and sweaty}, passing out {Syncope}, vasovagal {Vasovagal syncope}, fall {Falls}, orthostatic hypotension {Orthostatic hypotension}, syncope {Syncope}, t anti-hypertensives {On treatment for hypertension}, coughing {Cough}, sneezing {Sneezing}, effort syncope {Effort syncope}, faecal {Incontinence of feces}, urinary 
incontinence {Urinary incontinence}, confusion {Clouded consciousness}, syncope {Syncope}, seizure {Seizure}, chest pain {Chest pain}, palpitations {Palpitations}, SOB {Dyspnea}, headache {Headache}, unremarkable cardiovascular exam {Cardiovascular system normal}, ECG {Electrocardiographic procedure}, atrial {Atrial structure}, enlargement {Enlargement}, intraventricular delay {Non-specific intraventricular conduction delay}, r cardiac workup {Examination of heart}, arrhythmia {Cardiac arrhythmia}, syncopal {Syncope}, ECG {Electrocardiographic procedure}, no ST/T wave change {Electrocardiogram normal}, troponin {Troponin measurement}, telemetry  {Electroencephalogram telemetry}, ECHO {Echocardiography}, valvular {Structure of heart valve tissue}, aortic stenosis {Aortic valve stenosis}, PCP {Primary care management}, cardiology appointments {Cardiac care management}, Left hip {Left hip region structure}, pain {Pain in scrotum}, fracture {Fracture}, contusion of left hip {Contusion of left hip region}, sacrum {Structure of sacral vertebral column}, back pain {Backache}, GI bleed {Gastrointestinal hemorrhage}, pre-renal failure {Pre-renal acute kidney injury}, pain {Pain}, Back pain {Backache}, osteopenia {Osteopenia}, Compression 
fracture seen in lumbar spine L2 level {Compression fracture of second lumbar vertebra}, thoracic spine {Structure of thoracic vertebral column}, fall {Falls}, thoracic spine {Structure of thoracic vertebral column}, Leukocytosis {Leukocytosis}, stress {Stress}, signs {Sign}, infection {Infectious disease}, Hypothyroidism {Hypothyroidism}, HL {Hyperlipidemia}, Anxiety/depression {Mixed anxiety and 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: Medications on Admission:
 sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
 levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
 simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).  

 oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 
times a day).  

 
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: ___ Tablets PO every six (6) 
hours.  
2. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
5. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 
times a day).  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
-Syncope
-Lumbar level 2 fracture

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Syncope {Syncope}, Lumbar level 2 fracture {Fracture of second lumbar vertebra}, Mental Status {Neurological mental status determination}, Clear {No abnormality detected}, 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:
Dear ___,

___ were admitted to the ___ on the ___ after ___ 
experienced a black out and subsequent back pain.  Hip x-rays 
and back x-rays were done on ___.  Hip x-rays showed no hip 
fracture but back x-ray revealed a fracture at the L2 level of 
your spine.  Your previous diagnosis of osteopenia likely 
contributed to this.

Your black out episode sounds like it could have been like your 
previous episodes.  However, in order to rule out a cardiac 
cause, we took an image of your heart with an ""echo"" which was 
normal.  We will still send ___ home with an event recorder 
which ___ will have for two weeks.  The results of this can be 
reviewed with Dr. ___ and with Dr. ___ as per your 
appointments below.

Your medications will continue as per your home regimen:
Oxybutinin 5mg twice daily
Simvastatin 20mg Once daily
Levothyroxine 75mcg once daily
Sertraline 50mg once daily
As acetominophen helped your pain, ___ may take the 500mg 
tablets ___ tablets upto 4 times per day, but don't take more 
than 6 in a day
Please ensure ___ attend your follow up appointments as 
described below.

It was a pleasure looking after ___ here at the ___.
 

###RESPONSE: black out {Syncope}, back pain {Backache}, Hip x-rays {Radiography of hip}, back {Structure of back of trunk}, x-rays {Radiographic imaging procedure}, Hip x-rays {Radiography of hip}, hip 
fracture {Fracture of proximal end of femur}, back {Structure of back of trunk}, x-ray {Radiographic imaging procedure}, fracture at the L2 level of 
your spine {Fracture of second lumbar vertebra}, osteopenia {Osteopenia}, black out {Syncope}, cardiac {Heart structure}, image of your heart {Imaging of heart}, echo {Echocardiography}, normal {No abnormality detected}, pain {Pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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
 
Attending: ___.
 
Chief Complaint:
mouth pain, odynophagia, rash 
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, mouth pain {Painful mouth}, odynophagia {Swallowing painful}, 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: History of Present Illness:
___ year old male with history of recently diagnosed HIV/AIDS, 
PCP pneumonia treated with 21 days of high dose bactrim, now 
presenting with 4 days of diffuse maculopapular rash, mouth 
pain, and fevers to 102.
.
Patient requested HIV test approximately one month ago after 
learning that a prior partner was HIV positive. He then 
developed shortness of breath and cough and presented to the 
emergency department. CXR demonstrated multifocal infiltrates 
and he was diagnosed with PCP pneumonia by bronchoscopy. At that 
time his HIV antibody was positive, his CD4 count was 54 
(___), and his HIV VL was 321,000. He was treated with 
bactrim DS 2 tabs TID for 21 days, and with a prednisone taper.
.
Since this time, he has been started on atripla as an outpatient 
on ___. Over the last week he noticed a rash on his chest 
and arms that worsened. It was itchy but not painful. He also 
noted steadily worsening oral pain and pain with swallowing. He 
also had fevers to 102 with chills for the past two nights and 
poor PO intake. He presented to outpatient clinic and was 
treated with fluconazole for thrush, and with valtrex for oral 
herpes.
.
He then presented to outpatient clinic, and was noted to have a 
diffuse maculopapular rash and mucositis. he was referred to the 
ED with concern for ___ syndrome. 
 

###RESPONSE: HIV {Human immunodeficiency virus infection}, AIDS {Acquired immune deficiency syndrome}, PCP pneumonia {Pneumocystosis jirovecii pneumonia}, maculopapular rash {Maculopapular rash}, mouth 
pain {Painful mouth}, fevers {Fever}, HIV {Human immunodeficiency virus infection}, HIV positive {Human immunodeficiency virus detected}, shortness of breath {Dyspnea}, cough {Cough}, CXR {Plain chest X-ray}, infiltrates {Infiltration}, PCP pneumonia {Pneumocystosis jirovecii pneumonia}, bronchoscopy {Bronchoscopy}, HIV antibody {Human immunodeficiency virus antibody test}, CD4 count {Absolute CD4 count procedure}, HIV VL {Human immunodeficiency virus viral load}, started {New medication added}, rash {Eruption of skin}, chest {Skin structure of chest}, arms {Upper limb structure}, itchy {Itching}, painful {Pain}, worsening {Increased pain}, oral pain {Painful mouth}, pain with swallowing {Swallowing painful}, fevers {Fever}, chills {Chill}, poor PO intake {Decrease in appetite}, thrush {Candidiasis}, oral 
herpes {Oral herpes simplex infection}, maculopapular rash {Maculopapular rash}, mucositis {Inflammatory disease of mucous membrane}, referred to the 
ED {Referral to accident and emergency service}, syndrome {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: Past Medical History:
Esophageal candidiasis
HIV/AIDS
Pneumocystis pneumonia
Hypertension
Vitamin D Deficiency
Tinea Barbae
Alcohol Abuse 
 

###RESPONSE: Esophageal candidiasis {Candidiasis of the esophagus}, HIV {Human immunodeficiency virus infection}, AIDS {Acquired immune deficiency syndrome}, Pneumocystis pneumonia {Pneumocystosis jirovecii pneumonia}, Hypertension {Hypertensive disorder, systemic arterial}, Vitamin D Deficiency {Vitamin D deficiency}, Tinea Barbae {Tinea barbae}, Alcohol Abuse {Alcohol abuse}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History: Mother with DM, HTN, father with DM, HTN and 
pacemaker. 
 

###RESPONSE: DM {Diabetes mellitus}, HTN {Hypertensive disorder, systemic arterial}, DM {Diabetes mellitus}, HTN {Hypertensive disorder, systemic arterial}, pacemaker {Implantation of cardiac pacemaker}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
PHYSICAL EXAM:
Vitals - T: 98.6 BP: 140/90 HR: 120 RR: 18 02 sat:98/RA
GENERAL: Pleasant, well appearing in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No 
scleral icterus. PERRLA/EOMI. Desquamation of mouth, lips, 
oozing blood on lips, ginigivitis.
SKIN: Diffuse maculopapular rash, with red papules over chest, 
arms, face, scrotum and legs.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, 
rubs or gallops.
LUNGS: CTAB, no wheezes, rales, rhonchi, good air movement 
biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior 
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved 
sensation throughout. ___ strength throughout. ___ reflexes, 
equal ___. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant 

 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, 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}, well appearing {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, conjunctival pallor {Pale conjunctiva}, scleral icterus {Scleral icterus}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, Desquamation {Peeling of skin}, mouth {Mouth region structure}, lips {Lip structure}, oozing {Wound discharge}, ginigivitis {Gingivitis}, SKIN {Examination of skin}, rash {Eruption of skin}, papules {Papular eruption of chin}, over chest {Skin structure of chest}, arms {Upper limb structure}, face {Face structure}, scrotum {Scrotal structure}, legs {Lower limb structure}, CARDIAC {Cardiovascular physical examination}, Regular rhythm {Normal sinus rhythm}, normal rate {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, LUNGS {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, good air movement {Breath normal}, ABDOMEN {Examination of abdomen}, NABS {Normal bowel sounds}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, edema {Edema}, pain {Pain}, 2+ dorsalis pedis {Dorsalis pulse present}, posterior 
tibial pulses {Posterior tibial pulse present}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, ecchymoses {Ecchymosis}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, Appropriate {Appropriate affect}, grossly intact {Normal nervous system function}, Preserved 
sensation {Normal sensation}, reflexes {Normal reflex}, Normal coordination {Normal coordination}, Gait assessment {Gait evaluation}, PSYCH {Psychological assessment}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Admission Labs:
___ 11:50AM BLOOD WBC-5.7 RBC-3.94* Hgb-11.7* Hct-34.1* 
MCV-87 MCH-29.7 MCHC-34.4 RDW-16.3* Plt ___
___ 11:50AM BLOOD Neuts-63 Bands-2 Lymphs-12* Monos-19* 
Eos-3 Baso-1 ___ Myelos-0
___ 11:50AM BLOOD ___ PTT-29.7 ___
___ 11:50AM BLOOD Glucose-107* UreaN-14 Creat-1.8* Na-126* 
K-4.8 Cl-95* HCO3-20* AnGap-16
___ 11:50AM BLOOD ALT-34 AST-32 LD(LDH)-273* AlkPhos-50 
TotBili-0.3
___ 05:56AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9
___ 11:45AM BLOOD Lactate-1.2 K-5.1
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Serum total lactate dehydrogenase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Lactate {Lactic acid measurement}, K {Blood potassium 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:
# ___: Bactrim was considered the most 
likely causal agent was held.  Dermatology was consulted on 
admission.  Skin biopsies were taken and he was started on 
prednisone 80mg PO daily, with a planned taper over 4 weeks.  
His bactrim, fluconazole and valtrex were stopped.  Opthomology 
was consulted and found no ocular involvement.  His muscositis 
pain was managed with lidocaine mouthwash, dexamthasone 
mouthwash and PO vicodin.  His rash and mucositis improved, 
though he still had substantial painful desquamation of the 
scrotuim on discharge.
.
# HIV/AIDS: Patient had recently been started on atripla.  This 
medication was initially held due to concern for low serum 
bicarbonate, but was restarted once this resolved.  He was 
treated with inhaled pentamindine once for PCP ___.  CXR 
demonstrated no evidence of pneumonia. 
.
# Hypertension/Tachycardia: On admission, patient was 
tachycardic and hypertensive.  He was intially restarted on his 
home amlodipine and given IVF as there was concern that he was 
hypovolemic.  His amlodipine was stopped, and he was started on 
metoprolol.  His dose was titrated up to 50mg PO bid.
.
# Hyponatremia/ ARF: On admission, serum sodium was 126 and 
creatine was 1.8.  With aggresive fluid resusciation with normal 
saline, these values returned the the normal range. 
 

###RESPONSE: held {Recommendation to stop drug treatment}, Skin biopsies {Biopsy of skin}, started {New medication added}, stopped {Recommendation to stop drug treatment}, pain {Pain}, rash {Eruption of skin}, mucositis {Inflammatory disease of mucous membrane}, improved {Patient's condition improved}, painful {Pain}, desquamation {Peeling of skin}, scrotuim {Scrotal structure}, HIV {Human immunodeficiency virus infection}, AIDS {Acquired immune deficiency syndrome}, started {New medication added}, held {Recommendation to stop drug treatment}, restarted {Restart of medication}, resolved {Problem resolved}, PCP {Pneumocystosis jirovecii pneumonia}, CXR {Plain chest X-ray}, no evidence {No abnormality detected}, pneumonia {Pneumonia}, Hypertension {Hypertensive disorder, systemic arterial}, Tachycardia {Tachycardia}, tachycardic {Tachycardia}, hypertensive {Finding of increased blood pressure}, restarted {Restart of medication}, IVF {Administration of intravenous fluids}, hypovolemic {Hypovolemia}, stopped {Recommendation to stop drug treatment}, started {New medication added}, Hyponatremia {Hyponatremia}, ARF {Acute kidney injury}, serum sodium {Sodium measurement, serum}, creatine {Creatine measurement}, fluid resusciation {Resuscitation using intravenous fluid}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Vitamin D 50,000 units q weekly
Nizoral 2% shampoo
Azithromycin 1000 mg po weekly
Atripla 1 po daily
Norvasc 10 mg po daily
Fluconazole 200 mg po daily x 10 days ___ day 1)
Ambien ___ mg po qhs prn insonia
Valtrex 1 gm po BID x 10 days for initial HSV outbreak ___ day 
1)
Ibuprofen 600 mg po QID with meals prn pain, fever
Ammonium Lactate one application for dry skin 
 
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One 
(1) Appl Ophthalmic TID (3 times a day).  
2. Hydrocodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
Q6H (every 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID 
(2 times a day).
Disp:*qs Tablet(s)* Refills:*2*
4. Zolpidem 5 mg Tablet Sig: ___ Tablets PO HS (at bedtime) as 
needed for insomnia.  
5. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed for pain/fever.  
6. Lidocaine HCl 2 % Solution Sig: Ten (10) ML Mucous membrane 
QID (4 times a day) as needed for mouth pain.
Disp:*qs 100 ml* Refills:*5*
7. Prednisone 10 mg Tablet Sig: Please see below Tablet PO once 
a day: 60mg daily (6 pills) for ___
then switch to 40 mg (4 pills) for 5 days, 20mg (2 pills) for 5 
days, 10 mg (1 pills) for 5 days then stop.
Disp:*60 Tablet(s)* Refills:*0*
8. ATRIPLA ___ mg Tablet Sig: One (1) Tablet PO once a 
day.  
9. Dexamethasone 0.5 mg/5 mL Elixir Sig: ___ MLs PO BID (2 
times a day).
Disp:*qs ML(s)* Refills:*2*
10. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO once a 
week: As directed by Dr. ___.  
11. Pentamidine 300 mg Recon Soln Sig: One (1) inhaler 
Inhalation once a month: As directed by Dr. ___.  
12. Maalox/Viscous Lidocaine 2%
1 part maalox (aluminum hydroxide/magnesium hydroxide), 1 part 
viscous lidocaine 2%.  Swish and swallow, four times daily as 
needed for oral pain.  

 

###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:
___
HIV/AIDS
Hypertension
Tachycardia

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: HIV {Human immunodeficiency virus infection}, AIDS {Acquired immune deficiency syndrome}, Hypertension {Hypertensive disorder, systemic arterial}, Tachycardia {Tachycardia}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted with ___ syndrome, a condition 
which affects the skin and mucous membranes.  We think this was 
caused by the antibiotic bactrim.  You were treated with 
steroids and pain medications. You will continue to take 
steroids (prednisone) for several weeks as we taper the dose 
down from 80mg to zero. You will take 60mg for 5 days, 40mg for 
5 days, 20 mg for 5 days, 10 mg for 5 days, and then stop taking 
it all together.

You should not take bactrim in the future. You can continue 
taking atripla for your HIV infection, and will continue taking 
weekly azithromax and monthly pentamidine to prevent you from 
getting opportunistic infections, until your CD4 count raises or 
your primary HIV doctor decides that you no longer need them. 
These drugs should be safe and will not cause recurrence of your 
___.

While you were here, you also showed signs of elevated heart 
rate and blood pressure. We saw that Dr. ___ 
Cardiologist, had suggested you change from amlodipine (Norvasc) 
to Metoprolol (Toprol), which will help keep your heart from 
beating too fast and also help lower your blood pressure. We are 
sending you home on a dose of 50mg Metoprolol twice daily, and 
you should follow up with Dr. ___ to see if this is 
appropriately controlling your heart rate and blood pressure.

The last thing you were followed for while here was your 
shortness of breath. Given your history of PCP, we performed two 
xrays to make sure you didn't have ongoing pneumonia. Your lungs 
are currently clear, but you should ensure that you continue 
taking your monthly pentamadine.

Please stop taking valtex and fluconazole.  Discuss all 
medication changes with your primary care doctor, ___.
 

###RESPONSE: syndrome {Disease}, skin {Skin structure}, mucous membranes {Mucous membrane structure}, antibiotic {Antibiotic therapy}, steroids {Steroid therapy}, pain medications {Administration of analgesic}, steroids {Steroid therapy}, stop taking {Recommendation to stop treatment}, continue 
taking {Recommendation to continue with drug treatment}, HIV infection {Human immunodeficiency virus infection}, continue taking {Recommendation to continue with drug treatment}, prevent {Preventive procedure}, infections {Infectious disease}, CD4 count {Absolute CD4 count procedure}, HIV {Human immunodeficiency virus infection}, recurrence {Recurrent disease}, signs {Sign}, elevated heart 
rate {Tachycardia}, blood pressure {Finding of increased blood pressure}, heart {Heart structure}, blood pressure {Finding of increased blood pressure}, heart rate {Cardiotachometry}, blood pressure {Blood pressure monitoring}, shortness of breath {Dyspnea}, PCP {Pneumocystosis jirovecii pneumonia}, pneumonia {Pneumonia}, lungs {Lung structure}, continue 
taking {Recommendation to continue with drug treatment}, stop taking {Recommendation to stop treatment}, medication changes {Change of medication}, 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:   F
 
Service: NEUROLOGY
 

###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:
dizziness and worsening right sided weakness
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, dizziness {Dizziness}, right sided weakness {Right hemiparesis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ Stroke Scale Score: 9

NIHSS performed within 6 hours of presentation at: ___ at
2325
NIHSS Total: 9
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0 
2.  Best gaze: 0
3.  Visual fields: 0
4.  Facial palsy: 2 (residual)
5a. Motor arm, left: 0
5b. Motor arm, right: 2 (residual)
6a. Motor leg, left: 0
6b. Motor leg, right: 1 (residual)
7.  Limb Ataxia: 0
8.  Sensory: 1 (residual?)
9.  Language: 1 (residual?)
10. Dysarthria: 1 (residual?)
11. Extinction and Neglect: 1 (residual?)
 
REASON FOR CONSULTATION: dizziness, intermittent right lower
extremity weakness throughout day

HPI: 

___ is a ___ year old woman with history of
hypertension, hyperlipidemia, prior stroke with residual right
hemiparesis, localization-related epilepsy on Keppra and
lamotrigine, hypothyroidism, and glaucoma who presented to ED
from nursing home after new-onset dizziness this morning with
subsequent acute-on-chronic right lower extremity weakness.
History obtained by patient and as per chart review. 

The patient reports that she was she had seen Dr. ___
yesterday in clinic to establish new neurology clinic follow-up.
No outside records were available for evaluation at that time 
but
her baseline exam prior to new symptom onset was documented.
After her clinic appointment, she returned to her nursing home 
in
usual state of health. She woke up this morning and felt well. 
At
around 11AM, while urinating, she suddenly felt room-spinning
dizziness that resolved but was followed by an atypical 
sensation
in her right lower extremity, described as heaviness and
weakness. She notes that she has lived with her residual stroke
deficits for ___ years and never felt anything like this in her
right leg. She tried to get up from the commode but did not have
the strength and as such called for help. Throughout the rest of
the day, she notes that her right sided weakness and heaviness
was intermittent. Her dizziness has since resolved. This 
evening,
she noted that she was again feeling weaker in her right lower
extremity, requiring assistance to mobilize which is atypical 
for
her. She thus requested ED evaluation and was brought to ___.
Since arrival at ___ (~ 15 minutes prior to my evaluation) she
notes her symptoms have started to improve again. She now thinks
she may be back at baseline, or close to it. 

Per Dr. ___ initial clinic note on ___:
"" Based on history, the patient suffered a stroke ___ years ago
and was left with right hemiparesis. Since the stroke she has
been on ASA 81 mg and had no recurrent events. She also suffers
from seizures with mouth foaming, shaking and urinary
incontinence, but no generalization. She is on Keppra for
her seizures and she has not had a seizure for a long time."" His
exam at the time was notable for ""mild aphasia and dysarthria
with right facial droop and right hemiparesis."" He had no 
outside
records at that time and as primary reason for visit was to
establish neurological care, he continued her on home dose of
atorvastatin 60mg, aspirin 81 mg per his note, Keppra, and
lamictal (for mood? is what is questioned in Dr. ___. 
 
ROS: 
Notable for above findings, otherwise noncontributory
 
PMH:
====
HYPERTENSION                                                    
HYPERLIPIDEMIA                                                  
HYPOTHYROIDISM                                                  
STROKE                                                          
SEIZURE DISORDER                                                
GLAUCOMA        
                                                
Surgical History  (Last Verified ___ by ___,
MD):
Surgical History updated, no known surgical history.            

Medications:
===========
***NEEDS MEDICATION RECONCILLIATION***
Keppra 500mg BID
lamotrigine 200mg BID (for mood)
Aspirin (either 81 or 325, unclear per chart review/med review 
in
OMR)
metoprolol succinate 25mg ER qday
levothyroxine 50ucg qday
furosemide 20mg qday
baclofen 10mg PRN muscle spasm (BID)
atorvastin 60mg qPM


###RESPONSE: Stroke {Cerebrovascular accident}, NIHSS performed {Assessment using National Institutes of Health stroke scale}, Level of Consciousness {Assessment of consciousness level}, Visual fields {Visual field study}, Facial palsy {Facial palsy}, Motor {Motor testing}, arm, left {Structure of left upper limb}, Motor {Motor testing}, arm, right {Structure of right upper limb}, Motor {Motor testing}, leg, left {Structure of left lower limb}, Motor {Motor testing}, leg, right {Structure of right lower limb}, Limb {All extremities}, Ataxia {Ataxia}, Sensory {Sensory testing}, Dysarthria {Dysarthria}, dizziness {Dizziness}, lower
extremity weakness {Paresis of lower extremity}, hypertension {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, stroke {Cerebrovascular accident}, right
hemiparesis {Right hemiparesis}, localization-related epilepsy {Focal epilepsy}, hypothyroidism {Hypothyroidism}, glaucoma {Glaucoma}, dizziness {Dizziness}, chronic {Chronic disease}, right lower extremity weakness {Paresis of right lower limb}, chart review {Chart evaluation by healthcare professional}, evaluation {Evaluation procedure}, baseline {Baseline state}, exam {Physical examination procedure}, dizziness {Dizziness}, resolved {Problem resolved}, atypical 
sensation {Abnormal sensation}, right lower extremity {Structure of right lower limb}, heaviness {Sensation of heaviness in limbs}, weakness {Asthenia}, stroke {Cerebrovascular accident}, deficits {Neurological deficit}, right leg {Structure of right lower leg}, right sided weakness {Right hemiparesis}, heaviness {Sensation of heaviness in limbs}, dizziness {Dizziness}, resolved {Problem resolved}, feeling weaker {Asthenia}, right lower
extremity {Structure of right lower limb}, assistance to mobilize {Difficulty mobilizing}, evaluation {Evaluation procedure}, evaluation {Evaluation procedure}, baseline {Baseline state}, stroke {Cerebrovascular accident}, right hemiparesis {Right hemiparesis}, stroke {Cerebrovascular accident}, seizures {Seizure}, mouth {Mouth region structure}, shaking {Tremor}, urinary
incontinence {Urinary incontinence}, seizures {Seizure}, seizure {Seizure}, exam {Physical examination procedure}, mild {Symptom mild}, aphasia {Aphasia}, dysarthria {Dysarthria}, right facial droop {Weakness of right facial muscle}, right hemiparesis {Right hemiparesis}, neurological care {Care of neurological patient}, mood {Mood management}, HYPERTENSION {Hypertensive disorder, systemic arterial}, HYPERLIPIDEMIA {Hyperlipidemia}, HYPOTHYROIDISM {Hypothyroidism}, STROKE {Cerebrovascular accident}, SEIZURE DISORDER {Seizure disorder}, GLAUCOMA {Glaucoma}, surgical {Surgical 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: Allergies:
=========
no known drug allergies         

SOCIAL HISTORY:
Social History  (Last Verified ___ by ___, 
MD):
Lives with:         Group setting                               
Tobacco use:        Never smoker                                
Alcohol use:        Denies                                      
Recreational drugs  Denies                                      
(marijuana, heroin,                                             
crack pills or                                                  
other):                                                         

- Modified Rankin Scale:
[] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[x] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
 
FAMILY HISTORY:
notable for stroke and hypertension            

PHYSICAL EXAMINATION: 
Vitals: 
T96.9, HR70-80s, RR16-24, BP140-180/70s 95 SaO2
Orthostatics:
137/81 supine with HR 78 --> standing HR 95; BP 161/92

General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple,  No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: trace pedal edema.

Neurologic:
-Mental Status: Alert and interactive with examiner. Oriented to
self and to situation. Able to follow midline and appendicular
commands. Has difficulty with two-step commands. Able to name
high and low frequency objects with exception of wristwatch 
clasp
(refers to as band). Difficulty with ___ backwards and ___
backwards, after multiple attempts with either task says
___ Repetition intact.
No neglect. 

-Cranial Nerves: PERRL 3>2. No nystagmus. Right eye does not
fully bury sclera on lateral gaze. Visual fields full to finger
counting. ? prior left bells palsy?. Right NLFF with delayed
activation. Facial musculature symmetric. Hearing intact to
conversation. Tongue midline. Slight dysarthria with guttural
sounds. 
 
-Motor: Right hemibody is with increased tone and spasticity at
baseline. No adventitious movements. 
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L  5    ___   ___  5   5    5  5     5     5
R  3    ___   0  0  0  3   4    4  4     4     0
 Per Dr. ___ ___
""R  2    ___   0  0  0  2   -___     4     2""

-Sensory: Diminished sensation to pinprick on right lower
extremity compared to left. Extinguishes to light touch with DSS
on right. Temperature, proprioception intact.

-Reflexes:
  Bi Tri ___ Pat Ach
L  2  2    2    3   2
R  2  3    2    3   3
Plantar response was ? extensor on right, flexor on left. 

-Coordination: No intention tremor. No dysmetria on FNF on left
and no decreased augmentation of movements with heel tapping on
right or left lower extremity.

-Gait: Deferred in setting of acute illness, without baseline
walker on hand

LABORATORY DATA:
___ 12:00AM BLOOD WBC: 4.4 RBC: 4.24 Hgb: 11.7 Hct: 38.5
MCV: 91 MCH: 27.6 MCHC: 30.4* RDW: 15.2 RDWSD: 50.4* Plt Ct: 244 

___ 12:10AM BLOOD ___: 11.8 PTT: 28.3 ___: 1.1 
___ 12:00AM BLOOD Glucose: 82 UreaN: 9 Creat: 0.8 Na: 142 
K:
4.0 Cl: 104 HCO3: 28 AnGap: 10 
___ 12:00AM BLOOD ALT: 18 AST: 28 AlkPhos: 90 TotBili: 0.5 
___ 12:00AM BLOOD cTropnT: <0.01 
___ 12:00AM BLOOD Albumin: 4.3 Calcium: 10.0 Phos: 2.7 Mg:
2.1 
___ 12:00AM BLOOD ASA: NEG Ethanol: NEG Acetmnp: 8* 
Tricycl:
NEG 
___ 12:06AM BLOOD Glucose: 82 Lactate: 1.5 Creat: 0.7 Na:
139 K: 4.7 Cl: 108 calHCO3: 29 
___ 12:06AM BLOOD Hgb: 12.5 calcHCT: 38 
___ 02:36AM URINE Blood: NEG Nitrite: NEG Protein: NEG
Glucose: NEG Ketone: NEG Bilirub: NEG Urobiln: NEG pH: 6.5 
Leuks:
NEG 
___ 02:36AM URINE bnzodzp: NEG barbitr: NEG opiates: NEG
cocaine: NEG amphetm: NEG oxycodn: NEG mthdone: NEG 

EKG: NSR

IMAGING: 
NCHCT: multiple areas of encephalomalacia, including left
frontoparietal, left occipital, right frontal and right parietal
lobe suggestive of chronic incarcts. Prominent ventricles. ?
periventricular white matter hypodensity.

CTA head and neck: no large vessel occlusion, no significant
intracranial disease. 

ASSESSMENT:

THis is a ___ year old woman with HTN, hyperlipidemia, prior
stroke with right hemiparesis, recently seen in stroke neurology
clinic, who presents today for new onset dizziness and
intermittent stuttering right lower extremity 
weakness/heaviness.
Exam is notable for mild aphasia, which I suspect is at her
baseline as per Dr. ___ on ___. She is 
slightly
inattentive to ___, which his mental exam also suggests was the
case two days prior. However, I do not some slightly more
profound right hemibody weakness as compared to his exam, with 0
in ___ (previously documented as 2). The patient also endorses
loss of pinprick sensation in right lower extremity and
extinguishes on the right with DSS. 

The underlying etiology for her new symptoms remains unclear. I
am reassured by the resolution since arrival to the ED but am
concerned about the possibility of a stuttering lacune given the
intermittent right lower extremity weakness vs flow-dependent
perfusion states vs subclinical seizures vs stroke 
recrudescence.
No obvious infectious triggers on routine lab work in ED. Given
new onset of waxing/waning symptoms with significant stroke risk
factors, admission is warranted for expedited management.

PLAN:
- Admit to stroke neurology service under attending Dr. ___.

# Neuro:
- MRI head 
- Check risk factors: fasting lipid panel and HBA1c  
- Consider increasing/transitioning aspirin  
- Allow BP to autoregulate as below
- ___ consults
 
# CV:  
- R/o MI with cardiac enzymes 
- Monitor cardiac telemetry  
- Allow BP to autoregulate with goal SBP<180 (goal 140-180s)  
- Hydralazine 10 mg IV q6h prn SBP > 180  
- Hold home antihypertensives / halve dose of beta-blocker  
- Trans-thoracic echo  
 
# Pulmonary:
- Monitor oximetry
- Screening CXR
 
# GI/Nutrition:
- NPO until passes water swallowing screen
- Cardiac heart healthy diet once passess
- Bowel regimen with Senna, Colace 
 
# Renal: 
- Baseline Cr: 0.7
- Continue to trend
- mIVF @ 70cc/hr for 1L pending PO eval 
 
# Endocrine:
- TSH, A1c
- Finger sticks QID
- Insulin sliding scale  
 
# Toxic/Metabolic:  
- Check LFTs  
- Check urine and serum toxin screens 
 
# ID:  
- Check UA  
- Check CXR
 
# Heme:
- Baseline Hgb: 11.7

# Psychiatric/Behavioral: 
- No active issues
  
# Hospital Issues: 
- DVT PPx: Pneumoboots, SQ heparin 
- Precautions: Fall, Aspiration 
- Restraints: none 
- Health Care Proxy: unknown
- Code Status:  full

 

###RESPONSE: drug allergies {Allergy to drug}, Never smoker {Never smoked tobacco}, disability {Disability}, able to carry out all usual
activities {Able to carry out daily routine}, disability {Disability}, disability {Disability}, able to walk {Able to walk}, disability {Disability}, unable to walk {Unable to walk}, disability {Disability}, requires constant nursing care {Nursing assistance required}, Dead {Dead}, stroke {Cerebrovascular accident}, hypertension {Hypertensive disorder, systemic arterial}, standing {Orthostatic body position}, Awake {Awake}, cooperative {Cooperative mental state}, scleral icterus {Scleral icterus}, MMM {Moist oral mucosa}, lesions noted in
oropharynx {Lesion of oropharynx}, Supple {Normal movement of neck}, nuchal rigidity {Nuchal rigidity}, RRR {Normal heart rate}, warm {Warm skin}, well-perfused {Normal tissue perfusion}, Soft {Abdomen soft}, non-distended {Normal abdominal contour}, pedal edema {Edema of foot}, Mental Status {Neurological mental status determination}, Alert {Mentally alert}, interactive {Does communicate}, Oriented {Oriented to person}, Repetition {Verbal repetition}, PERRL {Pupils equal and reacting to light}, nystagmus {Nystagmus}, Right eye {Right eye structure}, sclera {Scleral structure}, Visual fields {Visual field study}, full to finger
counting {Full to finger counting}, bells palsy {Bell's palsy}, Facial musculature symmetric {Facial symmetry}, Hearing intact {Hearing normal}, Tongue {Tongue structure}, dysarthria {Dysarthria}, increased tone {Increased muscle tone}, spasticity {Spasticity}, baseline {Baseline state}, adventitious movements {Involuntary movement}, Delt {Structure of deltoid muscle}, Bic {Biceps brachii muscle structure}, Tri {Triceps brachii muscle structure}, WrE {Structure of extensor of wrist joint}, FFl {Structure of flexor of interphalangeal joint of finger}, FE {Structure of extensor muscle of forearm}, IO {Structure of intrinsic muscle of hand}, IP {Structure of iliopsoas muscle}, Quad {Structure of quadriceps femoris muscle}, Ham {Posterior muscle of thigh structure}, TA {Tibialis anterior muscle structure}, Diminished sensation {Hypesthesia}, pinprick {Finding of pin prick discrimination}, right lower
extremity {Structure of right lower limb}, left {Structure of left lower limb}, light touch {Light touch sensation present}, right {Structure of right lower limb}, proprioception intact {Normal joint position sense}, Plantar response was ? extensor on right {Extensor plantar response right}, flexor on left {Plantar response-L=flexor}, intention tremor {Intention tremor}, dysmetria {Dysmetria}, FNF {Finger-to-nose test}, heel {Heel structure}, right {Structure of right lower limb}, left lower extremity {Structure of left lower limb}, baseline {Baseline state}, walker {Uses zimmer frame}, NSR {Normal sinus rhythm}, NCHCT {Computed tomography of head without contrast}, encephalomalacia {Encephalomalacia}, left
frontoparietal {Left frontal and parietal lobes (combined site)}, left occipital {Left occipital lobe structure}, right frontal {Right frontal lobe structure}, right parietal
lobe {Right parietal lobe structure}, chronic {Chronic disease}, incarcts {Infarct}, ventricles {Brain ventricle structure}, periventricular white matter {Structure of periventricular white matter}, CTA head and neck {Computed tomography angiography of head and neck with contrast}, large vessel {Large blood vessel structure}, occlusion {Complete obstruction}, intracranial {Intracranial structure}, disease {Disease}, HTN {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, stroke {Cerebrovascular accident}, right hemiparesis {Right hemiparesis}, stroke {Cerebrovascular accident}, dizziness {Dizziness}, lower extremity 
weakness {Paresis of lower extremity}, heaviness {Sensation of heaviness in limbs}, Exam {Physical examination procedure}, mild {Symptom mild}, aphasia {Aphasia}, baseline {Baseline state}, right hemibody weakness {Right hemiparesis}, exam {Physical examination procedure}, pinprick {Finding of pin prick discrimination}, sensation {Abnormal sensation}, right lower extremity {Structure of right lower limb}, lacune {Lacunar infarction}, right lower extremity weakness {Paresis of right lower limb}, perfusion {Perfusion}, seizures {Seizure}, stroke {Cerebrovascular accident}, infectious {Infectious disease}, significant stroke risk {At increased risk of cerebrovascular accident}, neurology service {Neurology service}, Neuro {Neurological examination}, MRI head {Magnetic resonance imaging of head}, fasting {Fasting}, lipid panel {Lipid panel}, MI {Myocardial infarction}, cardiac enzymes {Cardiac enzymes/isoenzymes measurement}, cardiac telemetry {Cardiac telemetry}, IV {Administration of drug or medicament via intravenous route}, Trans-thoracic echo {Transthoracic echocardiography}, oximetry {Oximetry}, CXR {Plain chest X-ray}, NPO {Nil by mouth}, healthy diet {Healthy diet}, regimen {Therapeutic regimen}, Baseline {Baseline state}, TSH {Thyroid stimulating hormone measurement}, Finger sticks {Finger-prick sampling}, Insulin sliding scale {Sliding scale insulin regime}, LFTs {Hepatic function panel}, urine {Urinalysis}, UA {Urinalysis}, CXR {Plain chest X-ray}, Baseline {Baseline state}, Hgb {Measurement of total hemoglobin concentration}, DVT {Deep venous thrombosis}, PPx {Preventive procedure}, Precautions {Safety precautions}, Fall {Falls}, Aspiration {Pulmonary aspiration}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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                                                  
HYPOTHYROIDISM                                                  
STROKE                                                          
SEIZURE DISORDER                                                
GLAUCOMA    
 

###RESPONSE: HYPERTENSION {Hypertensive disorder, systemic arterial}, HYPERLIPIDEMIA {Hyperlipidemia}, HYPOTHYROIDISM {Hypothyroidism}, STROKE {Cerebrovascular accident}, SEIZURE DISORDER {Seizure disorder}, GLAUCOMA {Glaucoma}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
notable for stroke and hypertension   
 

###RESPONSE: stroke {Cerebrovascular accident}, hypertension {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
24 HR Data (last updated ___ @ 423)
    Temp: 98.3 (Tm 98.4), BP: 113/71 (113-145/71-84), HR: 72
(65-94), RR: 16 (___), O2 sat: 96% (96-98), O2 delivery: Ra   

General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple,  No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Extremities: trace pedal edema.

Neurologic:
-Mental Status: Alert and interactive with examiner. Oriented to
self and to situation. Able to follow midline and appendicular
commands. Has difficulty with two-step commands. Repetition
intact. 

-Cranial Nerves: PERRL 3>2. No nystagmus. Right eye does not
fully bury sclera on lateral gaze. Visual fields full to finger
counting. Right NLFF with delayed activation. Facial musculature
symmetric. Hearing intact to conversation. Tongue midline. 
Slight
dysarthria with guttural sounds. 
 
-Motor: Right hemibody is with increased tone and spasticity at
baseline. No adventitious movements. 
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L  5    ___   ___  5   5    5  5     5     5
R  3    4   4-   0   0  0 0  3   4    4  4-    4     0
 Per Dr. ___ ___
""R  2    ___   0  0  0  2   -___     4     2""

-Sensory: deferred

-Reflexes: deferred
Plantar response was extensor on right, flexor on left. 

-Coordination: No intention tremor. No dysmetria on FNF on left
and no decreased augmentation of movements with heel tapping on
right or left lower extremity.

-Gait: Deferred

 

###RESPONSE: O2 sat {Oxygen saturation measurement}, General {General examination of patient}, Awake {Awake}, cooperative {Cooperative mental state}, HEENT {Physical examination procedure}, scleral icterus {Scleral icterus}, MMM {Moist oral mucosa}, lesions noted in
oropharynx {Lesion of oropharynx}, Supple {Normal movement of neck}, nuchal rigidity {Nuchal rigidity}, Pulmonary {Examination of respiratory system}, Cardiac {Cardiovascular physical examination}, RRR {Normal heart rate}, warm {Warm skin}, well-perfused {Normal tissue perfusion}, Extremities {Examination of limb}, pedal edema {Edema of foot}, Neurologic {Neurological examination}, Mental Status {Neurological mental status determination}, Alert {Mentally alert}, interactive {Does communicate}, Oriented {Oriented to person}, Repetition {Verbal repetition}, Cranial Nerves {Examination of cranial nerve}, PERRL {Pupils equal and reacting to light}, nystagmus {Nystagmus}, Right eye {Right eye structure}, sclera {Scleral structure}, Visual fields {Visual field study}, full to finger
counting {Full to finger counting}, Facial musculature
symmetric {Facial symmetry}, Hearing intact {Hearing normal}, Tongue {Tongue structure}, dysarthria {Dysarthria}, Motor {Motor testing}, increased tone {Increased muscle tone}, spasticity {Spasticity}, baseline {Baseline state}, adventitious movements {Involuntary movement}, Delt {Structure of deltoid muscle}, Bic {Biceps brachii muscle structure}, Tri {Triceps brachii muscle structure}, WrE {Structure of extensor of wrist joint}, FFl {Structure of flexor of interphalangeal joint of finger}, FE {Structure of extensor muscle of forearm}, IO {Structure of intrinsic muscle of hand}, IP {Structure of iliopsoas muscle}, Quad {Structure of quadriceps femoris muscle}, Ham {Posterior muscle of thigh structure}, TA {Tibialis anterior muscle structure}, Sensory {Sensory testing}, Reflexes {Reflex studies}, Plantar response was extensor on right {Extensor plantar response right}, flexor on left {Plantar response-L=flexor}, intention tremor {Intention tremor}, dysmetria {Dysmetria}, FNF {Finger-to-nose test}, heel {Heel structure}, right {Structure of right lower limb}, left lower extremity {Structure of left lower limb}, Gait {Examination of gait}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:00AM   ALT(SGPT)-16 AST(SGOT)-22 LD(LDH)-236 
CK(CPK)-134 ALK PHOS-83 TOT BILI-0.4
___ 06:00AM   CK-MB-3 cTropnT-<0.01
___ 06:00AM   ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-2.6* 
MAGNESIUM-2.1 CHOLEST-154
___ 06:00AM   %HbA1c-5.3 eAG-105
___ 06:00AM   TRIGLYCER-40 HDL CHOL-76 CHOL/HDL-2.0 
LDL(CALC)-70
___ 06:00AM   TSH-7.9*
___ 06:00AM   T4-8.1
___ 06:00AM   WBC-4.7 RBC-4.00 HGB-11.0* HCT-36.4 MCV-91 
MCH-27.5 MCHC-30.2* RDW-15.2 RDWSD-50.2*
___ 06:00AM   ___ PTT-28.2 ___
___ 02:36AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG 
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 12:10AM   ___ PTT-28.3 ___
___ 12:06AM   GLUCOSE-82 LACTATE-1.5 CREAT-0.7 NA+-139 
K+-4.7 CL--108 TCO2-29
___ 12:06AM   HGB-12.5 calcHCT-38
___ 12:00AM   ASA-NEG ETHANOL-NEG ACETMNPHN-8* 
tricyclic-NEG

CT Head/ neck:
1. Multifocal areas of encephalomalacia as described above, 
largest in the 
left frontoparietal lobe.  This limits sensitivity for acute 
territorial 
infarction.  Consider further evaluation with MRI. 
2. Small chronic infarct left thalamus. 
3. No evidence of acute intracranial hemorrhage. 
4. Patent head and neck vasculature with no evidence of focal 
stenosis, 
occlusion, or aneurysm. 
5. Right thyroid lobe nodule measuring 1.9 cm. 

MR brain:
1. Study is moderately degraded by motion. 
2. Multiple bilateral supratentorial chronic infarcts, largest 
in the left MCA territory, with evidence of probable chronic 
blood products within right parieto-occipital infarct. 
3. No acute infarct or extra-axial collection. 

 

###RESPONSE: ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, PHOS {Phosphate, total measurement}, TOT BILI {Bilirubin, total measurement}, cTropnT {Troponin T cardiac measurement}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium measurement}, CHOLEST {Cholesterol measurement}, eAG {Glucose measurement estimated from glycated hemoglobin}, TSH {Thyroid stimulating hormone measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, CL {Chloride measurement, blood}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, encephalomalacia {Encephalomalacia}, left frontoparietal lobe {Left frontal and parietal lobes (combined site)}, infarction {Cerebral infarction}, evaluation {Evaluation procedure}, MRI {Magnetic resonance imaging of head}, infarct left thalamus {Thalamic infarction}, No evidence {No abnormality detected}, intracranial hemorrhage {Intracranial hemorrhage}, no evidence {No abnormality detected}, stenosis {Stenosis of artery}, occlusion {Occlusion of artery}, aneurysm {Arterial aneurysm}, thyroid lobe nodule {Thyroid nodule}, supratentorial {Supratentorial brain structure}, infarcts {Cerebral infarction}, left MCA {Structure of left middle cerebral artery}, right parieto-occipital {Right parietal and occipital lobes (combined site)}, infarct {Right sided cerebral infarction}, acute infarct {Cerebral infarction}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Hospital Course:
___ is a ___ year old woman with history of 
hypertension, hyperlipidemia, prior stroke with residual right 
hemiparesis, localization-related epilepsy on Keppra and 
lamotrigine, hypothyroidism, and glaucoma who presented to ED
from nursing home after new-onset dizziness with subsequent 
acute-on-chronic right lower extremity weakness. Dizziness 
resolved but reported right sided ""heaviness"" persisted more so 
than her baseline deficit and thus was admitted to the stroke 
service. Upon admission to stroke service, underlying etiology 
for her new symptoms remained unclear. Cardiac origin ruled out 
with EKG and telemetry. There was resolution since arrival to 
the ED but concerning with possibility of a stuttering lacune 
given the intermittent right lower extremity weakness vs 
flow-dependent perfusion states vs subclinical seizures vs 
stroke recrudescence. No obvious infectious triggers on routine 
lab work in ED. Ultimately determined to have no stroke on MRI 
but given risk factors and past stroke burden, diagnosis of 
nonspecific sequela of cerebral infarction. 

#Nonspecific Sequela of infarction: patient reportedly had 
intermittent weakness and dizziness while at her facility. Upon 
assessment in the ED, her symptoms had significantly improved 
and she reported basically being back to baseline. NCHCT was 
ordered and read as showing multiple areas of encephalomalacia, 
including left frontoparietal, left occipital, right frontal and 
right parietal lobe suggestive of chronic infarcts. Prominent 
ventricles and periventricular white matter hypodensity. CTA 
head and neck showed no large vessel occlusion, no significant 
and no intracranial disease. She was admitted to the stroke 
service and an MRI brain was ordered. MR brain read as: Multiple 
bilateral supratentorial chronic infarcts, largest in the left 
MCA territory, with evidence of probable chronic blood products 
within right parieto-occipital infarct. No acute infarct or 
extra-axial collection. Stroke risk factor labs sent. TTE was 
done and found to have EF of 60, no cardiac origin of emboli 
observed and no PFO. ___ recommended ___ rehab. She was 
kept on ASA 325 mg. Atorvastatin 60mg kept on. 

#HYPERTENSION
She was initially taken off of her home BP meds and given BP 
chance to autoregulate given concern for stroke. Once new 
infarct ruled out on imaging, home BP meds added back. 
Metoprolol 25mg PO daily 

#HYPERLIPIDEMIA
She will be sent home on atorvastatin 60mg. 

#HYPOTHYROIDISM 
Her TSH was found to be elevated at 7.9 and her home 
levothyroxine was increased from 50 to 62mg qday. Her PCP ___ 
need to continue trending TSH while outpatient. 
 #SEIZURE DISORDER
Initial concern that her symptoms potentially were related to 
seizure however no further concern and home medications were not 
changed. She arrived on lamotrigine 200mg BID and keppra 500 BID 
which she remained on. 

#GLAUCOMA 
No issues while inpatient. 

Transitional Issues:
[ ] PCP: trend TSH. Levothyroxine increased from 50 to 62.5mcg 
daily given TSH 7.9. 

Core Measures:
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic 
Attack 
1. Dysphagia screening before any PO intake? (x) Yes, confirmed 
done - () Not confirmed () No. If no, reason why: 
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not 
(I.e. bleeding risk, hemorrhage, etc.) 
3. Antithrombotic therapy administered by end of hospital day 2? 
(x) Yes - () No. If not, why not? (I.e. bleeding risk, 
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL =70 ) - () No 
5. Intensive statin therapy administered? atorvastatin 60mg LDL 
> 70) (x) Yes - () No
6. Smoking cessation counseling given? () Yes - () No [reason 
(x) non-smoker - () unable to participate] 
7. Stroke education (personal modifiable risk factors, how to 
activate EMS for stroke, stroke warning signs and symptoms, 
prescribed medications, need for followup) given in written 
form? (x) Yes - () No 
8. Assessment for rehabilitation or rehab services considered? 
(x) Yes - () No. If no, why not? (I.e. patient at baseline 
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, 
reason not given: 
10. Discharged on antithrombotic therapy? ASA 325 
11. Discharged on oral anticoagulation for patients with atrial 
fibrillation/flutter? () Yes - (x) No - If no, why not (I.e. 
bleeding risk, etc.) 

 

###RESPONSE: hypertension {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, stroke {Cerebrovascular accident}, right 
hemiparesis {Right hemiparesis}, localization-related epilepsy {Focal epilepsy}, hypothyroidism {Hypothyroidism}, glaucoma {Glaucoma}, dizziness {Dizziness}, right lower extremity weakness {Paresis of right lower limb}, Dizziness {Dizziness}, resolved {Problem resolved}, right sided {Structure of right half of body}, heaviness {Sensation of heaviness in limbs}, baseline {Baseline state}, deficit {Neurological deficit}, Cardiac {Heart disease}, EKG {Electrocardiographic procedure}, telemetry {Cardiac telemetry}, lacune {Lacunar infarction}, right lower extremity weakness {Paresis of right lower limb}, perfusion {Perfusion}, seizures {Seizure}, stroke {Cerebrovascular accident}, infectious {Infectious disease}, stroke {Cerebrovascular accident}, MRI {Magnetic resonance imaging of head}, risk factors and past stroke burden {At increased risk of cerebrovascular accident}, cerebral infarction {Cerebral infarction}, infarction {Cerebral infarction}, weakness {Asthenia}, dizziness {Dizziness}, assessment {Evaluation procedure}, improved {Patient's condition improved}, baseline {Baseline state}, NCHCT {Computed tomography of head without contrast}, encephalomalacia {Encephalomalacia}, left frontoparietal {Left frontal and parietal lobes (combined site)}, left occipital {Left occipital lobe structure}, right frontal {Right frontal lobe structure}, right parietal lobe {Right parietal lobe structure}, infarcts {Cerebral infarction}, ventricles {Brain ventricle structure}, periventricular white matter {Structure of periventricular white matter}, CTA 
head and neck {Computed tomography angiography of head and neck with contrast}, large vessel {Large blood vessel structure}, occlusion {Occlusion of cerebral artery}, intracranial {Intracranial structure}, disease {Disease}, MRI brain {Magnetic resonance imaging of brain}, MR brain {Magnetic resonance imaging of brain}, supratentorial {Supratentorial brain structure}, infarcts {Cerebral infarction}, left 
MCA {Structure of left middle cerebral artery}, right parieto-occipital {Right parietal and occipital lobes (combined site)}, infarct {Cerebral infarction}, acute infarct {Acute infarct}, Stroke {Cerebrovascular accident}, TTE {Transthoracic echocardiography}, cardiac {Heart structure}, emboli {Embolus}, HYPERTENSION {Hypertensive disorder, systemic arterial}, stroke {Cerebrovascular accident}, infarct {Cerebral infarction}, imaging {Imaging}, HYPERLIPIDEMIA {Hyperlipidemia}, HYPOTHYROIDISM {Hypothyroidism}, TSH was found to be elevated {Thyroid stimulating hormone level above reference range}, PCP {Primary care management}, SEIZURE DISORDER {Seizure disorder}, seizure {Seizure}, GLAUCOMA {Glaucoma}, PCP {Primary care management}, Ischemic Stroke {Ischemic stroke}, Transient Ischemic 
Attack {Transient ischemic attack}, Dysphagia screening {Screening for dysphagia}, DVT Prophylaxis {Prevention of deep vein thrombosis}, bleeding risk {At increased risk of hemorrhage}, hemorrhage {Bleeding}, Antithrombotic therapy {Continuous infusion of antithrombotic}, bleeding risk {At increased risk of hemorrhage}, hemorrhage {Bleeding}, LDL {Low density lipoprotein cholesterol measurement}, statin therapy {Administration of prophylactic statin}, Smoking cessation counseling {Smoking cessation education}, non-smoker {Non-smoker}, Stroke education {Education about cerebrovascular accident}, stroke {Cerebrovascular accident}, stroke {Cerebrovascular accident}, warning signs and symptoms {Discussion about clinical red flag warning sign}, Assessment for rehabilitation {Assessment for rehabilitation}, baseline {Baseline state}, statin therapy {Administration of prophylactic statin}, oral {Administration of drug or medicament via oral route}, anticoagulation {Anticoagulant therapy}, atrial 
fibrillation {Atrial fibrillation}, flutter {Atrial flutter}, bleeding risk {At increased risk of hemorrhage}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Levothyroxine Sodium 50 mcg PO DAILY 
2. Aspirin 325 mg PO DAILY 
3. Vitamin D ___ UNIT PO MONTHLY 
4. Multivitamins W/minerals 1 TAB PO DAILY 
5. Metoprolol Succinate XL 25 mg PO DAILY 
6. LevETIRAcetam 500 mg PO BID 
7. LamoTRIgine 200 mg PO BID 
8. Furosemide 20 mg PO DAILY 
9. Baclofen 15 mg PO QPM 
10. Atorvastatin 60 mg PO QPM 

 
Discharge Medications:
1.  Aspirin 325 mg PO DAILY  
2.  Atorvastatin 60 mg PO QPM  
3.  Baclofen 15 mg PO QPM  
4.  Furosemide 20 mg PO DAILY  
5.  LamoTRIgine 200 mg PO BID  
6.  LevETIRAcetam 500 mg PO BID  
7.  Levothyroxine Sodium 50 mcg PO DAILY  
8.  Metoprolol Succinate XL 25 mg PO DAILY  
9.  Multivitamins W/minerals 1 TAB PO DAILY  
10.  Vitamin D ___ UNIT PO MONTHLY  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Nonspecific Sequela of Infarction

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: Infarction {Cerebral infarction}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}, walker {Uses zimmer frame}, cane {Uses single walking stick}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,  
You were hospitalized due to symptoms of dizziness and right 
sided weakness resulting from what we believe to be nonspecific 
sequela of cerebral infarction. You were not found to have a new 
stroke on MRI, however you have a history of residual problems 
from past stroke and your new symptoms seemed consistent with 
stroke. We believe that your new symptoms are likely secondary 
to your stroke risk factors and related to old stroke. We would 
like you to continue your current home meds and to continue 
following closely with outpatient neurology in order to best 
prevent further strokes. A stroke is a condition where a blood 
vessel providing oxygen and nutrients to the brain is blocked by 
a clot. The brain is the part of your body that controls and 
directs all the other parts of your body, so damage to the brain 
from being deprived of its blood supply can result in a variety 
of symptoms.  

Stroke can have many different causes, so we assessed you for 
medical conditions that might raise your risk of having stroke. 
In order to prevent future strokes, we plan to modify those risk 
factors. Your risk factors are: high blood pressure, high 
cholesterol. 

We are not changing your home medications. 
 
Please take your other medications as prescribed.  

Please follow up with Neurology and your primary care physician 
as listed below.  
If you experience any of the symptoms below, please seek 
emergency medical attention by calling Emergency Medical 
Services (dialing 911). In particular, since stroke can recur, 
please pay attention to the sudden onset and persistence of 
these symptoms:  
 - Sudden partial or complete loss of vision  
 - Sudden loss of the ability to speak words from your mouth  
 - Sudden loss of the ability to understand others speaking to 
you  
 - Sudden weakness of one side of the body  
 - Sudden drooping of one side of the face  
 - Sudden loss of sensation of one side of the body  

 Sincerely,  
 Your ___ Neurology Team  

 

###RESPONSE: dizziness {Dizziness}, right 
sided weakness {Right hemiparesis}, cerebral infarction {Cerebral infarction}, stroke {Cerebrovascular accident}, MRI {Magnetic resonance imaging of head}, problems {Problem}, stroke {Cerebrovascular accident}, stroke {Cerebrovascular accident}, stroke {Cerebrovascular accident}, stroke {Cerebrovascular accident}, strokes {Cerebrovascular accident}, stroke {Cerebrovascular accident}, blood 
vessel {Blood vessel structure}, brain {Brain structure}, clot {Blood clot}, brain {Brain structure}, damage {Damage}, brain {Brain structure}, Stroke {Cerebrovascular accident}, stroke {Cerebrovascular accident}, strokes {Cerebrovascular accident}, high blood pressure {Hypertensive disorder, systemic arterial}, high 
cholesterol {Hypercholesterolemia}, follow up with Neurology {Follow-up neurological assessment}, stroke {Cerebrovascular accident}, loss of vision {Functional visual loss}, loss of the ability to speak {Follow-up neurological assessment}, mouth {Mouth region structure}, loss of the ability to understand {Abnormal ability to understand}, weakness of one side of the body {Hemiparesis}, drooping of one side of the face {Facial hemiparesis}, loss of sensation {Numbness}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: CARDIOTHORACIC
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Codeine / adhesive tape / Percocet
 
Attending: ___.
 
Chief Complaint:
Recurrent chest pain, fatigue
 
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Grafting x 2 (left internal mammary 
artery to the left anterior descending coronary artery; 
saphenous vein graft to the obtuse marginal branch)
 

###RESPONSE: Codeine {Allergy to codeine}, adhesive tape {Allergy to adhesive agent}, chest pain {Chest pain}, fatigue {Fatigue}, Coronary Artery Bypass Grafting x 2 {Coronary artery bypass grafts x 2}, left internal mammary 
artery {Structure of left internal thoracic artery}, left anterior descending coronary artery {Structure of anterior descending branch of left coronary artery}, saphenous vein graft {Aortocoronary artery bypass of one coronary artery with saphenous vein graft}, obtuse marginal {Structure of obtuse marginal branch of circumflex branch of left coronary artery}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mrs. ___ is a ___ year old female with multiple cardiac risk 
factors who
presented with recurrent chest pain concerning for angina. 
Stress test was notable for mild anteroseptal ischemia. 
Subsequent cardiac catheterization showed 60% left main lesion. 
Of note, she has history of SVT. She reported
occasional episodes of palpitations and diaphoresis sometimes 
associated with chest pain. These episodes occurred several 
times per week.  Based upon the above findings, she was referred 
to Dr. ___ surgical revascularization.
 

###RESPONSE: cardiac risk 
factors {Assessment for risk of cardiovascular disease}, chest pain {Chest pain}, angina {Angina}, Stress test {Electrocardiogram with exercise test}, anteroseptal ischemia {Ischemia of myocardium of anteroseptal region}, cardiac catheterization {Cardiac catheterization}, left main {Left coronary artery structure}, lesion {Lesion}, SVT {Supraventricular tachycardia}, palpitations {Palpitations}, diaphoresis {Excessive sweating}, chest pain {Chest pain}, surgical {Surgical procedure}, revascularization {Heart revascularization}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1.  Hypertension
2.  Dyslipidemia
3.  Type II Diabetes Mellitus
4.  History of SVT
5.  Abdominal Aortic Aneurysm - incidental finding on cath

Past Surgical History: 
1.  s/p Open Cholecystectomy
2.  s/p Appendectomy

 

###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, Dyslipidemia {Dyslipidemia}, Type II Diabetes Mellitus {Diabetes mellitus type 2}, SVT {Supraventricular tachycardia}, Abdominal Aortic Aneurysm {Abdominal aortic aneurysm}, cath {Cardiac catheterization}, Cholecystectomy {Cholecystectomy}, Appendectomy {Excision of appendix}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father - died of myocardial infarction in his ___
 

###RESPONSE: died {Dead}, myocardial infarction {Myocardial infarction}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
HR: 77  BP: 133/77  RR: 16  O2 sat: 99% RA
Height: 61 inches    Weight: 145 lbs

General: Well-developed female in no acute distress
Skin: Warm [X] Dry [X] Intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X] JVD []
Chest: Lungs clear bilaterally [X]
Heart: RRR [X], No murmur/rub/Gallop
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds 
+ [X]
Extremities: Warm [X], well-perfused [X] Edema -, Slight rash on 
bilateral forearms. 
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral      Right: 2+  Left: 2+
DP           Right: 2+  Left: 2+
___           Right: 2+  Left: 2+
Radial       Right: 2+  Left: 2+

Discharge Exam:

Carotid Bruit    Right: -   Left: -

Discharge Exam:
VS: T: 98.3  HR: 80-90's SR  BP: 98-111/60  Sats: 96% RA  
WT: 65 Kg preop 65.7 Kg
General: ___ year-old female in no apparent distress
HEENT: normocephalic
Card: RRR normal S1,S2 no murmur
Resp: clear breath sounds throughout
GI: benign
Extr: warm no edema
Wound: sternal and RLE clean dry intact no erythema. sternum 
stable
Neuro: awake, alert oriented. ambulating in halls
 

###RESPONSE: HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, Height {Height / growth finding}, Weight {Weight finding}, General {General examination of patient}, distress {Distress}, Skin {Examination of skin}, Warm {Warm skin}, Intact {Intact skin}, HEENT {Physical examination procedure}, NC {Normal head}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, Full ROM {Normal range of cervical spine movement}, JVD {Jugular venous engorgement}, Chest {Examination of respiratory system}, Lungs {Examination of respiratory system}, Heart {Cardiovascular physical examination}, RRR {Normal heart rate}, murmur {Murmur}, rub {Pleural friction rub}, Gallop {Gallop rhythm}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-distended {Normal abdominal contour}, non-tender {Abdominal tenderness}, bowel sounds {Normal bowel sounds}, Extremities {Examination of limb}, Warm {Warm skin}, well-perfused {Normal tissue perfusion}, Edema {Edema}, rash {Eruption of skin}, forearms {Forearm structure}, Varicosities {Venous varices}, Neuro {Neurological examination}, Grossly intact {Normal nervous system function}, Femoral {Structure of femoral artery}, Right: 2+ {Pulse present in right femoral artery}, Left: 2+ {Pulse present in left femoral artery}, DP {Structure of dorsalis pedis artery}, Right: 2 {Pulse present in right dorsalis pedis artery}, Left: 2+ {Pulse present in left dorsalis pedis artery}, Right: 2 {Normal pulse in right dorsalis pedis artery}, Left: 2 {Pulse present in left femoral artery}, Radial {Structure of radial artery}, Right {Structure of right radial artery}, Left {Structure of left radial artery}, Carotid Bruit {Carotid bruit}, Right {Structure of right carotid artery}, Left {Structure of left carotid artery}, VS {Vital signs finding}, RA {Breathing room air}, preop {Preoperative state}, General {General examination of patient}, distress {Distress}, HEENT {Physical examination procedure}, normocephalic {Normal head}, Card {Structure of cardiovascular system}, RRR {Normal heart rate}, normal S1,S2 {Heart sounds normal}, murmur {Murmur}, Resp {Examination of respiratory system}, clear breath sounds {Normal breath sounds}, GI {Examination of digestive system}, Extr {Examination of limb}, warm {Warm skin}, edema {Edema}, sternal {Sternal skin structure}, RLE {Skin structure of right lower limb}, clean dry intact {Wound healing well}, erythema {Erythema}, sternum {Sternal skin structure}, Neuro {Neurological examination}, awake {Awake}, alert {Mentally alert}, oriented {Orientated}, ambulating {Fully mobile}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Cardiac Catheterization
Right dominant system.  Left main coronary artery with ostial 
60% stenosis. Left anterior descending and left circumflex 
arteries had no aniographically apparent coronary artery 
disease. The right coronary artery had proximal 30% lesion. 
Estimated LVEF was 60%. Abdominal aortogram showed distal 
aneurysm.

Labs:
___ WBC-7.1 RBC-3.11* Hgb-9.5* Hct-27.8* MCV-90 MCH-30.5 
MCHC-34.0 RDW-12.8 Plt ___
___ WBC-7.6# RBC-3.29*# Hgb-10.2*# Hct-28.6*# MCV-87 
MCH-30.9 MCHC-35.5* RDW-12.8 Plt ___

___ Glucose-158* UreaN-12 Creat-0.6 Na-129* K-4.2 Cl-91* 
HCO3-34
___ Glucose-128* UreaN-11 Creat-0.5 Na-127* K-4.1 Cl-90* 
HCO3-33
___ Glucose-148* UreaN-10 Creat-0.6 Na-130* K-4.1 Cl-92* 
HCO3-29 
___ UreaN-9 Creat-0.4 Na-137 K-3.3 Cl-108 HCO3-23 

___ Mg-1.9
___ Hgb-8.7* calcHCT-26

___ MRSA SCREEN (Final ___:    No MRSA isolated. 

Chest X-Ray ___: There is evidence of bilateral basal 
atelectasis, left more than right.  In addition, a minimal left 
pleural 
effusion cannot be excluded.  The sternal wires and the 
postoperative clips are in unchanged position.  No overt 
pulmonary edema.  No pneumothorax. 

 

###RESPONSE: Cardiac Catheterization {Cardiac catheterization}, Right dominant system {Right dominant coronary system}, Left main coronary artery {Structure of left coronary artery main stem}, stenosis {Stenosis}, Left anterior descending {Structure of anterior descending branch of left coronary artery}, left circumflex 
arteries {Structure of circumflex branch of left coronary artery}, disease {Disease}, right coronary artery had proximal {Structure of proximal portion of right coronary artery}, lesion {Lesion}, Abdominal aortogram {Abdominal aortogram}, aneurysm {Aneurysm}, 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}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride 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}, Mg {Blood magnesium measurement}, Hgb {Measurement of total hemoglobin concentration}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, MRSA {Methicillin resistant Staphylococcus aureus infection}, Chest X-Ray {Plain chest X-ray}, atelectasis {Atelectasis}, left {Left lung structure}, right {Right lung structure}, left {Structure of left pleural cavity}, pleural 
effusion {Pleural effusion}, sternal {Structure of sternal region}, pulmonary edema {Pulmonary edema}, pneumothorax {Pneumothorax}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
She was admitted to ___ on ___ and was taken to the 
operating room.  She underwent Coronary Artery Bypass Grafting x 
2 (left internal mammary artery to the left anterior descending 
coronary artery; saphenous vein graft to the obtuse marginal 
branch).  She tolerated the procedure well and post-operatively 
was transferred to the CVICU in stable condition for recovery 
and invasive monitoring. 
She weaned from sedation, awoke neurologically intact and was 
extubated on POD 1.  She was weaned from inotropic and 
vasopressor support. She remained hemodynamically stable and was 
transferred to the telemetry floor for further recovery.  Chest 
tubes and pacing wires were discontinued without complication.  

Respiratory: aggressive pulmonary toilet and nebs she titrated 
off oxygen.

Cardiac: Beta-blockers were titrated for rate control Lopressor 
50 mg tid.  She remained in sinus rhythm without ectopy.  Blood 
pressure was initially high 130-140's her losartan 50 mg was 
restarted but required titration down to 25 mg daily for SBP 
98-111.  Aspirin and Statin were resumed.

GI: benign PPI and bowel regime continued

Renal: renal function within normal limits.  She was gently 
diuresed to her preop weight of 65.7 Kg.

Hyponatremia: Na+ 12. With free water restriction it slowly 
trend ed up. Discharge Na 129. She was asymptomatic.

Endocrine: IV insulin and sliding scale for good blood sugar 
control.  Once taken PO medication her metformin and Glyburide 
were resumed.

Disposition: She was evaluated by the physical therapy service 
for assistance with strength and mobility.  By the time of 
discharge on POD 4 she was ambulating freely, the wound was 
healing, and pain was controlled with oral analgesics.  She was 
discharged home with ___ in good condition with appropriate 
follow up instructions.
 

###RESPONSE: Coronary Artery Bypass Grafting x 
2 {Coronary artery bypass grafts x 2}, left internal mammary artery {Structure of left internal thoracic artery}, left anterior descending 
coronary artery {Structure of anterior descending branch of left coronary artery}, saphenous vein graft {Aortocoronary artery bypass of one coronary artery with saphenous vein graft}, obtuse marginal {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, procedure {Surgical procedure}, post-operatively {Postoperative state}, stable condition {Patient's condition stable}, monitoring {Monitoring procedure}, sedation {Administration of sedative}, neurologically intact {Normal nervous system function}, extubated {Removal of endotracheal tube}, vasopressor support {Vasopressor therapy}, hemodynamically stable {Hemodynamically stable}, telemetry {Cardiac telemetry}, Chest 
tubes {Insertion of pleural tube drain}, pulmonary toilet {Airway toilet}, sinus rhythm {Sinus rhythm}, Blood 
pressure {Blood pressure finding}, restarted {Restart of medication}, Aspirin {Administration of aspirin}, bowel {Intestinal structure}, renal function {Renal function monitoring}, diuresed {Diuretic therapy}, preop {Preoperative state}, weight {Weight finding}, Hyponatremia {Hyponatremia}, asymptomatic {Asymptomatic}, sliding scale {Sliding scale insulin regime}, blood sugar {Blood sugar management}, evaluated {Evaluation procedure}, physical therapy {Physical therapy assessment}, ambulating {Fully mobile}, wound was 
healing {Wound healing well}, pain was controlled with oral analgesics {Demonstrates adequate pain control}, good {Patient's condition satisfactory}, instructions {Recommendation to}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Atenolol 50 mg PO DAILY 
2. GlyBURIDE 5 mg PO BID 
3. Hydrochlorothiazide 50 mg PO DAILY 
4. Losartan Potassium 50 mg PO DAILY 
5. MetFORMIN (Glucophage) 850 mg PO BID 
6. Aspirin 162 mg PO DAILY 
7. Calcium Carbonate 500 mg PO BID 
8. Multivitamins 1 TAB PO DAILY 
9. Fish Oil (Omega 3) 1000 mg PO BID 

 
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY 
2. Calcium Carbonate 500 mg PO BID:PRN indigestion 
3. GlyBURIDE 5 mg PO BID 
4. Losartan Potassium 25 mg PO DAILY 
RX *losartan 25 mg 1 tablet(s) by mouth once a day Disp #*30 
Tablet Refills:*0
5. Fish Oil (Omega 3) 1000 mg PO BID 
6. MetFORMIN (Glucophage) 850 mg PO BID 
7. Multivitamins 1 TAB PO DAILY 
8. Acetaminophen 650 mg PO Q6H:PRN pain, fever 
9. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain 
RX *hydromorphone 2 mg 1 tablet(s) by mouth every six (6) hours 
Disp #*50 Tablet Refills:*0
10. Lovastatin *NF* 40 mg Oral daily Reason for Ordering: Wish 
to maintain preadmission medication while hospitalized, as there 
is no acceptable substitute drug product available on formulary.
11. Metoprolol Tartrate 50 mg PO TID 
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth every eight 
(8) hours Disp #*90 Tablet Refills:*5
12. Senna 2 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 With Service
 
Facility:
___
 
___ Diagnosis:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Type II Diabetes Mellitus
History of SVT

 
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage

 

###RESPONSE: Home With Service {Home health aide service management}, Coronary Artery Disease {Coronary arteriosclerosis}, Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, Type II Diabetes Mellitus {Diabetes mellitus type 2}, SVT {Supraventricular tachycardia}, Alert {Mentally alert}, oriented x3 {Oriented to person, time and place}, Ambulating {Fully mobile}, gait steady {Gait normal}, Sternal pain {Pain of sternum}, oral analgesics {Administration of analgesic}, Sternal Incision {Wound of structure of sternal region}, healing well {Wound healing well}, erythema {Erythema}, drainage {Wound discharge}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
1. Please shower daily including washing incisions gently with 
mild soap, no baths or swimming, and look at your incisions
2). Please NO lotions, cream, powder, or ointments to incisions
3). Each morning you should weigh yourself and then in the 
evening take your temperature, these should be written down on 
the chart
4). No driving for approximately one month and while taking 
narcotics, will be discussed at follow up appointment with 
surgeon when you will be able to drive
5). No lifting more than 10 pounds for 10 weeks
6). Please wear a bra to reduce pulling on the sternal incision

**Please call cardiac surgery office with any questions or 
concerns ___. Answering service will contact on call 
person during off hours**

 

###RESPONSE: shower {Functional activity education}, incisions {Surgical incision wound}, incisions {Surgical incision wound}, incisions {Surgical incision wound}, temperature {Body temperature finding}, while taking 
narcotics {Narcotherapy}, No lifting {Functional activity education}, sternal incision {Wound of structure of sternal region}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
atorvastatin
 
Attending: ___.
 
Chief Complaint:
L ankle pain
 
Major Surgical or Invasive Procedure:
___ - ORIF L Ankle (___)
 

###RESPONSE: atorvastatin {Allergy to atorvastatin}, ankle pain {Ankle pain}, ORIF {Open reduction of fracture with internal fixation}, L Ankle {Structure of left ankle}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ y/o F presenting s/p mechanical fall this evening. She 
reports immediate pain of the left ankle after feeling it twist. 
She was also unable to bear weight. Currently denies parathesias 
or numbness. 
 

###RESPONSE: fall {Falls}, pain {Pain}, left ankle {Structure of left ankle}, unable to bear weight {Unable to weight-bear}, parathesias {Paresthesia}, numbness {Numbness}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
PMH/PSH: 
1.  Hypertension.
2.  Hyperlipidemia.
3.  Glucose intolerance.
4.  Gastroesophageal reflux.
5.  Allergic rhinitis.
6.  Status post H. pylori infection - confirmed eradicated ___.
7.  Breast biopsy bilateral in the ___ and ___.  The patient
denies any cancer.
8.  Bilateral oophorectomy and hysterectomy - ___.
 

###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, Glucose intolerance {Impaired glucose tolerance}, Gastroesophageal reflux {Gastroesophageal reflux disease}, Allergic rhinitis {Allergic rhinitis}, H. pylori infection {Infection caused by Helicobacter pylori}, Breast biopsy {Biopsy of breast}, cancer {Malignant neoplasm of colon}, Bilateral oophorectomy {Excision of bilateral ovaries}, hysterectomy {Hysterectomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
NC
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VS: 99.1  103  148/72  18  98ra
Gen: NAD, AAOx3
LLE exam:
SILT S/S/SP/DP/T
fires ___
WWP
Splint in place
 

###RESPONSE: Physical Exam {Physical examination procedure}, VS {Vital signs finding}, Gen {General examination of patient}, NAD {No abnormality detected}, Ox3 {Oriented to person, time and place}, LLE {Structure of left lower limb}, SILT {Light touch sensation present}, DP {Structure of dorsalis pedis artery}, WWP {Normal tissue perfusion}, Splint {Application of splint}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 07:10AM BLOOD WBC-7.0 RBC-4.03* Hgb-11.1* Hct-33.4* 
MCV-83 MCH-27.6 MCHC-33.3 RDW-14.9 Plt ___

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 presented to the emergency department and was 
evaluated by the orthopedic surgery team. The patient was found 
to have L ankle fracture and was admitted to the orthopedic 
surgery service.  The patient was taken to the operating room on 
___ for ORIF L ankle, which the patient tolerated well (for 
full details please see the separately dictated operative 
report). The patient was taken from the OR to the PACU in stable 
condition and after recovery from anesthesia was transferred to 
the floor.  The patient was initially given IV fluids and IV 
pain medications, and progressed to a regular diet and oral 
medications by POD#1. The patient was given perioperative 
antibiotics and anticoagulation per routine.  The patients home 
medications were continued throughout this hospitalization.  The 
patient worked with ___ who determined that discharge to rehab 
was appropriate. The ___ hospital course was otherwise 
unremarkable.

At the time of discharge the patient was afebrile with stable 
vital signs that were within normal limits, pain was well 
controlled with oral medications, incisions were 
clean/dry/intact, and the patient was voiding/moving bowels 
spontaneously. The patient is touchdown weightbearing in the 
left lower extremity, and will be discharged on Lovenox for DVT 
prophylaxis.  The patient will follow up in two weeks per 
routine. A thorough discussion was had with the patient 
regarding the diagnosis and expected post-discharge course, and 
all questions were answered prior to discharge.
 
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H pain 
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp 
#*60 Tablet Refills:*2
2. Amlodipine 2.5 mg PO DAILY 
3. Calcium Carbonate 500 mg PO BID 
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 
5. Omeprazole 20 mg PO BID 
6. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN pain 
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp 
#*61 Tablet Refills:*0
7. Pravastatin 40 mg PO DAILY 
8. Vitamin D 400 UNIT PO DAILY 
9. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Days 
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*14 Syringe 
Refills:*0
10. Docusate Sodium 100 mg PO BID 
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice 
daily Disp #*30 Capsule Refills:*2
11. Senna 1 TAB PO BID:PRN constipation 
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp 
#*30 Tablet Refills:*2

 

###RESPONSE: emergency {Emergency treatment}, evaluated by the orthopedic surgery team {Orthopedic assessment}, L ankle {Structure of left ankle}, admitted to the orthopedic 
surgery service {Admission by orthopedic surgeon}, ORIF {Open reduction of fracture with internal fixation}, L ankle {Structure of left ankle}, operative {Surgical procedure}, PACU {Postanesthesia care}, stable 
condition {Patient's condition stable}, anesthesia {Administration of general anesthetic}, given IV fluids {Administration of intravenous fluids}, IV {Intravenous therapy}, pain medications {Administration of analgesic}, regular diet {Normal diet}, oral 
medications {Administration of drug or medicament via oral route}, antibiotics {Antibiotic therapy}, anticoagulation {Anticoagulant therapy}, medications {Administration of drug or medicament}, unremarkable {No abnormality detected}, afebrile {Temperature normal}, stable 
vital signs {Normal vital signs}, normal {No abnormality detected}, pain was well 
controlled with oral medications {Demonstrates adequate pain control with oral analgesics}, incisions {Surgical incision wound}, clean/dry/intact {Wound healing well}, voiding {Normal micturition}, moving bowels {Finding of defecation}, weightbearing {Weight-bearing}, left lower extremity {Structure of left lower limb}, DVT 
prophylaxis {Prevention of deep vein thrombosis}, follow up {Postoperative follow-up visit}, discussion {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: Discharge Disposition:
Extended Care
 
Facility:
___
 
___ Diagnosis:
L bimalleolar ankle fracture
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).
 

###RESPONSE: bimalleolar ankle fracture {Bimalleolar fracture of ankle}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}, walker {Uses zimmer frame}, cane {Uses single walking stick}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians 
at discharge.
- Continue all home medications unless specifically instructed 
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate 
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should 
drink eight 8oz glasses of water daily and take a stool softener 
(colace) to prevent this side effect.

ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks

WOUND CARE:
- Please be careful to keep your splint dry until your follow-up 
appointment.  
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken 
out at your 2-week follow up appointment.

ACTIVITY AND WEIGHT BEARING:
- Touchdown weightbearing left lower extremity
Physical Therapy:
Touchdown weightbearing in left lower extremity.
Please keep splint on until your follow-up appointment.
Treatment Frequency:
Please keep splint on until your follow-up appointment. Please 
keep your splint dry. You may elevate your foot for comfort as 
you like. Any sutures/staples will be removed at your follow up 
appointment.
 

###RESPONSE: MEDICATIONS {Administration of drug or medicament}, medications {Administration of drug or medicament}, medications {Administration of drug or medicament}, Do not drink alcohol {Education about alcohol consumption}, while taking narcotic pain relievers {Narcotics education}, Narcotic pain relievers can cause {Narcotics education}, constipation {Constipation}, take a stool softener {Administration of laxative}, side effect {Medication side effects present}, ANTICOAGULATION {Anticoagulant therapy}, WOUND CARE {Wound care}, splint {Application of splint}, stitches {Removal of suture}, staples that need to be removed {Removal of staples}, ACTIVITY AND WEIGHT BEARING {Education about increasing activity tolerance}, weightbearing {Weight-bearing}, left lower extremity {Structure of left lower limb}, Physical Therapy {Physical therapy procedure}, weightbearing {Weight-bearing}, left lower extremity {Structure of left lower limb}, splint {Application of splint}, splint {Application of splint}, splint {Application of splint}, foot {Structure of left foot}, sutures {Removal of suture}, staples will be removed {Removal of staples}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
volume overload 
 
Major Surgical or Invasive Procedure:
G-J Tube removed by interventional radiology ___

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, volume overload {Hypervolemia}, G-J Tube removed by interventional radiology {Removal of gastrojejunostomy tube using fluoroscopic guidance}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mr. ___ is a ___ with T1DM (c/b multiple toe
amputations, gastroparesis & prior DKA), ESRD on HD (likely ___
DM, no biopsy on file), bilateral ___ DVT s/p IVC filter ___
and on warfarin, L non-occlusive jugular thrombus (___), R
thalamic bleed in the setting of HTN emergency w/ residual L
hemiparesis (___), & L hip fracture s/p fixation ___, and
recent admission from ___ for MRSA bacteremia ___ PNA on
vancomycin with HD sessions (scheduled course through ___, who
presents from rehab with a 25-lb weight gain and worsening ___
edema since discharge. The patient also had a new 2L O2
requirement in the ED. 
 
The patient is on a MWF HD session, and had not received his
___ session. Per NP at his rehab facility, the patient had
recently been becoming hypotensive while receiving HD at his
facility, with a progressive volume overload and inability to
increase UF. He has not been on diuretics, and was not started 
on
any at facility.

 

###RESPONSE: T1DM {Diabetes mellitus type 1}, toe
amputations {Amputated toe}, gastroparesis {Gastroparesis}, DKA {Ketoacidosis due to diabetes mellitus}, ESRD on HD {End stage renal failure on dialysis}, DM {Diabetes mellitus}, biopsy {Biopsy}, DVT {Deep venous thrombosis}, IVC filter {Inferior vena cava filter in situ}, on warfarin {Warfarin therapy}, L non-occlusive jugular {Structure of left jugular vein}, thrombus {Thrombus}, thalamic {Thalamic structure}, bleed {Bleeding}, HTN emergency {Hypertensive emergency}, L
hemiparesis {Left hemiparesis}, hip fracture {Fracture of proximal end of femur}, fixation {Fixation}, MRSA bacteremia {Bacteremia caused by Methicillin resistant Staphylococcus aureus}, PNA {Pneumonia}, vancomycin {Antibiotic therapy}, HD {Hemodialysis}, weight gain {Weight gain}, worsening {Patient's condition worsened}, edema {Edema}, HD {Hemodialysis}, hypotensive {Low blood pressure}, HD {Hemodialysis}, volume overload {Hypervolemia}, diuretics {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:
-type I DM (A1C 4.9 ___ w/ prior DKA
-multiple amputations
-gastroparesis
-ESRD (likely ___ DM, no biopsy on file) on HD
-bilateral ___ DVT s/p IVC filter ___
-L non-occlusive jugular thrombus ___
-R thalamic bleed in the setting of HTN emergency w/ residual L
hemiparesis (___)
-L hip fracture s/p fixation ___
 

###RESPONSE: type I DM {Diabetes mellitus type 1}, DKA {Ketoacidosis due to diabetes mellitus}, amputations {Amputated toe}, gastroparesis {Gastroparesis}, ESRD {End-stage renal disease}, DM {Diabetes mellitus}, biopsy {Biopsy}, HD {Hemodialysis}, DVT {Deep venous thrombosis}, IVC filter ___ {Inferior vena cava filter in situ}, L non-occlusive jugular {Structure of left jugular vein}, thrombus {Thrombus}, thalamic {Thalamic structure}, bleed {Bleeding}, HTN emergency {Hypertensive emergency}, L
hemiparesis {Left hemiparesis}, hip fracture {Fracture of proximal end of femur}, fixation {Fixation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
___ significant for stroke. 
 

###RESPONSE: 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: ___ Temp: 98.4 PO BP: 114/69 R Lying HR: 128 RR: 
20
O2 sat: 94% O2 delivery: RA 
GENERAL: Patient lying in bed, NAD, interactive 
HEAD: NC/AT, R pupil non-reactive (patient reports that it is a
false eye). L pupil reactive. EOMI intact on left side. Oral
mucosa w/o lesions, MMM. 
NECK: Supple, no LAD, no thyromegaly. Elevated JVP. 
CARDIAC: Tachycardic, irregular rhytm. No m/r/g. 
RESPIRATORY: Speaking in full sentences. Decreased bibasilar
breath rounds and mild crackles, L > R. 
ABDOMEN: Unremarkable inspection, soft, NT, +BS. No palpable
organomegaly. PEG tube in place, dressings c/d/I, no erythema or
tenderness around site. 
EXTREMITIES: Severe 2+ petting edema, L > R, in both UE and ___. 
SKIN: Scattered ecchymoses across both arms b/l, no other 
lesions
or rashes. 
NEUROLOGIC: ___ strength on left side; unable to lift L arm or L
leg (baseline per patient). Normal strength on R side.  
PSYCHIATRIC: Pleasant and cooperative. 

DISCHARGE PHYSICAL EXAM
========================
Temp: 98.1 PO BP: 125/76 R Lying HR: 101 RR: 18 O2
sat: 97% O2 delivery: Ra FSBG: 267 
GENERAL: sitting up in bed, NAD, interactive 
HEAD: NC/AT, R pupil non-reactive (false eye). L pupil reactive.
EOMI intact on left side. Oral mucosa w/o lesions, MMM. 
NECK: JVP normal
CARDIAC: Tachycardic, irregular rhythm. No m/r/g. 
RESPIRATORY: Nonlabored breathing, CATB.
ABDOMEN: Unremarkable inspection, soft, NT. PEG tube in place,
dressings c/d/I, no erythema or tenderness around site. 
EXTREMITIES: 1+ pitting edema in left arm and leg, no edema R
SKIN: Scattered ecchymoses across both arms b/l, no other 
lesions
or rashes. 
NEUROLOGIC: ___ strength on left side; unable to lift L arm or L
leg (baseline per patient). Normal strength on R side.  
PSYCHIATRIC: Pleasant and cooperative.
 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, Lying {Lying in bed}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, GENERAL {General examination of patient}, lying in bed {Lying in bed}, NAD {No abnormality detected}, interactive {Does communicate}, HEAD {Physical examination procedure}, NC {Normal head}, R pupil {Structure of pupil of right eye}, non-reactive {No pupillary reaction to light}, false eye {Prosthetic eye in situ}, L pupil {Structure of pupil of left eye}, EOMI {Normal ocular motility}, left {Left eye structure}, Oral
mucosa {Oral mucous membrane structure}, lesions {Lesion}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, LAD {Lymphadenopathy}, thyromegaly {Goiter}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, Tachycardic {Tachycardia}, irregular rhytm {Irregular heart beat}, No m/r/g {Heart sounds normal}, RESP {Examination of respiratory system}, RA {Breathing room air}, bibasilar {Structure of base of lung}, mild {Symptom mild}, crackles {Respiratory crackles}, ABDOMEN {Examination of abdomen}, inspection {Inspection}, soft {Abdomen soft}, NT {Abdominal tenderness}, BS {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, erythema {Erythema}, tenderness {Tenderness}, EXTREMITIES {Examination of limb}, edema {Edema}, UE {Upper limb structure}, SKIN {Examination of skin}, ecchymoses {Ecchymosis}, both arms {Both upper arms}, lesions {Lesion}, rashes {Eruption of skin}, NEURO {Neurological examination}, GI {Examination of digestive system}, unable to lift {Unable to lift}, L arm {Structure of left upper limb}, L
leg {Structure of left lower limb}, baseline {Baseline state}, cooperative {Cooperative mental state}, PHYSICAL EXAM {Physical examination procedure}, Temp {Body temperature finding}, BP {Blood pressure finding}, Lying {Lying in bed}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2
sat {Oxygen saturation measurement}, GENERAL {General examination of patient}, sitting {Sitting position}, NAD {No abnormality detected}, interactive {Does communicate}, HEAD {Physical examination procedure}, NC {Normal head}, R pupil {Structure of pupil of right eye}, non-reactive {No pupillary reaction to light}, (false eye) {Prosthetic eye in situ}, L pupil {Structure of pupil of left eye}, EOMI {Normal ocular motility}, left {Left eye structure}, Oral mucosa {Oral mucous membrane structure}, lesions {Lesion}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, Tachycardic {Tachycardia}, irregular rhythm {Irregular heart beat}, No m/r/g {Heart sounds normal}, RESP {Examination of respiratory system}, RA {Breathing room air}, CATB {Normal breath sounds}, ABDOMEN {Examination of abdomen}, inspection {Inspection}, soft {Abdomen soft}, NT {Abdominal tenderness}, erythema {Erythema}, tenderness {Tenderness}, EXTREMITIES {Examination of limb}, edema {Edema}, left arm {Structure of left upper limb}, leg {Structure of left lower limb}, edema {Edema}, SKIN {Examination of skin}, ecchymoses {Ecchymosis}, both arms {Both upper arms}, lesions {Lesion}, rashes {Eruption of skin}, NEURO {Neurological examination}, GI {Examination of digestive system}, unable to lift {Unable to lift}, L arm {Structure of left upper limb}, L
leg {Structure of left lower limb}, baseline {Baseline state}, cooperative {Cooperative mental state}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS
==============
___ 10:15AM BLOOD WBC-15.4* RBC-2.27* Hgb-7.6* Hct-24.4* 
MCV-108* MCH-33.5* MCHC-31.1* RDW-14.1 RDWSD-54.4* Plt ___
___ 10:15AM BLOOD Neuts-63.3 Lymphs-4.4* Monos-5.6 
Eos-25.0* Baso-1.1* Im ___ AbsNeut-9.72* AbsLymp-0.67* 
AbsMono-0.86* AbsEos-3.84* AbsBaso-0.17*
___ 10:15AM BLOOD ___ PTT-32.9 ___
___ 07:52PM BLOOD ___ 03:50PM BLOOD Ret Aut-2.4* Abs Ret-0.05
___ 10:15AM BLOOD Glucose-222* UreaN-107* Creat-3.8*# 
Na-132* K-6.7* Cl-92* HCO3-26 AnGap-14
___ 03:50PM BLOOD ALT-23 AST-18 LD(LDH)-178 AlkPhos-190* 
TotBili-0.2 DirBili-<0.2 IndBili-0.2
___ 10:15AM BLOOD ___
___ 10:15AM BLOOD Calcium-9.8 Phos-3.8 Mg-1.8
___ 03:50PM BLOOD calTIBC-165* Hapto-223* Ferritn-1616* 
TRF-127*
___ 03:50PM BLOOD TSH-1.5

TROP TREND:
___ 10:15AM BLOOD cTropnT-0.56*
___ 07:52PM BLOOD cTropnT-0.61*
___ 06:47AM BLOOD cTropnT-0.63*
___ 05:25PM BLOOD CK-MB-3 cTropnT-0.72*
___ 07:40AM BLOOD CK-MB-2 cTropnT-0.62*

INR TREND:
___ 05:08AM BLOOD ___ PTT-36.3 ___
___ 06:14AM BLOOD ___ PTT-87.1* ___
___ 07:00AM BLOOD ___ PTT-63.3* ___

INTERVAL LABS
==============
___ 05:28AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 05:28AM BLOOD HCV Ab-NEG
___ 06:00PM BLOOD ___ pO2-187* pCO2-42 pH-7.39 
calTCO2-26 Base XS-0 Comment-GREEN TOP 
___ 06:00PM BLOOD Lactate-1.9

DISCHARGE LABS
==============
___ 05:08AM BLOOD WBC-9.2 RBC-2.40* Hgb-7.8* Hct-25.7* 
MCV-107* MCH-32.5* MCHC-30.4* RDW-14.6 RDWSD-57.0* Plt ___
___ 05:08AM BLOOD Glucose-122* UreaN-44* Creat-3.0* Na-141 
K-4.4 Cl-102 HCO3-26 AnGap-13
___ 05:08AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.8

MICRO:
=========
___ 10:40 am BLOOD CULTURE      2 OF 2. 
                            **FINAL REPORT ___
   Blood Culture, Routine (Final ___:    NO GROWTH. 

___ 6:00 pm STOOL     CONSISTENCY: NOT APPLICABLE
      Source: Stool. 
                            **FINAL REPORT ___
   C. difficile PCR (Final ___: 
      NEGATIVE. 
           (Reference Range-Negative). 
      The C. difficile PCR is highly sensitive for toxigenic 
strains of C.
      difficile and detects both C. difficile infection (CDI) 
and
      asymptomatic carriage. 
      A negative C. diff PCR test indicates a low likelihood of 
CDI or
      carriage. 

___ 7:15 pm MRSA SCREEN      Source: Nasal swab. 
                            **FINAL REPORT ___
   MRSA SCREEN (Final ___:    No MRSA isolated. 

RADIOLOGY
==========
___ CXR
IMPRESSION: Interval significant increase in left base 
consolidation, worrisome for ongoing, worsened pneumonia.  
Possible small left pleural effusion.  Equivocal new right base 
opacity. Mild pulmonary vascular congestion without overt 
pulmonary edema. 

___ LOWER EXTREMITY US:
IMPRESSION: 
1. No evidence of acutedeep venous thrombosis in the left lower 
extremity 
veins.  A focal area of thickening along the posterior wall of 
femoral vein could represent chronic changes from the previously 
treated thrombus. 
2. Nonspecific subcutaneous edema. 

___:
CONCLUSION:
The left atrial volume index is normal. There is mild symmetric 
left ventricular hypertrophy with a normal
cavity size. There is normal regional and global left 
ventricular systolic function. Quantitative biplane left
ventricular ejection fraction is 58 %. Left ventricular cardiac 
index is normal (>2.5 L/min/m2). There is
no resting left ventricular outflow tract gradient. Mildly 
dilated right ventricular cavity with normal free wall
motion. The aortic sinus diameter is normal for gender with 
normal ascending aorta diameter for gender. The
aortic valve leaflets (3) appear structurally normal. There is 
no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets are mildly thickened 
with no mitral valve prolapse. There is mild [1+]
mitral regurgitation. The pulmonic valve leaflets are normal. 
The tricuspid valve leaflets appear structurally
normal. There is mild [1+] tricuspid regurgitation. The 
estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Dilated right ventricle. Mild symmetric left 
ventricular hypertrophy with normal
cavity size and regional/global biventricular systolic function. 
mild mitral and tricuspid
regurgitation.
Compared with the prior TTE (images not available for review) of 
___ , the left ventricular systolic
function appears to have improved.

___ CTA CHEST 
IMPRESSION: 
1. No evidence of pulmonary embolism or aortic abnormality. 
2. Multifocal pulmonary opacities in bilateral lungs have 
progressed compared to ___ concerning for progression 
of pneumonia. 
3. Small to moderate bilateral pleural effusions. 

___ G-J REMOVAL:
IMPRESSION:  
Technically successful gastrojejunostomy tube removal and T 
fastener button removal.
RECOMMENDATION(S):  Please re-consult interventional radiology 
if there is 
further need for enteral access in the future.  The gastrostomy 
site may leak for the next few days while the site closes. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Serum lactate dehydrogenase level above reference range}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, TSH {Thyroid stimulating hormone measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, HCV {Viral hepatitis type C}, pH {pH measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, CONSISTENCY {Finding of consistency of stool}, asymptomatic {Asymptomatic}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, Nasal {Nasal structure}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, MRSA {Methicillin resistant Staphylococcus aureus infection}, CXR {Plain chest X-ray}, left base 
consolidation {Lung consolidation}, pneumonia {Pneumonia}, left {Left lung structure}, pleural effusion {Pleural effusion}, right base {Structure of base of right lung}, opacity {Abnormally opaque structure}, Mild {Symptom mild}, pulmonary vascular {Structure of pulmonary blood vessel}, congestion {Congestion}, pulmonary edema {Pulmonary edema}, No evidence {No abnormality detected}, acutedeep venous thrombosis {Acute deep venous thrombosis}, left lower 
extremity 
veins {Structure of vein of left lower limb}, thickening {Increased thickness}, femoral vein {Femoral vein structure}, chronic {Chronic disease}, thrombus {Thrombus}, subcutaneous {Subcutaneous tissue structure of lower extremity}, edema {Edema}, left atrial {Left atrial structure}, volume index is normal {Normal size cardiac chamber}, mild symmetric 
left ventricular hypertrophy {Mild left ventricular hypertrophy}, normal
cavity {Normal size cardiac chamber}, normal regional and global left 
ventricular systolic function {Echocardiogram shows normal left ventricular function}, left
ventricular {Left cardiac ventricular structure}, Left ventricular {Left cardiac ventricular structure}, cardiac 
index is normal {Normal cardiac index}, left ventricular outflow tract {Structure of outflow tract of left ventricle}, dilated {Dilatation}, right ventricular cavity {Structure of cavity of right cardiac ventricle}, free wall
motion {Normal ventricular wall motion}, aortic sinus {Structure of sinus of Valsalva}, ascending aorta {Ascending aorta structure}, aortic valve leaflets {Structure of cardiac valve leaflet}, structurally normal {Aortic valve normal}, aortic valve stenosis {Aortic valve stenosis}, aortic
regurgitation {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}, pulmonic valve leaflets {Structure of cusp of pulmonic valve}, normal {No abnormality detected}, tricuspid valve leaflets appear structurally
normal {Tricuspid valve normal}, mild [1+] tricuspid regurgitation {Mild tricuspid valve regurgitation}, pulmonary artery {Pulmonary artery structure}, systolic pressure is
normal {Normal systolic arterial pressure}, pericardial effusion {Pericardial effusion}, Dilated {Dilatation}, right ventricle {Right cardiac ventricular structure}, Mild symmetric left 
ventricular hypertrophy {Mild left ventricular hypertrophy}, normal
cavity {Normal size cardiac chamber}, biventricular {Cardiac ventricular structure}, systolic function {Normal left ventricular systolic function and wall motion}, mild mitral {Mild mitral valve regurgitation}, tricuspid
regurgitation {Tricuspid valve regurgitation}, TTE {Transthoracic echocardiography}, left ventricular systolic
function {Normal left ventricular systolic function and wall motion}, improved {Patient's condition improved}, CTA CHEST {Computed tomography of chest}, No evidence {No abnormality detected}, pulmonary embolism {Pulmonary embolism}, aortic {Aortic structure}, abnormality {No abnormality detected}, pulmonary {Lung structure}, opacities {Abnormally opaque structure}, lungs {Lung structure}, pneumonia {Pneumonia}, bilateral pleural effusions {Bilateral pleural effusion}, l gastrojejunostomy tube removal {Removal of gastrojejunostomy tube using fluoroscopic guidance}, removal {Removal}, gastrostomy {Gastrostomy}, leak {Anastomosis, leaking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
SUMMARY STATEMENT
=========================================================
___ chronically-ill male with T1DM, ESRD on HD, bilateral ___ 
DVT
s/p IVC filter ___ and on warfarin, L non-occlusive jugular
thrombus (___), R thalamic bleed in the setting of HTN
emergency w/ residual L hemiparesis (___), and recent
admission from ___ for MRSA bacteremia ___ PNA on 
vancomycin
with HD sessions (scheduled course through ___, who presents
from rehab with a 25-lb weight gain and worsening ___ edema on 
___.

ACTIVE ISSUES
=========================================================
# Dysphagia, s/p G-J tube placement ___
# Severe Protein Calorie Nutrition
Patient noted to have high aspiration risk over course for last
hospitalization, but decided to accept risks and trial pureed 
solids with nectar-thick liquids during prior hospitalization. 
Patient's G-J tube became clogged during admission. As patient 
was maintaining good PO intake and eating food was important to 
patient's GOC, the clogged G-J tube was pulled ___. On 
discharge, patient was eating solid diet.

# ESRD on HD, secondary to T1D 
Pre-admission HD sessions at facility were reported to have been 
limited by hypotension and tachycardia, and with an inability to 
increase UF as a result. Here, patient received hemodialysis 
through admission with ultrafiltration to remove excess volume. 
Repeat Echo showed recovered EF at 58%. By ___ patient did 
not appear volume overloaded on clinical exam. 

# HF w recovered EF (EF 45% ___ 
# Elevated troponins 
Patient presented with volume overload and elevated proBNP, 
consistent with HF exacerbation. Patient's discharge weight was 
66.3kg, and reported dry weight is 63kg. Admission weight was 
74.3kg. EKG w/o new ischemic changes, despite mild trop 
elevation. Infectious workup negative, other than ongoing 
aspiration. While here, a repeat Echo showed a recovered EF at 
58%. His metoprolol was uptitrated for better rate control, and 
his atorvastatin was continued. 

# Pneumonia 
# Recent MRSA Bacteremia 
# Leukocytosis
Patient had recent admission from ___ for MRSA bacteremia
___ PNA, and has been dosed with vancomycin with HD sessions
(scheduled course through ___. He presented with increased 
leukocytosis, and CXR consistent with worsened bilateral 
pneumonia, likely secondary to aspiration. He received a few 
days of broad spectrum treatment, prior to return to his 
original Vancomycin course. Vancomycin was transitioned to 
linezolid ___, as vancomycin may have been contributing to 
eosinophilia (3.84 on admission). All antibiotics were stopped 
on day of discharge (___) as patient had completed course 
for hospital associated pneumonia.

# Anemia 
Hgb notably below baseline; 7.6 on admission, from discharge Hgb 
of 8.3. Had Hgb drop from 7.6 to 6.5 on ___. Anemia likely 
multifactorial, including acute suppression iso infection, and 
anemia of chronic disease from ESRD. Less likely GI bleed, as 
patient has had no complaints of melena or BRBPR. Patient was 
transfused for Hgb < 7 throughout admission. Hb was 7.8 at 
discharge.

# T1DM
Patient has very brittle T1DM, and presented in DKA on recent 
admission in ___. He is very sensitive to insulin and has had 
hypoglycemic episodes in the past. He was continued on home 
glargine 7U with Q6H insulin sliding scale for tube feeds on 
admission. He was transitioned to glargine 8U and insulin lispro 
2U with meals after he began to eat meals. He was discharge on 
glargine 8U with lispro 2U at meals.

# Hypoxia (resolved) 
Had new 2L O2 requirement in ED, after satting in low ___ on RA.
Most likely volume overload iso vs progression of pneumonia.
Resolved by time of arrival to floor. 

# Goals of Care 
A family meeting was held in which patient's family expressed a 
clear understanding that patient was seriously ill and that 
DNR/DNI status was consistent with the patient's goals. He 
himself confirmed these wishes to his providers as well. At end 
of hospitalization, patient filled out MOLST with DNR/DNI 
status. He would like to keep eating for comfort and understands 
the risks of aspiration and death. 

CHRONIC ISSUES
=========================================================
# Atrial Fibrillation and tachycardia
Patient presented with HR in 120s. Patient's home metoprolol 
dose was increased from 25mg q6h to 50 mg q6h.

# History of VTE
Complicated coagulation history. Patient had bilateral ___ DVT 
s/p IVC 
filter ___, L non-occlusive jugular thrombus (___), R 
thalamic bleed in the setting of HTN emergency w/ residual L 
hemiparesis (___). Patient was briefly subtherapeutic, and 
therefore bridged with a heparin gtt until therapeutic again. 
Patient was discharged on home dose of warfarin 2.5 mg with 
therapeutic INR of 2.5 at discharge. 

# GERD: 
Home Pantoprazole 40 mg PO Q12H was continued.

# Mood: 
Home mirtazapine 15 mg PO QHS was continued. Sertraline 25 mg PO 
DAILY were held while patient was receiving Linezolid due to 
risk of serotonin syndrome. 

TRANSITIONAL ISSUES
=========================================================
#MRSA bacteremia s/p treatment
[ ] Surveillance blood cultures after HD on ___

#Hypertension
[ ] Uptitrate lisinopril as tolerated to goal SBP <130/80.

#Atrial fibrillation:
[ ] Uptitrated metoprolol to 50mg q6h while inpatient. If 
requires further rate control, could add diltiazem or consider 
amiodarone, with discussion with cardiologist.
[ ] Can consolidate Metop tartrate into Metop Succinate 200mg 
daily if tolerating well. 

#Diabetes mellitus
[ ] Insulin dose was increased to 8U glargine at baseline, 2U 
short-acting with meals, and sliding scale. Please titrate as 
needed.

#Depression:
[ ] Holding sertraline due to interaction w Linezolid (risk of 
serotonin syndrome) until ___, then ok to restart.

CODE: DNR/DNI
CONTACT: ___ 
Relationship: wife 
Phone number: ___ 

The total time spent today on discharge planning, counseling and 
coordination of care today was greater than 30 minutes.
 

###RESPONSE: T1DM {Diabetes mellitus type 1}, ESRD on HD {End stage renal failure on dialysis}, DVT {Deep venous thrombosis}, IVC filter {Inferior vena cava filter in situ}, on warfarin {Warfarin therapy}, L non-occlusive jugular {Structure of left jugular vein}, thrombus {Thrombus}, thalamic {Thalamic structure}, bleed {Bleeding}, HTN
emergency {Hypertensive emergency}, L hemiparesis {Left hemiparesis}, MRSA bacteremia {Bacteremia caused by Methicillin resistant Staphylococcus aureus}, PNA {Pneumonia}, vancomycin {Antibiotic therapy}, HD {Hemodialysis}, weight gain {Weight gain}, edema {Edema}, Dysphagia {Dysphagia}, placement {Implantation procedure}, Severe Protein Calorie Nutrition {Severe protein-calorie malnutrition (Gomez: less than 60 percent of standard weight)}, aspiration risk {At increased risk for aspiration}, nectar-thick liquids {Dietary liquid consistency - nectar thick liquid}, good PO intake and eating food {Eating normal}, diet {Normal diet}, ESRD on HD {End stage renal failure on dialysis}, T1D {Diabetes mellitus type 1}, HD {Hemodialysis}, hypotension {Low blood pressure}, tachycardia {Tachycardia}, hemodialysis {Hemodialysis}, ultrafiltration {Ultrafiltration}, excess volume. {Hypervolemia}, Echo {Echocardiography}, volume overloaded {Hypervolemia}, exam {Physical examination procedure}, Elevated troponins {Troponin I above reference range}, volume overload {Hypervolemia}, HF exacerbation {Exacerbation of congestive heart failure}, weight {Weight finding}, weight {Weight finding}, weight {Weight finding}, EKG {Electrocardiographic procedure}, ischemic changes {Electrocardiographic myocardial ischemia}, Infectious {Infectious disease}, workup {Evaluation procedure}, aspiration {Aspiration pneumonia}, Echo {Echocardiography}, Pneumonia {Pneumonia}, MRSA Bacteremia {Bacteremia caused by Methicillin resistant Staphylococcus aureus}, Leukocytosis {Leukocytosis}, MRSA bacteremia {Bacteremia caused by Methicillin resistant Staphylococcus aureus}, PNA {Pneumonia}, vancomycin {Antibiotic therapy}, HD {Hemodialysis}, leukocytosis {Leukocytosis}, CXR {Plain chest X-ray}, bilateral 
pneumonia {Bilateral pneumonia}, aspiration {Pulmonary aspiration}, Vancomycin {Antibiotic therapy}, Vancomycin {Antibiotic therapy}, vancomycin {Antibiotic therapy}, eosinophilia {Eosinophil count above reference range}, antibiotics {Antibiotic therapy}, hospital associated pneumonia {Nosocomial pneumonia}, Anemia {Anemia}, Hgb notably below baseline; {Hemoglobin below reference range}, Hgb {Measurement of total hemoglobin concentration}, Hgb {Measurement of total hemoglobin concentration}, Anemia {Anemia}, infection {Infectious disease}, anemia of chronic disease {Anemia of chronic disorder}, ESRD {End-stage renal disease}, GI bleed {Gastrointestinal hemorrhage}, no complaints {No complaints}, melena {Melena}, BRBPR {Hematochezia}, Hgb {Measurement of total hemoglobin concentration}, T1DM {Diabetes mellitus type 1}, T1DM {Diabetes mellitus type 1}, DKA {Ketoacidosis due to diabetes mellitus}, hypoglycemic {Hypoglycemia}, insulin sliding scale {Sliding scale insulin regime}, Hypoxia {Hypoxia}, resolved {Problem resolved}, satting {Finding of oxygen saturation}, RA {Breathing room air}, volume overload {Hypervolemia}, pneumonia {Pneumonia}, Resolved {Problem resolved}, meeting {Meetings}, DNR {Not for resuscitation}, DNR {Not for resuscitation}, aspiration {Pulmonary aspiration}, death {Dead}, Atrial Fibrillation {Atrial fibrillation}, tachycardia {Tachycardia}, HR {Finding of heart rate}, VTE {Thromboembolism of vein}, coagulation {Coagulation}, DVT {Deep venous thrombosis}, IVC 
filter ___, {Inferior vena cava filter in situ}, thrombus {Thrombus}, thalamic {Thalamic structure}, bleed {Bleeding}, HTN emergency {Hypertensive emergency}, L 
hemiparesis {Left hemiparesis}, heparin {Heparin therapy}, GERD {Gastroesophageal reflux disease}, serotonin syndrome {Serotonin syndrome}, MRSA bacteremia {Bacteremia caused by Methicillin resistant Staphylococcus aureus}, Surveillance blood cultures {Infection surveillance}, HD {Hemodialysis}, Hypertension {Hypertensive disorder, systemic arterial}, discussion {Discussion}, Diabetes mellitus {Diabetes mellitus}, baseline {Baseline state}, sliding scale {Sliding scale insulin regime}, serotonin syndrome {Serotonin syndrome}, DNR {Not for resuscitation}, discharge planning {Discharge planning}, counseling {Counseling}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Atorvastatin 40 mg PO QPM 
2. Nephrocaps 1 CAP PO DAILY 
3. Sertraline 25 mg PO DAILY 
4. sevelamer CARBONATE 800 mg PO TID W/MEALS 
5. Warfarin 2.5 mg PO DAILY16 
6. Metoprolol Succinate XL 50 mg PO BID 
7. Pantoprazole 40 mg PO Q12H 
___  MD to order daily dose IV HD PROTOCOL 
9. melatonin 6 mg oral QHS 
10. Mirtazapine 15 mg PO QHS 
11. Sucralfate 1 gm PO QID 
12. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 
13. ProMod Protein (protein supplement) 30 cc oral QID 
14. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 
15. Senna 17.2 mg PO BID:PRN Constipation - First Line 
16. Glargine 7 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
17. Bisacodyl ___VERY OTHER DAY 

 
Discharge Medications:
1.  Lisinopril 2.5 mg PO DAILY  
2.  Metoprolol Tartrate 50 mg PO Q6H  
3.  Miconazole Powder 2% 1 Appl TP BID rash  
4.  Ramelteon 8 mg PO QHS:PRN insomnia  
5.  Sarna Lotion 1 Appl TP TID:PRN dry skin  
6.  Glargine 8 Units Breakfast
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin 
7.  Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever  
8.  Atorvastatin 40 mg PO QPM  
9.  Bisacodyl ___VERY OTHER DAY  
10.  Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 
 
11.  melatonin 6 mg oral QHS  
12.  Mirtazapine 15 mg PO QHS  
13.  Nephrocaps 1 CAP PO DAILY  
14.  Pantoprazole 40 mg PO Q12H  
15.  ProMod Protein (protein supplement) 30 cc oral QID  
16.  Senna 17.2 mg PO BID:PRN Constipation - First Line  
17.  sevelamer CARBONATE 800 mg PO TID W/MEALS  
18.  Sucralfate 1 gm PO QID  
19.  Warfarin 2.5 mg PO DAILY16  
20. HELD- Sertraline 25 mg PO DAILY  This medication was held. 
Do not restart Sertraline until ___

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
End stage renal disease
Pneumonia
Heart failure with reduced ejection fraction
Anemia
Leukocytosis
Type 1 Diabetes
Dysphagia
Hypoxia
Atrial fibrillation
Deep vein thrombosis

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or 
wheelchair.

 

###RESPONSE: End stage renal disease {End-stage renal disease}, Pneumonia {Pneumonia}, Heart failure with reduced ejection fraction {Heart failure with reduced ejection fraction}, Anemia {Anemia}, Leukocytosis {Leukocytosis}, Type 1 Diabetes {Diabetes mellitus type 1}, Dysphagia {Dysphagia}, Hypoxia {Hypoxia}, Atrial fibrillation {Atrial fibrillation}, Deep vein thrombosis {Deep venous thrombosis}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Out of Bed with assistance {Difficulty getting off a bed}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
======================  
DISCHARGE INSTRUCTIONS  
======================  
Dear Mr. ___,
It was a pleasure caring for you at ___ 
___.

WHY WAS I IN THE HOSPITAL?  
- You came to the hospital from rehab because you had gained 25 
pounds of fluid and developed swelling in your legs. 

WHAT HAPPENED TO ME IN THE HOSPITAL?  
- When you came to the hospital you were found to have symptoms 
and signs on an infection in your lung, likely related to 
swallowing food into your lungs. You underwent dialysis in the 
hospital to remove fluid from your body. You also received 
antibiotics to treat the infection in your lung. We removed your 
feeding tube because you preferred to eat food, even with the 
increased risk of infections in your lungs.

WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your 
appointments.

We wish you the best!
 

###RESPONSE: swelling {Swelling}, legs {Lower limb structure}, signs {Sign}, infection {Infectious disease}, lung {Metastatic malignant neoplasm to lung}, lungs {Lung structure}, dialysis {Dialysis procedure}, antibiotics {Antibiotic therapy}, infection {Infectious disease}, lung {Lung structure}, removed {Removal}, infections {Local infection of wound}, lungs {Examination of respiratory 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: 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: 
Vicodin
 
Attending: ___.
 
Chief Complaint:
Elevated creatinine
.
 
Major Surgical or Invasive Procedure:
None
.
 

###RESPONSE: Elevated creatinine {Serum creatinine above reference range}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ yo M hx etoh cirrhosis who presented yesterday to liver 
clinic for second opinion. He was diagnosed with cirrhosis in 
___, course complicated by variceal bleeding, ascites. On blood 
work yesterday noted to have elevated Cr to 2.8, no prior 
knowledge of renal insufficiency admitted today for further 
evaluation.
Pt has had a sore threat starting 5 d PTA associated with cough 
productive of yellow sputum. No fever, chills, dyspnea. +Nausea 
and vomiting about twice daily for 5 days, poor appetite. Urine 
output unchanged. No abdominal pain, diarrhea. + sick contact, 
wife had URI with sore throat and cough last week, now resolved.
.
 

###RESPONSE: etoh cirrhosis {Alcoholic cirrhosis}, liver {Disorder of liver}, cirrhosis {Cirrhosis of liver}, variceal bleeding {Bleeding esophageal varices}, ascites {Ascites}, elevated {Elevation}, Cr {Finding of creatinine level}, renal insufficiency {Renal insufficiency}, evaluation {Evaluation procedure}, sore {Soreness}, cough 
productive of yellow sputum {Productive cough-yellow sputum}, fever {Fever}, chills {Chill}, dyspnea {Dyspnea}, Nausea 
and vomiting {Nausea and vomiting}, poor appetite {Decrease in appetite}, Urine 
output unchanged {Normal urinary stream}, diarrhea {Diarrhea}, sick {Illness}, URI {Upper respiratory infection}, sore throat {Sore throat}, cough {Cough}, resolved {Problem resolved}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Etoh cirrhosis, diagnosed in ___
- hx variceal bleeding in ___, controlled with medications
- hx ascites requiring periodic paracenteses
Hx sepsis from dog bite in ___ c/b multiorgan failure
L4-5 spinal fusion ___ at ___
hx heart murmur, last echo at ___ 2 weeks ago
HTN
Hypercholesterolemia
hx aortic aneurysm, stable for last ___ yrs
.
 

###RESPONSE: Etoh cirrhosis {Alcoholic cirrhosis}, variceal bleeding {Bleeding esophageal varices}, ascites {Ascites}, paracenteses {Abdominal paracentesis}, sepsis {Sepsis}, dog bite {Dog bite - wound}, multiorgan failure {Multiple organ failure}, spinal fusion {Spinal arthrodesis}, heart murmur {Heart murmur}, echo {Echocardiography}, HTN {Hypertensive disorder, systemic arterial}, Hypercholesterolemia {Hypercholesterolemia}, aortic aneurysm {Aortic aneurysm}, stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father had CABG in ___, father and paternal grandmother with 
leukemia, uncle with unknown liver problem. No hx pulmonary 
disease, diabetes, stroke.
.
 

###RESPONSE: CABG {Coronary artery bypass grafting}, leukemia {Leukemia}, liver problem {Liver problem}, pulmonary 
disease {Disorder of lung}, diabetes {Diabetes mellitus}, 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:
VS: T 972, BP 119/72, HR 66, RR 16, O2 sat 98% on RA
Gen: pleasant male, ill appearing, no acute distress, AOx3, NAD
HEENT: anicteric, MM dry, clear nasal discharge
Neck: no JVD
Resp: good air movement bilaterall, scaterred coarse ronchi 
which improve with coughing, no wheezing
CV: RRR, nl s1, s2, III/VI systolic murmur over apex, radiates 
into abdomen
Abd: +BS, soft, ND, NT, no HSM, + ascites, not tense
Extr: warm, no edema, 2+ distal pulses
Neuro: minimal asterixis, moves all exremities, no sensory 
deficits
.
 

###RESPONSE: VS {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, Gen {General examination of patient}, ill appearing {Looks ill}, distress {Distress}, AOx3 {Oriented to person, time and place}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, anicteric {White sclera}, MM dry {Mucous membrane dryness}, clear {Normal breath sounds}, nasal discharge {Nasal discharge}, Neck {Physical examination procedure}, JVD {Jugular venous engorgement}, Resp {Examination of respiratory system}, good {No abnormality detected}, ronchi {Wheeze - rhonchi}, coughing {Cough}, wheezing {Wheezing}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, nl s1, s2 {Heart sounds normal}, murmur {Murmur}, apex {Structure of apex of heart}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, Abd {Examination of abdomen}, BS {Normal bowel sounds}, soft {Abdomen soft}, ND {Swollen abdomen}, NT {Abdominal tenderness}, HSM {Hepatosplenomegaly}, ascites {Ascites}, tense {Shoulder stiff}, Extr {Examination of limb}, warm {Warm skin}, edema {Edema}, 2+ distal pulses {Peripheral pulses normal}, Neuro {Neurological examination}, asterixis {Asterixis}, moves all exremities {Does move all four limbs}, sensory 
deficits {Sensory disability}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
PERTINENT LABS:

___ 04:20PM BLOOD WBC-8.1 RBC-4.06* Hgb-13.9* Hct-42.7 
MCV-105* MCH-34.4* MCHC-32.7 RDW-13.4 Plt ___
___ 05:10AM BLOOD WBC-7.5 RBC-3.32* Hgb-11.1* Hct-33.5* 
MCV-101* MCH-33.6* MCHC-33.3 RDW-14.3 Plt ___
___ 09:20PM BLOOD Neuts-77.3* Lymphs-11.1* Monos-7.5 
Eos-3.9 Baso-0.3
___ 04:20PM BLOOD ___ PTT-38.1* ___
___ 04:20PM BLOOD UreaN-27* Creat-2.8* Na-134 K-5.6* Cl-102 
HCO3-24 AnGap-14
___ 04:20PM BLOOD ALT-37 AST-66* AlkPhos-227* TotBili-2.3*
___ 04:20PM BLOOD TotProt-7.9 Albumin-2.9* Globuln-5.0*
___ 05:45AM BLOOD Hapto-65
___ 04:20PM BLOOD TSH-3.7
___ 04:20PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE 
HBcAb-NEGATIVE IgM HAV-NEGATIVE
___:20PM BLOOD AFP-3.6
___ 08:16PM URINE Color-Amber Appear-Hazy Sp ___
___ 08:16PM URINE Blood-LG Nitrite-NEG Protein-TR 
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG
___ 08:16PM URINE ___ Bacteri-FEW Yeast-NONE 
___ 08:16PM URINE ___ 08:16PM URINE Eos-POSITIVE  
___ 08:12AM URINE Hours-RANDOM UreaN-539 Creat-133 Na-35 
TotProt-48 Prot/Cr-0.4*
.
MICRO DATA:
URINE CX (___): negative
.
STUDIES:
CXR (___): The suggestion of a small region of increased 
radiopacity in the left mid lung at the level of the anterior 
fourth rib, may correspond to a similar abnormality on the 
lateral view projecting over the posterior aspect of the mid 
thoracic spine. This could be a superimposition of normal 
shadows or alternatively a very small focus of consolidation in 
the left lung. Lungs are otherwise clear. There is no pleural 
effusion or evidence of central adenopathy. Oblique chest views 
might be helpful in determining whether the abnormality is real.
.
ABDOMINAL ULTRASOUND WITH DOPPLER (___): 
1. Echogenic micronodular liver with no focal abnormalities 
identified.
2. Reverse flow in the right portal vein up into the left portal 
vein. Patent umbilical vein.
3. Single small gallstone with no signs of cholecystitis.
4. Large amount of ascites.
5. No hydronephrosis.
.
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, 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}, PTT {Partial thromboplastin time, activated}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, TSH {Thyroid stimulating hormone measurement}, HBsAg-NEGATIVE {Hepatitis B surface antigen not detected}, NEGATIVE {No abnormality detected}, NEGATIVE {No abnormality detected}, NEGATIVE {No abnormality detected}, AFP {Alpha-1-Fetoprotein measurement}, URINE {Urine culture}, Color {Color finding}, URINE Blood {Urine blood test}, Ketone {Urinalysis, acetone or ketone bodies measurement}, pH {pH measurement}, URINE {Urine culture}, URINE {Urine culture}, URINE {Urine culture}, POSITIVE {Detected by cytology}, URINE {Urine culture}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, URINE CX {Urine culture}, negative {No abnormality detected}, CXR {Plain chest X-ray}, left {Left lung structure}, lung {Lung structure}, fourth rib {Bone structure of fourth rib}, lateral {Diagnostic radiography of chest, lateral}, thoracic spine {Structure of thoracic vertebral column}, superimposition {Superimposition}, normal {No abnormality detected}, shadows {Shadow}, consolidation {Consolidation}, left lung {Left lung structure}, Lungs {Lung structure}, clear {Normal breath sounds}, pleural 
effusion {Pleural effusion}, adenopathy {Lymphadenopathy}, Oblique {Fracture, oblique}, chest {Plain chest X-ray}, abnormality {No abnormality detected}, ABDOMINAL ULTRASOUND {Ultrasonography of abdomen}, liver {Liver structure}, abnormalities {No abnormality detected}, right portal vein {Structure of right main branch of portal vein}, left portal 
vein {Structure of left main branch of portal vein}, umbilical vein {Structure of umbilical vein}, gallstone {Gallbladder calculus}, signs {Sign}, cholecystitis {Cholecystitis}, ascites {Ascites}, hydronephrosis {Hydronephrosis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 EtOH cirrhosis admitted with elevated 
creatinine.
.
# Acute renal failure - Creatinine was 3.1 on admission. No 
known history of kidney disease and PCP records showed that his 
creatinine had been 1.1 a few months ago. Diuretics were held. 
He received albumin and a fluid challenge overnight when he was 
admitted without any significant effect. Started midodrine and 
octreotide as well as daily albumin in case hepatorenal was 
playing a role. No new meds. No signs of obstruction and no 
hydronephrosis on ultrasound. Renal was consulted. Urine 
sediment with acanthocytes and possibly a couple red cell casts. 
UA with small amount of hematuria ___ RBC, ___ RBC on 
repeat). The renal team felt that his renal failure was likely 
due to renal hypoperfusion (could even be HRS) from combination 
of cirrhosis and aortic stenosis, with multiple recent large 
volume paracenteses. ___ also have underlying IgA nephropathy 
given proteinuria. Hep B/C serologies negative so not likely a 
GN related to those. Creatinine remained stable and he was 
discharged with the plan to follow-up with Renal as an 
outpatient for biopsy and further evaluation.
.
# Cough - Association with sore throat, rhinorrhea, similar sick 
contacts symptoms made a viral URI most likely. He remained 
afebrile without leukocytosis. A very small opacity in left lung 
was noted on CXR however given bacterial pneumonia was felt 
unlikely, he was not treated with antibiotics.
.
# Alcoholic Cirrhosis - Complicated by varices and recurrent 
ascites requiring large volume paracentesis. MELD 25. Most 
recent paracentesis on ___ with 9L removed, did not receive 
albumin. Diuretics were held as above for renal failure. 
Continued nadolol, MVI, folate. Discontinued lactulose as 
patient has no history of encephalopathy.
.
# HTN - Continued amlodipine.
.
# Hypercholesterolemia - Continued statin.
.
# Full code
 

###RESPONSE: EtOH cirrhosis {Alcoholic cirrhosis}, elevated 
creatinine {Serum creatinine above reference range}, Acute renal failure {Acute kidney injury}, Creatinine {Creatinine measurement}, creatinine {Creatinine measurement}, Diuretics {Diuretic therapy}, received albumin {Administration of albumin}, fluid {Administration of intravenous fluids}, albumin {Administration of albumin}, signs {Sign}, obstruction {Obstruction}, hydronephrosis {Hydronephrosis}, ultrasound {Ultrasonography}, Renal {Kidney structure}, Urine {Urine culture}, cell casts {Cellular casts}, hematuria {Blood in urine}, RBC {Red blood cell count}, RBC {Red blood cell count}, renal failure {Renal failure syndrome}, renal {Kidney structure}, HRS {Hepatorenal syndrome}, cirrhosis {Cirrhosis of liver}, aortic stenosis {Aortic valve stenosis}, paracenteses {Abdominal paracentesis}, IgA nephropathy {Immunoglobulin A nephropathy}, proteinuria {Proteinuria}, Hep B {Viral hepatitis type B}, negative {No abnormality detected}, Creatinine {Creatinine measurement}, stable {Patient's condition stable}, biopsy {Biopsy}, evaluation {Evaluation procedure}, Cough {Cough}, sore throat {Sore throat}, rhinorrhea {Nasal discharge}, sick {Illness}, viral {Viral disease}, URI {Upper respiratory infection}, afebrile {Fever}, leukocytosis {Leukocytosis}, opacity {Abnormally opaque structure}, left lung {Left lung structure}, CXR {Plain chest X-ray}, bacterial pneumonia {Bacterial pneumonia}, treated with antibiotics {Antibiotic therapy}, Alcoholic Cirrhosis {Alcoholic cirrhosis}, varices {Esophageal varices}, ascites {Ascites}, paracentesis {Abdominal paracentesis}, paracentesis {Centesis}, removed {Drainage of ascites}, albumin {Administration of albumin}, Diuretics {Diuretic therapy}, renal failure {Renal failure syndrome}, encephalopathy {Disorder of brain}, HTN {Hypertensive disorder, systemic arterial}, Hypercholesterolemia {Hypercholesterolemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Amlodipine 5mg daily
Nadolol 80mg daily
Protonix 40mg bid
Folic acid 1mg daily
Lipitor 20mg daily
Lactulose 3tsp BID
Spironolactone 50mg BID
.

###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: vicodin - itchy
.
 
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

2. Nadolol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).  
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
6. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).  
.
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary: Acute renal failure
.
Secondary: EtOH cirrhosis, hypertension, hypercholesterolemia
.
 
Discharge Condition:
Stable.
.
 

###RESPONSE: Acute renal failure {Acute kidney injury}, EtOH cirrhosis {Alcoholic cirrhosis}, hypertension {Hypertensive disorder, systemic arterial}, hypercholesterolemia {Hypercholesterolemia}, Stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted to the hospital for evaluation and treatment 
of kidney failure. Several labs were sent to work up your kidney 
failure; these were still pending at time of discharge. You will 
need to have a biopsy of your kidney to help make a diagnosis. 
.
You will have to follow up with the nephrologists next week for 
your biopsy. 
.
If you develop a tense swollen abdomen, confusion, fevers>101, 
shortness of breath, chest pain, or other symptoms that are 
concerning to you, you should return to the emergency room.
.
 

###RESPONSE: evaluation {Evaluation procedure}, kidney failure {Renal failure syndrome}, kidney 
failure {Renal failure syndrome}, biopsy {Biopsy}, biopsy {Biopsy}, tense {Feeling tense}, swollen abdomen {Swollen abdomen}, confusion {Clouded consciousness}, fevers {Fever}, shortness of breath {Dyspnea}, chest pain {Chest pain}, return to the emergency room {Emergency treatment management}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Sulfa (Sulfonamide Antibiotics) / Ciprofloxacin / adhesive tape 
/ Floxin / Neurontin / generic brand meds
 
Attending: ___.
 
Chief Complaint:
left knee OA
 
Major Surgical or Invasive Procedure:
left knee replacement ___, ___

 

###RESPONSE: Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, Ciprofloxacin {Allergy to ciprofloxacin}, adhesive tape {Allergy to adhesive agent}, left knee OA {Osteoarthritis of left knee joint}, left knee replacement {Total replacement of left knee joint}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ year old female with left knee OA s/p L TKR.
 

###RESPONSE: left knee OA {Osteoarthritis of left knee joint}, L TKR {Total replacement of left knee joint}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
BMI 31.68, thyroid dz, dyslipidemia, eczema
Bursitis
Low back pain                                                   
Arthroscopy in ___ with Dr. ___ ___ 
 
___ History:
___

###RESPONSE: thyroid dz {Disorder of thyroid gland}, dyslipidemia {Dyslipidemia}, eczema {Eczema}, Bursitis {Bursitis}, Low back pain {Low back pain}, Arthroscopy {Arthroscopy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Non-contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Well appearing in no acute distress  
 Afebrile with stable vital signs  
 Pain well-controlled  
 Respiratory: CTAB  
 Cardiovascular: RRR  
 Gastrointestinal: NT/ND  
 Genitourinary: Voiding independently  
 Neurologic: Intact with no focal deficits  
 Psychiatric: Pleasant, A&O x3  
 Musculoskeletal Lower Extremity:  
 * Incision healing well with staples
 * Thigh full but soft  
 * No calf tenderness  
 * ___ strength  
 * SILT, NVI distally  
 * Toes warm
 

###RESPONSE: Physical Exam {Physical examination procedure}, Well appearing {Well cared for appearance}, distress {Distress}, Afebrile {Fever}, stable vital signs {Normal vital signs}, Pain {Pain}, Respiratory {Examination of respiratory system}, CTAB {Normal breath sounds}, Cardiovascular {Cardiovascular physical examination}, RRR {Normal heart rate}, Gastrointestinal {Examination of digestive system}, NT {Abdominal tenderness}, ND {Swollen abdomen}, Gen {General examination of patient}, Voiding independently {Normal micturition}, Neurologic {Neurological examination}, no focal deficits {Normal nervous system function}, O x3 {Oriented to person, time and place}, Musculoskeletal {Musculoskeletal system physical examination}, Lower Extremity {Lower limb structure}, Incision {Surgical incision wound}, healing well {Wound healing well}, Thigh {Thigh structure}, soft {Abdomen soft}, tenderness {Tenderness}, SILT {Light touch sensation present}, NVI distally {Normal peripheral neurovascular function}, Toes {Structure of all toes}, warm {Warm skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:03AM BLOOD Hgb-8.4* Hct-26.6*
___ 06:07AM BLOOD Hgb-9.5* Hct-29.3*
___ 06:03AM BLOOD Creat-0.6
___ 06:07AM BLOOD Creat-0.6
 

###RESPONSE: Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, Creat {Creatinine measurement}, Creat {Creatinine 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:
The patient was admitted to the orthopedic surgery service and 
was taken to the operating room for above described procedure. 
Please see separately dictated operative report for details. The 
surgery was uncomplicated and the patient tolerated the 
procedure well. Patient received perioperative IV antibiotics.

Postoperative course was remarkable for the following:
POD #0 overnight, patient had high drain output and knee was 
flexed with drain clamped for 4 hours with appropriate effect.
POD #1, drain was discontinued. Dressing was changed per patient 
request as she felt she was developing a rash. No rash noted.
POD #2, patient complained of itchiness in morning.  A dose of 
Benadryl was given and the itchiness resolved. Patient cleared 
___ without further issues.

Otherwise, pain was controlled with a combination of IV and oral 
pain medications.  The patient received Aspirin 325 mg twice 
daily for DVT prophylaxis starting on the morning of POD#1.  The 
surgical dressing was changed on POD#2 and the surgical incision 
was found to be clean and intact without erythema or abnormal 
drainage. The patient was seen daily by physical therapy. Labs 
were checked throughout the hospital course and repleted 
accordingly. At the time of discharge the patient was tolerating 
a regular diet and feeling well.  The patient was afebrile with 
stable vital signs.  The patient's hematocrit was acceptable and 
pain was adequately controlled on an oral regimen. The operative 
extremity was neurovascularly intact and the wound was benign. 

The patient's weight-bearing status is weight bearing as 
tolerated on the operative extremity with no range of motion 
restrictions.
  
Ms. ___ is discharged to home with services in stable 
condition.
 

###RESPONSE: admitted to the orthopedic surgery service {Admission by orthopedic surgeon}, procedure {Surgical procedure}, operative {Surgical procedure}, surgery {Surgical procedure}, procedure {Surgical procedure}, IV antibiotics {Intravenous antibiotic therapy}, Postoperative course {Postoperative state}, drain {Wound discharge}, knee {Structure of left knee region}, drain clamped {Clamping of drain}, drain was discontinued {Removal of drain}, Dressing was changed {Change of dressing}, rash {Eruption of skin}, rash {Eruption of skin}, itchiness {Itching}, itchiness {Itching}, pain was controlled {Demonstrates adequate pain control}, IV {Intravenous therapy}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, Aspirin {Administration of aspirin}, DVT prophylaxis {Prevention of deep vein thrombosis}, surgical dressing was changed {Change of dressing}, surgical incision {Surgical incision wound}, intact {Intact skin}, erythema {Erythema}, drainage {Wound discharge}, physical therapy {Physical therapy procedure}, regular diet {Normal diet}, feeling well {Well in self}, afebrile {Fever}, stable vital signs {Normal vital signs}, hematocrit was acceptable {Stable hematocrit}, pain was adequately controlled {Demonstrates adequate pain control}, oral {Administration of drug or medicament via oral route}, regimen {Therapeutic regimen}, operative {Operative site}, extremity {All extremities}, neurovascularly intact {Normal peripheral neurovascular function}, wound {Wound}, weight-bearing {Weight-bearing}, weight bearing {Weight-bearing}, operative {Surgical procedure}, extremity {Limb structure}, stable 
condition {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
1. BuPROPion (Sustained Release) 450 mg PO QHS 
2. ClonazePAM 1 mg PO BID 
3. Propranolol 20 mg PO BID 
4. Atorvastatin 40 mg PO QPM 
5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild 
6. FLUoxetine 60 mg PO QHS 
7. Levothyroxine Sodium 75-150 mcg PO DAILY 

 
Discharge Medications:
1.  Acetaminophen 1000 mg PO Q8H  
2.  Aspirin EC 325 mg PO BID  
3.  Docusate Sodium 100 mg PO BID  
4.  OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - 
Moderate 
5.  Pantoprazole 40 mg PO Q24H 
Continue while on 4-week course of Aspirin 325 mg twice daily.  
6.  Senna 8.6 mg PO BID  
7.  Atorvastatin 40 mg PO QPM  
8.  BuPROPion (Sustained Release) 450 mg PO QHS  
9.  ClonazePAM 1 mg PO BID  
10.  FLUoxetine 60 mg PO QHS  
11.  Levothyroxine Sodium 75-150 mcg PO DAILY  
12.  Propranolol 20 mg PO BID  
13. HELD- Ibuprofen 800 mg PO Q8H:PRN Pain - Mild  This 
medication was held. Do not restart Ibuprofen until you've been 
cleared by your surgeon

 

###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:
left knee OA

 
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}, left knee OA {Osteoarthritis of left knee joint}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, 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:
1. Please return to the emergency department or notify your 
physician if you experience any of the following: severe pain 
not relieved by medication, increased swelling, decreased 
sensation, difficulty with movement, fevers greater than 101.5, 
shaking chills, increasing redness or drainage from the incision 
site, chest pain, shortness of breath or any other concerns.

2. Please follow up with your primary physician regarding this 
admission and any new medications and refills. 

3. Resume your home medications unless otherwise instructed.

4. You have been given medications for pain control. Please do 
not drive, operate heavy machinery, or drink alcohol while 
taking these medications. As your pain decreases, take fewer 
tablets and increase the time between doses. This medication can 
cause constipation, so you should drink plenty of water daily 
and take a stool softener (such as Colace) as needed to prevent 
this side effect.  Call your surgeons office 3 days before you 
are out of medication so that it can be refilled.  These 
medications cannot be called into your pharmacy and must be 
picked up in the clinic or mailed to your house.  Please allow 
an extra 2 days if you would like your medication mailed to your 
home.

5. You may not drive a car until cleared to do so by your 
surgeon.

6. Please call your surgeon's office to schedule or confirm your 
follow-up appointment.

7. SWELLING: Ice the operative joint 20 minutes at a time, 
especially after activity or physical therapy. Do not place ice 
directly on the skin. You may wrap the knee with an ace bandage 
for added compression. Please DO NOT take any non-steroidal 
anti-inflammatory medications (NSAIDs such as Celebrex, 
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by 
your physician.

8. ANTICOAGULATION: Please continue your Aspirin 325 mg twice 
daily for four (4) weeks to help prevent deep vein thrombosis 
(blood clots).  Continue Pantoprazole daily while on Aspirin to 
prevent GI upset (x 4 weeks). If you were taking Aspirin prior 
to your surgery, take it at 325 mg twice daily until the end of 
the 4 weeks, then you can go back to your normal dosing.
 
9. WOUND CARE: Please keep your incision clean and dry. It is 
okay to shower five days after surgery but no tub baths, 
swimming, or submerging your incision until after your four (4) 
week checkup. Please place a dry sterile dressing on the wound 
each day if there is drainage, otherwise leave it open to air. 
Check wound regularly for signs of infection such as redness or 
thick yellow drainage. Staples will be removed at your follow-up 
appointment in two weeks.

10. ___ (once at home): Home ___, dressing changes as 
instructed, wound checks.

11. ACTIVITY: Weight bearing as tolerated on the operative 
extremity. Mobilize.  ROM as tolerated. No strenuous exercise or 
heavy lifting until follow up appointment.
Physical Therapy:
WBAT LLE
ROMAT
Wean assistive device as able (i.e. 2 crutches or walker)
Mobilize frequently 
Treatments Frequency:
daily dressing changes as needed for drainage
wound checks daily
ice
staple removal and replace with steri-strips at follow up visit 
in clinic
 

###RESPONSE: severe pain {Severe pain}, medication {Administration of drug or medicament}, swelling {Swelling}, decreased 
sensation {Abnormal sensation}, difficulty with movement {Difficulty moving}, fevers {Fever}, shaking {Tremor}, chills {Chill}, redness {Redness of skin over lesion}, drainage {Discharge}, incision 
site {Surgical incision wound}, chest pain {Chest pain}, shortness of breath {Dyspnea}, primary physician {Primary care management}, medications {Prescription of drug}, medications {Prescription of drug}, medications {Prescription of drug}, pain control {Pain control}, while 
taking these medications {Patient medication education}, pain {Pain}, medication can 
cause {Patient medication education}, constipation {Constipation}, take a stool softener {Administration of laxative}, side effect {Medication side effects present}, medication so that it can be refilled {Medication prefill education}, medications {Prescription of drug}, medication {Prescription of drug}, u may not drive {Functional activity education}, SWELLING {Swelling}, Ice {Application of ice}, operative joint {Operative site}, activity {Functional activity education}, physical therapy {Physical therapy procedure}, Do not place {Wound treatment education}, ice {Application of ice}, skin {Skin structure}, knee {Structure of left knee region}, compression {Compression}, DO NOT take {Patient medication education}, non-steroidal 
anti-inflammatory medications {Non-steroidal anti-inflammatory agent therapy}, ANTICOAGULATION {Anticoagulant therapy}, Aspirin {Administration of aspirin}, prevent deep vein thrombosis {Prevention of deep vein thrombosis}, blood clots {Blood clot}, Aspirin {Administration of aspirin}, GI upset {Gastrointestinal irritation}, surgery {Surgical procedure}, WOUND CARE {Wound care}, incision {Surgical incision wound}, shower {Able to shower self}, after surgery {Postoperative state}, incision {Surgical incision wound}, place a dry sterile dressing {Application of dressing}, wound {Surgical incision wound}, drainage {Wound discharge}, wound {Surgical incision wound}, signs of infection {Monitoring for signs and symptoms of infection}, redness {Redness of skin over lesion}, drainage {Wound discharge}, Staples will be removed {Removal of staples}, dressing changes {Change of dressing}, wound checks {Wound assessment}, ACTIVITY {Functional activity education}, Weight bearing {Weight-bearing}, operative {Operative site}, extremity {Limb structure}, Mobilize {Mobilizing exercises}, ROM {Range of motion activity}, exercise {Exercises}, lifting {Does lift}, Physical Therapy {Physical therapy procedure}, LLE {Structure of left lower limb}, ROM {Range of motion activity}, Mobilize {Does mobilize}, Treatments Frequency {Wound treatment education}, dressing changes {Change of dressing}, drainage {Wound discharge}, wound checks {Wound assessment}, ice {Application of ice}, staple removal {Removal of staples}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: CARDIOTHORACIC
 

###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:
Type A aortic dissection involving b/l carotids and severe
neurologic deficits,
 
Major Surgical or Invasive Procedure:
none
 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Type A aortic dissection {Dissection of proximal aorta}, carotids {Carotid artery structure}, neurologic deficits {Neurological deficit}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ found down at home approximately 2 hours prior to
presentation, EMS called immediately by wife.  EMS noted unequal
pulses in his upper extremities during transport.  Upon arrival,
he was found to be minimally responsive with a GCS of 5, with a
fixed and dilated right pupil and posturing movements of his 
left
arm.  He was intubated and underwent a CT of the head, which was
negative, and then a CTA of the torso with dissection protocol. 
This demonstrated an aortic dissection from the root into the
abdomen with involvement of the brachiocephalic artery as well 
as
the left carotid.Cardiac surgery was consulted for possible 
dissection repair.

 

###RESPONSE: unequal
pulses {Unequal pulse}, upper extremities {Upper limb structure}, GCS of 5 {Glasgow coma scale, 5}, fixed and dilated right pupil {Fixed dilatation of right pupil}, posturing movements {Abnormal posture}, left
arm {Structure of left upper limb}, intubated {Intubation}, CT of the head {Computed tomography of head}, negative {No abnormality detected}, CTA {Computed tomography angiography of head with contrast}, torso {Trunk structure}, dissection protocol {Dissection procedure}, aortic dissection {Dissection of aorta}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, brachiocephalic artery {Structure of brachiocephalic artery}, left carotid {Structure of left carotid artery}, Cardiac surgery {Operation on heart}, dissection {Dissection of aorta}, repair {Surgical repair}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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, HTN, lipids, BPH

 

###RESPONSE: CAD {Coronary arteriosclerosis}, HTN {Hypertensive disorder, systemic arterial}, BPH {Benign prostatic hyperplasia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
unknown
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
PE in ED:
Pulse: Resp:intubated  O2 sat:100%
B/P  ___  HR 44 (SR)

 

###RESPONSE: Pulse {Finding of pulse rate}, Resp {Examination of respiratory system}, intubated {Intubation}, O2 sat {Oxygen saturation measurement}, B/P {Blood pressure finding}, HR {Finding of heart rate}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:01AM BLOOD WBC-10.7 RBC-4.89 Hgb-14.5 Hct-43.8 
MCV-90 MCH-29.6 MCHC-33.0 RDW-13.7 Plt ___
___ 06:01AM BLOOD ___ PTT-24.7* ___
___ 06:01AM BLOOD Glucose-178* UreaN-18 Creat-1.0 Na-143 
K-4.1 Cl-108 HCO3-21* AnGap-18
    ___ ___ M  ___  ___ 
 
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study 
Date of ___ 6:17 AM 
 
  
___   ___ 6:17 AM 
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD & PELVIS   Clip # 
___   
Reason: aortic dissection?  
Contrast: OMNIPAQUE Amt: 80 
 

 
UNDERLYING MEDICAL CONDITION: 
   ___ with decreased pulse R hand, diaphoretic, fall, altered  
REASON FOR THIS EXAMINATION: 
   aortic dissection?  
CONTRAINDICATIONS FOR IV CONTRAST: 
   None. 

 
 
Wet Read: SJBj SAT ___ 7:41 AM 
Extensive type A aortic dissection extending from the aortic 
root to the 
distal abdominal aorta. Dissection extends up left 
bracheocephalic and left 
common carotid. RCC extension cannot be assessed. Diffuse large 
bowel wall 
thickening raises the possibility of ischemic bowel even though 
the ___ 
appears patent from the true lumen. 
  

 
Wet Read Audit # 1  
Wet Read Audit # 2 SJBj SAT ___ 6:46 AM 
Extensive type A aortic dissection extending from the aortic 
root to the 
distal abdominal aorta. Dissection extends up both carotids.  
  
Wet Read Audit # 3 SJBj SAT ___ 7:40 AM 
Extensive type A aortic dissection extending from the aortic 
root to the 
distal abdominal aorta. Dissection extends up left 
bracheocephalic and left 
common carotid. RCC extension cannot be assessed.  
  

 
Final Report 
INDICATION: ___ man with collapse, decreased right hand 
pulse, 
question dissection. 
  
COMPARISON: None. 
  
TECHNIQUE: MDCT data were acquired through the chest, abdomen 
and pelvis 
after the administration of 80 cc of IV contrast. Images were 
displayed in 
multiple planes. 
  
FINDINGS: The exam is limited by suboptimal contrast bolus 
timing. 
  
There is an extensive type-A aortic dissection extending from 
the aortic root, 
to the descending and abdominal aorta, to the level of the 
infrarenal 
abdominal aorta. Evaluation for carotid extension is severely 
limited by poor 
contrast bolus timing and streak artifact through the neck. The 
dissection at 
least extends into the proximal left subclavian and into the 
proximal right 
brachiocephalic artery. Approximately 1.2 cm distal to the right 

brachiocephalic origin, there is a 1.3 x 0.6 cm outpouching 
(300b:18) which 
may represent a pseudoaneurysm. Extension into the right common 
carotid 
cannot be assessed. The celiac, SMA and right and left renal 
arteries 
originate from the true lumen. The ___ from the true 
lumen. 
  
There is no hemopericardium. There is fat stranding within the 
mediastinum 
without frank extravasation. Numerous chest wall collateral 
vessels are 
noted.  
  
CHEST: There is dependent atelectasis plus aspiration at both 
lung bases.  
The remainder of the lungs are clear. The airways are patent to 
the 
subsegmental level. An endotracheal tube ends in the upper 
trachea.  
  
ABDOMEN: The liver parenchyma is homogeneous. The gallbladder is 
thin-walled 
and not distended. The pancreas, spleen, and adrenal glands are 
unremarkable. 
The kidneys enhance symmetrically. The stomach, small and large 
bowel are of 
normal caliber and appearance. 
  
PELVIS: Diffuse diverticulosis is seen throughout the colon. 
There is a 
right inguinal hernia (2:35) containing loops of small bowel 
with mild 
fecalization, but no wall thickening or adjacent stranding. 
There is no free 
pelvic fluid. There is no inguinal or pelvic adenopathy. The 
appendix is 
normal. 
  
BONE WINDOWS: There are moderate multilevel degenerative changes 
throughout 
the thoracolumbar spine. No concerning lytic or sclerotic 
lesions. 
  
IMPRESSION: 
  
1. Extensive type-A dissection extending from the aortic root to 
the 
infrarenal abdominal aorta. The dissection extends into the 
proximal left 
subclavian and right brachiocephalic arteries. There is a small 
thrombosed 
pseudoaneurysm in the proximal right brachiocephalic artery. 
Evaluation for 
extension into the common carotid arteries is markedly limited 
by poor 
contrast bolus timing. Should further evaluation of the carotid 
arteries be 
necessary, neck CTA could be performed. 
  
2. Right inguinal hernia containing a loop of fecalized ileum 
without 
inflammation or wall thickening. 
  
3. Dependent atelectasis versus possible aspiration. 
  
4. Haziness of the mediastinal fat may be inflammatory although 
hematoma is 
not excluded. 
  
Findings were urgently conveyed to the ER physicians by Dr. ___ 
___ 
immediately after the completion of the scan by telephone on the 
morning of 
___ and discussed with ___ on the morning of 
___ @ 
9:55 am by Dr. ___. 
  
  
  
The study and the report were reviewed by the staff radiologist. 

  
___. ___ 
___. ___ 
___: SAT ___ 9:55 AM 
 
  Imaging Lab 
 
There is no report history available for viewing. 
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, 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}, CORONARY {Atherosclerosis of coronary artery}, ABD {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, PELVIS {Structure of pelvis}, aortic dissection {Dissection of aorta}, pulse {Pulse finding}, R hand {Structure of right hand}, diaphoretic {Excessive sweating}, fall {Falls}, aortic dissection {Dissection of aorta}, AST {Aspartate aminotransferase measurement}, type A aortic dissection {Dissection of proximal aorta}, aortic 
root {Supraaortic valve area structure}, abdominal aorta {Abdominal aorta structure}, Dissection {Dissection of artery}, left 
bracheocephalic {Structure of left brachial artery}, left 
common carotid {Left common carotid artery structure}, RCC {Renal cell carcinoma}, large 
bowel wall {Structure of wall of large intestine}, thickening {Increased thickness}, ischemic bowel {Vascular insufficiency of intestine}, lumen {Structure of lumen of body system}, type A aortic dissection {Dissection of proximal aorta}, aortic 
root {Supraaortic valve area structure}, abdominal aorta {Abdominal aorta structure}, Dissection {Dissection of artery}, carotids {Carotid artery structure}, type A aortic dissection {Dissection of proximal aorta}, aortic 
root {Supraaortic valve area structure}, abdominal aorta {Abdominal aorta structure}, Dissection {Dissection of artery}, left 
bracheocephalic {Structure of left brachial artery}, left 
common carotid {Left common carotid artery structure}, RCC {Renal cell carcinoma}, collapse {Collapsing pulse}, right hand {Structure of right hand}, pulse {Pulse finding}, dissection {Dissection of artery}, chest, abdomen 
and pelvis {Chest and/or abdomen and/or pelvis structure}, exam {Physical examination procedure}, type-A aortic dissection {Dissection of proximal aorta}, aortic root {Supraaortic valve area structure}, descending {Descending aorta structure}, abdominal aorta {Abdominal aorta structure}, infrarenal 
abdominal aorta {Structure of infrarenal aorta}, Evaluation {Evaluation procedure}, carotid {Carotid artery structure}, artifact {Artifact}, neck {Neck structure}, dissection {Dissection of artery}, left subclavian {Structure of left subclavian artery}, right {Structure of right main branch of portal vein}, brachiocephalic artery {Structure of brachiocephalic artery}, right {Structure of right main branch of portal vein}, brachiocephalic {Structure of brachiocephalic artery}, pseudoaneurysm {Pseudoaneurysm}, right common 
carotid {Right common carotid artery structure}, celiac {Structure of celiac artery}, SMA {Superior mesenteric artery structure}, right {Structure of right renal artery}, left renal 
arteries {Structure of left renal artery}, lumen {Structure of lumen of body system}, lumen {Structure of lumen of body system}, hemopericardium {Hemopericardium}, fat {Structure of adipose tissue}, stranding {Density above reference range}, mediastinum {Mediastinal structure}, extravasation {Extravasation}, chest wall {Chest wall structure}, vessels {Blood vessel structure}, CHEST {Plain chest X-ray}, atelectasis {Atelectasis}, aspiration {Pulmonary aspiration}, both 
lung {Both lungs}, bases {Structure of base of lung}, lungs are clear {Normal lung}, airways {Airway structure}, endotracheal tube {Insertion of endotracheal tube}, trachea {Tracheal structure}, ABDOMEN {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, liver parenchyma {Structure of parenchyma of liver}, gallbladder {Gallbladder structure}, distended {Swollen abdomen}, pancreas {Pancreatic structure}, spleen {Splenic structure}, adrenal glands {Bilateral adrenal glands}, unremarkable {No abnormality detected}, kidneys {Kidney structure}, stomach {Stomach structure}, small {Structure of small intestine}, large 
bowel {Structure of large intestine}, normal {No abnormality detected}, PELVIS {Structure of pelvis}, diverticulosis {Diverticulosis of colon}, colon {Colon structure}, right inguinal hernia {Right inguinal hernia}, small bowel {Structure of small intestine}, wall {Colon wall structure}, thickening {Increased thickness}, pelvic {Structure of pelvis}, inguinal {Inguinal lymphadenopathy}, pelvic adenopathy {Pelvic lymphadenopathy}, appendix {Appendix structure}, normal {No abnormality detected}, BONE {Bone structure}, degenerative changes {Degeneration of spine}, thoracolumbar {Structure of thoracic and/or lumbar region of back}, spine {Structure of vertebral column}, lytic {Lysis}, sclerotic {Sclerosis}, lesions {Lesion}, type-A dissection {Dissection of proximal aorta}, aortic root {Supraaortic valve area structure}, infrarenal {Structure of infrarenal aorta}, abdominal aorta {Abdominal aorta structure}, dissection {Dissection of artery}, left 
subclavian {Structure of left subclavian artery}, right {Structure of right main branch of portal vein}, brachiocephalic arteries {Structure of brachiocephalic artery}, thrombosed {Thrombus}, pseudoaneurysm {Pseudoaneurysm}, right {Structure of right main branch of portal vein}, brachiocephalic artery {Structure of brachiocephalic artery}, common carotid arteries {Common carotid artery structure}, evaluation {Evaluation procedure}, carotid 
arteries {Carotid artery structure}, Right inguinal hernia {Right inguinal hernia}, ileum {Ileal structure}, inflammation {Inflammatory disorder}, wall {Colon wall structure}, thickening {Increased thickness}, atelectasis {Atelectasis}, aspiration {Pulmonary aspiration}, mediastinal fat {Structure of pericardial fat}, inflammatory {Inflammatory disorder}, hematoma {Hematoma}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 presents with abdominal pain secondary to back pain 
and rapidly deteriorating mental status with left hemi-neglect. 
He was intubated for airway protection. CT of the head was 
negative, CTA of the chest showing diffuse type A dissection. 
Stat consult to cardiac surgery and vascular surgery was done.
The family discussed with ___ risks of surgery. The 
family were in agreement at having the pt extubated and allowing 
him to die, knowing that it is what Mr. ___ would want; they 
did not want to wait until his children, who live out of state, 
arrive. Ms. ___ does not want an organ donation or
an autopsy. ___ was taken off the ventilator and shortly 
thereafter pronounced dead. The appropriate post mortem agencies 
were contacted per hospital policy.
 

###RESPONSE: abdominal pain {Abdominal pain}, back pain {Backache}, deteriorating {Patient's condition deteriorating}, mental status {Neurological mental status determination}, hemi-neglect {Hemi-neglect}, intubated {Intubation}, airway {Airway structure}, CT of the head {Computed tomography of head}, negative {No abnormality detected}, CTA of the chest {Computed tomography of chest}, type A dissection {Dissection of proximal aorta}, cardiac surgery {Operation on heart}, vascular surgery {Vascular surgery procedure}, surgery {Surgical procedure}, extubated {Removal of endotracheal tube}, autopsy {Autopsy examination}, dead {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: Medications on Admission:
Amlodipine 10'
Isosorbinde mononitrate 100'
Metoprolol 50''
Nitroglycerin PRN
Pravastatin 40'
Tamsulosin 0.8'
ASA 325'

 
Discharge Medications:
none
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Expired
 
Discharge Diagnosis:
Type A dissection
 
Discharge Condition:
expired
 
                             ___ MD ___
 
Completed by: ___

###RESPONSE: Type A dissection {Dissection of proximal aorta}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Trauma activation from 5 foot fall 
 
Major Surgical or Invasive Procedure:
___ Exploratory laparotomy and splenectomy

 

###RESPONSE: Penicillins {Allergy to penicillin}, Trauma {Traumatic injury}, fall {Falls}, Exploratory laparotomy {Exploratory laparotomy}, splenectomy {Splenectomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
ACS is consulted to evaluate this ___ man status post
witnessed 5 foot fall into ___ pit presenting with multiple PL
Left sided rib fx, hemoperitoneum w/ liver, spleen, and left
kidney lacerations. 

Per documentation following his fall he was pulled out by
bystanders and ambulatory on scene per EMS. At that time patient
unable to complete full interview secondary to intoxication with
ETOH, benzos.  Patient states he is drinking, may have used 
drugs
but he is not sure. Also endorses epigastric pain. States he has
history of hepatitis C, no other medical problems.

On evaluation, patient HDS. GCS 15. Abdomen soft, tender to
palpation to LUQ. Non-peritoneal.

 

###RESPONSE: fall {Falls}, Left sided {Bone structure of left rib}, rib fx {Fracture of rib}, hemoperitoneum {Nontraumatic hemoperitoneum}, liver {Laceration of liver}, spleen {Laceration of spleen}, left
kidney lacerations {Laceration of left kidney}, fall {Falls}, intoxication with
ETOH {Alcohol intoxication}, benzos {Benzodiazepine intoxication}, epigastric pain {Epigastric pain}, hepatitis C {Viral hepatitis type C}, evaluation {Evaluation procedure}, Abdomen soft {Abdomen soft}, tender to
palpation to LUQ {Tenderness of left upper quadrant of abdomen}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
PMH: 
Hep C - untreated 
Depression/anxiety
History of polysubstance abuse
Right PTX s/p gunshot wound to right chest ___ 

PSH: 
Right chest tube placement ___
Laceration repair back, posterior leg s/p stabbing 

 

###RESPONSE: Hep C {Viral hepatitis type C}, Depression {Depressive disorder}, anxiety {Anxiety}, polysubstance abuse {Polysubstance abuse}, Right PTX {Right pneumothorax}, gunshot wound {Gunshot wound}, right chest {Right thorax structure}, Right {Right thorax structure}, chest tube placement {Insertion of pleural tube drain}, Laceration {Laceration}, repair {Surgical repair}, back {Structure of posterior surface of lower leg}, posterior leg {Structure of posterior surface of lower leg}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
FH: 
No known family history
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VS:  
General : In no acute distress
Cardio: Normal S1, S2
Pulmonary: CTAB
Abdomen: Soft, mildy distended, mild LUQ tenderness, midline 
closed with staples 
Extremities: no edema, no erythema

 

###RESPONSE: VS {Vital signs finding}, General {General examination of patient}, distress {Distress}, Cardio {Cardiovascular physical examination}, S2 {Normal second heart sound, S>2<}, Pulm {Examination of respiratory system}, CTAB {Normal breath sounds}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, distended {Swollen abdomen}, mild {Symptom mild}, tenderness {Tenderness}, Extremities {Examination of limb}, edema {Edema}, erythema {Erythema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 07:00AM BLOOD WBC-11.6* RBC-2.86* Hgb-8.5* Hct-25.9* 
MCV-91 MCH-29.7 MCHC-32.8 RDW-13.9 RDWSD-45.4 Plt ___
___ 06:56AM BLOOD WBC-10.7* RBC-2.74* Hgb-8.4* Hct-25.0* 
MCV-91 MCH-30.7 MCHC-33.6 RDW-13.9 RDWSD-46.1 Plt ___
___ 05:44PM BLOOD WBC-11.7* RBC-2.64* Hgb-8.0* Hct-24.2* 
MCV-92 MCH-30.3 MCHC-33.1 RDW-14.0 RDWSD-46.5* Plt ___
___ 06:50AM BLOOD WBC-12.9* RBC-2.23* Hgb-6.9* Hct-21.0* 
MCV-94 MCH-30.9 MCHC-32.9 RDW-13.7 RDWSD-46.4* Plt ___
___ 06:42AM BLOOD WBC-15.9* RBC-2.41* Hgb-7.4* Hct-22.8* 
MCV-95 MCH-30.7 MCHC-32.5 RDW-14.1 RDWSD-47.8* Plt ___
___ 01:59AM BLOOD WBC-15.8* RBC-2.45* Hgb-7.6* Hct-22.4* 
MCV-91 MCH-31.0 MCHC-33.9 RDW-14.0 RDWSD-46.8* Plt ___
___ 07:25AM BLOOD WBC-15.3* RBC-2.62* Hgb-8.1* Hct-23.7* 
MCV-91 MCH-30.9 MCHC-34.2 RDW-14.1 RDWSD-46.1 Plt ___
___ 12:05AM BLOOD WBC-14.5* RBC-2.70* Hgb-8.4* Hct-24.1* 
MCV-89 MCH-31.1 MCHC-34.9 RDW-14.1 RDWSD-45.8 Plt ___
___ 10:17PM BLOOD WBC-15.8* RBC-2.89* Hgb-9.0* Hct-26.1* 
MCV-90 MCH-31.1 MCHC-34.5 RDW-14.3 RDWSD-47.0* Plt ___
___ 03:22PM BLOOD WBC-12.4* RBC-2.99* Hgb-9.3* Hct-27.0* 
MCV-90 MCH-31.1 MCHC-34.4 RDW-14.2 RDWSD-46.7* Plt ___
___ 12:00PM BLOOD WBC-13.3* RBC-3.34* Hgb-10.5* Hct-30.1* 
MCV-90 MCH-31.4 MCHC-34.9 RDW-14.2 RDWSD-46.5* Plt ___
___ 05:09AM BLOOD WBC-12.6* RBC-2.45* Hgb-7.6* Hct-22.3* 
MCV-91 MCH-31.0 MCHC-34.1 RDW-13.2 RDWSD-43.8 Plt Ct-78*
___ 04:00AM BLOOD WBC-13.6* RBC-1.95* Hgb-6.1* Hct-18.2* 
MCV-93 MCH-31.3 MCHC-33.5 RDW-13.3 RDWSD-45.2 Plt Ct-93*
___ 07:43AM BLOOD WBC-9.2 RBC-2.52* Hgb-8.0* Hct-24.2* 
MCV-96 MCH-31.7 MCHC-33.1 RDW-12.6 RDWSD-43.3 Plt ___
___ 10:07AM BLOOD WBC-5.2 RBC-2.56* Hgb-8.1* Hct-25.0* 
MCV-98 MCH-31.6 MCHC-32.4 RDW-12.8 RDWSD-45.1 Plt ___
___ 04:08AM BLOOD WBC-4.9 RBC-2.48* Hgb-8.0* Hct-23.9* 
MCV-96 MCH-32.3* MCHC-33.5 RDW-12.7 RDWSD-44.8 Plt ___
___ 09:30PM BLOOD WBC-5.3 RBC-2.71* Hgb-8.5* Hct-26.6* 
MCV-98 MCH-31.4 MCHC-32.0 RDW-12.9 RDWSD-45.8 Plt ___
___ 04:20PM BLOOD WBC-5.7 RBC-2.71* Hgb-8.6* Hct-26.0* 
MCV-96 MCH-31.7 MCHC-33.1 RDW-13.0 RDWSD-45.6 Plt ___
___ 02:04PM BLOOD WBC-1.9* RBC-2.33* Hgb-7.4* Hct-22.6* 
MCV-97 MCH-31.8 MCHC-32.7 RDW-13.1 RDWSD-46.7* Plt Ct-80*
___ 05:45AM BLOOD WBC-7.6 RBC-2.98* Hgb-9.5* Hct-29.1* 
MCV-98 MCH-31.9 MCHC-32.6 RDW-13.0 RDWSD-46.5* Plt ___
___ 02:17AM BLOOD WBC-9.5 RBC-3.05* Hgb-9.8* Hct-29.6* 
MCV-97 MCH-32.1* MCHC-33.1 RDW-12.9 RDWSD-46.0 Plt ___
___ 10:05PM BLOOD WBC-12.9* RBC-3.48* Hgb-11.2* Hct-33.7* 
MCV-97 MCH-32.2* MCHC-33.2 RDW-12.8 RDWSD-45.5 Plt ___
___ 01:59AM BLOOD Neuts-78.8* Lymphs-11.8* Monos-8.2 
Eos-0.1* Baso-0.1 NRBC-0.3* Im ___ AbsNeut-12.44* 
AbsLymp-1.86 AbsMono-1.29* AbsEos-0.02* AbsBaso-0.02
___ 04:00AM BLOOD Neuts-74.2* Lymphs-15.3* Monos-6.3 
Eos-0.1* Baso-0.1 NRBC-0.2* Im ___ AbsNeut-10.11* 
AbsLymp-2.09 AbsMono-0.86* AbsEos-0.02* AbsBaso-0.02
___ 10:05PM BLOOD Neuts-66.6 ___ Monos-10.2 
Eos-0.8* Baso-0.2 Im ___ AbsNeut-8.58* AbsLymp-2.81 
AbsMono-1.32* AbsEos-0.10 AbsBaso-0.03
___ 07:00AM BLOOD Plt ___
___ 06:56AM BLOOD Plt ___
___ 05:44PM BLOOD Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:42AM BLOOD Plt ___
___ 01:59AM BLOOD Plt ___
___ 09:37AM BLOOD ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD ___ PTT-24.6* ___
___ 12:05AM BLOOD Plt ___
___ 10:17PM BLOOD Plt ___
___ 03:22PM BLOOD Plt ___
___ 12:00PM BLOOD Plt ___
___ 05:09AM BLOOD Plt Ct-78*
___ 05:09AM BLOOD ___ PTT-24.1* ___
___ 04:00AM BLOOD Plt Ct-93*
___ 03:49AM BLOOD ___ PTT-22.7* ___
___ 07:43AM BLOOD Plt ___
___ 10:07AM BLOOD Plt ___
___ 04:08AM BLOOD Plt ___
___ 04:08AM BLOOD ___ PTT-24.3* ___
___ 09:30PM BLOOD Plt ___
___ 08:13PM BLOOD Plt Ct-UNABLE TO 
___ 04:20PM BLOOD Plt ___
___ 02:04PM BLOOD Plt Smr-VERY LOW* Plt Ct-80*
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD ___ PTT-23.9* ___
___ 10:05PM BLOOD Plt ___
___ 10:05PM BLOOD ___ PTT-22.8* ___
___ 03:49AM BLOOD ___ 04:00AM BLOOD Ret Aut-2.8* Abs Ret-0.05
___ 07:00AM BLOOD Glucose-89 UreaN-7 Creat-0.6 Na-139 K-3.9 
Cl-101 HCO3-25 AnGap-13
___ 06:56AM BLOOD Glucose-92 UreaN-6 Creat-0.5 Na-137 K-3.8 
Cl-97 HCO3-25 AnGap-15
___ 06:50AM BLOOD Glucose-92 UreaN-7 Creat-0.6 Na-135 K-3.8 
Cl-99 HCO3-25 AnGap-11
___ 06:42AM BLOOD Glucose-99 UreaN-8 Creat-0.6 Na-137 K-4.2 
Cl-100 HCO3-26 AnGap-11
___ 01:59AM BLOOD Glucose-101* UreaN-8 Creat-0.6 Na-135 
K-4.1 Cl-98 HCO3-26 AnGap-11
___ 07:25AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-137 
K-4.6 Cl-101 HCO3-25 AnGap-11
___ 07:25AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-137 
K-4.6 Cl-101 HCO3-25 AnGap-11
___ 12:05AM BLOOD Glucose-120* UreaN-9 Creat-0.6 Na-135 
K-4.3 Cl-102 HCO3-25 AnGap-8*
___ 10:17PM BLOOD Glucose-117* UreaN-9 Creat-0.7 Na-135 
K-4.5 Cl-102 HCO3-25 AnGap-8*
___ 03:22PM BLOOD Glucose-128* UreaN-11 Creat-0.9 Na-136 
K-4.3 Cl-101 HCO3-25 AnGap-10
___ 05:09AM BLOOD Glucose-168* UreaN-12 Creat-0.9 Na-136 
K-3.4* Cl-104 HCO3-22 AnGap-10
___ 01:58AM BLOOD Glucose-269* UreaN-8 Creat-0.7 Na-131* 
K-3.5 Cl-97 HCO3-14* AnGap-20*
___ 04:08AM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-134* 
K-3.9 Cl-99 HCO3-27 AnGap-8*
___ 05:45AM BLOOD Glucose-111* UreaN-10 Creat-0.8 Na-139 
K-4.5 Cl-104 HCO3-21* AnGap-14
___ 10:05PM BLOOD Glucose-127* UreaN-10 Creat-1.0 Na-142 
K-4.5 Cl-104 HCO3-21* AnGap-17
___ 04:08AM BLOOD ALT-24 AST-39 LD(LDH)-238 AlkPhos-63 
TotBili-0.6
___ 10:05PM BLOOD ALT-31 AST-61* AlkPhos-66 TotBili-0.2
___ 07:00AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0
___ 06:56AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.0
___ 06:50AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.0
___ 06:42AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.2
___ 01:59AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.2
___ 07:25AM BLOOD Calcium-7.8* Phos-2.2* Mg-2.2
___ 12:05AM BLOOD Calcium-7.7* Phos-2.6* Mg-1.7
___ 10:17PM BLOOD Calcium-7.6* Phos-2.9 Mg-1.8
___ 03:22PM BLOOD Calcium-7.4* Phos-3.2 Mg-1.8
___ 05:09AM BLOOD Calcium-7.0* Phos-4.5 Mg-2.2
___ 04:08AM BLOOD Albumin-3.6 Calcium-8.4 Phos-2.7 Mg-1.9
___ 05:45AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.8
___ 10:05PM BLOOD Albumin-4.0 Calcium-8.8 Phos-4.5 Mg-2.0
___ 10:05PM BLOOD ASA-NEG ___ Acetmnp-NEG 
Tricycl-NEG
___ 05:31AM BLOOD Type-ART pO2-170* pCO2-45 pH-7.32* 
calTCO2-24 Base XS--3
___ 04:00AM BLOOD Type-ART Rates-___/ Tidal V-600 PEEP-5 
FiO2-50 pO2-210* pCO2-44 pH-7.29* calTCO2-22 Base XS--4 
Intubat-INTUBATED Vent-CONTROLLED
___ 05:31AM BLOOD Lactate-2.0
___ 04:00AM BLOOD Glucose-272* Lactate-4.9* K-3.2* 
calHCO3-22
___ 02:10AM BLOOD Lactate-14.0*
___ 10:14PM BLOOD Lactate-2.5*
___ 09:00AM BLOOD Hgb-11.0* calcHCT-33
___ 04:00AM BLOOD Hgb-5.2* calcHCT-16 O2 Sat-96
___ 04:00AM BLOOD freeCa-1.09*
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, Neuts {Neutrophil count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, 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}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, 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}, 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}, 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}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, 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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, pH {pH measurement}, pH {pH measurement}, Glucose {Glucose measurement, blood}, K {Blood potassium measurement}, Hgb {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, Hgb {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Mr. ___ is a ___ male with Past Medical History 
significant for untreated Hep C, EtOH substance use disorder, 
polysubstance use disorder who presented to ___ s/p witnessed 
fall 5' into pit at ___ station. He was found to have multiple 
left rib fx (___), liver, spleen, & left kidney lacerations. 
eFAST w/ positive fluid in RUQ, CT scan with fluid in pelvis. He 
was admitted to the trauma surgery icu for close monitoring. He 
underwent serial abdominal exams, Q6H CBC and Phenobarbital 
loading for ETOH prophylaxis. His hematocrit remained relatively 
stable and he was called out to the floor on HD 2. He was stable 
on the floor until HD 4 when he acutely decompensated with 
tachycardia to the 140s with SBP ___.  We gained access and took 
him to the operating room emergently for an exploratory 
laparotomy where he underwent a splenectomy. He received 5uprbc 
total, 1 uffp. He was stabilized, extubated in the pacu and 
transferred back to the floor for further management. 

On 

___ - discharged. Tolerating regular diet. Passing flatus 
and having bowel movements. Patient received post splenectomy 
vaccines on discharge with instruction to follow up with PCP for 
continuous booster shots.  Midline abdominal Staples to be 
removed in clinic. 
___ Tolerating clears and some limited regular diet. 
Ambulating independently . 
___ Advanced diet to regular, H/H stable. ambulating with 
RN. reassess needs.  
 ___ 1 unit PRBCs for Hct 21. post tx Hct: 24.2 , 
suppository, small liquid BM  
 ___ blood cx, u cx pending, UA neg, walking with walker, 
___ consult, oxy ___ q4hr  
 ___ foley/JP DC  
 ___ Temp 101.8 at ___. Resolved with Tylenol. CBC, CXR, 
blood cx, UA sent stat  
 ___ tachy 130s, SBP ___, 1L fluid, 2 uprbc, OR ex lap  
 

 

###RESPONSE: Hep C {Viral hepatitis type C}, EtOH substance use disorder {Alcohol abuse}, polysubstance use disorder {Polysubstance abuse}, fall {Falls}, left {Bone structure of left rib}, rib fx {Fracture of rib}, liver {Laceration of liver}, spleen {Laceration of spleen}, left kidney lacerations {Laceration of left kidney}, eFAST {Focused assessment with ultrasonography for trauma}, RUQ {Structure of right upper quadrant of abdomen}, CT scan {Computed tomography}, pelvis {Structure of pelvis}, monitoring {Monitoring response to treatment}, abdominal exams {Examination of abdomen}, CBC {Complete blood count}, prophylaxis {Preventive procedure}, hematocrit remained relatively 
stable {Stable hematocrit}, tachycardia {Tachycardia}, exploratory 
laparotomy {Exploratory laparotomy}, splenectomy {Splenectomy}, extubated {Removal of endotracheal tube}, regular diet {Normal diet}, Passing flatus {Passing flatus}, splenectomy {Splenectomy}, vaccines {Administration of vaccine to produce active immunity}, Staples to be 
removed {Removal of staples}, clinic {Outpatient care management}, regular diet {Normal diet}, Ambulating independently {Independent walking}, regular {Normal diet}, stable {Patient's condition stable}, ambulating {Fully mobile}, blood cx {Blood culture}, u cx {Urine culture}, UA {Urinalysis}, walking with walker {Does mobilize using walker}, Temp {Body temperature finding}, CBC {Complete blood count}, CXR {Plain chest X-ray}, blood cx {Blood culture}, UA {Urinalysis}, tachy {Tachycardia}, fluid {Administration of fluid therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 80 mg PO DAILY 
2. ProAir HPA - 2 puffs, every 4 hours as needed for wheezing 
 
Discharge Medications:
1.  Docusate Sodium 100 mg PO BID  
2.  Docusate Sodium 100 mg PO BID  
3.  HydrOXYzine 25 mg PO TID Anxiety  
Take 1 capsule three times as needed for anxiety   
4.  OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - 
Moderate  
5.  ProAir HFA (albuterol sulfate) Other  inhalation Other 
2 PUFFS , EVERY 4 HOURS AS NEEDED FOR WHEEZING 
6.  Methadone 80 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:
1. Nondisplaced fracture posterior left 12th rib,  
2. Mildly displaced, comminuted fracture posterior left ___ & 
11th ribs  
3. Mildly displaced fracture posterolateral left 9th rib  
4. Nondisplaced fracture anterolateral left 8th rib  
5. Left kidney laceration (possible extension to renal pelvis & 
collecting system)  
6. Multiple splenic lacerations  
7. Peripheral inferior liver laceration    

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: Nondisplaced fracture {Undisplaced fracture}, left {Bone structure of left rib}, 12th rib {Bone structure of twelfth rib}, displaced {Fracture with displacement}, comminuted fracture {Fracture, comminuted}, left {Bone structure of left rib}, 11th ribs {Bone structure of eleventh rib}, displaced fracture {Fracture with displacement}, left {Bone structure of left rib}, 9th rib {Bone structure of ninth rib}, Nondisplaced fracture {Undisplaced fracture}, left {Bone structure of left rib}, 8th rib {Bone structure of eighth rib}, Left kidney laceration {Laceration of left kidney}, renal pelvis {Renal pelvis structure}, splenic lacerations {Laceration of spleen}, liver laceration {Laceration of liver}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___,

You were admitted to the Acute Care Surgery Service on ___ 
after a fall sustaining left sided rib fractures, and injuries 
to you spleen, liver, and left kidney. You had a large bleed 
from your spleen and therefore you were taken to the operating 
room and had it removed. Your spleen is important for your 
immune system to function and therefore you were given vaccines 
(Influenza. PCV13, Menactra, HIB) prior to leaving the hospital. 
You should follow up with your primary care provider for ongoing 
vaccines. 

You are now doing better, tolerating a regular diet, having 
bowel function (gas and bowel movements) and pain is better 
controlled. 

You are now ready to be discharged to home with the following 
discharge instructions:

Please call your doctor or nurse practitioner or return to the 
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or 
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your 
medications.
*You are getting dehydrated due to continued vomiting, diarrhea, 
or other reasons. Signs of dehydration include dry mouth, rapid 
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a 
bowel movement.
*You experience burning when you urinate, have blood in your 
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone 
within 24 hours. Call or return immediately if your pain is 
getting worse or changes location or moving to your chest or 
back.
*You have shaking chills, or fever greater than 101.5 degrees 
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern 
you.

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.

Avoid driving or operating heavy machinery while taking pain 
medications.

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.
*If you have staples, they will be removed at your follow-up 
appointment.
*If you have steri-strips, they will fall off on their own. 
Please remove any remaining strips ___ days after surgery.

Liver/ Spleen lacerations:

*AVOID contact sports and/or any activity that may cause injury 
to your abdominal area for the next ___ weeks.
 
*If you suddenly become dizzy, lightheaded, feeling as if you 
are going to pass out go to the nearest Emergency Room as this 
could be a sign that you are having internal bleeding from your 
liver or spleen injury.
 
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin, 
Aspirin, Coumadin or Plavix for at least ___ days unless 
otherwise instructed by the MD/NP/PA.

 

###RESPONSE: fall {Falls}, left sided {Bone structure of left rib}, rib fractures {Fracture of rib}, injuries {Traumatic or non-traumatic injury}, spleen {Splenic structure}, liver {Liver structure}, left kidney {Traumatic injury of left kidney}, bleed {Bleeding}, spleen {Splenic structure}, removed {Splenectomy}, spleen {Splenic structure}, immune system {Structure of immune system}, vaccines {Administration of vaccine to produce active immunity}, regular diet {Normal diet}, pain {Pain}, chest pain {Chest pain}, pressure {Tight chest}, squeezing {Squeezing chest pain}, tightness {Tight chest}, cough {Cough}, shortness of breath {Dyspnea}, wheeze {Wheezing}, vomiting {Vomiting}, cannot keep down fluids {Nausea and vomiting}, dehydrated {Dehydration}, vomiting {Vomiting}, diarrhea {Diarrhea}, Signs {Sign}, dehydration {Dehydration}, dry mouth {Xerostomia}, rapid 
heartbeat {Tachycardia}, dizzy {Dizziness}, faint {Feeling faint}, standing {Orthostatic body position}, blood or dark/black material when you vomit {Vomit contains blood}, bowel movement {Hematochezia}, burning {Burning sensation}, urinate {Micturition finding}, blood in your 
urine {Blood in urine}, discharge {Discharge}, pain {Pain}, pain {Pain}, chest {Thoracic structure}, back {Structure of back of trunk}, shaking {Tremor}, chills {Chill}, fever {Fever}, ambulate {Ambulation training}, increased pain {Increased pain}, swelling {Swelling}, redness {Redness of skin over lesion}, drainage {Discharge}, incision 
site {Surgical incision wound}, surgical incisions {Surgical incision wound}, injury {Traumatic or non-traumatic injury}, abdominal {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, dizzy {Dizziness}, lightheaded {Lightheadedness}, feeling as if you 
are going to pass out {Feeling faint}, sign {Sign}, bleeding {Bleeding}, liver {Injury of liver}, spleen injury {Injury of spleen}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
abdominal pain
 
Major Surgical or Invasive Procedure:
___ - exploratory laparotomy, ileotomy, gallstone removal
 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, abdominal pain {Abdominal pain}, exploratory laparotomy {Exploratory laparotomy}, ileotomy {Ileotomy}, gallstone removal {Cholelithotomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 dementia transfered from OSH with a 3-day history of 
nausea and vomiting. Per patient/family report, pt developed 
nausea with a few episodes of nonbloody, nonbilious emesis three 
days ago. He became progressively weaker in the setting of 
almost no oral intake during this time.  The patient and family
otherwise deny complaints of abdominal pain, fevers/chills, 
diarrhea, or hematochezia. He cannot recall his last bowel 
movement, but feels he has not passed stool or flatus in at 
least 48 hours. He presented to ___ last evening 
for evaluation, and CT imaging revealed findings consistent with
gallstone ileus causing small bowel obstruction.  He was 
transfered to ___ for further management.

On arrival to ___, pt was found to be tachycardic (HR 115) 
with mild hypotension (SBP 90), for which he was started on IVF 
resuscitation. During placement of a nasogastric tube the pt 
vomited, suffering a concomitant aspiration. He subsequently 
developed respiratory distress and eventually required 
intubation after failing noninvasive support.
 

###RESPONSE: dementia {Dementia}, nausea and vomiting {Nausea and vomiting}, nausea {Nausea}, emesis {Vomiting}, no oral intake {Inadequate oral intake}, abdominal pain {Abdominal pain}, fevers {Fever}, chills {Chill}, diarrhea {Diarrhea}, hematochezia {Hematochezia}, bowel 
movement {Altered bowel function}, not passed stool or flatus {Constipation}, evaluation {Evaluation procedure}, CT imaging {Computed tomography}, gallstone ileus {Gallstone ileus}, small bowel obstruction {Small bowel obstruction}, tachycardic {Tachycardia}, hypotension {Low blood pressure}, IVF 
resuscitation {Resuscitation using intravenous fluid}, placement of a nasogastric tube {Insertion of nasogastric tube}, vomited {Vomiting}, aspiration {Pulmonary aspiration}, respiratory distress {Respiratory distress}, intubation {Insertion of endotracheal tube}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
PMH: HTN, Dementia, HLD
PSH: denies

 

###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, Dementia {Dementia}, HLD {Hyperlipidemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
N/C

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Admission Exam:
Vitals: 98.9  110  105/68  18  95% facemask
GEN: NAD. Alert w/ mild confusion.
HEENT: No scleral icterus. Mucous membranes dry.
CV: Reg rhythm but tachycardic.
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender to deep palpation.
DRE: Normal tone. No gross blood. Heme-occult negative.
Ext: ___ warm with palpable DP pulses and no edema.

Physical examination upon discharge:  ___:

Vital signs:  t=97.9, bp=135/80, hr=72, rr=20

General:  Sitting comfortably in chair

CV:  Ns1, s2, -3, -s4
LUNGS:  Clear
ABDOMEN:  soft, non-tender, midline incision with steri-strips
EXT:  no pedal edema bil., + dp bil., no calf tenderness bil
NEURO:  oriented to name, disoriented to time, place, 
cooperative, follows commands

 

###RESPONSE: Vitals {Vital signs finding}, GEN {General examination of patient}, NAD {No abnormality detected}, Alert {Mentally alert}, confusion {Clouded consciousness}, HEENT {Physical examination procedure}, scleral icterus {Scleral icterus}, Mucous membranes dry {Mucous membrane dryness}, CV {Cardiovascular physical examination}, Reg rhythm {Finding of regularity of heart rhythm}, tachycardic {Tachycardia}, PULM {Examination of respiratory system}, Clear to auscultation b/l {Normal breath sounds}, ABD {Examination of abdomen}, Soft {Abdomen soft}, nondistended {Normal abdominal contour}, nontender {Abdominal tenderness}, palpation {Palpation}, Heme-occult negative {Occult blood not detected in feces}, Ext {Examination of limb}, warm {Warm skin}, palpable DP pulses {Dorsalis pulse present}, edema {Edema}, Sitting {Sitting position}, Clear {Normal breath sounds}, soft {Abdomen soft}, midline incision {Midline incision}, pedal edema {Edema of foot}, calf tenderness {Pain in calf}, oriented to name {Oriented to person}, disoriented to time {Disorientated in time}, place {Disorientated in place}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:55AM BLOOD WBC-6.9 RBC-3.84* Hgb-11.8* Hct-37.3* 
MCV-97 MCH-30.8 MCHC-31.7 RDW-12.9 Plt ___
___ 06:55AM BLOOD Glucose-110* UreaN-20 Creat-0.9 Na-140 
K-3.9 Cl-111* HCO3-22 AnGap-11
___ 06:55AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.0
___ 01:55PM BLOOD WBC-7.2 RBC-3.83* Hgb-11.9* Hct-37.3* 
MCV-98 MCH-31.1 MCHC-31.9 RDW-12.9 Plt ___
___ 02:06AM BLOOD WBC-12.5* RBC-3.40* Hgb-10.5* Hct-32.3* 
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.2 Plt ___
___ 07:15PM BLOOD WBC-6.0 RBC-4.26* Hgb-13.6* Hct-41.6 
MCV-98 MCH-32.0 MCHC-32.7 RDW-13.3 Plt ___
___ 09:21AM BLOOD WBC-5.0 RBC-4.57* Hgb-14.3 Hct-42.9 
MCV-94 MCH-31.3 MCHC-33.4 RDW-12.9 Plt ___
___ 01:20AM BLOOD WBC-5.4 RBC-5.06 Hgb-16.1 Hct-46.7 MCV-92 
MCH-31.8 MCHC-34.5 RDW-12.8 Plt ___
___ 01:57AM BLOOD Neuts-69 Bands-5 Lymphs-12* Monos-7 Eos-0 
Baso-0 ___ Metas-5* Myelos-2*
___ 01:55PM BLOOD Plt ___
___ 02:16AM BLOOD Plt ___
___ 12:34AM BLOOD ___ PTT-28.6 ___
___ 01:20AM BLOOD ___ PTT-28.6 ___
___ 01:55PM BLOOD Glucose-130* UreaN-21* Creat-1.0 Na-140 
K-4.7 Cl-108 HCO3-19* AnGap-18
___ 02:16AM BLOOD Glucose-116* UreaN-22* Creat-0.9 Na-140 
K-3.6 Cl-108 HCO3-19* AnGap-17
___ 01:54AM BLOOD Glucose-115* UreaN-25* Creat-1.0 Na-143 
K-3.8 Cl-110* HCO3-25 AnGap-12
___ 07:15PM BLOOD Glucose-142* UreaN-77* Creat-1.5* Na-137 
K-3.7 Cl-106 HCO3-23 AnGap-12
___ 09:21AM BLOOD Glucose-133* UreaN-91* Creat-1.8* Na-139 
K-3.9 Cl-105 HCO3-23 AnGap-15
___ 01:20AM BLOOD Glucose-162* UreaN-102* Creat-2.1* Na-134 
K-3.6 Cl-97 HCO3-21* AnGap-20
___ 06:04PM BLOOD CK(CPK)-25*
___ 10:04PM BLOOD Lipase-49
___ 01:08AM BLOOD CK-MB-1 cTropnT-0.40*
___ 02:00AM BLOOD cTropnT-0.68*
___ 06:04PM BLOOD CK-MB-1 cTropnT-0.78*
___ 01:55PM BLOOD Calcium-8.6 Phos-2.8 Mg-2.1
___ 02:16AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0
___ 01:57AM BLOOD Triglyc-254*
___ 10:04PM BLOOD Cortsol-28.3*
___ 08:30AM BLOOD Vanco-20.3*
___ 01:20AM BLOOD freeCa-1.09*
___ 06:51PM BLOOD freeCa-1.17

___:  EKG:  

Sinus rhythm. A-V conduction delay. Inferior myocardial 
infarction, age 
indeterminate. No previous tracing available for comparison.

___:  chest x-ray:

  
1. Enlarged aortic arch and extensively calcified aortic arch, 
worrisome for aneurysmal dilatation. If warranted by clinical 
situation, further evaluation could be performed with Chest CTA. 
 
  
2. Reticular pulmonary opacities, most compatible with chronic 
lung disease. 
  
3. Bibasilar atelectasis

___:  chest x-ray:

 
FINDINGS: New right internal jugular line tip is at lower 
SVC/cavoatrial 
junction approximately 3.2 cm from the carina. Orogastric tube 
courses below the diaphragm and ends into the body of the 
stomach and is appropriately positioned. Since prior radiograph 
acquired several hours apart, bibasilar atelectasis persists 
with interval worsening on the right side and unchanged on the 
left side. Small pleural effusion on the right side is similar. 
Upper lungs are clear. There is no pneumothorax. Heart size, 
mediastinal and hilar contours have stable appearance.

___:  EKG:

 Supraventricular rhythm at the upper limits of normal rate with 
P-R interval 
prolongation. Low amplitude P waves merged with the T wave. 
Cannot rule out atrial tachycardia with 2:1 block. RSR' pattern 
in leads V1-V2. Q waves in leads III and aVF - consider inferior 
myocardial infarction. Since the previous tracing the rate is 
faster. The P-R interval is longer with a difference in the P 
wave which may be related to fusion with a T wave. 
Clinical correlation is suggested.  
TRACING #1

___:  ECHO:

 IMPRESSION: Mild symmetric left ventricular hypertrophy with 
preserved global systolic function. The left ventricle is 
compressed by a severely dilated and hypokinetic right 
ventricle. The RV apical function is relatively preserved which 
is a non-specific sign but could be due to pulmonary embolism. 
Moderate tricuspid regurgitation and at least moderate pulmonary 
hypertension.

___:  EKG:

Sinus bradycardia with sinus arrhythmia and P-R interval 
prolongation. 
Prolonged Q-T interval. Borderline low precordial QRS votlage. T 
wave 
inversions in leads VI-V4 and in the inferior leads. Slightly 
delayed anterior R wave progression - cannot exclude prior 
anteroseptal myocardial infarction. 
Compared to the previous tracing of ___ T wave inversion is 
more prominent in leads II and V3. RSR' pattern has resolved, 
likely due to changes in electrode placement. Anterior R wave 
progression has improved.An ongoing inferior and anterior 
ischemic process cannot be excluded. Clinical correlation is 
suggested 

___:  chest x-xay:

Moderate cardiomegaly is stable. Left lower lobe retrocardiac 
consolidation and ill-defined opacities in the right mid and 
lower lungs are stable, concerning for aspiration. There are no 
new lung abnormalities, pneumothorax or enlarging pleural 
effusions. Lines and tubes are in unchanged standard 
position 

___:  x-ray of the abdomen:

IMPRESSION: Findings consistent with resolving small-bowel 
obstruction from ___ with decreased gaseous distention of the 
small bowel and progression of oral contrast into the proximal 
colon.

___:  cat scan of abdomen and chest:

 Multifocal pneumonia/aspiration pneumonia within the right 
upper, middle, 
and lower lobes. 
  
2. Small bilateral pleural effusions with associated 
atelectasis. 
  
3. Fusiform infrarenal abdominal aortic aneurysm as well as 
aneurysmal 
dilatation of the right common iliac artery and a saccular 
aneurysm arising off the right internal iliac artery with 
significant mural thrombus. 
  
4. Dilatation of loops of small bowel within the left abdomen 
and pelvis.  
The degree of small bowel dilatation overall has generally 
decreased and this likely reflects a persistent ileus, although 
a partial small bowel obstruction is not entirely excluded. 
  
5. Enlarged right hilar lymph node presumably reactive. 
Following resolution of acute symptoms a follow-up Chest CT is 
recommended. 
  
6. Emphysema. 
  
7. Pulmonary arterial hypertension. 
  
8. Probably duodenal lipoma

___:  EKG:

Sinus bradycardia. P-R interval prolongation. Borderline low 
limb lead 
voltage. Mild Q-T interval prolongation. Early R wave 
progression. 
RSR' pattern in lead V1. Borderline intraventricular conduction 
delay.  
ST-T wave abnormalities. Since the previous tracing of ___ 
the Q-T interval is now shorter. Otherwise, unchanged.  
TRACING #1 

___:  EKG:

Probable sinus rhythm with atrial premature beats. Since the 
previous tracing the rate has increased. Atrial ectopy is new. 
The QRS complex is narrower. ST-T wave abnormalities are less 
prominent.

___:  chest x-ray:

FINDINGS: As compared to the previous radiograph, the known 
multifocal 
pneumonia, with a maximum manifestation at the right lung base, 
is unchanged in extent and severity. Unchanged moderate 
cardiomegaly without pulmonary edema. Unchanged monitoring and 
support devices. No newly appeared focal parenchymal opacities.

___:  chest x-ray:

Compared to the prior radiograph, there has been no change. 
Right sided 
extensive opacities remain. Left-sided patchy opacities also 
remain. Moderate cardiomegaly and areas of atelectasis 
bilaterally is unchanged. Right-sided IJ terminates in the 
mid-to-distal SVC.

___:  chest x-ray:

Rotated lordotic positioning. Allowing for this, the 
cardiomediastinal 
silhouette is likely stable. There are patchy opacities at the 
right and left bases, similar, possibly minimally improved, 
compared with ___ at 5:46 a.m. Doubt CHF. No gross 
effusion.

___ 5:01 pm SPUTUM      Source: Endotracheal. 

                            **FINAL REPORT ___

   GRAM STAIN (Final ___: 
      >25 PMNs and <10 epithelial cells/100X field. 
      NO MICROORGANISMS SEEN. 

   RESPIRATORY CULTURE (Final ___: 
      Commensal Respiratory Flora Absent. 
      YEAST.    SPARSE GROWTH. 

___ 12:29 am SPUTUM      Source: Endotracheal. 

                            **FINAL REPORT ___

   GRAM STAIN (Final ___: 
      ___ PMNs and <10 epithelial cells/100X field. 
      1+    (<1 per 1000X FIELD):   BUDDING YEAST. 

   RESPIRATORY CULTURE (Final ___: 
      Commensal Respiratory Flora Absent. 
      YEAST.    SPARSE GROWTH. 

___ 8:28 am MRSA SCREEN      Source: Nasal swab. 

                            **FINAL REPORT ___

   MRSA SCREEN (Final ___: 
      POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. 

 
  
 
 
  
 

  

 
  

  

  

  
 
  

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, 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}, 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}, 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}, 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}, 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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Triglyc {Triglycerides measurement}, EKG {Electrocardiographic procedure}, Sinus rhythm {Sinus rhythm}, A-V conduction delay {Atrioventricular block}, Inferior myocardial 
infarction {Inferior myocardial infarction on electrocardiogram}, Enlarged aortic arch {Abnormality of aortic arch}, aortic arch {Aortic arch structure}, aneurysmal dilatation {Aneurysm}, evaluation {Evaluation procedure}, Chest CTA {Computed tomography angiography of chest with contrast}, pulmonary {Examination of respiratory system}, opacities {Abnormally opaque structure}, chronic 
lung disease {Chronic lung disease}, Bibasilar {Structure of base of lung}, atelectasis {Atelectasis}, chest x-ray {Plain chest X-ray}, lower 
SVC {Structure of low superior vena cava}, carina {Structure of carina of trachea}, diaphragm {Diaphragm structure}, stomach {Stomach structure}, radiograph {Plain radiography}, bibasilar {Structure of base of lung}, atelectasis {Atelectasis}, pleural effusion {Pleural effusion}, Upper lungs {Structure of upper zone of lung}, are clear {Normal lung}, pneumothorax {Pneumothorax}, Heart {Heart structure}, mediastinal {Mediastinal structure}, stable appearance {Patient's condition stable}, upper limits of normal rate {Measurement finding above reference range}, P-R interval 
prolongation {Prolonged PR interval}, Low amplitude P waves {Flattened P wave}, atrial tachycardia {Atrial tachycardia}, 2:1 block {Electrocardiogram: partial atrioventricular block - 2:1}, RSR' pattern 
in leads V1-V2 {rSr pattern in V1 and V2}, leads III {Lead III}, inferior 
myocardial infarction {Inferior myocardial infarction on electrocardiogram}, P-R interval is longer {Prolonged PR interval}, Mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, left ventricle {Left cardiac ventricular structure}, hypokinetic right 
ventricle {Hypokinetic right ventricular wall}, RV apical {Structure of apex of right ventricle}, pulmonary embolism {Pulmonary embolism}, Moderate tricuspid regurgitation {Moderate tricuspid valve regurgitation}, moderate pulmonary 
hypertension {Moderate pulmonary hypertension}, EKG {Electrocardiographic procedure}, Sinus bradycardia {Sinus bradycardia}, sinus arrhythmia {Nodal rhythm disorder}, P-R interval 
prolongation {Prolonged PR interval}, Prolonged Q-T interval {Prolonged QT interval}, low precordial QRS votlage {Low QRS voltages in the precordial leads}, T 
wave 
inversions {Inverted T wave}, delayed anterior R wave progression {Electrocardiographic R wave abnormal}, anteroseptal myocardial infarction {Anteroseptal infarction on electrocardiogram}, T wave inversion {Inverted T wave}, leads II {Lead II}, RSR' pattern {rSr pattern in V1 and V2}, Anterior R wave 
progression {Electrocardiographic R wave abnormal}, improved {Patient's condition improved}, anterior 
ischemic {Electrocardiographic anterior ischemia}, cardiomegaly {Cardiomegaly}, stable {Patient's condition stable}, Left lower lobe {Structure of lower lobe of left lung}, consolidation {Lung consolidation}, opacities {Abnormally opaque structure}, lower lungs {Structure of lower lobe of lung}, stable {Patient's condition stable}, aspiration {Aspiration pneumonia}, lung abnormalities {Imaging of lung abnormal}, pneumothorax {Pneumothorax}, pleural 
effusions {Pleural effusion}, small-bowel 
obstruction {Small bowel obstruction}, gaseous distention {Abdominal distension, gaseous}, small bowel {Structure of small intestine}, progression of oral contrast {Diagnostic radiography with oral contrast}, proximal 
colon {Ascending colon structure}, pneumonia {Pneumonia}, aspiration pneumonia {Aspiration pneumonia}, right 
upper, middle, 
and lower lobes {Right lung structure}, bilateral pleural effusions {Bilateral pleural effusion}, atelectasis {Atelectasis}, infrarenal abdominal aortic aneurysm {Aneurysm of infrarenal abdominal aorta}, aneurysmal 
dilatation {Aneurysm}, right common iliac artery {Structure of right common iliac artery}, saccular 
aneurysm {Saccular aneurysm}, right internal iliac artery {Structure of right internal iliac artery}, mural thrombus {Mural thrombus}, Dilatation {Dilatation}, small bowel {Structure of small intestine}, left abdomen {Structure of left side of abdomen}, pelvis {Structure of pelvis}, small bowel {Structure of small intestine}, partial small bowel obstruction {Partial obstruction of small bowel}, Enlarged right hilar lymph node {Localized enlarged lymph nodes}, Chest CT {Computed tomography of chest}, Emphysema {Emphysema}, Pulmonary arterial hypertension {Pulmonary hypertensive arterial disease}, duodenal {Duodenal structure}, lipoma {Lipoma}, EKG {Electrocardiographic procedure}, Sinus bradycardia {Sinus bradycardia}, P-R interval prolongation {Prolonged PR interval}, low 
limb lead 
voltage {Low QRS voltages in the limb leads}, Q-T interval prolongation {Prolonged QT interval}, R wave 
progression {Electrocardiographic R wave abnormal}, RSR' pattern in lead V1 {rSr pattern in V1 and V2}, ST-T wave abnormalities {Nonspecific ST-T abnormality on electrocardiogram}, Q-T interval is now shorter {Shortened QT interval}, EKG {Electrocardiographic procedure}, sinus rhythm {Sinus rhythm}, atrial premature beats {Atrial premature complex}, Atrial ectopy {Premature atrial contraction}, ST-T wave abnormalities {Nonspecific ST-T abnormality on electrocardiogram}, chest x-ray {Plain chest X-ray}, radiograph {Plain radiography}, pneumonia {Pneumonia}, right lung base {Structure of base of right lung}, cardiomegaly {Cardiomegaly}, pulmonary edema {Pulmonary edema}, monitoring {Monitoring response to treatment}, opacities {Abnormally opaque structure}, chest x-ray {Plain chest X-ray}, radiograph {Plain radiography}, opacities {Abnormally opaque structure}, opacities {Abnormally opaque structure}, cardiomegaly {Cardiomegaly}, atelectasis {Atelectasis}, SVC {Superior vena cava structure}, chest x-ray {Plain chest X-ray}, Rotated lordotic {Lordosis deformity of spine}, stable {Patient's condition stable}, opacities {Abnormally opaque structure}, bases {Structure of base of lung}, improved {Patient's condition improved}, CHF {Congestive heart failure}, effusion {Pleural effusion}, RESPIRATORY CULTURE {Respiratory microbial culture}, RESPIRATORY CULTURE {Respiratory microbial culture}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, MRSA SCREEN {Multi-resistant staphylococcus aureus screening}, POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS {Methicillin resistant Staphylococcus aureus detected}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 presented to the ___ 
___ with gallstone ileus. He had a gastric tube placed, but 
was removed during transport.  He was hypoxic upon admission.  A 
___ tube was replaced with subsequent vomitting.  He 
was emergently intubated and taken to the operating room  on 
___ for exploratory laparotomy, ileotomy and stone 
extraction. He tolerated the procedure well and was transferred 
to the intensive care unit for further care:

Posoperatively, the patient was hypotensive and required fluid 
boluses. A NICOM was placed that showed adequate cardiac output. 
He was then started on intermittent levophed, vasopressin, and 
dopamine.  As his hemodynamic status improved, the pressors were 
weaned off by HD# 5. The patient was also noted to have a 
troponin increase  to 0.8 and was intermittently bradycardic. He 
underwent an Echocardiogaram which showed left ventricular 
hypertrophy with an ejection fraction of >55%. He was seen by 
Cardiology who atributed the changes to demand ischemia. On HD#4 
the patient developed an arrythmia and there was concern for a 
pulmonary embolism.  A CTA was performed which was negative for 
a pulmonary embolism.  He otherwise had no cardiovascular 
issues.

During the hospital course, the patient required fluid 
resuscitation and became fluid overloaded.  As a result of this, 
he was difficult to ventilate and had to be paralyzed and 
required several ventilatory mode changes. He was started on a 
lasix drip to help decrease his overload.  This was discontinued 
after 48 hours because of an increase in his creatinine. He 
subsuequently auto-diuresised down to his dry weight. On HD #5, 
he was started on tube feedings and gradually advanced to his 
goal.   He was slowly weaned and extubated on POD#8. He was 
maintained on a face mask throught POD #9 and weaned to nasal 
cannula on POD #11.  He was placed on a 1 week course of zosyn 
and vancomycin for his aspiration pneumonitis.   His oxygen 
requirement slowly resolved.  He was evaluated by Speech and 
Swallow to determine his ability to safely swallow without 
aspiration.     

On HD #5, the patient was started on tube feedings and slowly 
advanced to goal.  He was evaluated by Speech and Swallow who 
advanced him to a soft solid diet.  By POD 10 he was on a 
regular diet and calorie counts were begun to measure the 
magnitude of his oral intake.  He was tolerating a regular diet 
upon discharge. 

He was transferred to the surgical floor on HD #13.  His vital 
signs have been stabie and he has been afebrile. His white blood 
cell count has normalized and his hematocrit has been stable.  
He was tolerating a regular diet.  He has been evaluated by 
physical therapy and recommendations made for discharge to an 
extended care facility where he can futhter regain his strength 
and mobility.

****Of note:  x-ray of the abdomen on ___ showed enlarged 
right hilar lymph node and recommendation per radiology for a 
repeat cat scan in the future.    

 

###RESPONSE: gallstone ileus {Gallstone ileus}, hypoxic {Hypoxia}, vomitting {Vomiting}, intubated {Intubation}, exploratory laparotomy {Exploratory laparotomy}, ileotomy {Ileotomy}, stone 
extraction {Bile duct stone removal}, hypotensive {Low blood pressure}, fluid 
boluses {Intravenous injection}, NICOM was placed {Non-invasive cardiac output monitoring}, adequate cardiac output {Normal cardiac output}, improved {Patient's condition improved}, bradycardic {Bradycardia}, Echocardiogaram {Echocardiography}, left ventricular 
hypertrophy {Left ventricular hypertrophy}, demand ischemia {Ischemia co-occurrent and due to increased oxygen demand}, arrythmia {Cardiac arrhythmia}, pulmonary embolism {Pulmonary embolism}, CTA {Computed tomography angiography with contrast}, pulmonary embolism {Pulmonary embolism}, fluid 
resuscitation {Resuscitation using intravenous fluid}, fluid overloaded {Hypervolemia}, lasix {Diuretic therapy}, increase in his creatinine {Creatine kinase level above reference range}, tube feedings {Tube feeding of patient}, face mask {Oxygen administration by mask}, nasal 
cannula {Oxygen administration by nasal cannula}, aspiration pneumonitis {Aspiration pneumonitis}, evaluated by Speech and 
Swallow {Evaluation of oral stage deglutition and pharyngeal stage deglutition}, swallow {Does swallow}, aspiration {Pulmonary aspiration}, tube feedings {Tube feeding of patient}, evaluated by Speech and Swallow {Seen by speech and language therapy service}, soft solid diet {Soft diet}, regular diet {Normal diet}, measure the 
magnitude of his oral intake {Nutritional monitoring}, tolerating a regular diet {Tolerating normal diet}, afebrile {Fever}, white blood 
cell count {White blood cell count}, hematocrit {Hematocrit determination}, tolerating a regular diet {Tolerating normal diet}, evaluated by 
physical therapy {Physical therapy management}, x-ray of the abdomen {Diagnostic radiography of abdomen}, enlarged 
right hilar lymph node {Localized enlarged lymph nodes}, cat scan {Computed tomography}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Atorvastatin 20', Amlodipine 10', Losartan 100', Vitamin B12, 
ASA (unknown dosage), Exelon patch 9.5mg/24hrs

 
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) 
units Injection TID (3 times a day).  
2. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical BID 
(2 times a day) as needed for fungal infection.  
3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal 
once a day as needed for constipation.  
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for 
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as 
needed for wheezing.  
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): 
hold for systolic blood pressure <110, hr <60.  
7. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
8. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).  
9. quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS (at 
bedtime).  
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H 
(every 6 hours) as needed for pain.  
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: 
hold for loose stool.  
12. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One 
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.  
13. Exelon 9.5 mg/24 hour Patch 24 hr Sig: One (1) patch 
Transdermal daily ().  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___ 
___)
 
Discharge Diagnosis:
aspiration
gallstone ileus
small bowel obstruction

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: aspiration {Pulmonary aspiration}, gallstone ileus {Gallstone ileus}, small bowel obstruction {Small bowel obstruction}, Mental Status {Neurological mental status determination}, Alert {Mentally alert}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted to the hospital with nausea and vomitting.  
You were found on cat scan to have a gallstone ileus and a small 
bowel obstruction.  You had a tube placed into your stomach for 
decompression and you subsequently vomitted with some fluid 
entering your lungs and causing pneumonia.  You were taken to 
the operating room where you had an exploratory laparotomy and 
removal of the gallstone which was causing the obstruction.  You 
were monitored in the intensive care unit after the surgery 
where you required intravenous medication to support your blood 
pressure.  You vital signs gradually improved and you were 
transferred to the surgical floor.  You are now preparing for 
discharge where you can regain your strength and mobility.   
 

###RESPONSE: nausea {Nausea}, cat scan {Computed tomography}, gallstone ileus {Gallstone ileus}, small 
bowel obstruction {Small bowel obstruction}, stomach {Stomach structure}, decompression {Decompression}, fluid 
entering your lungs {Pulmonary aspiration}, pneumonia {Pneumonia}, exploratory laparotomy {Exploratory laparotomy}, removal of the gallstone {Removal of gallstones from intestine}, obstruction {Intestinal obstruction}, surgery {Surgical procedure}, 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:   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:
hypoxia
 
Major Surgical or Invasive Procedure:
Radiation Treatments

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, hypoxia {Hypoxia}, Radiation {Radiation oncology AND/OR radiotherapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ M with history of SC lung cancer s/p RLL lobectomy ___, 
recent hospitalization with low back pain found to have new 
lesions in spine and hip, delerium, ARI improved with IVF, MSSA 
bacteremia/PNA discharged on Nafcillin to be completed ___, 
presents with sudden onset hypoxia this morning, with O2 sat 
dropping to 81% at rehab and associated shortness of breath. He 
was placed on 4L NC at that time. Notably patient also had some 
urinary retention yesterday when at the hospital to have 
radiation tattooing done, had a Foley placed yesterday, and he 
has had gross hematuria since. He was taken to ___ 
___ today where he was found to be anemic as well as to 
have a UTI, and an elevated troponin to .4 in the setting of 
atrial flutter/sinus tachycardia. Hct was also noted to drop 
from ___. H receved asa 162 mg, oxycodone 5mg, zofran 4mg and 
dilaudid 0.5 mg IV there.
.
Baseline sats at rehab have been ___ on 2L intermittently per 
patient. Today sat to ___ on 2L. Notes show right leg swelling 
U/S two days ago negative. 
.
Initial Vitals/Trigger: 97.6 114 179/95 19 97%6L. He denies 
chest pain or abdominal pain, however he does endorse shortness 
of breath which has somewhat resolved since he's been placed on 
a nasal cannula at 4 L.
.
EKG showed atrial flutter. He was guiaic negative. Ceftriaxone 
was given at 1245. Potassium was also give 1230 ___s 
Oxycodone. CTA showed b/l subsegmental PEs.  CT head with old 
lesions.
.
VS on transfer: afebrile 94 121/94 24 94% 2L.
.
On the floor, he denies ever having any shortness of breath, and 
attributes his recent symptoms to anxiety which has resolved.  
He denies any chest pain, and endorses a chronic cough which is 
unchanged with occasional sputum production. His hematuria began 
2 days ago, prior to that, he did not have dysuria.  He denies 
any f/c/n/v/diarrhea.  Also has bilateral ___ edema which is new. 
 Denies any new problems since transfer.
 

###RESPONSE: SC lung cancer {Squamous cell carcinoma of lung}, RLL lobectomy {Lobectomy of lower lobe of right lung}, low back pain {Low back pain}, lesions {Lesion}, spine {Structure of vertebral column}, hip {Hip region structure}, delerium {Delirium}, improved {Patient's condition improved}, IVF {Administration of intravenous fluids}, MSSA {Infection caused by methicillin susceptible Staphylococcus aureus}, bacteremia {Bacteremia caused by Staphylococcus aureus}, PNA {Pneumonia caused by methicillin susceptible Staphylococcus aureus}, hypoxia {Hypoxia}, O2 sat 
dropping to 81% {Oxygen saturation below reference range}, shortness of breath {Dyspnea}, NC {Oxygen administration by nasal cannula}, urinary retention {Retention of urine}, radiation {Radiation oncology AND/OR radiotherapy}, tattooing {Tattooing}, Foley placed {Catheterization of urinary bladder}, gross hematuria {Frank hematuria}, anemic {Anemia}, UTI {Urinary tract infectious disease}, elevated troponin {Troponin I above reference range}, atrial flutter {Atrial flutter}, sinus tachycardia {Sinus tachycardia}, IV {Intravenous therapy}, Baseline {Baseline state}, right leg swelling {Swelling of right lower limb}, U/S {Ultrasonography}, Vitals {Vital signs finding}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, shortness 
of breath {Dyspnea}, resolved {Problem resolved}, placed on 
a nasal cannula {Oxygen administration by nasal cannula}, EKG {Electrocardiographic procedure}, atrial flutter {Atrial flutter}, CTA {Computed tomography angiography with contrast}, PEs {Pulmonary emphysema}, CT head {Computed tomography of head}, lesions {Lesion}, VS {Vital signs finding}, afebrile {Fever}, shortness of breath {Dyspnea}, anxiety {Anxiety}, chest pain {Chest pain}, chronic cough {Chronic cough}, sputum production {Productive cough}, hematuria {Blood in urine}, dysuria {Dysuria}, f/c {Fever with chills}, n/v {Nausea and vomiting}, diarrhea {Diarrhea}, edema {Edema}, problems {Problem}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
-Squamous cell lung cancer: In remission for ___. s/p RLL 
resection, no chemo, radiation. 
-Head and neck cancer: Remote hx. Details unknown.
-HTN
-mild COPD 
-mild carotid stenosis
-Recent echo shows mild-moderate mitral valve stenosis/aortic 
stenosis with preserved EF
-hx of cardiac myxoma s/p resection with CVA

 

###RESPONSE: Squamous cell lung cancer {Squamous cell carcinoma of lung}, In remission {Malignant neoplasm in full remission}, RLL 
resection {Lobectomy of lower lobe of right lung}, chemo {Chemotherapy}, radiation {Radiation oncology AND/OR radiotherapy}, Head and neck {Structure of head and/or neck}, cancer {Malignant neoplasm}, HTN {Hypertensive disorder, systemic arterial}, COPD {Chronic obstructive lung disease}, carotid stenosis {Carotid artery stenosis}, echo {Echocardiography}, mild {Mild mitral valve stenosis}, moderate mitral valve stenosis {Moderate mitral valve stenosis}, aortic 
stenosis {Aortic valve stenosis}, cardiac myxoma {Myxoma of heart}, resection {Resection of neoplasm of heart}, CVA {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: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Daughter with breast cancer. Denies history of other cancers or
heart disease.

 

###RESPONSE: breast cancer {Malignant neoplasm of breast}, cancers {Malignant neoplasm}, heart disease {Heart 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: Physical Exam:
ON ADMISSION:
Vitals: 98.9, 97, 111/59, 65-90s, 18, 94/4L 
General: Alert, oriented, no acute distress, comfortable 
appearing  
HEENT: Sclera anicteric, MMM, oropharynx dry
Neck: supple, JVP elevated to earlobe
Lungs: b/l diffuse end expiratory high pitched wheeze loudest in 
upper lobes
CV: tachycardic rate and reg rhythm, normal S1 + S2, no murmurs, 
rubs, gallops  
Abdomen: soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding, no organomegaly  
GU: foley in place
Ext: warm, well perfused, 2+ pulses, b/l ___ edema pitting in R 
leg, greater than left
Neuro: CNS in tact, sensation and strength in tact upper and 
lower extremities, strength in left leg limited by left hip 
pain.
.
ON DISCHARGE:
Vitals: 96.5-97.6, 150-168/60-72, 76-83, ___, 94-97% 2L NC
General: Alert, oriented, no acute distress  
HEENT: Sclera anicteric, MMM, OP clear
Neck: supple, JVP elevated to earlobe
Lungs: b/l diffuse wheezing
CV: tachycardic rate and reg rhythm, normal S1 + S2, ___ SEM 
Abdomen: soft, non-tender, non-distended, bowel sounds (+) no 
rebound or guarding, no HSM
GU: foley
Ext: warm, well perfused, 2+ pulses, b/l ___ edema pitting in R 
leg, greater than left
Neuro: CNS in tact, sensation and strength in tact upper and 
lower extremities, strength in left leg limited by left hip 
pain.
 

###RESPONSE: Vitals {Vital signs finding}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx {Oropharyngeal structure}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, Lungs {Examination of respiratory system}, b/l {Lung structure}, expiratory high pitched wheeze {Expiratory wheezing}, upper lobes {Structure of upper lobe of lung}, CV {Cardiovascular physical examination}, tachycardic {Tachycardia}, reg rhythm {Finding of regularity of heart rhythm}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, foley in place {Urinary catheter in situ}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, edema {Edema}, R 
leg {Structure of right lower leg}, left {Structure of left lower leg}, Neuro {Neurological examination}, CNS in tact {Normal central nervous system}, sensation {Normal sensation}, upper {Upper limb structure}, lower extremities {Lower limb structure}, left leg {Structure of left lower leg}, left {Left hip region structure}, pain {Pain}, Vitals {Vital signs finding}, 2L NC {Oxygen administration by nasal cannula}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP elevated {Raised jugular venous pressure}, Lungs {Examination of respiratory system}, b/l {Lung structure}, wheezing {Wheezing}, CV {Cardiovascular physical examination}, tachycardic {Tachycardia}, reg rhythm {Finding of regularity of heart rhythm}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, SEM {Ejection murmur}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds (+) {Normal bowel sounds}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, HSM {Hepatosplenomegaly}, GU {Examination of genitourinary system}, Ext {Examination of limb}, warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, edema pitting {Pitting edema}, R 
leg {Structure of right lower leg}, left {Structure of left lower leg}, Neuro {Neurological examination}, CNS in tact {Normal central nervous system}, sensation {Normal sensation}, upper {Upper limb structure}, lower extremities {Lower limb structure}, left leg {Structure of left lower leg}, left {Left hip region structure}, hip 
pain {Hip pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Admission Labs:
___ 11:48AM BLOOD WBC-15.4* RBC-3.19* Hgb-9.4* Hct-27.1* 
MCV-85 MCH-29.6 MCHC-34.8 RDW-15.1 Plt ___
___ 11:48AM BLOOD Neuts-80.7* Lymphs-11.4* Monos-6.1 
Eos-1.1 Baso-0.7
___ 12:00PM BLOOD ___ PTT-25.0 ___
___ 11:48AM BLOOD UreaN-22* Creat-1.5* Na-138 K-3.3 Cl-95* 
HCO3-31 AnGap-15
___ 11:48AM BLOOD ALT-14 AST-21 AlkPhos-97 TotBili-0.4
___ 11:48AM BLOOD TotProt-6.9 Albumin-3.2* Globuln-3.7 
Calcium-8.9
___ 11:48AM BLOOD CEA-200*

Discharge Labs:
___ 07:05AM BLOOD WBC-8.8 RBC-3.31* Hgb-9.9* Hct-29.3* 
MCV-89 MCH-29.8 MCHC-33.6 RDW-15.8* Plt ___
___ 07:05AM BLOOD Glucose-147* UreaN-11 Creat-1.1 Na-135 
K-4.2 Cl-96 HCO3-33* AnGap-10
___ 07:05AM BLOOD ALT-19 AST-28 LD(LDH)-265* AlkPhos-80 
TotBili-0.6
___ 07:05AM BLOOD Albumin-3.0* Calcium-8.6 Phos-3.3 Mg-1.7

Imaging:
CT Chest:
IMPRESSION: 
1. Pulmonary emboli in the subsegmental branches of the left 
lower lobe and 
anterior left upper lobe with no evidence of right heart strain 
or pulmonary 
infarction. 
2. New patchy consolidation in the dependent portion of the 
right upper lobe 
likely represents pneumonia or aspiration. Ground glass 
opacities in a 
bronchovascular distribution in the left upper lobe may 
represent multifocal 
pneumonia or significant aspiration event. 
.
CT Head:
IMPRESSION:  
1. No brain metastases identified.  
2. There is no evidence of intra- or extra-axial hemorrhage; 
however, subtle 
subarachnoid hemorrhage cannot be excluded on this study due to 
circulating 
intravenous contrast. 
.
CXR:
FINDINGS: As compared to the previous radiograph, the right PICC 
line was 
removed. Status post right lower lobe resection with subsequent 
volume loss 
of the right lung. Presence of a minimal right pleural effusion 
cannot be 
excluded. 
  
No newly appeared parenchymal opacities. No pulmonary edema. No 
pneumonia.  
Unchanged asymmetry of the tracheal course through the 
mediastinum. 
.
___:
IMPRESSION: Peroneal calf veins not visualized in either lower 
extremities.  
Otherwise, no DVT present 
.
CXR:
Cardiomegaly and widened mediastinum are unchanged. Patient is 
status post 
right lower lobectomy. The lungs are grossly clear with the 
surgical clips 
projecting in the right medial upper hemithorax. Unchanged right 
apical 
pleural thickening and blunting of the right CP angle are likely 
postoperative 
changes. Aeration of the right lung has improved.
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, 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}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Imaging {Imaging}, CT Chest {Computed tomography of chest}, Pulmonary emboli {Pulmonary embolism}, left 
lower lobe {Structure of lower lobe of left lung}, anterior left upper lobe {Structure of anterior segment of upper division of left upper lobe of lung}, right heart {Structure of right side of heart}, pulmonary 
infarction {Pulmonary infarction}, consolidation {Consolidation}, right upper lobe {Structure of bronchus of right upper lobe}, pneumonia {Pneumonia}, aspiration {Pulmonary aspiration}, Ground glass 
opacities {Ground glass lung opacity}, left upper lobe {Structure of upper lobe of left lung}, pneumonia {Pneumonia}, aspiration {Pulmonary aspiration}, brain metastases {Metastatic malignant neoplasm to brain}, intra {Intracranial hemorrhage}, hemorrhage {Intracranial hemorrhage}, subarachnoid hemorrhage {Subarachnoid intracranial hemorrhage}, radiograph {Plain radiography}, right {Right atrial structure}, PICC 
line was 
removed {Removal of peripherally inserted central catheter}, right lower lobe resection {Lobectomy of lower lobe of right lung}, volume loss {Decreased size}, right lung {Right lung structure}, right {Right pleura structure}, pleural effusion {Pleural effusion}, opacities {Abnormally opaque structure}, pulmonary edema {Pulmonary edema}, pneumonia {Pneumonia}, mediastinum {Mediastinal structure}, Peroneal {Structure of peroneal vein}, lower 
extremities {Lower limb structure}, DVT {Deep venous thrombosis}, CXR {Plain chest X-ray}, Cardiomegaly {Cardiomegaly}, widened mediastinum {Widened mediastinum}, status post {Postoperative state}, right lower lobectomy {Lobectomy of lower lobe of right lung}, lungs {Lung structure}, clear {No abnormality detected}, surgical {Surgical procedure}, right {Right thorax structure}, hemithorax {Structure of half of thorax lateral to midsagittal plane}, right 
apical {Structure of apex of right lung}, pleural thickening {Thickening of pleura}, right {Structure of right common femoral artery}, CP angle {Structure of costophrenic angle}, postoperative {Postoperative state}, right lung {Right lung 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: Brief Hospital Course:
___ M with history of SC lung cancer s/p RLL lobectomy ___, 
recent hospitalization with low back pain found to have new 
lesions in spine and hip, delerium, ARI improved with IVF, MSSA 
bacteremia/PNA discharged on Nafcillin to be completed ___, 
presented with sudden onset hypoxia found to have bilateral 
subsegmental PEs, PNA and fluid overlead.
.
ACTIVE ISSUES:
# HYPOXIA: Initial deterioration was likely ___ PE and 
aspiration PNA. Patient was initially started heparin gtt then 
bridged to lovenox and was initially placed on Vanco/Zosyn. As 
patient became afebrile, he was placed on Augmentin and remained 
afebrile. ***LAST DAY OF ANTIBIOTICS WILL BE ON ___ Hypoxic 
continued despite adequate PE and PNA coverage; exam revealed 
hypervolemic state. Patient was diursed with IV lasix 20mg. 
Serum Bicarbonate started raising patient and diuresis 
terminated. Patient was briefly off oxygen however then 
restarted o2 at 2 liters. This remaining hypoxia was attributed 
to PE. Patient will remain on lovenox indefinitely. 
.
# LOWER EXTREMITY WEAKNESS/HIP PAIN/URINARY RETENTION: Symptoms 
were attributed bony metastasis. Patient started radiation 
therapy and will compelte treatments on ___. Patient was 
started on steroids to help with inflammation. Patient will 
remain on this dose of steroids until ___ then he can began 
taper (2mg Q12h for 3 days then 2mg Q24h then off). Outpatient 
oncology will reassess him to see if further treatments are 
necessary. Physical therapy saw patient and recommended 
rehabilitation for strength training. Foley holiday was 
attempted however patient continued to have retention of urine 
upto 1L. Foley was then replaced resulting in hematuria, likely 
___ trauma v. radiation cystitis. Hematocrit was stable and 
patient was hemodynamically stable. 
.
# HYPERTENSION: Patient was markedly hypertensive during this 
admission and amlodipine was started with better control of BP
.
# ELEVATED TROPONIN: Patient had initial troponin leak on 
admission likely ___ tachycardia and PE; there was associated 
EKG changes. No changes made to medications and no further 
interventions were needed.
.
# ATRIAL FLUTTER: On initially presentation, patient was 
elevated HR to 120s however with treatment of PE and continued 
use of metoprolol, patient had HR returned to normal.
.
# CODE STATUS: DNR/DNI
 

###RESPONSE: SC lung cancer {Squamous cell carcinoma of lung}, RLL lobectomy {Lobectomy of lower lobe of right lung}, low back pain {Low back pain}, lesions {Lesion}, spine {Structure of vertebral column}, hip {Hip region structure}, delerium {Delirium}, improved {Patient's condition improved}, IVF {Administration of intravenous fluids}, MSSA {Infection caused by methicillin susceptible Staphylococcus aureus}, bacteremia {Bacteremia caused by Staphylococcus aureus}, PNA {Pneumonia caused by methicillin susceptible Staphylococcus aureus}, hypoxia {Hypoxia}, PEs {Pulmonary emphysema}, PNA {Pneumonia}, fluid overlead {Hypervolemia}, HYPOXIA {Hypoxia}, PE {Pulmonary emphysema}, aspiration PNA {Aspiration pneumonia}, afebrile {Fever}, afebrile {Fever}, ANTIBIOTICS {Antibiotic therapy}, Hypoxic {Hypoxia}, PE {Pulmonary emphysema}, PNA {Pneumonia}, hypervolemic {Hypervolemia}, diursed {Diuresis}, IV {Intravenous therapy}, lasix {Diuretic therapy}, diuresis {Diuresis}, o2 {Oxygen therapy}, hypoxia {Hypoxia}, PE {Pulmonary emphysema}, LOWER EXTREMITY WEAKNESS {Paresis of lower extremity}, HIP PAIN {Hip pain}, URINARY RETENTION {Retention of urine}, bony metastasis {Metastatic malignant neoplasm to bone}, radiation 
therapy {Radiation oncology AND/OR radiotherapy}, steroids {Steroid therapy}, inflammation {Inflammatory disorder}, Outpatient {Outpatient care management}, Physical therapy {Physical therapy procedure}, rehabilitation {Rehabilitation therapy}, strength training {Exercise promotion: strength training}, Foley {Catheterization of urinary bladder}, retention of urine {Retention of urine}, Foley {Catheterization of urinary bladder}, hematuria {Blood in urine}, trauma {Injury of urinary tract proper}, radiation cystitis {Irradiation cystitis}, Hematocrit was stable {Stable hematocrit}, hemodynamically stable {Hemodynamically stable}, HYPERTENSION {Hypertensive disorder, systemic arterial}, hypertensive {Hypertensive disorder, systemic arterial}, ELEVATED TROPONIN {Troponin I above reference range}, tachycardia {Tachycardia}, PE {Pulmonary emphysema}, EKG changes {Electrocardiogram abnormal}, medications {Administration of drug or medicament}, ATRIAL FLUTTER {Atrial flutter}, elevated HR {Tachycardia}, PE {Pulmonary emphysema}, DNR {Not for resuscitation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:   per ___ form
 Lasix 20mg daily, last ___
 KCl 20meq daily, last ___
 Asa 81 mg daily, last ___
 Oxycontin 20mg BID, last 6am ___
 Hydralazine 50 mg BID, last ___
 Calcium carbonate 1250mg PO TID last ___
 Oxycodone 5mg PO Q3H prn, last ___
 Ativan 1mg PO Q8H prn last ___
 lidoderm 5% patch topically to left hip last ___ at 7am
 iron 325mg daily
 metoprolol tartrate 25 mg Tab BID
 colace 100mg BID prn 
 senna 1 tabe BID prn
 insulin humalog starting at 200 increase by 2 units every 50 up 
to 400

House regular Texture, Necture thick liquid

hydrochlorothiazide 25 mg daily (stopped ___
 nafcillin in D2.4W 2 gram/100 mL IV Piggy Back (stopped ___  
 plan to change to Dicloxacillin 500 mg qid through ___

 
Discharge Medications:
1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily).  
3. hydralazine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times 
a day).  
4. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) 
Tablet PO Q12H (every 12 hours): Last dose on ___.  
5. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) 
Tablet Extended Release 12 hr PO Q8H (every 8 hours).  
6. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO Q8H (every 8 
hours) as needed for anxiety.  
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: 
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).  
8. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One 
(1) Tablet PO TID (3 times a day).  
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID 
(2 times a day).  
10. enoxaparin 100 mg/mL Syringe Sig: One (1) syringe 
Subcutaneous Q12H (every 12 hours).  
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)  
PO DAILY (Daily) as needed for constipation.  
12. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
13. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 
hours) as needed for pain.  
14. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 
12 hours).  
15. insulin lispro 100 unit/mL Solution Sig: One (1) bottle 
Subcutaneous QACHS: For ___ 150-200 give 2 units; if 201-250 give 
4 units, if 251-300 give 6 units, for 301-350 give 8 units, if > 
350 alert MD; At bed time, give 1 unit 201-250, give 2 units for 
251-300, give 3 units for 301-350, alert MD for > 350.  
16. guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6 
hours) as needed for cough.  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Pulmonary Emboli
Aspiration Pneumonia
Metastatic Lung Cancer

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or 
wheelchair.

 

###RESPONSE: Pulmonary Emboli {Pulmonary embolism}, Aspiration Pneumonia {Aspiration pneumonia}, Metastatic {Metastatic malignant neoplasm}, Lung Cancer {Malignant tumor of lung}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Out of Bed with assistance {Difficulty getting off a bed}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 because you were having shortness of breath. 
When you were admitted you were found to have blood clots in 
your lungs. You were started on a blood thinning medication to 
help stabilize the clots. You will remain this medication 
indefinitely. You were also diagnosed pneumonia and placed on 
antibiotics. You also have fluid in your lungs which we used 
lasix to help remove the fluid. You however still require oxygen 
which may be a result of your the lung clots.

You began your radiation treatments while you were in the 
hospital for your hip pain and urinary retention. You had 4 of 
the 5 treatments and will return on ___ for your final 
treatment. You will be followed by your oncologist to determine 
if you need treatment. We are expecting you to start feeling 
better in ___ weeks. In the mean time you will be going to an 
excellent rehabilitation center to get stronger.

You continue to have urinary retention likely from your cancer. 
A catheter remains in your bladder to help drain the urine. 
There is some blood in your urine from the catheter insertion 
and should resolve within a few days.

Please see the attached sheet for your medications. Please take 
them as directed
 

###RESPONSE: shortness of breath {Dyspnea}, blood clots {Blood clot}, lungs {Lung structure}, blood thinning medication {Administration of anticoagulant}, clots {Blood clot}, medication {Administration of drug or medicament}, pneumonia {Pneumonia}, antibiotics {Antibiotic therapy}, fluid in your lungs {Pleural effusion}, lasix {Diuretic therapy}, lung clots {Pulmonary embolism}, radiation {Radiation oncology AND/OR radiotherapy}, hip pain {Hip pain}, urinary retention {Retention of urine}, feeling 
better {Well in self}, rehabilitation {Rehabilitation therapy}, urinary retention {Retention of urine}, cancer {Malignant neoplasm}, catheter remains in your bladder {Urinary catheter in situ}, blood in your urine {Blood in urine}, catheter insertion {Catheterization of urinary bladder}, medications {Administration of drug or medicament}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: CARDIOTHORACIC
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Codeine / Quinine
 
Attending: ___
 
Chief Complaint:
non-small cell lung cancer
 
Major Surgical or Invasive Procedure:
video assisted cervical mediastinoscopy, flexible bronchoscopy

 

###RESPONSE: Codeine {Allergy to codeine}, Quinine {Allergy to quinine}, non-small cell lung cancer {Non-small cell lung cancer}, cervical mediastinoscopy {Cervical mediastinoscopy}, flexible bronchoscopy {Flexible bronchoscopy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Mr. ___ is a ___ current ___ py smoker, hx Hep C & HCC s/p
liver transplant ___, with 3cm RUL PET-avid nodule with
pathology showing non-small cell carcinoma, here for follow-up.

He has been asymptomatic since previous visit. No SOB, cough. No
fevers, chills, nightsweats. He had EBUS which biopsied lesion
showing non-small cell carcinoma. Lymph nodes were not biopsied. 

PET negative for distant metastasis.
 

###RESPONSE: smoker {Smoker}, Hep C {Viral hepatitis type C}, HCC {Liver cell carcinoma}, liver transplant {Transplantation of liver}, RUL {Structure of upper lobe of right lung}, PET {Positron emission tomography}, nodule {Nodule}, non-small cell carcinoma {Non-small cell carcinoma}, asymptomatic {Asymptomatic}, SOB {Dyspnea}, cough {Cough}, fevers {Fever}, chills {Chill}, nightsweats {Night sweats}, biopsied {Biopsy}, lesion {Lesion}, non-small cell carcinoma {Non-small cell carcinoma}, Lymph nodes {Structure of lymph node}, biopsied {Biopsy}, PET {Positron emission tomography}, distant metastasis {Distant metastasis 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: Past Medical History:
HEPATITIS C (genotype 1a, no sequelae of chronic liver disease 
at this point, stage III fibrosis on biopsy; now s/p liver 
transplant)                                                  
HEPATOCELLULAR CARCINOMA (s/p RFA on ___ to segment VIa 
lesion; now s/p liver transplant)                                
     
HYPERTENSION                                                     
                                                   
LUNG NODULE                                                     
DIABETES MELLITUS                                                
                                              
H/O ALCOHOL ABUSE                                               
H/O INTRAVENOUS DRUG ABUSE    
 

###RESPONSE: HEPATITIS C {Viral hepatitis type C}, genotype {Genotype determination}, no sequelae {Sequelae of disorders}, chronic liver disease {Chronic liver disease}, fibrosis {Fibrosis of lung}, biopsy {Biopsy}, liver 
transplant {Transplantation of liver}, HEPATOCELLULAR CARCINOMA {Hepatocellular carcinoma}, RFA {Radiofrequency ablation}, lesion {Lesion}, liver transplant {Transplantation of liver}, HYPERTENSION {Hypertensive disorder, systemic arterial}, LUNG NODULE {Nodule of lung}, DIABETES MELLITUS {Diabetes mellitus}, ALCOHOL ABUSE {Alcohol abuse}, DRUG ABUSE {Drug abuse}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Positive for a mother with stomach cancer diagnosed at age of ___ 
and father with diabetes and also alcoholic with diabetes and 
coronary artery disease. 
 

###RESPONSE: stomach cancer {Malignant tumor of stomach}, diabetes {Diabetes mellitus}, alcoholic {Problem drinker}, diabetes {Diabetes mellitus}, coronary artery disease {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:
Gen: Awake, alert, NAD 
CV: +RRR
Chest: incisions and dressing over prior CT site c/d/i 
Resp: Normal WOB, no distress on 2L NC; +CTAB, no wheezes or 
crackles
Abdomen: Soft, non-distended, non-TTP 
Ext: Warm, well-perfused 

 

###RESPONSE: Gen {General examination of patient}, Awake {Awake}, alert {Mentally alert}, NAD {No abnormality detected}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, Chest {Examination of respiratory system}, incisions {Surgical incision wound}, dressing {Application of dressing}, Resp {Examination of respiratory system}, WOB {Labored breathing}, distress {Distress}, NC {Normal head}, CTAB {Normal breath sounds}, wheezes {Wheezing}, crackles {Respiratory crackles}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, non-distended {Normal abdominal contour}, TTP {Tenderness}, Ext {Examination of limb}, Warm {Warm skin}, well-perfused {Normal tissue perfusion}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ Liver Doppler US:
IMPRESSION: 
  
1. Patent transplant hepatic vasculature with appropriate 
waveforms. 
2. Unremarkable appearance of the transplant liver with no 
biliary dilatation. 
3. Small left pleural effusion noted. 

GRAM STAIN (Final ___: 
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR 
LEUKOCYTES. 
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE DIPLOCOCCI. 

   RESPIRATORY CULTURE (Final ___: 
      ~3000 CFU/mL Commensal Respiratory Flora. 
      MORAXELLA CATARRHALIS.    >100,000 CFU/mL. 

 

###RESPONSE: Liver {Liver structure}, Doppler US {Doppler ultrasonography}, transplant {Structure of transplant}, hepatic vasculature {Vascular structure of liver}, transplant {Structure of transplant}, liver {Liver structure}, biliary dilatation {Hypertrophy of bile duct}, left {Left lung structure}, pleural effusion {Pleural effusion}, GRAM STAIN {Gram stain method}, CULTURE {Microbial culture}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ presented to ___ pre-op holding on ___ and 
underwent video assisted right upper lobectomy and flexible 
bronchoscopy (please see operative note for details). Patient 
was extubated post procedure, however in the OR, he became 
dyspneic, moving minimal air. He was reintubated given his 
respiratory distress and transferred to the ICU (___). 
The details of his/her course are as follows:

Neuro: Given history of chronic pain on home suboxone, patient 
was maintained on Tylenol and narcotics and the suboxone was 
held. He was ultimately discharged with a supply of oxycodone 
called to his pharmacy to last until his next appointment with 
his PCP ___ ___. 

CV: History of hypertension, continued on home lisinopril and 
carvedilol. Remained hemodynamically stable, no active issues. 

Pulm: Respiratory distress was likely secondary to lung 
contusion when attempting to remove specimen, as well as post op 
pain. He was extubated on POD1. He underwent bedside 
bronchoscopies for clearing of mucous plugs, with BAL (___) 
growing Moraxella. Both ___ drain and chest tube was put to 
water seal on POD1. ___ drain was pulled on POD5, chest tube 
was pulled on POD9, both with stable post pull films. His 
progress was monitored with daily CXR. Encouraged IS, 
ambulation. 

FEN/GI: Transplant hepatology following, given his history of 
___ s/p liver transplant. He was continued on home tacrolimus 
dosing with monitoring of tacrolimus levels (goal ___ and LFTs. 
Liver duplex was done due to persistently elevated LFTs per 
hepatology recs, which showed no abnormalities. LFTs continued 
to trend down. Follow up was set up with transplant hepatology 
to recheck labs outpatient. Once extubated, diet was advanced as 
tolerated. He tolerated a regular diet without nausea/vomiting 
and was passing flatus and stool appropriately. 

GU: He was able to void spontaneously without issue after foley 
removal. Initial ___ with Cr 1.8 post op, which returned to his 
baseline. History of CKD with baseline Cr 1.3-1.5.  

Heme: H/H remained stable and he did not require any 
transfusions. He was kept on prophylactic SQH while inpatient. 

ID: He was treated with azithromycin x5 days for Moraxella 
growing on BAL. 

Dispo: He worked with physical therapy with a final 
recommendation for discharge to home with home ___ services.  

By day of discharge on ___, he was hemodynamically stable, 
pain was well controlled on oral medications, he was tolerating 
a regular diet without issue, and was ready for discharge.

 

###RESPONSE: right upper lobectomy {Lobectomy of upper lobe of right lung}, flexible 
bronchoscopy {Flexible bronchoscopy}, extubated {Removal of endotracheal tube}, procedure {Procedure}, dyspneic {Dyspnea}, moving minimal air {Difficulty breathing}, reintubated {Intubation}, respiratory distress {Respiratory distress}, Neuro {Neurology service}, chronic pain {Chronic pain}, CV {Cardiovascular physical examination}, hypertension {Hypertensive disorder, systemic arterial}, hemodynamically stable {Hemodynamically stable}, Pulm {Examination of respiratory system}, Respiratory distress {Respiratory distress}, lung {Metastatic malignant neoplasm to lung}, contusion {Contusion}, pain {Abdominal pain}, extubated {Removal of endotracheal tube}, bronchoscopies {Bronchoscopy}, CXR {Plain chest X-ray}, GI {Structure of digestive system}, Transplant {Transplantation}, liver transplant {Transplantation of liver}, LFTs {Hepatic function panel}, Liver {Liver structure}, elevated {Elevation}, LFTs {Hepatic function panel}, abnormalities {No abnormality detected}, LFTs {Hepatic function panel}, transplant {Transplantation}, extubated {Removal of endotracheal tube}, diet {Dietary finding}, regular diet {Normal diet}, nausea/vomiting {Nausea and vomiting}, passing flatus {Passing flatus}, GU {Examination of genitourinary system}, able to void {Normal micturition}, foley 
removal {Removal of urinary bladder catheter}, CKD {Chronic kidney disease}, Heme {Hematology test}, H {Hemoglobin finding}, stable {Patient's condition stable}, transfusions {Transfusion}, ID {Infectious disease}, physical therapy {Physical therapy procedure}, hemodynamically stable {Hemodynamically stable}, pain was well controlled {Demonstrates adequate pain control}, oral medications {Administration of drug or medicament via oral route}, regular diet {Normal diet}, ready for discharge {Ready for discharge}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list may be inaccurate and requires 
further investigation.
1. Lisinopril 5 mg PO DAILY 
2. Nicotine Patch 21 mg/day TD DAILY 
3. Nicotine Polacrilex 4 mg PO Q2H:PRN cigarette craving 
4. CARVedilol 25 mg PO BID 
5. Tacrolimus 1.5 mg PO QAM 
6. docosahexanoic acid-epa 120-180 mg oral DAILY 
7. Multivitamins 1 TAB PO DAILY 
8. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL BID 
9. sildenafil 25 mg oral DAILY:PRN ED 
10. Calcium 500 + D (calcium carbonate-vitamin D3) 500 
mg(1,250mg) -400 unit oral BID 
11. Tacrolimus 1 mg PO QPM 
12. Chantix Starting Month Box (varenicline) 0.5 mg (11)- 1 mg 
(42) oral ASDIR 

 
Discharge Medications:
1.  OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain - Severe 

  Reason for PRN duplicate override: Alternating agents for 
similar severity
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours 
Disp #*12 Tablet Refills:*0 
2.  Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL BID 
Consider prescribing naloxone at discharge  
3.  Calcium 500 + D (calcium carbonate-vitamin D3) 500 
mg(1,250mg) -400 unit oral BID  
4.  CARVedilol 25 mg PO BID  
5.  Chantix Starting Month Box (varenicline) 0.5 mg (11)- 1 mg 
(42) oral ASDIR  
6.  docosahexanoic acid-epa 120-180 mg oral DAILY  
7.  Lisinopril 5 mg PO DAILY  
8.  Multivitamins 1 TAB PO DAILY  
9.  Nicotine Patch 21 mg/day TD DAILY  
10.  Nicotine Polacrilex 4 mg PO Q2H:PRN cigarette craving  
11.  sildenafil 25 mg oral DAILY:PRN ED  
12.  Tacrolimus 1.5 mg PO QAM  
13.  Tacrolimus 1 mg PO QPM  

 

###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:
right upper lobe non-small cell lung cancer

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: right upper lobe {Structure of upper lobe of right lung}, non-small cell lung cancer {Non-small cell lung cancer}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
* You were admitted to the hospital for lung surgery and you've 
recovered well. You are now ready for discharge.  

* Continue to use your incentive spirometer 10 times an hour 
while awake.

* Check your incisions daily and report any increased redness or 
drainage.   Cover the area with a gauze pad if it is draining.

* Your chest tube dressing may be removed in 48 hours.  If it 
starts to drain, cover it with a clean dry dressing and change 
it  as needed to keep site clean and dry.

* You may need pain medication once you are home but you can 
wean it over the next week as the discomfort resolves.  Make 
sure that you have regular bowel movements while on narcotic 
pain medications as they are constipating which can cause more 
problems.  Use a stool softener or gentle laxative to stay 
regular.

* No driving while taking narcotic pain medication.

* Take Tylenol on a standing basis to avoid more opiod use.

* Continue to stay well hydrated and eat well to heal your 
incisions

* Shower daily. Wash incision with mild soap & water, rinse, pat 
dry
 * No tub bathing, swimming or hot tubs until incision healed
 * No lotions or creams to incision site

* Walk ___ times a day and gradually increase your activity as 
you can tolerate.

Call Dr. ___ ___ if you experience:
 -Fevers > 101 or chills
 -Increased shortness of breath, chest pain or any other 
symptoms that concern you.

** If pathology specimens were sent at the time of surgery, the 
reports will be reviewed with you in detail at your follow up 
appointment. This will give both you and your doctor time to 
understand the pathology, its implications and discuss options 
going forward.**

 
 

###RESPONSE: lung {Lung structure}, surgery {Surgical procedure}, ready for discharge {Ready for discharge}, incisions {Surgical incision wound}, redness {Redness of skin over lesion}, drainage {Discharge}, draining {Discharge}, removed {Removal of dressing}, drain {Discharge}, dressing {Application of dressing}, pain medication {Administration of analgesic}, discomfort {Discomfort}, pain medications {Administration of analgesic}, constipating {Constipation}, problems {Problem}, stool softener {Administration of laxative}, regular {Normal heart rate}, while taking narcotic pain medication {Narcotics education}, incision {Surgical incision wound}, incision {Surgical incision wound}, Fevers {Fever}, chills {Chill}, shortness of breath {Dyspnea}, chest pain {Chest pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___              Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   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:
fever
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, fever {Fever}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
HISTORY OF PRESENTING ILLNESS:
Mr. ___ is a ___ male with asplenia,
polycythemia ___, and secondary AML with CNS disease s/p allo
SCT (D0 = ___ with relapsed disease s/p 3 cycles of
decitabine/venetoclax and DLI on ___ currently on ___
with recent admission for pneumonia who presents with fever.

Patient was recently admitted ___ to ___ with right lower lobe
pneumonia in the setting of neutropenia. He was treated with
14-day course of meropenem and vancomycin. Infectious work-up,
including bronchoscopy, was unrevealing. Hospitalization was
complicated by transaminitis, presumed to be due to drug-induced
liver injury, and persistent thrombocytopenia requiring several
transfusions. He was also seen by dermatology for new nodules on
his lower extremities and had a biopsy. Repeat chest imaging
prior to discharge showed resolving right lower lobe pneumonia
containing a fluid filled pneumatocele or early lung abscess. He
was discharged to complete a further 14-day course of
levofloxacin and metronidazole.

He reports fever to ___ yesterday and 101.7 the morning of
admission. He notes feeling more flushed. He also notes mild
rhinorrhea over past few days which seems to be improving as 
well
as right ear discomfort. He also notes some right lung pain 
which
feels different and less intense then the pain he had prior to
his last admission. The notes a mild cough, poor appetite, and
chronic right foot neuropathy.

On arrival to the ED, initial vitals were 98.3 86 113/85 20 98%
RA. Exam was unremarkable. Labs were notable for WBC 6.9 (ANC
100), H/H 7.7/24.0, Plt 12, INR 1.6, fibrinogen 761, Na 137, K
4.1, BUN/Cr ___, ALP 266, LDH 317, and lactate 1.6. Influenza
PCR was negative. CXR showed worsening right lower lobe
consolidative opacity. Patient was given cefepime 2g IV and
flagyl 500mg IV. Prior to transfer vitals were 99.2 100 122/70 
16
96% RA.

On arrival to the floor, patient endorses the above history. He
has no acute issues or concerns. He headache, vision changes,
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, hemoptysis, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, and hematuria.
 

###RESPONSE: asplenia {Asplenia}, polycythemia {Erythrocytosis}, secondary {Metastatic malignant neoplasm}, AML {Acute myeloid leukemia}, CNS disease {Disorder of the central nervous system}, allo
SCT {Allogeneic peripheral blood stem cell transplant}, relapsed {Relapsing acute myeloid leukemia}, disease {Disease}, pneumonia {Pneumonia}, fever {Fever}, right lower lobe
pneumonia {Right lower zone pneumonia}, neutropenia {Neutropenia}, vancomycin {Antibiotic therapy}, Infectious {Infectious disease}, work-up {Evaluation procedure}, bronchoscopy {Bronchoscopy}, transaminitis {Aspartate transaminase level above reference range}, drug-induced
liver injury {Drug-induced disorder of liver}, thrombocytopenia {Thrombocytopenic disorder}, transfusions {Transfusion}, nodules {Nodule}, lower extremities {Lower limb structure}, biopsy {Biopsy}, chest imaging {Chest imaging}, right lower lobe pneumonia {Right lower zone pneumonia}, fluid {Effusion}, pneumatocele {Air cyst}, lung abscess {Abscess of lung}, fever {Fever}, mild {Symptom mild}, rhinorrhea {Nasal discharge}, right ear {Right ear structure}, discomfort {Discomfort}, right lung {Right lung structure}, pain {Pain}, pain {Pain}, mild {Symptom mild}, cough {Cough}, poor appetite {Decrease in appetite}, chronic {Chronic disease}, right foot {Structure of right foot}, neuropathy {Neuropathy}, vitals {Vital signs finding}, RA {Breathing room air}, unremarkable {No abnormality detected}, WBC {White blood cell count}, H/H {Measurement of total hemoglobin concentration and hematocrit}, INR {Calculation of international normalized ratio}, LDH {Serum total lactate dehydrogenase measurement}, lactate {Lactic acid measurement}, Influenza
PCR {Detection of Influenza A virus using polymerase chain reaction technique}, CXR {Plain chest X-ray}, right lower lobe {Structure of lower lobe of right lung}, consolidative {Lung consolidation}, opacity {Abnormally opaque structure}, vitals {Vital signs finding}, RA {Breathing room air}, headache {Headache}, vision changes {Visual disturbance}, dizziness {Dizziness}, lightheadedness {Lightheadedness}, weakness {Asthenia}, numbnesss {Numbness}, shortness of
breath {Dyspnea}, hemoptysis {Hemoptysis}, chest pain {Chest pain}, palpitations {Palpitations}, abdominal pain {Abdominal pain}, nausea/vomiting, diarrhea {Nausea, vomiting and diarrhea}, hematemesis {Hematemesis}, hematochezia {Hematochezia}, melena {Melena}, 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:
PAST ONCOLOGIC HISTORY:
- ___: Initial BMBx, dx AML 
- ___: Leukopheresis
- ___: Induction Therapy 7+3 cytarabine + daunorubicin
- ___: Hypercellular marrow with extensive fibrosis, 5%
blasts
- ___: IT Ara-C, TNC2 postive cytospin
- ___: Triple therapy TNC 1, negative cytospin
- ___: Triple therapy TNC 1 negative cytospin
- ___: Triple therapy TNC 1 negative cytospin
- ___: Triple therapy TNC 6 negative cytospin
- ___: Admitted for URD ablative Allogeneic stem cell
transplant with Fludarabine/Busulfan for conditioning regimen.
Day 0 = ___. Enrolled into ___.
- ___: BMBX D+24, PB Chimerism CD33 100 D, CD3 70%. BM JAK2
1%
- ___: BM Chimerism D87% (CD33 100 CD3 D68%)
- ___: BM Chimerism D91% (DCD33 100 CD3 D68%)
- ___ apheresis unsuccessful
- ___: PB chimersims D93% (CD33 100, CD3 80%)
- ___: RLE DVT started on LMWH
- ___: PB chimersims D97% (CD33 99, CD3 97%)
- ___: BMBX 8% blasts, Stoped tacrolimus
- ___: C1D1 Dacogen/Venetoclax
- ___: C2D1 Dacogen/Venetoclax
- ___: DLI
- ___: C3D1 Dacogen/Venetoclax

Polycythemia ___ as described above
-CAD status post PCI
___ Splenectomy 
 

###RESPONSE: BMBx {Bone marrow sampling}, AML {Acute myeloid leukemia}, Leukopheresis {Leukopheresis}, Therapy {Therapy}, fibrosis {Fibrosis}, Allogeneic stem cell
transplant {Allogeneic peripheral blood stem cell transplant}, regimen {Therapeutic regimen}, BMBX {Bone marrow sampling}, Chimerism {Cellular mosaicism}, BM {Bone marrow structure}, BM {Bone marrow structure}, Chimerism {Cellular mosaicism}, BM {Bone marrow structure}, Chimerism {Cellular mosaicism}, apheresis {Apheresis}, RLE {Structure of right lower limb}, DVT {Deep venous thrombosis}, BMBX {Bone marrow sampling}, Polycythemia {Erythrocytosis}, CAD {Coronary arteriosclerosis}, status post {Postoperative state}, PCI {Percutaneous coronary intervention}, Splenectomy {Splenectomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother with polycythemia ___.
 

###RESPONSE: polycythemia {Erythrocytosis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: Temp 99.6, BP 118/69, HR 89, RR 18, O2 sat 97% RA.
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, no murmurs.
LUNG: Appears in no respiratory distress, right basilar rhonchi.
ABD: Soft, non-tender, non-distended, positive bowel sounds,.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: Multiple pink-to-violaceous firm papules on bilateral 
lower
extremities as well as several on bilateral upper extremities.

DISCHARGE PHYSICAL EXAM:
moderate distress apneic restless at times
 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, GENERAL {General examination of patient}, distress {Distress}, lying in bed {Lying in bed}, HEENT {Physical examination procedure}, Anicteric {White sclera}, PERLL {Pupils equal, react to light and accommodation}, OP clear {Pharynx normal}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, murmurs {Murmur}, LUNG {Examination of respiratory system}, distress {Distress}, right basilar {Structure of base of right lung}, rhonchi {Wheeze - rhonchi}, ABD {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, positive bowel sounds {Normal bowel sounds}, EXT {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, edema {Edema}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, attention {Finding related to attentiveness}, sensation intact {Normal sensation}, SKIN {Examination of skin}, papules {Papule}, bilateral 
lower
extremities {Both lower extremities}, bilateral upper extremities {Both upper extremities}, moderate {Symptom moderate}, distress {Distress}, apneic {Apnea}, restless {Restlessness}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 05:55PM BLOOD WBC: 6.9 RBC: 2.46* Hgb: 7.7* Hct: 24.0*
MCV: 98 MCH: 31.3 MCHC: 32.1 RDW: 16.6* RDWSD: 54.1* Plt Ct: 12*
___ 05:55PM BLOOD Neuts: 1* Lymphs: ___ Monos: 9 Eos: 1 
Baso:
0 Blasts: 69* NRBC: 108.0* AbsNeut: 0.10* AbsLymp: 1.92 AbsMono:
0.62 AbsEos: 0.07 AbsBaso: 0.00*
___ 05:55PM BLOOD ___: 17.2* PTT: 30.2 ___: 1.6*
___ 05:55PM BLOOD Fibrino: ___
___ 05:55PM BLOOD Glucose: 104* UreaN: 14 Creat: 0.8 Na: 
137
K: 4.1 Cl: 99 HCO3: 26 AnGap: 12
___ 05:55PM BLOOD ALT: 22 AST: 33 LD(LDH): 317* AlkPhos:
266* TotBili: 0.8
___ 05:55PM BLOOD Albumin: 3.4*
___ 06:16PM BLOOD Lactate: 1.6

DISCHARGE LABS
none-CMO
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hct {Hematocrit determination}, BLOOD Glucose {Glucose measurement, blood}, TotBili {Bilirubin, total measurement}, Lactate {Lactic acid measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Mr. ___ is a ___ male with asplenia, 
polycythemia ___, and secondary AML with CNS disease s/p allo 
SCT (D0 = ___ with relapsed disease s/p 3 cycles of 
decitabine/venetoclax and DLI on ___ most recently on 
Ivisidenib with recent admission for pneumonia who presented 
with febrile neutropenia with persistent RLL pneumonia with 
course c/b SVT with unfortunate overwhelming infection now 
transitioned to comfort measures only and transition to home 
hospice.

ACUTE CONDITIONS
==================== 

#RIGHT LOWER LOBE PNEUMONIA: 
#FEBRILE NEUTROPENIA (Fevers persist]: 
Patient is status post recent prolonged admission with right 
lobe pneumonia that was concerning for possible abscess as well 
as viral or fungal etiology. BAL and induced sputum studies were 
negative at the time. He recently completed prolonged course of
antibiotics; however, he was re-admitted with febrile 
neutropenia and persistent RLL pneumonia concerning of fungal 
etiology on imaging vs. lung abscess formation per ID. Further 
work up of PNA with urine legionella (neg), strep pneumo (neg), 
MRSA (neg) and parvovirus (neg). Sinus CT ___ obtained for 
continued sinus
pressure showed a right obstructive sinusitis. He was started on 
IV Vancomycin (D1 ___ and IV Ceftaz 2gm Q8 hours 
(D1 ___. Beta glucan elevated at 424, could be 
false elevation, galactomannan negative. Repeat BD glucan 
negative, Asp galactomannan ___ PND. MRSA negative; 
therefore, vancomycin
was discontinued. Patient had continued fevers, which prompted 
re-imaging on ___. Chest CT showed progression of pneumonia, 
now involving majority of the right lower lobe with surrounding 
ground-glass opacities. Given concern for fungal pneumonia, 
patient was started on Ambisone. ID re-consulted ___, recs 
biopsy and induced sputum. Per ID, would need biopsy of his RLL 
consolidation but deferred in light of profound TCP and GOC.

Unfortunately, patient developed worsening pulmonary symptoms 
(increased WOB ___ and tachycardia) and his 
antibiotics was escalated from ceftazidime to meropenem (D1: 
___. He also developed new SVT which may have 
exacerbated his pulmonary symptoms. He was given Solumedrol 50mg 
IVPx1 and was continued daily through ___, d/c'd as has not 
been efficacious for his pulmonary symptoms. Given ongoing high 
fevers, added Linezolid (D1 ___. Chest CT showed 
worsening PNA on ___, after discussing the results with 
primary oncologist, patient decided to transition care from 
aggressive treatment to focus on symptom management and comfort. 
His antibiotics were discontinued on ___ and he was started 
on Morphine IV/PO for dyspnea management. He was discharged home 
on ___ and after multiple discussions, agreed to home with 
hospice services.
-per palliative recommendations will be discharged home with: 
morphine ___ po suspension q2 prn, Ativan 0.5-1mg po q4 prn, 
Tylenol ___ po prn.

#RELAPSED AML: He is s/p allogeneic SCT (D0 = ___ with 
relapsed disease s/p 3 cycles of decitabine/venetoclax and DLI 
on ___. BMBx ___ consistent with persistent leukemia, 
based on (+)IDH1 mutation. He was started on ivosidenib ___, 
and venetoclax was stopped. Patient w/ lesions to extremities 
that
was concerning for leukemia cutis. Dermatology biopsied site on 
___ result c/w leukemia cutis. Given persistent PNA despite 
ABX and progressive disease, had GOC discussion with primary 
oncologist on ___ and patient was made DNR/DNI, and on 
___ as above with transition to CMO. 

#DISCHARGE PLANNING: patient with difficult non compliance in 
the past and patient was eager to leave the hospital ASAP ___ 
AM. He initially was refusing home services, including hospice 
care but after discussion with RN, SW, palliative team agreed to 
go home with hospice services. Initially consulted ethics and 
psychiatry with concern of patient leaving AMA however after 
multiple discussions with ___ team patient agreed to resuming 
hospice services and abiding by recommendations. Patient had 
safety evaluation before discharge and appropriate to discharge 
home with hospice. 

d/c planning > 30 min

 

###RESPONSE: asplenia {Asplenia}, polycythemia {Erythrocytosis}, secondary {Metastatic malignant neoplasm}, AML {Acute myeloid leukemia}, CNS disease {Disorder of the central nervous system}, allo 
SCT {Allogeneic peripheral blood stem cell transplant}, relapsed {Relapsing acute myeloid leukemia}, disease {Disease}, pneumonia {Pneumonia}, febrile neutropenia {Febrile neutropenia}, RLL pneumonia {Right lower zone pneumonia}, SVT {Supraventricular tachycardia}, infection {Infectious disease}, comfort measures {Comfort measures}, RIGHT LOWER LOBE PNEUMONIA {Right lower zone pneumonia}, FEBRILE NEUTROPENIA {Febrile neutropenia}, Fevers {Fever}, status post {Postoperative state}, right 
lobe pneumonia {Right lower zone pneumonia}, abscess {Abscess of lung}, viral {Viral disease}, fungal {Mycosis}, induced sputum {Collection of induced sputum}, antibiotics {Antibiotic therapy}, febrile 
neutropenia {Febrile neutropenia}, RLL pneumonia {Right lower zone pneumonia}, fungal {Mycosis}, imaging {Imaging}, lung abscess {Abscess of lung}, PNA {Pneumonia}, urine {Evaluation of urine specimen}, legionella {Legionella infection}, MRSA {Methicillin resistant Staphylococcus aureus infection}, parvovirus {Parvovirus infection}, Sinus {Nasal sinus structure}, CT {Computed tomography}, sinus
pressure {Sensation of nasal sinus pressure}, right {Right sphenoid sinus structure}, obstructive sinusitis {Obstructive sinusitis}, Vancomycin {Antibiotic therapy}, MRSA {Methicillin resistant Staphylococcus aureus infection}, vancomycin {Antibiotic therapy}, fevers {Fever}, imaging {Imaging}, Chest CT {Computed tomography of chest}, pneumonia {Pneumonia}, right lower lobe {Structure of lower lobe of right lung}, ground-glass opacities {Ground glass lung opacity}, fungal pneumonia {Fungal pneumonia}, biopsy {Biopsy}, induced sputum {Collection of induced sputum}, biopsy {Biopsy}, RLL {Structure of lower lobe of right lung}, consolidation {Consolidation}, TCP {Thrombocytopenic disorder}, worsening pulmonary symptoms {Decreased respiratory function}, WOB {Labored breathing}, tachycardia {Tachycardia}, antibiotics {Antibiotic therapy}, SVT {Supraventricular tachycardia}, exacerbated his pulmonary symptoms {Decreased respiratory function}, pulmonary {Structure of respiratory system}, fevers {Fever}, Chest CT {Computed tomography of chest}, PNA {Pneumonia}, symptom management {Symptom management}, antibiotics {Antibiotic therapy}, dyspnea {Dyspnea}, discussions {Discussion}, RELAPSED AML {Relapsing acute myeloid leukemia}, allogeneic SCT {Allogeneic peripheral blood stem cell transplant}, relapsed {Relapsing acute myeloid leukemia}, disease {Disease}, BMBx {Bone marrow sampling}, leukemia {Leukemia}, mutation {Genetic mutation}, lesions {Skin lesion}, extremities {All extremities}, leukemia cutis {Leukemic infiltration of skin}, Dermatology biopsied {Biopsy of skin}, leukemia cutis {Leukemic infiltration of skin}, PNA {Pneumonia}, ABX {Antibiotic therapy}, disease {Disease}, discussion {Discussion}, DNR {Not for resuscitation}, non compliance {Drug compliance poor}, hospice 
care {Hospice care}, discussion {Discussion}, hospice services {Hospice care}, leaving AMA {Patient self-discharge against medical advice}, discussions {Discussion}, hospice services {Hospice care}, evaluation {Evaluation procedure}, hospice {Hospice care}, d/c planning {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:
The Preadmission Medication list is accurate and complete.
1. LevoFLOXacin 750 mg PO DAILY 
2. Ursodiol 300 mg PO QAM 
3. Ursodiol 600 mg PO QPM 
4. Magnesium Oxide 800 mg PO DAILY 
5. Vitamin D ___ UNIT PO DAILY 
6. Isavuconazonium Sulfate 372 mg PO DAILY 
7. Gabapentin 400 mg PO DAILY 
8. Multivitamins W/minerals 1 TAB PO DAILY 
9. FoLIC Acid 1 mg PO DAILY 
10. Acyclovir 400 mg PO Q8H 
11. Pentamidine-Inhalation 300 mg IH MONTHLY 
12. Tibsovo (ivosidenib) 500 mg PO DAILY 

 
Discharge Medications:
1.  Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever  
2.  LORazepam 0.5-1 mg PO Q4H:PRN anxiety 
RX *lorazepam 0.5 mg ___ tabs by mouth every 4 hours as needed 
Disp #*42 Tablet Refills:*0 
3.  Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q2H:PRN 
pain/dyspnea 
RX *morphine 10 mg/5 mL ___ ml by mouth every 2 hours as needed 
Refills:*0 
4.  Gabapentin 400 mg PO DAILY  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary Diagnosis
=============
febrile neutropenia 
AML
Pneumonia
Sinusitis

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: With Service {Home health aide service management}, febrile neutropenia {Febrile neutropenia}, AML {Acute myeloid leukemia}, Pneumonia {Pneumonia}, Sinusitis {Sinusitis}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - 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:
Mr. ___, 

You were admitted for fevers while your blood counts were low. 
You were found to have persistent pneumonia which did not 
improve with antibiotics. With worsening pneumonia, you 
transitioned to comfort measures and supportive care. You are 
not being discharge home. 

Sincerely, 
Your ___ team
 

###RESPONSE: fevers {Fever}, blood counts {Blood test}, pneumonia {Pneumonia}, antibiotics {Antibiotic therapy}, pneumonia {Pneumonia}, comfort measures {Comfort measures}, supportive care {Support}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
left ankle cellulitis
 
Major Surgical or Invasive Procedure:
none 

 

###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, left ankle cellulitis {Cellulitis of left ankle}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ y/o female with HCV p/w 2 days of left ankle pain and redness 
and also new low back/buttocks pain.  She recently attempted to 
clip an ingrown toenail on her left foot although she reports no 
toe pain or redness.  She denies fevers and chills although has 
been having daily hot flashes.  Denies trauma to the ankle.  No 
prior cellulitis or joint infections.
.
Ortho was consulted in ED in regards to question of a septic 
joint.  No joint aspiration was performed as clinically felt to 
be low chance of joint involvement.  She was given Vanco and 
Cefazolin and pain control in ER.
.
Also got Cipro for + UA.
 

###RESPONSE: HCV {Viral hepatitis type C}, left ankle {Structure of left ankle}, pain {Pain}, redness {Redness of skin over lesion}, low back {Low back pain}, buttocks pain {Pain in buttock}, ingrown toenail {Ingrowing toenail}, left foot {Structure of left foot}, toe pain {Pain in toe}, redness {Redness of skin over lesion}, fevers {Fever}, chills {Chill}, hot flashes {Menopausal flushing}, trauma {Traumatic injury}, ankle {Structure of left ankle}, cellulitis {Cellulitis}, joint infections {Infectious disorder of joint}, septic 
joint {Arthritis of knee}, joint aspiration {Arthrocentesis}, joint {Joint structure}, pain control {Pain control}, ER {Emergency treatment}, + UA {Abnormal urinalysis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
HCV
Hypertension  
Hypothyroidism
h/o pneumonia at ___ yrs and ___ yrs  
MR/CHF - in the setting of pneumonia  
Preeclampsia  
Anxiety  
h/o Kidney stones  
s/p C-section  
Chronic pain secondary to bilateral foot deformities.
s/p removal of left breast cysts  
left neck cyst removal  
anemia
 

###RESPONSE: HCV {Viral hepatitis type C}, Hypertension {Hypertensive disorder, systemic arterial}, Hypothyroidism {Hypothyroidism}, pneumonia {Pneumonia}, MR {Mitral valve regurgitation}, CHF {Congestive heart failure}, pneumonia {Pneumonia}, Preeclampsia {Pre-eclampsia}, Anxiety {Anxiety}, Kidney stones {Kidney stone}, C-section {Cesarean section}, Chronic pain {Chronic pain}, foot deformities {Deformity of foot}, removal {Removal}, left breast {Left breast structure}, cysts {Cyst}, left neck {Structure of left half of neck}, cyst {Cyst}, removal {Removal}, anemia {Anemia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother with hypothyroidism. Father with hypertension and 
alcoholism. Grandfather with jaw cancer. No known family history 
of liver disease. 
 

###RESPONSE: hypothyroidism {Hypothyroidism}, hypertension {Hypertensive disorder, systemic arterial}, alcoholism {Alcoholism}, jaw {Structure of left half of neck}, cancer {Malignant neoplasm}, liver disease {Disorder of liver}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VS:  97.2   140/100    72   20 100%RA
GEN: Well appearing, Comfortable, NAD
HEENT: NCAT, PERRL, OP clear, no thrush
NECK: Supple, no LAD
CV: RRR, III/VI SM LSB
LUNGS: CTABL
ABD: Soft, NTND, no masses, no bruits
EXT: No ___ edema, erythema and warmth present over left ankle 
and anterior leg.  Slightly decreased ROM on active and passive 
movement.  2+ ___ pulses.  Right knee without warmth or 
swelling.  No palpable LNs in popliteal fossa.
BACK: No midline tenderness.  Small, mobile, tender lymph nodes 
palpable over bilateral iliac crests.
 

###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, GEN {General examination of patient}, Well appearing {Well cared for appearance}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, PERRL {Pupils equal and reacting to light}, OP clear {Pharynx normal}, thrush {Candidiasis}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, SM {Systolic murmur}, LUNGS {Examination of respiratory system}, CTABL {Normal breath sounds}, ABD {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, masses {Abdominal mass}, EXT {Examination of limb}, edema {Edema}, erythema {Erythema}, warm {Warm skin}, left ankle {Structure of left ankle}, anterior leg {Skin structure of anterior surface of lower leg}, decreased ROM {Limitation of joint movement}, active {Active range of joint movement reduced}, passive 
movement {Passive range of joint movement reduced}, 2+ ___ pulses {Lower limb pulse present}, Right knee {Structure of right knee region}, warm {Warm skin}, swelling {Joint swelling}, palpable {Finding by palpation}, LNs in popliteal fossa {Popliteal lymph node structure}, tenderness {Tenderness}, tender {Abdominal tenderness}, palpable {Finding by palpation}, iliac crests {Structure of iliac lymph node}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 08:50AM BLOOD WBC-9.6
___ 10:00PM BLOOD WBC-7.1 RBC-4.00* Hgb-12.2 Hct-35.0* 
MCV-88 MCH-30.6 MCHC-35.0 RDW-13.3 Plt ___
___ 10:00PM BLOOD Neuts-54.5 ___ Monos-4.9 Eos-3.8 
Baso-0.6
___ 08:50AM BLOOD UreaN-13 Creat-0.9
___ 10:00PM BLOOD Glucose-118* UreaN-18 Creat-0.9 Na-141 
K-4.1 Cl-107 HCO3-28 AnGap-10
___ 10:00PM BLOOD CRP-14.5*
___ 10:10PM BLOOD Lactate-1.5
___ 12:50AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG 
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
___ 12:50AM URINE RBC-0 ___ Bacteri-NONE Yeast-NONE 
___
Blood and urine culture neg (urine culture was done after 
antibiotics)
 

###RESPONSE: WBC {White blood cell count}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, URINE {Evaluation of urine specimen}, Color {Color finding}, Clear {Urine looks clear}, Protein {Measurement of protein in urine}, pH {pH measurement}, URINE {Evaluation of urine specimen}, RBC {Red blood cell count}, Blood {Blood culture}, urine culture {Urine culture}, urine culture {Urine culture}, antibiotics {Antibiotic therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Left ankle celluliis improved with vancomycin and pt was 
discharged on keflex. Oxycodone controlled pain well. 
Cipro was continued for UTI. 
Patient is known to have intraabdominal lymphadenopathy in past 
and has noted low back lymph nodes. She was advised to follow up 
with PCP regarding further follow up. 
Also she was concered of a breast mass and was advised to 
discuss with PCP ___. mammogram/US. 
 

###RESPONSE: Left ankle {Structure of left ankle}, celluliis {Cellulitis}, improved {Patient's condition improved}, vancomycin {Antibiotic therapy}, controlled pain {Demonstrates adequate pain control}, UTI {Urinary tract infectious disease}, intraabdominal lymphadenopathy {Disorder of intra-abdominal lymph nodes}, low back {Lower back structure}, lymph nodes {Structure of lymph node}, follow up {Follow-up arranged}, PCP {Primary care management}, follow up {Follow-up arranged}, breast mass {Breast lump}, PCP {Primary care management}, mammogram {Mammography}, US {Ultrasonography of bilateral breasts}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Clonazepam 1mg BID at 7PM and bedtime
Clonazepam 2 mg BID prn
Diltiazem 240mg daily
HCTZ 25mg daily
Synthroid ___ microgram daily x 6 days and then 100 microgram on 
___ day
Olmesartan 40 mg daily
Darvon 65mg PRN
Prilosec OTC
Propanolol 40 mg TID
 
Discharge Medications:
1. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO twice a day as 
needed for anxiety: Do not take with alcohol, do not drive or 
use machinery while on this medicaton. Can make you drowsy. .  
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY AT 7PM 
(): Do not take with alcohol, do not drive or use machinery 
while on this medicaton. Can make you drowsy. .  
3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day 
(at bedtime)) as needed: Do not take with alcohol, do not drive 
or use machinery while on this medicaton. Can make you drowsy. . 
 
4. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2) 
Capsule, Sustained Release PO DAILY (Daily).  
5. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO 
DAILY (Daily).  
6. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO 6X/WEEK 
(___).  
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 1X/WEEK 
(___).  
8. Olmesartan 20 mg Tablet Sig: Two (2) Tablet PO Daily () as 
needed for HTN.  
9. Propranolol 40 mg Tablet Sig: One (1) Tablet PO TID (3 times 
a day).  
10. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO once a day.  
11. Oxycodone 5 mg Tablet Sig: ___ Tablets PO every eight (8) 
hours as needed for pain: Do not take with alcohol, do not drive 
or use machinery while on this medicaton. Can make you drowsy. .
Disp:*10 Tablet(s)* Refills:*0*
12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Left leg/ankle cellulitis
Urinary tract infection, bacterial likely
Lymphadenopathy
Concern for breast mass
History of hypertension and anxiety
Tobacco user

 
Discharge Condition:
stable 

 

###RESPONSE: Left leg {Structure of left lower leg}, ankle {Structure of left ankle}, cellulitis {Cellulitis}, Urinary tract infection {Urinary tract infectious disease}, bacterial {Bacterial infectious disease}, Lymphadenopathy {Lymphadenopathy}, breast mass {Breast lump}, hypertension {Hypertensive disorder, systemic arterial}, anxiety {Anxiety}, Tobacco user {Tobacco user}, stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Return to the hospital if you have new fevers, chills, worsening 
ankle swelling or pain or any new symptoms of concern to you. 

Take the antibiotocs as prescribed for cellulitis. 

Keep your appointments. 

Discuss your concern about breast mass and also enlarged lymph 
nodes with your primary care doctor - Dr ___ you se him 
this week. You will need further work up for it. Dr ___ 
arrange for it in clinic. 

Do not take oxycodone and drive or use machinery or cook. 

 

###RESPONSE: Discharge Instructions {Final inpatient visit with instructions at discharge}, fevers {Fever}, chills {Chill}, ankle swelling {Swollen ankle}, pain {Abdominal pain}, antibiotocs {Ankle pain}, cellulitis {Cellulitis}, breast mass {Breast lump}, enlarged lymph 
nodes {Lymphadenopathy}, work up {Evaluation procedure}, clinic {Outpatient 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:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Penicillins / Aspirin / Sulfa (Sulfonamide Antibiotics) / Latex 
/ banana / kiwi / peanut / clindamycin / salicylates
 
Attending: ___.
 
Chief Complaint:
shortness of breath
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Penicillins {Allergy to penicillin}, Aspirin {Allergy to aspirin}, Antibiotics {Antibiotic therapy}, peanut {Allergy to peanut}, 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:
Ms. ___ is a ___ history of
asthma, PCOS, hypertension, G6PD, and PTSD, presenting with
worsening shortness of breath with concern for asthma
exacerbation.

Of note, patient recently presented to ___ ___ with
worsening shortness of breath and coughing. Patient stated this
felt like her prior asthma exacerbations. Given documented
minimal wheezing on exam and with normal O2 saturation, she was
treated with duonebs as well as prednisone. She was discharged 
on
prednisone 50 mg daily x 5 days. 

Patient states that she never felt better after being discharged
from the ___. She completed her 5 day course of
prednisone 50 mg daily ___. She has continued to have 
worsening
shortness of breath, was told by co-workers this morning that 
she
was gasping for air and he could hear her audibly wheezing.
States she has been adherent to her home Advair inhalers, has
been using her albuterol rescue inhaler every couple of minutes
without relief. Today has noted new worsening productive cough
with phlegm. Denies any fevers or chills. Denies any sore throat
or rhinorrhea.

In the ED, initial VS were: T 98.1 HR 106 BP 175/96 RR 24 O2
100%RA

On Exam:
Gen: Moderate distress, unable to speak in full sentences, 
severe
cough
CV: RRR, normal S1/S2
Pulm: +accessory muscle use, diffuse end expiratory wheezing,
diminished breath sounds R lung base, bibasilar crackles

Labs notable for: 
- WBC 8.1, Hb 11.7, PLT 280
- Na 142, K 3.8, BUN 5, Cr 0.5
- VBG 7.41/___
- Flu: Negative
- UA: Moderate leuks, negative nitrite, 2 WBC, few bacteria  

Imaging showed:
CXR ___:
1. Slightly increased interstitial opacities in the right lower
lung field may represent bronchovascular crowding secondary to
decreased inspiratory effort however an early infectious or
inflammatory process cannot be excluded, particularly in this
patient with productive cough.

Consults: None

Patient received:
___ 07:51 IH Albuterol 0.083% Neb Soln
___ 07:51 IH Ipratropium Bromide Neb 1 NEB  
___ 08:09 IH Albuterol 0.083% Neb Soln 1 NEB 
___ 08:09 IH Ipratropium Bromide Neb 1 NEB  
___ 08:09 PO Ondansetron ODT 4 mg 
___ 09:51 IV Magnesium Sulfate  
___ 09:51 IV MethylPREDNISolone Sodium Succ 125 mg 
___ 09:53 IH Albuterol 0.083% Neb Soln 1 NEB 
___ 09:53 IH Ipratropium Bromide Neb 1 NEB   
___ 10:53 IV Magnesium Sulfate 2 gm 
___ 11:09 IV Azithromycin  
___ 13:10 IV Azithromycin 500 mg 
___ 14:22 IV CefTRIAXone   
___ 14:29 IV CefTRIAXone 2 g  
___ 16:16 PO/NG Spironolactone 100 mg 
___ 16:16 IVF  LR  
___ 17:39 IVF  LR 1000 mL 
___ 20:21 PO/NG Acetaminophen 1000 mg 
___ 20:38 PO TraMADol 50 mg 

Transfer VS were: T 98.9 HR 114, BP 158/89 RR 18 O2 100%RA

On arrival to the floor, patient confirms the above
history. States that at present she does not feel short of
breath, however endorsing frequent coughing (with occasional
brownish phlegm).

 

###RESPONSE: asthma {Asthma}, PCOS {Polycystic ovary syndrome}, hypertension {Hypertensive disorder, systemic arterial}, G6PD {Glucose-6-phosphate dehydrogenase deficiency anemia}, PTSD {Posttraumatic stress disorder}, shortness of breath {Dyspnea}, asthma
exacerbation {Exacerbation of asthma}, shortness of breath {Dyspnea}, coughing {Cough}, asthma exacerbations {Exacerbation of asthma}, wheezing {Wheezing}, normal O2 saturation {Oxygen saturation within reference range}, shortness of breath {Dyspnea}, gasping {Gasping for breath}, wheezing {Wheezing}, inhalers {Oxygen therapy}, inhaler {Oxygen therapy}, relief {Feeling relief}, productive cough {Productive cough}, fevers {Fever}, chills {Chill}, sore throat {Sore throat}, rhinorrhea {Nasal discharge}, VS {Vital signs finding}, RA {Breathing room air}, Gen {General examination of patient}, distress {Distress}, unable to speak {Unable to speak}, cough {Cough}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, Pulm {Examination of respiratory system}, accessory muscle {Accessory skeletal muscle}, expiratory wheezing {Expiratory wheezing}, diminished breath sounds {Decreased breath sounds}, R lung base {Structure of base of right lung}, bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, Flu {Influenza}, UA {Urinalysis}, CXR {Plain chest X-ray}, opacities {Abnormally opaque structure}, lung field {Structure of lung field}, infectious {Infectious disease}, inflammatory {Inflammatory disorder}, productive cough {Productive cough}, IV {Intravenous therapy}, IV {Intravenous therapy}, IV {Intravenous therapy}, IV {Intravenous therapy}, IV {Intravenous therapy}, IV {Intravenous therapy}, IV {Intravenous therapy}, IVF {Administration of intravenous fluids}, IVF {Administration of intravenous fluids}, VS {Vital signs finding}, RA {Breathing room air}, short of
breath {Dyspnea}, coughing {Cough}, brownish phlegm {Brown sputum}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Asthma
Obstructive sleep apnea
PCOS (polycystic ovarian syndrome)       
Psychosocial stressors, PTSD
Iron deficiency anemia                              
G6PD deficiency
Headaches/Migraines
Menorrhagia
Atypical squamous cells of undetermined significance (ASCUS) on 
___ smear of cervix
h/o STD, Herpes simplex vulvovaginitis

 

###RESPONSE: Asthma {Asthma}, Obstructive sleep apnea {Obstructive sleep apnea syndrome}, PCOS {Polycystic ovary syndrome}, polycystic ovarian syndrome {Polycystic ovary syndrome}, PTSD {Posttraumatic stress disorder}, Iron deficiency anemia {Iron deficiency anemia}, G6PD deficiency {Glucose-6-phosphate dehydrogenase deficiency anemia}, Headaches {Headache}, Migraines {Migraine}, Menorrhagia {Menorrhagia}, Atypical squamous cells of undetermined significance {Atypical squamous cells of undetermined significance}, smear of cervix {Cytopathology procedure, preparation of smear, genital source}, STD {Sexually transmitted infectious disease}, Herpes simplex {Herpes simplex}, vulvovaginitis {Vulvovaginitis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
- Sister w/ arrhythmia on rhythm control - unable to specify 
further 
- brother with cardiomyopathy
- low potassium in family
- Hypertension
- Malignancy (sarcoma in mother, leukemia in father)
- Depression
- Obesity
- T2DM
- Keratoconus (multiple family members)
 

###RESPONSE: arrhythmia {Cardiac arrhythmia}, cardiomyopathy {Cardiomyopathy}, low potassium {Hypokalemia}, Hypertension {Hypertensive disorder, systemic arterial}, Malignancy {Malignant neoplasm}, sarcoma {Sarcoma}, leukemia {Leukemia}, Depression {Depressive disorder}, Obesity {Obesity}, T2DM {Diabetes mellitus type 2}, Keratoconus {Keratoconus}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: T 98.2 BP 166/98 HR 118 RR 18 O2 97%RA
Gen: Intermittently coughing, however speaking in full sentences
HEENT: NC/AT, PERRLA, EOMI
Lungs: Decreased breath sounds throughout, however with good air
movement. Diffuse expiratory wheezing throughout all lung 
fields.
CV: Tachycardic, regular rhythm, no murmurs, rubs, or gallops
Abdomen: Soft, NT/ND.  Normoactive bowel sounds.  No evidence of
organomegaly
Neuro: CN II-XII intact. No focal neurological deficits.
Extremities: 2+ peripheral pulses, no C/C/E

DISCHARGE PHYSICAL EXAM:
========================
VS: ___ 0714 Temp: 98.2 PO BP: 130/88 HR: 91 RR: 20 O2 sat:
98% O2 delivery: RA 
Gen: Young F in NAD. Appears stated age. Intermittently coughing
HEENT: NC/AT, EOMI
Lungs: CTABL, no wheezes appreciated. Breathing comfortably on 
RA
without use of accessory muscles. 
CV: RRR, no murmurs, rubs, or gallops
Abdomen: Soft, NT/ND. NABS.  No evidence of organomegaly
Neuro: No focal neurological deficits. A&Ox3. Moving all
extremities.
Extremities: warm and well-perfused, no edema

 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, Gen {General examination of patient}, coughing {Cough}, HEENT {Physical examination procedure}, NC {Normal head}, AT {No injuries apparent}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, Lungs {Examination of respiratory system}, Decreased breath sounds {Decreased breath sounds}, wheezing {Wheezing}, lung 
fields {Structure of lung field}, CV {Cardiovascular physical examination}, Tachycardic {Tachycardia}, regular rhythm {Normal sinus rhythm}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, Normoactive bowel sounds {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, Neuro {Neurological examination}, CN II {Normal central nervous system}, XII intact {Normal central nervous system}, neurological deficits {Neurological deficit}, Extremities {Examination of limb}, 2+ peripheral pulses {Peripheral pulses normal}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, Gen {General examination of patient}, NAD {No abnormality detected}, coughing {Cough}, HEENT {Physical examination procedure}, NC {Normal head}, AT {No injuries apparent}, EOMI {Normal ocular motility}, Lungs {Examination of respiratory system}, CTABL {Normal breath sounds}, wheezes {Wheezing}, Breathing comfortably {Normal respiratory function}, RA {Breathing room air}, accessory muscles {Accessory skeletal muscle}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, NABS {Normal bowel sounds}, organomegaly {Abdominal organomegaly}, Neuro {Neurological examination}, neurological deficits {Neurological deficit}, all
extremities {All extremities}, Extremities {All extremities}, warm {Warm skin}, well-perfused {Normal tissue perfusion}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
===============
___ 08:08AM   HCG-<5
___ 08:08AM   CALCIUM-9.5 PHOSPHATE-4.6* MAGNESIUM-1.7
___ 08:08AM   GLUCOSE-107* UREA N-5* CREAT-0.5 SODIUM-142 
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-22 ANION GAP-16
___ 09:07AM URINE  MUCOUS-FEW*
___ 09:07AM URINE  RBC-1 WBC-2 BACTERIA-FEW* YEAST-NONE 
EPI-2
___ 09:07AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 
LEUK-MOD*
___ 09:07AM URINE  COLOR-Straw APPEAR-Hazy* SP ___
___ 09:07AM URINE  UCG-NEGATIVE
___ 12:06PM   PLT COUNT-280
___ 12:06PM   NEUTS-45.7 ___ MONOS-12.2 EOS-3.2 
BASOS-0.4 IM ___ AbsNeut-3.72 AbsLymp-3.12 AbsMono-0.99* 
AbsEos-0.26 AbsBaso-0.03
___ 12:06PM   WBC-8.1 RBC-4.59 HGB-11.7 HCT-38.1 MCV-83 
MCH-25.5* MCHC-30.7* RDW-13.5 RDWSD-40.3
___ 02:13PM   ___ PO2-49* PCO2-39 PH-7.41 TOTAL CO2-26 
BASE XS-0 COMMENTS-PERIPHERAL
___ 02:25PM OTHER BODY FLUID  FluAPCR-NEGATIVE 
FluBPCR-NEGATIVE

MICROBIOLOGY:
=============
__________________________________________________________
___ 7:57 am SPUTUM      Source: Expectorated. 

                            **FINAL REPORT ___

   GRAM STAIN (Final ___: 
      ___ PMNs and >10 epithelial cells/100X field. 
      Gram stain indicates extensive contamination with upper 
respiratory
      secretions. Bacterial culture results are invalid. 
      PLEASE SUBMIT ANOTHER SPECIMEN. 

   RESPIRATORY CULTURE (Final ___: 
      TEST CANCELLED, PATIENT CREDITED. 
__________________________________________________________
___ 2:25 pm Rapid Respiratory Viral Screen & Culture
      Source: Nasopharyngeal swab. 

                            **FINAL REPORT ___

   Respiratory Viral Culture (Final ___: 
      No respiratory viruses isolated. 
      Culture screened for Adenovirus, Influenza A & B, 
Parainfluenza type
      1,2 & 3, and Respiratory Syncytial Virus.. 
      Detection of viruses other than those listed above will 
only be
      performed on specific request. Please call Virology at 
___
      within 1 week if additional testing is needed. 

   Respiratory Viral Antigen Screen (Final ___: 
      Negative for Respiratory Viral Antigen. 
      Specimen screened for: Adeno, Parainfluenza 1, 2, 3, 
Influenza A, B,
      and RSV by immunofluorescence. 
      Refer to respiratory viral culture and/or Influenza PCR 
(results
      listed under ""OTHER"" tab) for further information.. 
__________________________________________________________
___ 11:05 am BLOOD CULTURE      SET#2. 

   Blood Culture, Routine (Pending):    No growth to date. 
__________________________________________________________
___ 11:02 am BLOOD CULTURE      SET#1. 

   Blood Culture, Routine (Pending):    No growth to date. 
__________________________________________________________
___ 9:07 am URINE

                            **FINAL REPORT ___

   URINE CULTURE (Final ___: 
      MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT 
WITH SKIN
      AND/OR GENITAL CONTAMINATION. 

IMAGING:
========
___ CXR
FINDINGS:  
When compared to most recent prior chest radiograph, there is 
slightly 
increased interstitial opacity projecting over the right lower 
lung field 
which appears more conspicuous .  This may represent crowding of 
pulmonary 
vasculature due to decreased inspiratory effort however an early 
infectious or inflammatory process cannot be excluded.  There is 
otherwise no other areas of focal consolidation.  There is no 
pleural effusion or pneumothorax.  The cardiomediastinal 
silhouette is within normal limits.  There is no acute osseous 
abnormality or free intraperitoneal air under the diaphragm. 
  
IMPRESSION: 
1. Slightly increased interstitial opacities in the right lower 
lung field may represent bronchovascular crowding secondary to 
decreased inspiratory effort however an early infectious or 
inflammatory process cannot be excluded, particularly in this 
patient with productive cough. 

DISCHARGE LABS:
===============
(from day prior, no labs obtained on day of discharge)
___ 06:50AM BLOOD WBC-15.1* RBC-4.91 Hgb-12.8 Hct-40.0 
MCV-82 MCH-26.1 MCHC-32.0 RDW-13.2 RDWSD-38.9 Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-84 UreaN-10 Creat-0.6 Na-142 
K-4.7 Cl-105 HCO3-25 AnGap-12
___ 06:50AM BLOOD Calcium-9.5 Phos-4.6* Mg-2.___RIEF HOSPITAL SUMMARY:
========================
Ms. ___ is a ___ history of asthma, PCOS, hypertension, G6PD 
deficiency, and PTSD, who recently presented to ___ 
with worsening shortness of breath treated with prednisone 
burst, now re-presenting with worsening shortness of breath and 
wheezing, admitted with asthma exacerbation and community 
acquired pneumonia. 

TRANSITIONAL ISSUES:
====================
[ ] Patient hypertensive and with headaches while hospitalized. 
Started on verapamil 120mg qd with some improvement in blood 
pressure and headaches. Will require close-follow up, especially 
once she completes the steroid taper as it was felt her steroids 
contributed to her hypertension. 
[ ] Patient discharged on steroid taper as follows: 50mg qd x2d, 
40mg x2d, 30mg x2d, 20mg x2d, and 10mg x2d. PCP should reassess 
respiratory symptoms and determine if a longer taper is 
necessary.
[ ] Pending tests: ___ Blood cultures x2- no growth to date.
[ ] Patient was tachycardic during admission to 100-120s. Was 
thought to be secondary to frequent albuterol use prior to 
admission and ultimately improved during the majority of her 
stay. Low risk for DVT/PE per Wells criteria and other vital 
signs remained stable. Please follow up at next PCP ___.
[ ] Patient had a significant headache during admission, with a 
known history of migraines. She required IV ketorolac, PO 
fioricet, and IV Compazine during admission. She was discharged 
with PO Compazine and ibuprofen. Further headache management 
should be considered in the outpatient setting. 

ACUTE ISSUES:
===============
#Asthma exacerbation
#?CAP 
Patient has a history of asthma and has approximately 5 
exacerbations per year with no prior intubations. She recently 
presented to ___ on ___ with worsening dyspnea, s/p 
inhalers and prednisone 50mg x5d completed ___ but without 
subjective improvement. She presented to ___ ED with severe 
dyspnea with diffuse wheezing on exam. She received 
methylprednisolone 125mg x1 in the ED and then was started on 
prednisone 60mg qd. There was question of new RLL infiltrate on 
CXR on admission concerning for pneumonia, which could possibly 
have been the trigger for her asthma exacerbation. She was 
afebrile and without leukocytosis on admission but did have a 
productive cough. Sputum culture was contaminated by upper 
respiratory flora. Influenza PCR was negative. Respiratory viral 
panel and culture were negative. She completed a 5-day course of 
Ceftriaxone and azithromycin for empiric CAP treatment prior 
discharge. There was some concern for PE in this young female 
with wheezing and tachycardia but had low risk per Wells 
criteria (see below), with ultimate improvement in her 
tachycardia for the majority of her hospitalization. She was 
continued on home Advair and received duonebs q6h. She was 
switched from her home albuterol to levalbuterol nebs q2h:prn 
given tachycardia, but was switched back to albuterol on 
discharge. Patient was discharged on steroid taper for 10 days 
(50mg qd x2d, 40 x2d, 30 x2d, 20 x2d, 10 x2d) and will follow up 
with her PCP prior to the end of the taper to assess symptom 
resolution. She also received guaifenison for cough. 

#HTN 
Patient hypertensive to 180s on admission. She is only on 
spironolactone at home. She was previously hospitalized in ___ 
for wide-ranging SBP to 180-190s, requiring nifedipine and was 
started on labetalol at that time. Neuro workup at that time 
with negative CTA/CTV. Subsequently had BP med overdose 
requiring dopamine in MICU during prior hospitalization. During 
hospitalization, her hypertension was felt to be related to 
steroids. She was continued on home spironolactone and received 
hydralazine prn. She was also started on verapamil 120mg qd for 
both hypertension and headache. BPs were improved with addition 
of verapamil and were 130-150s/70-90s on day of discharge. At 
her PCP follow up, please evaluate her blood pressures (given 
the prednisone will be tapering) and determine if Verapamil 
should be continued.

#Tachycardia 
Patient tachycardia to the 90-120s on admission. EKG showed 
sinus tachycardia. Differential included ___ albuterol (patient 
endorsed using albuterol frequently prior to admission) vs PE. 
There was lower suspicion for PE manifested as tachycardia and 
wheezing given recent high frequency of albuterol nebs and low 
risk per Wells criteria. Patient had no recent travel or 
immobilization, no history of DVT/PE, and no known 
hypercoagulable state. Her tachycardia improved during the 
majority of her hospitalization.

#Headache 
Patient presented with right sided headache since ED, no focal 
neurological deficits. Patient has history of migraines. No 
improvement with APAP, tramadol or ibuprofen so patient received 
ketorolac and Fioricet as well as IV Compazine as needed. 

CHRONIC ISSUES:
===============
#Hypokalemia - Continued on home K supplementation 

#PCOS - Continued on home spironolactone 100mg PO BID

#OSA - History of CPAP previously non-adherent. 

#CODE: Full (presumed)
#CONTACT:
Name of health care proxy: ___ 
Relationship: sister 
Phone number: ___ 

 
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO 1X/WEEK (WE) 
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN Shortness of breath 
3. Spironolactone 100 mg PO BID 
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze 
5. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH BID 
6. Vitamin D ___ UNIT PO DAILY 
7. Potassium Chloride 20 mEq PO TID 
8. Prenatal Vitamins 1 TAB PO DAILY 

 
Discharge Medications:
1.  Ibuprofen 600 mg PO Q6H:PRN Pain - Mild NOT relieved by 
Acetaminophen 
RX *ibuprofen 600 mg 1 tablet(s) by mouth four times a day Disp 
#*12 Tablet Refills:*0 
2.  PredniSONE 50 mg PO DAILY Duration: 2 Doses 
Start: Tomorrow - ___, First Dose: First Routine 
Administration Time 
This is dose # 1 of 5 tapered doses
RX *prednisone 10 mg 5 tablet(s) by mouth once a day Disp #*10 
Tablet Refills:*0 
3.  PredniSONE 40 mg PO DAILY Duration: 2 Doses 
Start: After 50 mg DAILY tapered dose 
This is dose # 2 of 5 tapered doses
RX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*8 
Tablet Refills:*0 
4.  PredniSONE 30 mg PO DAILY Duration: 2 Doses 
Start: After 40 mg DAILY tapered dose 
This is dose # 3 of 5 tapered doses
RX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*6 
Tablet Refills:*0 
5.  PredniSONE 20 mg PO DAILY Duration: 2 Doses 
Start: After 30 mg DAILY tapered dose 
This is dose # 4 of 5 tapered doses
RX *prednisone 10 mg 2 tablet(s) by mouth once a day Disp #*4 
Tablet Refills:*0 
6.  PredniSONE 10 mg PO DAILY Duration: 2 Doses 
Start: After 20 mg DAILY tapered dose 
This is dose # 5 of 5 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*2 
Tablet Refills:*0 
7.  Prochlorperazine 10 mg PO Q6H:PRN nausea 
RX *prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by 
mouth four times a day Disp #*12 Tablet Refills:*0 
8.  Verapamil SR 120 mg PO Q24H 
RX *verapamil [Calan SR] 120 mg 1 tablet(s) by mouth once a day 
Disp #*30 Tablet Refills:*0 
9.  Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze  
10.  Albuterol Inhaler 1 PUFF IH Q6H:PRN Shortness of breath  
11.  Fluticasone-Salmeterol Diskus (250/50)  1 INH IH BID  
12.  Potassium Chloride 20 mEq PO TID  
13.  Prenatal Vitamins 1 TAB PO DAILY  
14.  Spironolactone 100 mg PO BID  
15.  Vitamin D ___ UNIT PO DAILY  
16.  Vitamin D ___ UNIT PO 1X/WEEK (WE)  

 

###RESPONSE: CALCIUM {Blood calcium measurement}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, URINE {Urine culture}, 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}, COLOR {Color finding}, URINE {Urine culture}, 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}, RDWSD {Red cell distribution width determination}, PH {pH measurement}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, SPUTUM {Sputum finding}, Expectorated {Does expectorate}, GRAM STAIN {Gram stain method}, cells {Cell structure}, Gram stain {Gram stain method}, respiratory {Examination of respiratory system}, Bacterial culture {Bacterial culture}, invalid {Invalidism}, RESPIRATORY {Examination of respiratory system}, CULTURE {Microbial culture}, Respiratory {Examination of respiratory system}, Culture {Microbial culture}, Respiratory {Examination of respiratory system}, Viral Culture {Viral culture}, respiratory {Examination of respiratory system}, Culture {Microbial culture}, Influenza {Influenza}, Parainfluenza {Parainfluenza}, Respiratory {Examination of respiratory system}, Detection of viruses {Detection of virus}, Respiratory {Examination of respiratory system}, Respiratory {Examination of respiratory system}, Parainfluenza {Parainfluenza}, Influenza {Influenza}, immunofluorescence {Fluorescent immunoassay}, respiratory {Examination of respiratory system}, viral culture {Viral culture}, Influenza {Influenza}, tab {Therapeutic abortion procedure}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, BLOOD CULTURE {Blood culture}, Blood Culture {Blood culture}, URINE {Urine culture}, URINE CULTURE {Urine culture}, SKIN {Examination of skin}, CXR {Plain chest X-ray}, chest {Thoracic structure}, radiograph {Plain radiography}, opacity {Abnormally opaque structure}, lung field {Structure of lung field}, infectious {Infectious disease}, inflammatory {Inflammatory disorder}, consolidation {Consolidation}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, osseous {Bony labyrinth structure}, diaphragm {Diaphragm structure}, opacities {Abnormally opaque structure}, lung field {Structure of lung field}, infectious {Infectious disease}, inflammatory {Inflammatory disorder}, productive cough {Productive cough}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, asthma {Asthma}, PCOS {Polycystic ovary syndrome}, hypertension {Hypertensive disorder, systemic arterial}, G6PD 
deficiency {Glucose-6-phosphate dehydrogenase deficiency anemia}, PTSD {Posttraumatic stress disorder}, shortness of breath {Dyspnea}, shortness of breath {Dyspnea}, wheezing {Wheezing}, asthma exacerbation {Exacerbation of asthma}, community 
acquired pneumonia {Community acquired pneumonia}, hypertensive {Hypertensive disorder, systemic arterial}, headaches {Headache}, blood 
pressure {Blood pressure finding}, headaches {Headache}, hypertension {Hypertensive disorder, systemic arterial}, PCP {Primary care management}, respiratory {Examination of respiratory system}, Blood cultures {Blood culture}, tachycardic {Tachycardia}, improved {Patient's condition improved}, DVT {Deep venous thrombosis}, PE {Pulmonary embolism}, vital 
signs {Vital signs finding}, stable {Patient's condition stable}, PCP {Primary care management}, headache {Headache}, migraines {Migraine}, IV {Intravenous therapy}, IV {Intravenous therapy}, headache {Headache}, Asthma exacerbation {Exacerbation of asthma}, asthma {Asthma}, intubations {Intubation}, dyspnea {Dyspnea}, inhalers {Oxygen therapy}, dyspnea {Dyspnea}, wheezing {Wheezing}, infiltrate {Infiltration}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, asthma exacerbation {Exacerbation of asthma}, afebrile {Temperature normal}, leukocytosis {Leukocytosis}, productive cough {Productive cough}, Sputum culture {Microbial culture of sputum}, respiratory {Examination of respiratory system}, Influenza {Influenza}, Respiratory {Examination of respiratory system}, culture {Microbial culture}, PE {Pulmonary embolism}, wheezing {Wheezing}, tachycardia {Tachycardia}, tachycardia {Tachycardia}, tachycardia {Tachycardia}, PCP {Primary care management}, cough {Cough}, HTN {Hypertensive disorder, systemic arterial}, hypertensive {Hypertensive disorder, systemic arterial}, Neuro {Neurological examination}, CTA {Computed tomography angiography with contrast}, CTV {Computed tomography venography with contrast}, overdose {Overdose}, hypertension {Hypertensive disorder, systemic arterial}, hypertension {Hypertensive disorder, systemic arterial}, headache {Headache}, improved {Patient's condition improved}, PCP {Primary care management}, blood pressures {Blood pressure finding}, Tachycardia {Tachycardia}, tachycardia {Tachycardia}, sinus tachycardia {Sinus tachycardia}, PE {Pulmonary embolism}, suspicion {Suspicion}, PE {Pulmonary embolism}, tachycardia {Tachycardia}, wheezing {Wheezing}, frequency {Increased frequency of urination}, DVT {Deep venous thrombosis}, PE {Pulmonary embolism}, hypercoagulable state {Hypercoagulability state}, tachycardia {Tachycardia}, improved {Patient's condition improved}, Headache {Headache}, right sided headache {Unilateral headache on right side of head}, neurological deficits {Neurological deficit}, migraines {Migraine}, IV {Intravenous therapy}, Hypokalemia {Hypokalemia}, PCOS {Polycystic ovary syndrome}, OSA {Obstructive sleep apnea syndrome}, Inhaler {Oxygen therapy}, Shortness of breath {Dyspnea}, wheeze {Wheezing}, TAB {Therapeutic abortion 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: Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis:
Asthma exacerbation
Community acquired pneumonia

Secondary Diagnosis:
Hypertension
Tachycardia
Headache
Hypokalemia
Polycystic ovarian syndrome
Obstructive sleep apnea

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Asthma exacerbation {Exacerbation of asthma}, Community acquired pneumonia {Community acquired pneumonia}, Hypertension {Hypertensive disorder, systemic arterial}, Tachycardia {Tachycardia}, Headache {Headache}, Hypokalemia {Hypokalemia}, Polycystic ovarian syndrome {Polycystic ovary syndrome}, Obstructive sleep apnea {Obstructive sleep apnea syndrome}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,  

It was a pleasure to care for you at the ___ 
___.  

Why did you come to the hospital?  
- You came to the hospital because you were having difficulty 
breathing. 

What did you receive in the hospital?  
- You received steroids to treat an asthma exacerbation.
- You received antibiotics to treat any infection in lungs. 
- You received medications to treat your headache.
- You were started on a new blood pressure medication because 
your blood pressure was high.

What should you do once you leave the hospital?  
- You should take all of your medications as prescribed (see 
below).
- You should attend all of your scheduled outpatient 
appointments.  

We wish you the best!  
Your ___ Care Team  

 

###RESPONSE: difficulty 
breathing {Difficulty breathing}, asthma {Asthma}, antibiotics {Antibiotic therapy}, infection {Infectious disease}, lungs {Lung structure}, headache {Headache}, blood pressure {Blood pressure finding}, blood pressure was high {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                     Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Chest pain
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Chest pain {Chest pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ with prior history of cocaine abuse presents from jail with 
chest pain. He awoke from sleep at 1AM with sharp sub sternal 
chest pain, ___ in intensity, non-radiating, worse with deep 
inspiration. Pain has been constant. Never had this type of pain 
before. No recent chest wall injuries or strenuous activities. 
Went to ___ and had a concerning EKG with ?STE and 
hyperacute T's that didn't meet criteria. Got ASA, had negative 
trop @ 0230, negative d-dimer. Pain unrelieved with nitro, 
morphine, dilaudid so patient transferred to ___ for further 
eval.  
 
In the ED intial vitals were: 97 58 100/69 16 100%  
Labs were significant for WBC 12.1, Troponin <.01, Phos 1.4  
Patient was given: Dilaudid IV and lorazepam  
Vitals on transfer: 66 120/64 7 98%  

On the floor patient reports improvement in chest pain, now 
___. Denies fever, chills, cough, SOB, orthopnea.  

 

###RESPONSE: cocaine abuse {Cocaine abuse}, chest pain {Chest pain}, chest pain {Chest pain}, radiating {Radiating pain}, Pain {Pain}, constant {Constant pain}, pain {Pain}, chest wall injuries {Injury of chest wall}, EKG {Electrocardiographic procedure}, Pain {Pain}, vitals {Vital signs finding}, Vitals {Vital signs finding}, chest pain {Chest pain}, fever {Fever}, chills {Chill}, cough {Cough}, SOB {Dyspnea}, orthopnea {Orthopnea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
None
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
MGF- CAD
Father- cirrhosis
Mother- lung cancer 
 

###RESPONSE: CAD {Coronary arteriosclerosis}, lung cancer {Malignant tumor of lung}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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=97.6 BP=107/62 HR=68 RR=18 O2 sat=99% RA  
General: Well developed male in NAD 
HEENT: EOMI, PERRL, sclera anicteric 
Neck: JVP not elevated, supple, no LAD 
CV: RRR, normal S1 and S2, no mrg. Chest wall is mildly tender 
to palpation over left and right margins of sternum and xyphoid 
process 
Lungs: CTAB, no wheezes or rales 
Abdomen: Soft, nontender, non-distended, no palpable 
organomegaly 
GU: No foley  
Ext: Warm, well perfused, no edema, 2+ DP pulses 

Discharge:
General: Well developed male in NAD 
HEENT: EOMI, PERRL, sclera anicteric 
Neck: JVP not elevated, supple, no LAD 
CV: RRR, normal S1 and S2, no mrg. Chest wall is mildly tender 
to palpation over left and right margins of sternum and xyphoid 
process 
Lungs: CTAB, no wheezes or rales 
Abdomen: Soft, nontender, non-distended, no palpable 
organomegaly 
GU: No foley  
Ext: Warm, well perfused, no edema, 2+ DP pulses 

 

###RESPONSE: VS {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, General {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, sclera anicteric {White sclera}, Neck {Physical examination procedure}, JVP not elevated {Normal jugular venous pressure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, Chest {Examination of respiratory system}, tender {Abdominal tenderness}, palpation {Palpation}, sternum {Bone structure of sternum}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, nontender {Abdominal tenderness}, non-distended {Normal abdominal contour}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, foley {Catheterization of urinary bladder}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, edema {Edema}, 2+ DP pulses {All pulses present in bilateral lower limbs}, General {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, sclera anicteric {White sclera}, Neck {Physical examination procedure}, JVP not elevated {Normal jugular venous pressure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, normal S1 {Normal first heart sound, S>1<}, Chest wall is mildly tender {Chest wall tenderness}, sternum {Bone structure of sternum}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, organomegaly {Abdominal organomegaly}, GU {Examination of genitourinary system}, foley {Catheterization of urinary bladder}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, edema {Edema}, 2+ DP pulses {All pulses present in bilateral lower limbs}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 04:35AM BLOOD WBC-12.1* RBC-4.66 Hgb-14.3 Hct-42.7 
MCV-92 MCH-30.6 MCHC-33.5 RDW-11.8 Plt ___
___ 04:35AM BLOOD Neuts-86.0* Lymphs-9.9* Monos-3.3 Eos-0.2 
Baso-0.5
___ 04:35AM BLOOD Glucose-91 UreaN-17 Creat-0.9 Na-138 
K-4.1 Cl-104 HCO3-22 AnGap-16
___ 04:35AM BLOOD CK(CPK)-98
___ 04:35AM BLOOD cTropnT-<0.01
___ 04:35AM BLOOD CK-MB-2
___ 04:35AM BLOOD Calcium-9.3 Phos-1.4* Mg-1.6

Imaging: 
Surface Echo ___:
IMPRESSION: Normal biventricular regional/global systolic 
function.  

CTA ___:
1.  No evidence of acute aortic syndrome. 
2.  Heart size is top normal with a dilated right atrium.  No 
pericardial 
effusion.   
3.  No focal consolidation.  Bilateral centrilobular nodules may 
represent respiratory bronchiolitis in the setting of smoking 
history.  Mild paraseptal emphysema. 

Discharge:
___:05PM BLOOD CK-MB-2 cTropnT-<0.___ with prior history of cocaine abuse presents from jail with 
chest pain. 

#Chest Pain: Most likely costochondtritis versus other 
musculoskeletal pain. Pain is atypical for angina given lack of 
association with exertion, lack of improvement with nitro and 
reproducibility on exam albeit patient is at risk of CAD with 
history of cocaine use. CTA is unrevealing for aortic dissection 
or PE and troponin is negative x3 along with a normal surface 
ECHO which are reassuring. ECG shows submillimeter ST elevations 
that are concave up and may be normal variant. Patient was 
started on daily aspirin daily 81mg and pain was improved with 
tylenol and ibuprofen. Patient should continue to take ibuprofen 
as needed for pain anti-inflammatory effect.

#Hypophosphatemia: Patient was repleted with neutraphos.

#Psych: Continue home seroquel  

Transitional Issues:
-Patient was ruled out for MI with negative trop x3. EKG showed 
precordial J-point elevation which may be normal variant. 
-Patient was started on aspirin 81 mg daily
-Patient was advised to take ibuprofen for pain
-Patient will need to establish PCP once released from jail
-Full code
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, 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}, Imaging {Imaging}, regional/global systolic 
function {Normal left ventricular systolic function and wall motion}, aortic {Aortic structure}, syndrome {Disease}, Heart {Heart structure}, dilated right atrium {Right atrial dilatation}, pericardial 
effusion {Pericardial effusion}, consolidation {Consolidation}, nodules {Nodule}, bronchiolitis {Bronchiolitis}, smoking {Smoker}, paraseptal emphysema {Paraseptal emphysema}, cTropnT {Troponin T cardiac measurement}, cocaine abuse {Cocaine abuse}, chest pain {Chest pain}, Chest Pain {Chest pain}, costochondtritis {Costal chondritis}, musculoskeletal pain {Musculoskeletal pain}, Pain {Pain}, angina {Angina}, CAD {Coronary arteriosclerosis}, CTA {Computed tomography angiography with contrast}, aortic dissection {Dissection of aorta}, normal surface 
ECHO {Electrocardiogram normal}, ECG {Electrocardiographic procedure}, ST elevations {ST segment elevation}, aspirin {Administration of aspirin}, pain {Pain}, improved {Patient's condition improved}, pain {Pain}, Hypophosphatemia {Hypophosphatemia}, Psych {Psychiatric procedure, interview AND/OR consultation}, MI {Myocardial infarction}, EKG {Electrocardiographic procedure}, aspirin {Administration of aspirin}, pain {Pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. QUEtiapine Fumarate Dose is Unknown  PO DAILY 

 
Discharge Medications:
1. QUEtiapine Fumarate 0 mg PO DAILY 
2. Aspirin 81 mg PO DAILY 
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth 
once a day Disp #*30 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q8H:PRN pain 
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours 
Disp #*30 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN pain 
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth 
every six (6) hours Disp #*30 Tablet Refills:*0

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Discharge Diagnosis:
Chest pain

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Chest pain {Chest pain}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___,

You were admitted to ___ for chest pain. Based on your 
physical examination, EKG, ultrasound of your heart and blood 
tests we do not feel that your chest pain is related to a heart 
attack. Your pain may be from inflammation of you muscles or 
cartilage. Please take ibuprofen as needed for pain which will 
help with the inflammation. Please establish a primary care 
physician when you are released from jail. 
 

###RESPONSE: chest pain {Chest pain}, physical examination {Physical examination procedure}, EKG {Electrocardiographic procedure}, ultrasound of your heart {Echocardiography}, blood 
tests {Blood test}, chest pain {Chest pain}, heart 
attack {Myocardial infarction}, pain {Pain}, inflammation {Inflammatory disorder}, muscles {Skeletal and/or smooth muscle structure}, pain {Pain}, inflammation {Inflammatory disorder}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Chest pain
 
Major Surgical or Invasive Procedure:
Cardiac catheterization (___)
 

###RESPONSE: Chest pain {Chest pain}, Cardiac catheterization {Cardiac catheterization}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ yo male history of CAD IMI in ___ and 3VD with stent to LAD 
in ___, HTN, presenting with chest pain. Patient noitces for 
the last 2 weeks or so he has been having chest discomfort with 
minimal activity. Specifically having chest heaviness taking in 
his garbage cans, pushing a golf cart, or talking short walks. 
For the last 2 days, patient noticed with minimal exertion and 
short walks, would have chest heaviness/discomfort that would 
resolve after several minutes of rest. The day of presentation, 
the patient went for a walk at 3 ___ had had right sided chest 
pressure, which resolved with rest. He was home and doing 
chores, and decided to go for a walk again and said after about 
___ a mile the chest discomfort returned prompting him to go 
to the hospital for further evaluation.

He was seen at an outside hospital where a CTA of the chest was 
performed it showed no evidence of pulmonary embolism. He was 
sent here for further eval. He received an aspirin. Trop 0.02 at 
OSH.  
Initial VS in the ED: T 97.5 HR 68 BP 157/103 RR 16 satting 97% 
on RA. Labs were all normal including tropinins, CMP, CBC. EKG 
showed sinus rhythm Q waves inferiorly consistent with prior. 
VSS at time of transfer.  
 
CP feels different than his MI in the past, which was burning 
pain.  This has felt more like pressure.

Apparently gets nuclear studies as part of a research protocol 
at ___ serially.

On the floor, pt. in NAD.  

Review of systems:  
(+) Per HPI  
(-) Denies fever, chills, night sweats, recent weight loss or 
gain. Denies headache, sinus tenderness, rhinorrhea or 
congestion. Denied cough, shortness of breath. Denied nausea, 
vomiting, diarrhea, constipation or abdominal pain. No recent 
change in bowel or bladder habits. No dysuria. Denied 
arthralgias or myalgias.  
 

###RESPONSE: CAD {Coronary arteriosclerosis}, IMI {Old inferior myocardial infarction}, 3VD {Triple vessel disease of the heart}, stent to LAD {Placement of stent in anterior descending branch of left coronary artery}, HTN {Hypertensive disorder, systemic arterial}, chest pain {Chest pain}, chest discomfort {Chest discomfort}, chest {Thoracic structure}, heaviness {Heavy feeling}, walks {Does walk}, exertion {Chest pain on exertion}, short walks, would have chest heaviness/discomfort {Chest pain on exertion}, resolve {Problem resolved}, walk {Does walk}, right sided {Right thorax structure}, chest {Thoracic structure}, resolved {Problem resolved}, walk {Does walk}, chest discomfort {Chest discomfort}, evaluation {Evaluation procedure}, CTA of the chest {Computed tomography angiography of chest with contrast}, no evidence {No abnormality detected}, pulmonary embolism {Pulmonary embolism}, aspirin {Administration of aspirin}, VS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, satting {Finding of oxygen saturation}, RA {Breathing room air}, Labs {Laboratory test}, normal {No abnormality detected}, tropinins {Troponin measurement}, CBC {Complete blood count}, EKG {Electrocardiographic procedure}, sinus rhythm {Sinus rhythm}, VSS {Vital signs finding}, CP {Chest pain}, MI {Myocardial infarction}, burning 
pain {Burning pain}, pressure {Pressure}, nuclear studies {Nuclear medicine diagnostic procedure on cardiovascular system}, Review of systems {Review of systems}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, headache {Headache}, sinus tenderness {Tenderness over frontal sinus}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, cough {Cough}, shortness of breath {Dyspnea}, nausea, 
vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, change in bowel {Altered bowel function}, bladder habits {Alteration in patterns of urinary elimination}, dysuria {Dysuria}, arthralgias {Joint pain}, myalgias {Muscle pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- CAD s/p IMI ___ when playing basketball, cath about one year  

later showed 3VD, stent in ___ to LAD by Dr. ___.
- Hypertension  
- H/o hernia repair  
- H/o pilonidal cysts  
- Achilles tendon tear Left leg
 

###RESPONSE: CAD {Coronary arteriosclerosis}, IMI {Old inferior myocardial infarction}, cath {Cardiac catheterization}, 3VD {Triple vessel disease of the heart}, stent {Insertion of arterial stent}, LAD {Structure of anterior descending branch of left coronary artery}, Hypertension {Hypertensive disorder, systemic arterial}, hernia repair {Hernia repair}, pilonidal cysts {Pilonidal cyst}, Achilles tendon tear Left leg {Rupture of left Achilles tendon}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father died from MI, mother with valvular disorder in ___.  
 

###RESPONSE: died {Dead}, MI {Myocardial infarction}, valvular disorder {Heart valve 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: Physical Exam:
ADMISSION PHYSICAL EXAM
Gen: well appearing, NAD, lying flat  
Heent: OP clear, moist, anicteric  
Neck: supple, JVP flat  
Lungs: CTAB  
___: nl S1 S2 PMI non displaced, RRR, no m/r/g  
Abd: soft, NT/ND, BS+  
Ext: warm, 1+ edema to ankles b/l  
Neuro: A&O, appropriate, full strength, normal senstation  
throughout  

DISCHARGE PHYSICAL EXAM:
Vitals: T 97.5 BP 131/74 HR 69 RR 18 SaO2 98% on RA
Gen: well appearing, NAD, lying flat  
Heent: OP clear, moist, anicteric  
Neck: supple, JVP flat  
Lungs: CTAB  
___: nl S1 S2 PMI non displaced, RRR, no m/r/g  
Abd: soft, NT/ND, BS+  
Ext: warm, 1+ edema to ankles b/l  
Neuro: A&O, appropriate, full strength, normal senstation  
throughout  
 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, Gen {General examination of patient}, well appearing {Well cared for appearance}, NAD {No abnormality detected}, lying {Lying in bed}, Heent {Physical examination procedure}, OP clear {Pharynx normal}, moist {Moist oral mucosa}, anicteric {White sclera}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, S2 {Normal second heart sound, S>2<}, displaced {Apex beat displaced}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, Abd {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, BS+ {Normal bowel sounds}, Ext {Examination of limb}, warm {Warm skin}, edema {Edema}, Neuro {Neurological examination}, normal senstation {Normal sensation}, Vitals {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, Gen {General examination of patient}, well appearing {Well cared for appearance}, lying {Lying in bed}, Heent {Physical examination procedure}, OP clear {Pharynx normal}, moist {Moist oral mucosa}, anicteric {White sclera}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP flat {Normal jugular venous pressure}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, nl S1 S2 {Heart sounds normal}, displaced {Apex beat displaced}, RRR {Normal heart rate}, no m/r/g {Heart sounds normal}, Abd {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, BS+ {Normal bowel sounds}, Ext: {Examination of limb}, edema {Edema}, Neuro {Neurological examination}, normal senstation {Normal sensation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:58AM BLOOD cTropnT-<0.01
___ 02:00AM BLOOD cTropnT-<0.01
___ 02:00AM BLOOD Glucose-104* UreaN-20 Creat-1.0 Na-141 
K-4.1 Cl-106 HCO3-25 AnGap-14
___ 06:58AM BLOOD Glucose-94 UreaN-17 Creat-0.9 Na-143 
K-4.1 Cl-106 HCO3-28 AnGap-13
___ 02:00AM BLOOD WBC-5.1 RBC-4.68 Hgb-14.7 Hct-41.3 MCV-88 
MCH-31.4 MCHC-35.6* RDW-12.6 Plt ___
___ 06:58AM BLOOD WBC-4.4 RBC-4.63 Hgb-14.4 Hct-41.2 MCV-89 
MCH-31.1 MCHC-34.8 RDW-12.5 Plt ___

CARDIAC CATH (___)
- Final results pending at the time of discharge but verbal 
signout and images reviewed, revealing existing known CAD plus a 
lesion in the mLAD s/p DES.
 

###RESPONSE: cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, CARDIAC CATH {Cardiac catheterization}, CAD {Coronary arteriosclerosis}, lesion {Lesion}, mLAD {Structure of mid portion of anterior descending branch of left coronary artery}, DES {Endovascular insertion of drug eluting stent}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ yo male with CAD presenting with symptoms concerning for 
unstable angina.
 
#) UNSTABLE ANGINA: Known CAD with stent in past. Has stressed 
himself with pain with minimal exertion.  No evidence of cardiac 
enzyme leak.  TIMI risk = 4.  Started on heparin gtt.  Given 
atorvastatin 80mg, metoprolol.  Cath revealed similar findings 
as prior cath with known occluded RCA, but now mLAD lesion felt 
to be culprit s/p DES.

#) HYPERTENSION: Not optimally controlled. Consider increasing 
losartan as outpatient.
# Code: Full code
# Communication: Patient/ Wife ___ ___   
 
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY 
2. Clopidogrel 75 mg PO DAILY 
3. Atorvastatin 80 mg PO DAILY 
4. Metoprolol Succinate XL 25 mg PO DAILY 
hold for SBP<100/ HR<60 
5. Fish Oil (Omega 3) 2400 mg PO QHS 
6. Vitamin D ___ UNIT PO DAILY 
7. FoLIC Acid 1 mg PO DAILY 
8. Losartan Potassium 50 mg PO DAILY 
hold for SBP<100 or K+>5.5 

 
Discharge Medications:
1. Aspirin 325 mg PO DAILY 
2. Atorvastatin 80 mg PO DAILY 
3. Clopidogrel 75 mg PO DAILY 
4. Fish Oil (Omega 3) 2400 mg PO QHS 
5. FoLIC Acid 1 mg PO DAILY 
6. Losartan Potassium 50 mg PO DAILY 
7. Metoprolol Succinate XL 25 mg PO DAILY 
8. Vitamin D ___ UNIT PO DAILY 

 

###RESPONSE: CAD {Coronary arteriosclerosis}, unstable angina {Preinfarction syndrome}, UNSTABLE ANGINA {Preinfarction syndrome}, CAD {Coronary arteriosclerosis}, stent {Placement of stent in coronary artery}, pain with minimal exertion {Chest pain on exertion}, No evidence {No abnormality detected}, cardiac 
enzyme leak {Cardiac enzyme or marker above reference range}, heparin {Heparin therapy}, Cath {Cardiac catheterization}, cath {Cardiac catheterization}, occluded RCA {Right coronary artery occlusion}, mLAD {Structure of mid portion of anterior descending branch of left coronary artery}, lesion {Lesion}, DES {Endovascular insertion of drug eluting stent}, HYPERTENSION {Hypertensive disorder, systemic arterial}, increasing {Prescription dose change}, Aspirin {Administration of aspirin}, SBP {Blood pressure monitoring}, HR {Cardiotachometry}, SBP {Blood pressure monitoring}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Unstable angina
Coronary artery disease

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Unstable angina {Preinfarction syndrome}, Coronary artery disease {Coronary arteriosclerosis}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___,
   It was a pleasure taking care of you at ___.  You were 
admitted for chest pain and were found to have a blockage in one 
of your heart arteries.  A stent was placed in this artery, 
relieving the blockage.  Please refrain from vigorous physical 
activity for one week.  You must take your medications EVERY 
DAY.
 

###RESPONSE: chest pain {Chest pain}, blockage in one 
of your heart arteries {Coronary occlusion}, stent was placed in this artery {Placement of stent in coronary artery}, blockage {Coronary occlusion}, refrain from vigorous physical 
activity {Recommendation regarding functional activity}, must take your medications {Recommendation to continue with drug treatment}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___            Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   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:
Acute onset Nausea and vomiting 
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, Nausea and vomiting {Nausea and vomiting}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 panhypopituitarism presenting with acute onset nausea 
vomiting and fever. 

Patient had cough and congestion for approximately one week, 
mild chills, but no recorded fevers.  Yesterday prior to 
admission, he had sudden onset nausea, vomiting. He called his 
PCP, who told him to increase his dose of PO prednisone, but he 
was unable to tolerate PO.  He vomited a total of ___ times. At 
9PM, he vomited, then ""blacked out"" for ___ minutes, not 
responding to wife calling his name, woke up spontaneously and 
felt ok.  No abnormal limb movements, tongue biting, or 
incontinence.  Wife called ___ and he was brought to the 
emergency department.  No preceeding chest pain or palpitations. 
 This is his first syncopal episode.

Of note, per recent discharge summary, patient has a history of 
not consistently taking his medications, including his PO 
prednisone, resulting in nausea/vomiting, and admission for IV 
steroids.  It was emphasized at that time that he must take all 
his medications as prescribed.
In the ED, initial VS were: 101.3 82 159/64 18 96% 2L Nasal 
Cannula  
.  
Labs were notable for a TSH of 0.25 and a Lactate of 2.2. He was 
given 100 mg IV hydrocortisone, 1g of tylenol, zofran for his 
vomiting, 1 L NS.  
.  
On arrival to the floor he is in no pain and resting 
comfortably.  
He is most concerned about dizziness he has been experienced, 
which has been persistent since ___.  He 
experiences lightheadedness, inability to walk, feels 
disoriented ""loses himself in space"", and his legs feel weak.  
Dizziness occurs ___ times daily, and experiences this sensation 
for ___ minutes at a time.  He usually just rests and feels 
better.  Never had a loss of consciousness or fall.  No abnormal 
limb movements, no history of seizure, stroke, or MI.  Only 
experiences dizziness when moving, never while lying still in 
bed.

Also complains of chest pressure lasting ___ minutes at night, 
never occurs with activity, now happening ___ weekly.  Had this 
complaint during last hospitalization, was recommended to get 
outpatient nuclear stress.  No changes recently.
.  
REVIEW OF SYSTEMS:  
(+)Per HPI
Pertinent negatives:  abdominal pain, dysuria / polyuria, vision 
changes, unilateral weakness, confusion or altered mental 
status, abnormal limb movements
 

###RESPONSE: panhypopituitarism {Panhypopituitarism}, nausea 
vomiting {Nausea and vomiting}, fever {Fever}, cough {Cough}, congestion {Nasal congestion}, mild {Symptom mild}, chills {Chill}, fevers {Fever}, nausea, vomiting {Nausea and vomiting}, vomited {Vomiting}, vomited {Vomiting}, blacked out {Syncope}, not 
responding to wife calling {No response to sound}, No abnormal limb movements {Able to move all four limbs}, tongue biting {Tongue biting}, incontinence {Incontinence}, chest pain {Chest pain}, palpitations {Palpitations}, syncopal {Syncope}, not consistently taking his medications {Drugs - partial non-compliance}, nausea/vomiting {Nausea and vomiting}, IV {Intravenous therapy}, steroids {Steroid therapy}, VS {Vital signs finding}, Nasal 
Cannula {Oxygen administration by nasal cannula}, IV {Intravenous therapy}, vomiting {Vomiting}, dizziness {Dizziness}, lightheadedness {Lightheadedness}, inability to walk {Unable to walk}, disoriented ""loses himself in space"" {Spatial disorientation}, legs {Lower limb structure}, Dizziness {Dizziness}, loss of consciousness {Loss of consciousness}, fall {Falls}, No abnormal 
limb movements {Able to move all four limbs}, seizure {Seizure}, stroke {Cerebrovascular accident}, MI {Myocardial infarction}, dizziness {Dizziness}, chest pressure {Tight chest}, abdominal pain {Abdominal pain}, dysuria {Dysuria}, polyuria {Polyuria}, vision 
changes {Visual disturbance}, weakness {Asthenia}, confusion {Clouded consciousness}, altered mental 
status {Altered mental status}, limb {Limb structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- DM2  
- acromegaly s/p transsphenoidal resection and proton beam  
irradiation in ___  
- panhypopituitarism
- Multiple hospitalizations for nausea, vomiting, dizziness, 
most recently dc'ed ___ for n/v and was not taking PO 
prednisone consistently; had n/v and headache with negative 
neurologic workup ___
- Thyroid nodules  
- cholecystectomy  
 

###RESPONSE: DM2 {Diabetes mellitus type 2}, acromegaly {Acromegaly}, proton beam  
irradiation {External beam radiation therapy protons}, panhypopituitarism {Panhypopituitarism}, nausea, vomiting {Nausea and vomiting}, dizziness {Dizziness}, n/v {Nausea and vomiting}, n/v {Nausea and vomiting}, headache {Headache}, neurologic {Neurological examination}, Thyroid nodules {Thyroid nodule}, 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: 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:
Negative for headache, migraine, stroke.
 

###RESPONSE: headache {Headache}, migraine {Migraine}, 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 - 98.2 117/52 64 18 98% 3L
GENERAL - well-appearing man in NAD, comfortable, appropriate, 
large set jaw  
HEENT - NC/AT dry MM  
NECK - supple  
LUNGS - Bibasilar crackles, R > L
HEART - RRR, no MRG, nl S1-S2  
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no 
rebound/guarding  
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, 
DPs), +large hands and feet c/w acromegaly
SKIN - no rashes or lesions  
NEURO - A&O, answers questions appropriately, no nystagmus, gait 
steady

DISCHARGE PHYSICAL EXAM
VS - Tm 98.7 Tc 98.4 BP 102/46 64 18 89% on RA -> 100% on RA 
with deep breathing and coughing; ambulatory sats maintained at 
99%, transiently dropped only as low as 95%
GENERAL - well-appearing ___ man in NAD, comfortable, 
appropriate, large set jaw  
HEENT - NC/AT dry MM  
NECK - supple  
LUNGS - Bibasilar crackles, R > L
HEART - RRR, no MRG, nl S1-S2  
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no 
rebound/guarding  
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, 
DPs), +large hands and feet c/w acromegaly
SKIN - no rashes or lesions  
NEURO - A&O, answers questions appropriately, no nystagmus, gait 
steady
 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, GENERAL {General examination of patient}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, jaw {Jaw region structure}, HEENT {Physical examination procedure}, NC/AT {Normal head}, dry MM {Mucous membrane dryness}, NECK {Physical examination procedure}, LUNGS {Examination of respiratory system}, Bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, S2 {Normal second heart sound, S>2<}, ABDOMEN {Examination of abdomen}, NABS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, 2+ peripheral pulses {Peripheral pulses normal}, radials {Structure of radial artery}, DPs {Structure of dorsalis pedis artery}, large hands {Large hand}, feet {Large, broad feet}, acromegaly {Acromegaly}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, NEURO {Neurological examination}, nystagmus {Nystagmus}, gait 
steady {Gait normal}, PHYSICAL EXAM {Physical examination procedure}, VS {Vital signs finding}, BP {Blood pressure finding}, RA {Breathing room air}, RA {Breathing room air}, deep breathing {Deep breathing}, coughing {Cough}, GENERAL {General examination of patient}, well-appearing {Well cared for appearance}, NAD {No abnormality detected}, jaw {Jaw region structure}, HEENT {Physical examination procedure}, NC/AT {Normal head}, dry MM {Mucous membrane dryness}, NECK {Physical examination procedure}, supple {Normal movement of neck}, LUNGS {Examination of respiratory system}, Bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, HEART {Cardiovascular physical examination}, RRR {Normal heart rate}, no MRG {Heart sounds normal}, S2 {Normal second heart sound, S>2<}, ABDOMEN {Examination of abdomen}, NABS {Normal bowel sounds}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, masses {Abdominal mass}, HSM {Hepatosplenomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, 2+ peripheral pulses {Peripheral pulses normal}, radials {Structure of radial artery}, DPs {Structure of dorsalis pedis artery}, large hands {Large hand}, feet {Large, broad feet}, acromegaly {Acromegaly}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, NEURO {Neurological examination}, nystagmus {Nystagmus}, gait 
steady {Gait normal}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS
___ 01:10AM BLOOD WBC-6.4 RBC-3.79* Hgb-11.8* Hct-34.4* 
MCV-91 MCH-31.2 MCHC-34.3 RDW-14.4 Plt ___
___ 01:10AM BLOOD Neuts-84.4* Lymphs-9.0* Monos-5.5 Eos-1.0 
Baso-0.1
___ 09:00AM BLOOD ___ PTT-27.1 ___
___ 03:35PM BLOOD UreaN-32* Creat-1.1 Na-141 K-5.3* Cl-102 
HCO3-28 AnGap-16

OTHER RELEVANT LABS
___ 03:35PM BLOOD Albumin-4.1 Calcium-9.5 Cholest-127
___ 03:35PM BLOOD Triglyc-153* HDL-47 CHOL/HD-2.7 
LDLcalc-49
___ 03:35PM BLOOD %HbA1c-8.1* eAG-186*
___ 03:35PM BLOOD TSH-0.25*
___ 03:35PM BLOOD Free T4-1.1

DISCHARGE LABS
___ 12:45PM BLOOD WBC-6.3 RBC-3.37* Hgb-10.4* Hct-31.2* 
MCV-93 MCH-31.0 MCHC-33.5 RDW-14.4 Plt ___
___ 06:40AM BLOOD Glucose-182* UreaN-30* Creat-0.8 Na-140 
K-3.9 Cl-107 HCO3-25 AnGap-12
___ 06:40AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.8

IMAGING
CHEST X-RAY:  Peribronchial opacification at both lung bases is 
most likely atelectasis, but on the right, there is also a small 
right pleural effusion, raising concern for pneumonia.  Heart 
size is top normal, exaggerated by exceedingly low lung volumes. 
 There is no pulmonary edema.

MICROBIOLOGY
NEGATIVE:  Influenza A/B by ___ DIRECT INFLUENZA A ANTIGEN 
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL; Respiratory 
Viral Culture-FINAL INPATIENT 
___ URINE Legionella Urinary Antigen -FINAL 
INPATIENT 
___ URINE URINE CULTURE-FINAL INPATIENT 
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, AnGap {Anion gap measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Cholest {Cholesterol measurement}, Triglyc {Triglycerides measurement}, HDL {High density lipoprotein measurement}, CHOL/HD {Cholesterol/High density lipoprotein ratio measurement}, eAG {Glucose measurement estimated from glycated hemoglobin}, TSH {Thyroid stimulating hormone measurement}, Free T4 {T4 free measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, IMAGING {Imaging}, CHEST X-RAY {Plain chest X-ray}, lung bases {Structure of base of lung}, atelectasis {Atelectasis}, right {Right lung structure}, right pleural {Right pleura structure}, effusion {Pleural effusion}, pneumonia {Pneumonia}, Heart {Heart structure}, lung volumes {Finding of respiratory volume}, edema {Edema}, MICROBIOLOGY {Microbiology}, INFLUENZA B ANTIGEN TEST {Influenza B virus antigen assay}, Viral Culture {Viral culture}, URINE {Urine culture}, Urinary {Urinary system structure}, URINE {Urine culture}, URINE CULTURE {Urine culture}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ YOM with panhypopituitaryism presented to ___ with fever, 
sudden onset nausea/vomiting, syncope, and hypoxemia, found to 
have possible pneumonia on CXR.  He most likely had a viral 
illness and required stress-dose steroids, but was unable to 
tolerate PO due to inractable nausea/vomiting.  He likely 
experienced syncope from dehydration related to viral illness, 
nausea, vomiting.

# Panhypopituitarism, central adrenal insufficiency:  Patient 
presented with nausea, vomiting, diarrhea; has been admitted 
with similar presentations.  Nausea and vomiting improved with 1 
dose IV steroids, and was able to tolerate oral steroids.  Home 
prednisone was increased to 15mg daily.  Patient was instructed 
to continue stress dose prednisone 15mg daily for duration of 
pneumonia treatment, patient has appointment with outpatient 
endocrinologist on ___, who was endocrinologist was updated 
on hospitalization.

# Fever, Hypoxemia, Healthcare associated pneumonia vs 
aspiration:  Patient reported respiratory illness ongoing for 
approximately 1 week.  Chest x-ray showed possible pneumonia.  
His CURB-65 score was 2, moderate severity.  Alternatively, he 
may have had aspiration event during vomiting / syncopal 
episode.  He recently traveled to ___, but given Wells Score 
of 0, suspicion for PE was low.  Started levofloxacin 750 mg 
daily for HCAP (___).  He was successfully weaned off of 
supplemental O2, and ambulatory sats remained in the high ___.  
Influenza A/B and urine legionella were negative.  Other 
infectious workup with pertinent negatives:  Urinalysis and 
urine culture negative.  Blood cultures NGTD at the time this 
note is written.

# Syncope:  Likely vasovagal in setting of vomiting and 
dehydration versus orthostatic hypotension in the setting of 
inability to take PO steroids.  Family denies abnormal movements 
to suggest seizure, awoke spontaneously with no residual 
deficits.  EKG showed RBB but no significant change from prior.  
Was monitored on telemetry overnight with no events recorded.

# Dizziness: Adrenal insufficiency vs vertigo (associated with 
movement and relieved with meclizine); orthostatics were normal, 
negative workup on prior admissions.  

# Anemia:  HCT has been mid 30's in past, most recently 31 
___, with normal iron studies. Rectal exam done and was 
found to be guaiac negative.  HCT was stable

# Hypertension: Quinapril was held given low/normal blood 
pressures during hospitalization, and possible contribution to 
syncope.  PCP was informed and may restart if needed.

# Chest pain:  Patient presented with atypical chest pain during 
last admission, ruled out for MI seen by cardiology, recommended 
outpatient stress test; History not consistent with cardiac 
etiology, may be GI (esophageal irritation, acid reflux)
Continued home aspirin 325mg, atorva 80mg, quinapril 10mg daily. 
 Recommended outpatient stress test 

# DM: Held oral diabetes meds and placed on insulin SS 

# CONTACT: patient, son ___ ___ ___ 
(daughter in law)  

other transitional issues (per PACT):
- Inconsistent with metformin and glimeperide; consider reducing 
 regimen to single agent for compliance (perhaps XR version of 
metformin which would be $4/month and provide better daily 
coverage). Taking an ACEI (MA-) and an ASA.
- Overdue for eye clinic f/up. 
 

###RESPONSE: panhypopituitaryism {Panhypopituitarism}, fever {Fever}, nausea/vomiting {Nausea and vomiting}, syncope {Syncope}, hypoxemia {Hypoxemia}, pneumonia {Pneumonia}, CXR {Plain chest X-ray}, viral 
illness {Viral disease}, steroids {Steroid therapy}, nausea/vomiting {Nausea and vomiting}, syncope {Syncope}, dehydration {Dehydration}, viral illness {Viral disease}, nausea, vomiting {Nausea and vomiting}, Panhypopituitarism {Panhypopituitarism}, adrenal insufficiency {Adrenal cortical hypofunction}, nausea, vomiting {Nausea and vomiting}, Nausea and vomiting {Nausea and vomiting}, improved {Patient's condition improved}, IV {Intravenous therapy}, steroids {Steroid therapy}, oral {Administration of drug or medicament via oral route}, steroids {Steroid therapy}, pneumonia {Pneumonia}, Fever {Fever}, Hypoxemia {Hypoxemia}, Healthcare associated pneumonia {Nosocomial pneumonia}, aspiration {Aspiration pneumonia}, ted respiratory illness {Disorder of respiratory system}, Chest x-ray {Plain chest X-ray}, pneumonia {Pneumonia}, aspiration {Aspiration into respiratory tract}, vomiting {Vomiting}, syncopal {Syncope}, PE {Pulmonary embolism}, HCAP {Nosocomial pneumonia}, infectious {Infectious disease}, workup {Evaluation procedure}, Urinalysis {Urinalysis}, urine culture {Urine culture}, Blood cultures {Blood culture}, Syncope {Syncope}, vasovagal {Vasovagal syncope}, vomiting {Vomiting}, dehydration {Dehydration}, orthostatic hypotension {Orthostatic hypotension}, abnormal movements {Abnormal movement}, seizure {Seizure}, EKG {Electrocardiographic procedure}, RBB {Right bundle branch block}, telemetry {Electroencephalogram telemetry}, Dizziness {Dizziness}, Adrenal insufficiency {Adrenal cortical hypofunction}, vertigo {Vertigo}, orthostatics {Orthostatic body position}, Anemia {Anemia}, Rectal exam {Rectal examination}, guaiac {Guaiac test for occult blood in feces specimen}, HCT was stable {Stable hematocrit}, Hypertension {Hypertensive disorder, systemic arterial}, normal blood 
pressures {Normal blood pressure}, syncope {Syncope}, Chest pain {Chest pain}, atypical chest pain {Atypical chest pain}, MI {Myocardial infarction}, stress test {Electrocardiogram with exercise test}, cardiac {Heart structure}, GI {Structure of digestive system}, acid reflux {Acid reflux}, stress test {Electrocardiogram with exercise test}, DM {Diabetes mellitus}, diabetes {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: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY 
2. glimepiride *NF* 1 mg Oral daily 
3. Levothyroxine Sodium 75 mcg PO DAILY 
4. MetFORMIN (Glucophage) 1000 mg PO BID 
5. PredniSONE 5 mg PO DAILY 
6. Quinapril 10 mg PO DAILY 
7. Aspirin 81 mg PO DAILY 
8. Vitamin D 3000 UNIT PO DAILY 
9. Docusate Sodium 100 mg PO DAILY 
10. Senna 1 TAB PO BID:PRN constipation 

 
Discharge Medications:
1. Aspirin 81 mg PO DAILY 
2. Atorvastatin 80 mg PO DAILY 
3. Docusate Sodium 100 mg PO DAILY 
4. Levothyroxine Sodium 75 mcg PO DAILY 
5. PredniSONE 15 mg PO DAILY 
RX *prednisone 5 mg 3 tablet(s) by mouth DAILY Disp #*15 Tablet 
Refills:*0
6. Senna 1 TAB PO BID:PRN constipation 
7. Vitamin D 3000 UNIT PO DAILY 
8. Calcium Carbonate 1500 mg PO DAILY 
Do not take within 1 hour of taking levothyroxine 
9. Levofloxacin 750 mg PO DAILY Duration: 7 Days 
RX *levofloxacin 750 mg 1 tablet(s) by mouth DAILY Disp #*5 
Tablet Refills:*0
10. MetFORMIN (Glucophage) 1000 mg PO BID 

 

###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:
Community acquired pneumonia, panhypopituitarism

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Community acquired pneumonia {Community acquired pneumonia}, panhypopituitarism {Panhypopituitarism}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___, 
You were ___ to ___ for nausea, vomiting, and fever.  The 
nausea, vomiting, and dizziness that you experience periodically 
is most likely a result of low levels of steroids in your blood 
because your pituitary gland, which controls release of 
hormones, has been partially resected.  It is very important 
that you take prednisone as prescribed every day to prevent 
these symptoms.

You had fevers and your chest x-ray showed evidence of 
pneumonia, so we started you on an antibiotic called 
levofloxacin.
 

###RESPONSE: nausea, vomiting {Nausea and vomiting}, fever {Fever}, nausea, vomiting {Nausea and vomiting}, dizziness {Dizziness}, low levels of steroids {Abnormal steroid hormone}, pituitary gland {Pituitary structure}, fevers {Fever}, chest x-ray {Plain chest X-ray}, pneumonia {Pneumonia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: PSYCHIATRY
 

###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:
""What about my headaches?""

 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, headaches {Headache}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
HISTORY OF PRESENT ILLNESS: Please see Dr. ___ Dr.
___ consult note from ___ for further details of 
the
HPI, PPHx, PMHx, Substance Use Hx, SHx.
 
Briefly, this is a ___ year old woman with history of chronic
headaches and dyspepsia who originally came to the hospital on
___ for sudden catatonic like symptoms in the setting of
topiramate overuse for treatment of chronic headaches. She was
transferred to neurology for workup of her catatonic features,
her EEG showed diffuse slowing, and her symptoms improved
significantly after a trial of lorazepam 2mg IM x 1. 

She was revisited by psychiatry consult services who felt that
she seemed to have new-onset psychotic processes, expressing
paranoia and emotional lability.

Upon arrival to the unit she stated she did not understand why
she was on the psychiatric ward. She was concerned about her
previous headaches and felt they were not adequately addressed
but expressed she had not had a headache for the past 2 days. 
She
did not express any complaints, though stated she felt better
when she sang, and sang church hymns through the remainder of 
the
interview.

After speaking with her husband who came to visit, he states 
that
she is still, at times, not at her baseline. He stated she is
sometimes confused and has difficulty concentrating. He does
acknowledge that she is significantly improved from when she was
first admitted.

 

###RESPONSE: chronic
headaches {Chronic headache disorder}, dyspepsia {Indigestion}, catatonic {Catatonia}, chronic headaches {Chronic headache disorder}, neurology {Neurological examination}, workup {Evaluation procedure}, catatonic {Catatonia}, EEG {Electroencephalogram}, improved {Patient's condition improved}, paranoia {Paranoid disorder}, emotional lability {Mood swings}, psychiatric {Psychiatry procedure or service}, headaches {Headache}, headache {Headache}, baseline {Baseline state}, confused {Clouded consciousness}, difficulty concentrating {Unable to concentrate}, 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: Past Medical History:
Headaches
 

###RESPONSE: Headaches {Headache}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
SAFETY:  The pt. was placed on 15 minute checks on admission and 

remained here on that level of observation throughout.  She was 
unit-restricted.  There were no acute safety issues during this 
hospitalization.

LEGAL: ___
PSYCHIATRIC: 
Catatonia had resolved before admission with ativan. On 
admission, she endorsed depressed mood with neurovegetative 
symptoms including reduced sleep, interest, energy, 
concentration, and appetite. She exhibited transient psychotic 
symptoms including a paranoid delusion that somebody was coming 
to hurt her, and auditory hallucinations where she heard the 
voice of her cousin and her brother. On admission, pt was 
started on mirtazapine 7.5mg PO QHS, olanzapine 5mg PO BID, and 
lorazepam 1mg PO BID with 1mg PO Q6H prn. On this regimen, she 
improved significantly. Her mood improved, and her psychotic 
symptoms resolved. Whereas on admission she was significantly 
fixated on somatic symptoms, in which these complaints 
represented the ___ her focus, by the time of discharge, 
these complaints were only mentioned in passing. She has poor 
insight, and she does not wish to take medications after 
discharge, as she believes that taking medication will make her 
dependent on them for further functioning.
 

GENERAL MEDICAL CONDITIONS:

PSYCHOSOCIAL:
#) GROUPS/MILIEU: pt was visible on the unit but did not attend 
many groups.

#) COLLATERAL CONTACTS:
Husband denied previous depression or psychosis.

RISK ASSESSMENT:

#) Chronic/Static Risk Factors:
-mood disorder

#) Modifiable Risk Factors:
-mood disorder
-psychosocial stressors
-poor insight, doesn't believe medications have helped her

#) Protective Factors:
-married with children
-gender
-no past suicide attempts

PROGNOSIS: Guarded
Ms. ___ will need ___ follow-up with a 
psychiatrist and therapist. If she adheres to her medications 
and appointments, she will likely do well. However, as she does 
not believe that medications are helping her, and she does not 
want to take psychotropic medications long-term, non-compliance 
is a significant risk.
 

###RESPONSE: SAFETY {Safety case management}, level of observation {Levels of observation}, no acute {No abnormality detected}, PSYCHIATRIC {Psychiatry procedure or service}, Catatonia {Catatonia}, resolved {Problem resolved}, depressed mood {Depressed mood}, reduced sleep {Short-sleeper}, interest {Loss of interest}, energy {Lack of energy}, concentration {Unable to concentrate}, appetite {Decrease in appetite}, psychotic 
symptoms {Psychotic symptom present}, paranoid delusion {Paranoid delusion}, auditory hallucinations {Auditory hallucinations}, regimen {Therapeutic regimen}, improved {Patient's condition improved}, mood improved {Improved mood}, psychotic 
symptoms resolved {Psychotic symptom finding}, somatic symptoms {Somatic pain}, insight {Finding related to ability to comprehend}, does not wish to take medications {Non-compliance of drug therapy}, medication {Administration of drug or medicament}, MILIEU {Environmental intervention}, did not attend {Did not attend}, depression {Depressive disorder}, psychosis {Psychotic disorder}, mood disorder {Mood disorder}, mood disorder {Mood disorder}, insight {Finding related to ability to comprehend}, medications {Administration of drug or medicament}, married {Married}, suicide attempts {Suicidal intent}, PROGNOSIS {Determination of prognosis}, follow-up {Follow-up arranged}, psychiatrist {Psychiatric follow-up}, medications {Prescription of drug}, medications {Administration of drug or medicament}, psychotropic medications {On psychotropic medication}, non-compliance {Non-compliance of drug therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OLANZapine 2.5 mg PO QHS 
2. timolol maleate 5 mg oral BID 
3. Omeprazole 20 mg PO BID 

 

###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:
MDD with psychotic features

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: MDD with psychotic features {Severe mood disorder with psychotic features}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
-please take your medications as prescribed
-please follow-up with outpatient appointments
 
                             ___ MD ___
 
Completed by: ___

###RESPONSE: take your medications as prescribed {Patient medication education}, 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:  
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: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
chest pain
 
Major Surgical or Invasive Procedure:
___ Cardiac catheterization

 

###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, chest pain {Chest pain}, Cardiac catheterization {Cardiac catheterization}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Patient is a ___ year old male with history of coronary artery 
disease status-post catherization in ___ with stent to OM1, 
and hypertension who presents with chest pain.  
.  
Patient reports that he had a ""stabbing"" chest pain this 
morning. He states he had ""a lot"" of chest pain, more than the 
___ episodes per day he had been having previously. He states it 
improved with nitroglycerin that he took at home. He also had 
had a positive stress test about a week ago and an outpatient 
catherization at ___ had been planned.  
.  
He initially presented to ___, where he 
received nitropaste. Vitals there were 94/22, HR 94, RR 18, 97% 
on RA, and no pain. Cardiac enzymes there were CK 170 and 
Troponin 0.02 at 12:30 ___.  
Upon arrival to ___, his blood pressure was 104/52, HR 52, RR 
18, temperature 96.2, and respiratory rate of 18. He was given 
325 mg of aspirin and tolerated it well--of note there is a 
possible allergy to aspirin noted in his admission intake form.  

.  
Patient was resting comfortably in his bed without any 
complaints when interviewed. He denied chest pain or shortness 
of breath.  
.  
On review of systems, he denies any prior history of stroke, 
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the 
time of surgery, myalgias, cough, hemoptysis, black stools or 
red stools. He denies recent fevers, chills or rigors. No 
exertional buttock or calf pain. All of the other review of 
systems were negative except for pain in his right hand that 
patient relates has continued to bother him since a fall earlier 
in the year.  
.  
Cardiac review of systems is notable for chest pain as discussed 
above, accompanied by lightheadedness this morning. No worsening 
dypsnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, 
ankle edema, palpitations, syncope or presyncope.  
.  

 

###RESPONSE: coronary artery 
disease {Coronary arteriosclerosis}, stent {Insertion of arterial stent}, OM1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, hypertension {Hypertensive disorder, systemic arterial}, chest pain {Chest pain}, stabbing {Stabbing pain}, chest pain {Chest pain}, chest pain {Chest pain}, improved {Patient's condition improved}, stress test {Electrocardiogram with exercise test}, catherization {Cardiac catheterization}, Vitals {Vital signs finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, RA {Breathing room air}, pain {Chest pain}, Cardiac enzymes {Finding of cardiac enzyme levels}, Troponin {Troponin measurement}, blood pressure {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, temperature {Body temperature finding}, respiratory rate {Finding of rate of respiration}, allergy to aspirin {Allergy to aspirin}, chest pain {Chest pain}, shortness 
of breath {Dyspnea}, 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}, 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}, pain {Hand pain}, right hand {Structure of right hand}, fall {Falls}, Cardiac {Structure of cardiovascular system}, review of systems {Review of systems}, chest pain {Chest pain}, lightheadedness {Lightheadedness}, dypsnea on exertion {Dyspnea on exertion}, paroxysmal nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, ankle edema {Ankle edema}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- CAD s/p BMS to OM1  (see below)
- HTN  
- renal calculi s/p surgery  
- hip replacement x 2 on right r/t injuries  
- GSW to pelvis/femur WWII; left hip replacement r/t war 
injuries (left leg is shorter than right)  
- BPH  
- pneumonia  
- appendectomy  
.  
Cardiac Risk Factors: (-)Diabetes, (-)Dyslipidemia, 
(+)Hypertension  
.  
Cardiac History:  
Percutaneous coronary intervention, in ___ anatomy as 
follows: BMS to the OM with rotational atherectomy. Had to have 
___ cath 10 days after first as first attempt at stent placement 
was unsuccessful.  

 

###RESPONSE: CAD {Coronary arteriosclerosis}, OM1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, HTN {Hypertensive disorder, systemic arterial}, renal calculi {Kidney stone}, surgery {Surgical procedure}, hip replacement {Prosthetic arthroplasty of hip}, right {Structure of right knee region}, injuries {Traumatic or non-traumatic injury}, GSW {Gunshot wound}, pelvis {Structure of pelvis}, femur {Bone structure of femur}, left hip replacement {Total replacement of left hip joint}, war 
injuries {War injury}, left leg {Structure of left lower leg}, shorter {Short leg}, right {Structure of right lower limb}, BPH {Benign prostatic hyperplasia}, pneumonia {Pneumonia}, appendectomy {Excision of appendix}, Cardiac Risk Factors {Assessment for risk of cardiovascular disease}, Diabetes {Diabetes mellitus}, Dyslipidemia {Dyslipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, Cardiac {Structure of cardiovascular system}, Percutaneous coronary intervention {Percutaneous coronary intervention}, OM {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, rotational atherectomy {Atherectomy by rotary cutter}, cath {Cardiac catheterization}, stent placement {Placement of stent}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
There is no family history of premature coronary artery disease. 
A brother died suddenly in sleep at age ___. 
 

###RESPONSE: coronary artery disease {Coronary arteriosclerosis}, 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:
VS: 97.7, 158/67, 56, 18, 97% on RA, 161 lbs.  
GENERAL: Elderly male, sleeping, easily awaken, NAD. Oriented 
x3. Mood, affect appropriate.  
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were 
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.  

NECK: Supple with JVP of 8 cm.  
CARDIAC: PMI located in ___ intercostal space, midclavicular 
line. Bradycardic, irregularly irregular, 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, no crackles, 
wheezes or rhonchi. Transmitted noises from abdomen appreciated 
at times. Fleshy nodule in middle of upper back.  
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not 
enlarged by palpation. No abdominial bruits.  
EXTREMITIES: No c/c/e. No femoral bruits.  
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.  
PULSES:  
Bilateral: Carotid 2+ Very strong bilateral DP 2+ ___ 2+
 

###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, sleeping {Asleep}, awake {Awake}, NAD {No abnormality detected}, Oriented 
x3 {Oriented to person, time and place}, Mood {Level of mood - normal}, affect {Mood finding}, HEENT {Physical examination procedure}, NC {Normal head}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva were 
pink {Conjunctiva normal}, pallor {Pallor of skin of face}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthalesma {Xanthelasma}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, intercostal space {Structure of intercostal space}, midclavicular 
line {Midclavicular line}, Bradycardic {Bradycardia}, irregularly irregular {Heart irregularly irregular}, S2 {Normal second heart sound, S>2<}, thrills {Thrill}, No S3 {Third heart sound, S>3<, inaudible}, S4 {Fourth heart sound, S>4<, 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}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, Transmitted noises {Transmitted sounds}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, nodule {Nodule}, upper back {Upper back structure}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, Abd {Examination of abdomen}, enlarged {Enlargement}, palpation {Palpation}, abdominial bruits {Abdominal bruit}, EXTREMITIES {Examination of limb}, femoral bruits {Femoral bruit}, SKIN {Examination of skin}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, PULSES {Pulse finding}, 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:
___ Cardiac cath:
COMMENTS:      
1. Selective coronary angiography of this right dominant system 
demonstrated no significant obstructive CAD. The LMCA had mild 
disease. 
The LCX/OM1 stents were patent. The LA and RCA had moderate 
diffuse disease, unchanged from the prior catheterization in 
___. 
2. Limited resting hemodynamics demonstrated systemic arterial 
hypertension (154/61). 
  
FINAL DIAGNOSIS:     
1. No significant obstructive CAD. Patent OM stents. 

 

###RESPONSE: Cardiac cath {Cardiac catheterization}, coronary angiography {Angiography of coronary artery}, right {Right coronary artery structure}, CAD {Coronary arteriosclerosis}, LMCA {Structure of left coronary artery main stem}, disease {Disease}, LCX {Stent in circumflex branch of left coronary artery}, OM1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, stents were patent {Coronary stent patent}, LA {Structure of circumflex branch of left coronary artery}, RCA {Right coronary artery structure}, disease {Disease}, catheterization {Cardiac catheterization}, hemodynamics {Hemodynamic monitoring}, systemic arterial 
hypertension {Hypertensive disorder, systemic arterial}, CAD {Coronary arteriosclerosis}, OM {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, stents {Coronary stent patent}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Patient is a ___ year old male with history of coronary artery 
disease and hypertension who presents with chest pain in the 
setting of a recent positive stress test.  
.  
# CORONARIES: Patient has known CAD, has prior BMS to OM1 in 
___. His recurrent chest pain is concerning for stuttering 
angina given his known disease and response to nitroglycerin. 
Report of his out-patient stress test (reportedly positive per 
patient) was not available for review at time of admission, but 
plans were already being made for repeat catherization given 
worsening symptoms in the setting of a good medical regimen. 
Cardiac enzymes were negative times three and no ischemic 
changes were seen on EKG. Cardiac catheterization was performed 
which revealed no significant lesions or stenosis.  Pt remained 
pain free throughout his hospitalization. He was instructed to 
continue his home cardiac medications as previously directed and 
follow up with his primary care physician within one week of 
discharge.
.  
# RHYTHM: Pt has no history of arrhythmias. Sinus bradycardia 
with 1st degree AV block is an old finding. Given pts known 
bradycardia and new history of dizziness and fatigue, pt was 
evaluated by the Electrophysiology team.  There was no 
indication for pacemaker placement during this admission.  Pt 
was discharged home with a holter monitor to observe the extent 
of his bradycardia. Pt will follow up with his primary care 
provider and cardiologist to determine the benefit of a 
pacemaker in the future.  
.
# PUMP: No evidence of failure on history or exam.  
.   
# HTN: Continue home medications (mayzide, terazosin, diovan, 
metoprolol in lieu of atenolol given advanced age and atenolol 
is renally cleared)  
.  
# BPH: Continue terazosin.  
.  
# Anemia: Stable from one year ago. Will defer any desired 
further work-up to outpatient providers.  
.  
# FEN: Precath hydration was provided.  
.  
# ACCESS: PIV's   
.  
# CODE: Full  
.  
# Contact: Daughter ___:  
Phone: ___  

 

###RESPONSE: coronary artery 
disease {Coronary arteriosclerosis}, hypertension {Hypertensive disorder, systemic arterial}, chest pain {Chest pain}, stress test {Electrocardiogram with exercise test}, CAD {Coronary arteriosclerosis}, OM1 {Structure of first obtuse marginal branch of circumflex branch of left coronary artery}, chest pain {Chest pain}, angina {Angina}, stress test {Electrocardiogram with exercise test}, no ischemic 
changes {Electrocardiogram: no myocardial ischemia}, EKG {Electrocardiographic procedure}, Cardiac catheterization {Cardiac catheterization}, lesions {Lesion}, stenosis {Stenosis}, pain {Chest pain}, arrhythmias {Cardiac arrhythmia}, Sinus bradycardia {Sinus bradycardia}, 1st degree AV block {First degree atrioventricular block}, bradycardia {Bradycardia}, dizziness {Dizziness}, fatigue {Fatigue}, evaluated {Evaluation procedure}, pacemaker placement {Implantation of cardiac pacemaker}, bradycardia {Bradycardia}, follow up {Follow-up arranged}, HTN {Hypertensive disorder, systemic arterial}, BPH {Benign prostatic hyperplasia}, Anemia {Anemia}, Stable {Patient's condition stable}, PIV {Peripheral intravenous catheter care}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Atenolol 25 mg daily  
Plavix 75 mg daily  
___ 12.5 mg daily  
Omeprazole 40 mg daily  
Zocor 20 mg daily  
Terazosin 10 mg daily  
Diovan 80 mg daily  
Imdur 60 mg daily  
 
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) 
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.  
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO once a day.  
5. Terazosin 10 mg Capsule Sig: One (1) Capsule PO once a day.  
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr 
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).  
7. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

8. Maxzide-25mg  Oral

 

###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:
___
 
___ Diagnosis:
Primary
1. Coronary artery disease
2. Hypertension
3. Bradycardia

 
Discharge Condition:
Hemodynamically stable, chest pain free

 

###RESPONSE: Home With Service {Home health aide service management}, Coronary artery disease {Coronary arteriosclerosis}, Hypertension {Hypertensive disorder, systemic arterial}, Bradycardia {Bradycardia}, Hemodynamically stable {Hemodynamically stable}, 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: Discharge Instructions:
You came into the hospital because of chest pain. You underwent 
a repeat cardiac catheterization that showed no major new 
blockages.
.
At the other hospital, you had evidence of an irregular heart 
rhythm (atrial fibrillation or flutter) but your heart rhythm 
here looked regular. You will need a heart monitor for 48 hours 
following discharge from the hospital to see if the irregular 
rhythm recurs.
.
We stopped your atenolol because it may be contributing to the 
dizzy episodes you were having prior to coming into the 
hospital. 
Please take your medications as directed and keep your followup 
appointments.
.
Call your doctor and seek medical attention if you develop:
** worsening chest discomfort, shortness of breath, 
lightheadedness or dizziness, bleeding, swelling, or pain at the 
procedure site at your groin, or if you have any other symptoms 
that worry you
 

###RESPONSE: chest pain {Chest pain}, cardiac catheterization {Cardiac catheterization}, irregular heart 
rhythm {Irregular heart beat}, atrial fibrillation {Atrial fibrillation}, flutter {Atrial flutter}, heart rhythm {Finding of heart rhythm}, regular {Normal sinus rhythm}, irregular 
rhythm {Irregular heart beat}, dizzy {Dizziness}, chest discomfort {Chest discomfort}, shortness of breath {Dyspnea}, lightheadedness {Lightheadedness}, dizziness {Dizziness}, bleeding {Bleeding}, swelling {Swelling}, pain {Chest pain}, procedure {Procedure}, groin {Inguinal region structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___              Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
abdominal pain, diarrhea
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, 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: History of Present Illness:
Mr. ___ is a ___ yo M w/hx of DVT, hyponatremia, and chronic 
pancreatic abnormalitiy of unknown etiology presenting with 
lower abdominal pain and diarrhea. His symptoms began with 
diarrhea on ___ happening twice a day, was nonbloody.  He 
developed abdominal pain on ___, constant, 
nonradiating, and in the lower central abdomen. His abdominal 
pain progressed over three days to ___, and his diarrhea did 
not improve.  His last bowel movement was yesterday and is 
currently passing gas. He has been able to eat and drink, denies 
any fevers, chills, vomiting, hematemesis, melena, hematochezia, 
travel, sick contacts, food ingestion.  He finished triple 
therapy for H. Pylori 1 month ago. He did endorse urinary 
hesitancy, no dysuria. He has no history of alcohol use, did 
smoke with 2.5 pack years.  

On arrival to the ED, initial vitals were: T97.8 HR84 BP136/84 
RR16 O296% ra. Exam notable for mild diffuse ttp, no 
rebound/guarding. Labs notable for: ALT 87 AP 60 Tbili: 0.2 Na: 
129 BUN/crea: ___ Lip: 171 WBC: 8.2. CT abdomen showed 
pancreatitis of body and tail and likely distal splenic vein 
thrombosis. In ED, patient received  Morphine 5 mg IV, 4mg 
zofran, and 2L IV NS. Patient evaluated by ACS who recommended 
admission to medicine for suspected pancreatitis. VS prior to 
transfer: 98.3 76 116/72 14 100% RA. 

Currently, he is feeling ___ abdominal pain, which he calls 
comfortable.  It is in the center lower abdomen, nonradiating.  
He denies any vomiting, fevers, chills, or SOB.

Of note, he has had a 25 lb weight loss since ___ and has had 
a poor appetite.  He has some chronic symptoms that began with 
constipation.  Sometime in ___ he was admitted to the ___ 
for hyponatremia and was found to have a chronic pancreatic 
abnormality of unknown etiology s/p biopsy, colonoscopy, and 
endoscopy.  He also had a DVT that he is on Lovenox for 
currently.  He expresses some chronic lower abdominal pain that 
sometimes involves testicular pain.
 
ROS: per HPI, denies fever, chills, night sweats, vision 
changes,  shortness of breath, chest pain, vomiting, BRBPR, 
melena, hematochezia, dysuria, hematuria. Did endorse headache.

 

###RESPONSE: DVT {Deep venous thrombosis}, hyponatremia {Hyponatremia}, chronic 
pancreatic abnormalitiy {Disorder of pancreas}, lower abdominal pain {Lower abdominal pain}, diarrhea {Diarrhea}, diarrhea {Diarrhea}, abdominal pain {Abdominal pain}, constant {Constant pain}, nonradiating {Radiating pain}, lower central abdomen {Lower abdomen structure}, abdominal 
pain {Abdominal pain}, diarrhea {Diarrhea}, passing gas {Passing flatus}, able to eat {Able to eat}, fevers {Fever}, chills {Chill}, vomiting {Vomiting}, hematemesis {Hematemesis}, melena {Melena}, hematochezia {Hematochezia}, travel {Travel abroad}, triple 
therapy for H. Pylori {Triple therapy helicobacter pylori}, urinary 
hesitancy {Delay when starting to pass urine}, dysuria {Dysuria}, alcohol use {Current drinker of alcohol}, did 
smoke {Ex-smoker}, vitals {Vital signs finding}, diffuse {Diffuse pain}, ttp {Tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, ALT {Alanine aminotransferase above reference range}, WBC {White blood cell count}, CT abdomen {Computed tomography of abdomen}, pancreatitis {Pancreatitis}, splenic vein 
thrombosis {Splenic vein thrombosis}, pancreatitis {Pancreatitis}, VS {Vital signs finding}, RA {Breathing room air}, abdominal pain {Abdominal pain}, lower abdomen {Lower abdomen structure}, nonradiating {Radiating pain}, vomiting {Vomiting}, fevers {Fever}, chills {Chill}, SOB {Dyspnea}, weight loss {Weight loss}, poor appetite {Decrease in appetite}, constipation {Constipation}, hyponatremia {Hyponatremia}, chronic pancreatic 
abnormality {Disorder of pancreas}, biopsy {Biopsy}, colonoscopy {Colonoscopy}, endoscopy {Endoscopy}, DVT {Deep venous thrombosis}, lower abdominal pain {Lower abdominal pain}, testicular pain {Pain in testicle}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, vision 
changes {Visual disturbance}, shortness of breath {Dyspnea}, chest pain {Chest pain}, vomiting {Vomiting}, BRBPR {Hematochezia}, melena {Melena}, hematochezia {Hematochezia}, dysuria {Dysuria}, hematuria {Blood in urine}, headache {Headache}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
pancreatic mass s/p biopsy, colonoscopy, and endoscopy, the most 
recent endoscopy in ___
H pylori gastritis s/p triple therapy 1 month ago 
DVT in ___
Diabetes Mellitus (reported by patient, on no therapy)

 

###RESPONSE: pancreatic mass {Mass of pancreas}, biopsy {Biopsy}, colonoscopy {Colonoscopy}, endoscopy {Endoscopy}, endoscopy {Endoscopy}, H pylori gastritis {Gastritis caused by Helicobacter pylori}, triple therapy {Triple therapy helicobacter pylori}, DVT {Deep venous thrombosis}, Diabetes Mellitus {Diabetes mellitus}, therapy {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: 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:
Denies any family history of pancreatic or other GI disease, 
cancer, or autoimmune disease

 

###RESPONSE: pancreatic {Pancreatic structure}, GI disease {Disorder of gastrointestinal tract}, cancer {Malignant neoplasm}, autoimmune disease {Autoimmune 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: Physical Exam:
======================
Admission Physical Exam
======================
VS - Temp 97.8F, BP 125/62, HR 106, R 18, O2-sat 98% RA  
General: NAD, appears comfortable
HEENT: normocephalic, no scleral icterus, OP clear. 
Neck: supple, no cervical ___.
CV:  regular rhymthm, tachycardic, nl S1 S2, no r/m/g 
appreciated.
Lungs: CTAB, no rales
Abdomen: +BS.Soft,nondistended,tender to palpation in the 
central lower abdomen and epigastric regions, worse in lower 
abdomen. ___ and Grey-Turner's signs negative.  No fluid 
wave. No hepatosplenomegaly. No rebound or guarding.
GU: no Foley. No LAD,no testicular pain to palpation. No CVA 
tenderness.
Ext: WWP, +2 pulses. No pedal edema. 
Neuro: A+Ox3, attentive. Memory intact. Motor and sensory 
function grossly intact.
Skin: no rashes. No spider angiomata.

=====================
Discharge Physical Exam
=====================
VS- 98.7 119/72 83 18 95RA
General: NAD, appears comfortable
HEENT: no scleral icterus 
CV: regular rhythm, normal rate, S1 and S2 clear and of good 
quality, no r/m/g appreciated.
Lungs: CTAB bilaterally with good air movement. 
Abdomen: +BS. Soft, non-tender, slightly distended. No rebound 
or guarding.
Extremities: Warm and well perfused with 2+ DP pulses, no 
cyanosis, edema, or excoriations.
Neuro: A+Ox3, attentive. 

 

###RESPONSE: Physical Exam {Physical examination procedure}, VS {Vital signs finding}, Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, O2-sat {Oxygen saturation measurement}, RA {Breathing room air}, General {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, normocephalic {Normal head}, scleral icterus {Scleral icterus}, OP clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, cervical {Cervical lymphadenopathy}, CV {Cardiovascular physical examination}, regular rhymthm {Normal sinus rhythm}, tachycardic {Tachycardia}, S2 {Normal second heart sound, S>2<}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, rales {Respiratory crackles}, Abdomen {Examination of abdomen}, BS {Normal bowel sounds}, Soft {Abdomen soft}, nondistended {Normal abdominal contour}, tender {Abdominal tenderness}, palpation {Palpation}, lower abdomen {Lower abdomen structure}, epigastric regions {Epigastric region structure}, lower 
abdomen {Lower abdomen structure}, Grey-Turner's signs {Grey Turner's sign}, hepatosplenomegaly {Hepatosplenomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, GU {Examination of genitourinary system}, Foley {Catheterization of urinary bladder}, LAD {Lymphadenopathy}, pain {Pain}, palpation {Palpation}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, 2 pulses {Peripheral pulses normal}, edema {Edema}, Neuro {Neurological examination}, Ox3 {Oriented to person, time and place}, Memory intact {Memory function normal}, grossly intact {Normal nervous system function}, Skin {Examination of skin}, rashes {Eruption of skin}, spider angiomata {Spider telangiectasis of skin}, Physical Exam {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, scleral icterus {Scleral icterus}, CV {Cardiovascular physical examination}, regular rhythm {Normal sinus rhythm}, normal rate {Normal heart rate}, S2 {Normal second heart sound, S>2<}, Lungs {Examination of respiratory system}, CTAB {Normal breath sounds}, good air movement {Breath normal}, Abdomen {Examination of abdomen}, BS {Normal bowel sounds}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, distended {Swollen abdomen}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, Extremities {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ DP pulses {All pulses present in bilateral lower limbs}, cyanosis {Cyanosis}, edema {Edema}, excoriations {Excoriation}, Neuro {Neurological examination}, A {Mentally alert}, Ox3 {Oriented to person, time and place}, attentive {Well controlled integrated attention}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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
=============================
___ 12:45AM BLOOD WBC-8.2 RBC-4.53* Hgb-12.4* Hct-40.2 
MCV-89 MCH-27.4 MCHC-30.9* RDW-12.3 Plt ___
___ 12:45AM BLOOD Neuts-59.0 ___ Monos-7.6 Eos-2.0 
Baso-0.5
___ 12:45AM BLOOD Plt ___
___ 10:30AM BLOOD Glucose-110* UreaN-4* Creat-0.4* Na-134 
K-4.1 Cl-99 HCO3-27 AnGap-12
___ 12:45AM BLOOD Glucose-151* UreaN-6 Creat-0.6 Na-129* 
K-4.5 Cl-97 HCO3-27 AnGap-10
___ 12:45AM BLOOD ALT-87* AST-35 AlkPhos-60 TotBili-0.2
___ 12:45AM BLOOD Lipase-171*
___ 10:30AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.8
___ 12:45AM BLOOD Albumin-4.4 Calcium-8.9 Phos-4.3 Mg-2.0
___ 12:45AM BLOOD Osmolal-266*
___ 08:06PM BLOOD CA ___ -Test  
================
Imaging
================
CT Abd/Pelv w/Contrast ___: IMPRESSION:  
 
1.  Pancreatitis most prominent in the body and tail of the 
pancreas with
areas of pancreatic parenchymal hypoenhancement in the body and 
tail,
concerning for edema or impending pancreatic necrosis, involving 
less than ___ of the gland. The areas of hypodensity in the 
pancreas are round and focal lesions cannot be excluded. No 
peripancreatic fluid collection.  The splenic vein is attenuated 
proximally and likely narrowed in the region adjacent to the 
body and tail of the pancreas.
 
2.  Multiple bilateral solid and ground glass nodules throughout 
both lung
bases most likely represents infection, however, further 
characterization withdedicated chest CT could be considered on a 
non-emergent basis to exclude the possibility of malignancy.

==================
Discharge Results
==================   
___ 07:15AM BLOOD Hct-38.3*
___ 07:10AM BLOOD Na-132* K-3.9 Cl-97
___ 07:10AM BLOOD ALT-149* AST-50* AlkPhos-87 TotBili-0.4
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Lipase {Serum lipase measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Imaging {Imaging}, Pancreatitis {Pancreatitis}, pancreas {Pancreatic structure}, pancreatic parenchymal {Structure of parenchyma of pancreas}, edema {Edema}, pancreatic necrosis {Necrosis of pancreas}, pancreas {Pancreatic structure}, lesions {Lesion}, fluid collection {Accumulation of fluid}, splenic vein {Structure of splenic vein}, pancreas {Pancreatic structure}, ground glass {Ground glass lung opacity}, nodules {Nodule}, lung
bases {Structure of base of lung}, infection {Infectious disease}, malignancy {Malignant neoplasm}, Hct {Hematocrit determination}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, 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. ___ is a ___ yo M with hx of DVT, hyponatremia, and 
pancreatic mass suggestive of malignancy presenting with 
pancreatitis secondary to pancreatic mass.
  
# Pancreatitis: Patient was treated conservatively for 
pancreatitis. Morphine IV administered for pain control, he 
remained NPO and given intravenous fluids. Diet was advanced 
slowly once pain resolved and prior to discharge was tolerating 
food and fluids without pain. Started pancreatic enzymes for 
diarrhea.  He remained hemodynamically stable throughout.
   
# Pancreatic mass: FNA biopsy at outside hospital suggests 
adenocarcinoma versus neuroendocrine tumor. Records from ___ 
including MRI showed pancreatic ductal mass and PET with uptake 
in the lungs. Chest CT with nodules suggestive of metastatic 
disease.  The oncology team was consulted, and additional biopsy 
was recommended however can be completed in the outpatient 
setting. ___ was consulted and will set patient up for biopsy 
post discharge. 
  
# Hyponatremia: Secondary to SIADH given low sodium with 
euvolemia, elevated urine sodium, and improvement of sodium with 
fluid restriction. He has a history of SIADH and presented with 
a sodium of 129 that improved over the course of his admission 
with fluid restriction. He had no neurologic symptoms at any 
point during his admission.
   
# Splenic vein thrombosis: Imaging findings were suggestive of 
splenic vein thrombosis, which based on prior ___ imaging is 
chronic.  He was maintained on his home Lovenox dose.
     
==================
Transitions of Care
==================
- To undergo outpatient retroperitoneal lymph node biopsy for 
final diagnosis of his pancreatic mass
- Oncology outpatient eval to determine next treatment steps
- Follow up with PCP regarding ___ enzyme titration to 
help with diarrhea
- Follow up with PCP regarding BPH
- Monitor Hyponatremia
- Code Status: Full code
- Additional contact: Brother ___ ___
 

###RESPONSE: DVT {Deep venous thrombosis}, hyponatremia {Hyponatremia}, pancreatic mass {Mass of pancreas}, malignancy {Malignant neoplasm}, pancreatitis {Pancreatitis}, pancreatic mass {Mass of pancreas}, Pancreatitis {Pancreatitis}, pancreatitis {Pancreatitis}, pain control {Pain control}, remained NPO {On nothing by mouth status}, intravenous fluids {Intravenous infusion}, pain resolved {No present pain}, tolerating 
food {Tolerating normal diet}, fluids {Tolerating oral fluid}, without pain {No present pain}, diarrhea {Diarrhea}, hemodynamically stable {Hemodynamically stable}, Pancreatic mass {Mass of pancreas}, FNA biopsy {Fine needle biopsy}, adenocarcinoma {Adenocarcinoma}, neuroendocrine tumor {Neuroendocrine tumor}, MRI {Magnetic resonance imaging}, pancreatic ductal mass {Mass of pancreas}, PET {Positron emission tomography}, lungs {Metastatic malignant neoplasm to lung}, Chest CT {Computed tomography of chest}, nodules {Nodule}, metastatic 
disease {Metastatic malignant neoplasm}, biopsy {Biopsy}, biopsy {Biopsy}, Hyponatremia {Hyponatremia}, SIADH {Syndrome of inappropriate vasopressin secretion}, euvolemia {Normal blood volume}, urine sodium {Sodium measurement, urine}, fluid restriction {Fluid restriction}, SIADH {Syndrome of inappropriate vasopressin secretion}, sodium {Sodium measurement}, improved {Patient's condition improved}, fluid restriction {Fluid restriction}, no neurologic symptoms {Normal nervous system function}, Splenic vein thrombosis {Splenic vein thrombosis}, Imaging findings {Imaging finding}, splenic vein thrombosis {Splenic vein thrombosis}, imaging {Imaging}, retroperitoneal lymph node {Structure of retroperitoneal lymph node}, biopsy {Biopsy}, pancreatic mass {Mass of pancreas}, outpatient eval {Outpatient procedure}, PCP {Primary care management}, diarrhea {Diarrhea}, PCP {Primary care management}, BPH {Benign prostatic hyperplasia}, Hyponatremia {Hyponatremia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Enoxaparin Sodium 70 mg SC Q12H 
Start: ___, First Dose: Next Routine Administration Time 

 
Discharge Medications:
1. Pancrelipase 5000 1 CAP PO TID W/MEALS 
Please talk with your doctors about ___ the medicine to 
help with diarrhea. 
RX *lipase-protease-amylase [Pancrelipase 5000] 5,000 
unit-17,000 unit-27,000 unit 1 capsule(s) by mouth three times a 
day Disp #*90 Capsule Refills:*0
2. Enoxaparin Sodium 70 mg SC Q12H 
Start: ___, First Dose: First Routine Administration Time 
3. Tamsulosin 0.4 mg PO HS 
Follow up with your primary care doctor about this medication 
and your symptoms. 
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 
Capsule Refills:*0
4. Benzonatate 100 mg PO TID:PRN Cough 
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day 
Disp #*90 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:
Active:
- Pancreatitis
- Pancreatic malignancy
  
Chronic:
- Pancreatic cancer
- Hyponatremia

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Pancreatitis {Pancreatitis}, Pancreatic malignancy {Malignant tumor of pancreas}, Pancreatic cancer {Malignant tumor of pancreas}, Hyponatremia {Hyponatremia}, 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:
Mr. ___,
   
You were admitted to the hospital because of abdominal pain and 
diarrhea caused by inflammation of your pancreas.  You received 
fluids and pain medication and improved. You were tolerating 
food and liquids by mouth at discharge.  You were given some 
pancreatic enzymes to help with the diarrhea. 
   
We acquired records from the ___, which along with your 
symptoms of weight loss are concerning for cancer. We scheduled 
an outpatient biopsy of a lymph node for you. It is very 
important that you have that procedure done and follow up with 
the oncologists to continue your care. You were complaining of 
some tenderness around your bladder and some difficulty 
initiating urination, so you were starting on a medication to 
help with that and should follow up with your primary care 
doctor. Thank you for having us be a part of your care team.
 
The Interventional Radiology team will be contacting you to 
schedule an appointment for your biopsy. If you do not hear by 
___ next week please call the floor ___
 

###RESPONSE: abdominal pain {Abdominal pain}, diarrhea {Diarrhea}, inflammation of your pancreas {Pancreatitis}, pain medication {Administration of analgesic}, improved {Patient's condition improved}, tolerating 
food {Tolerating diet}, liquids by mouth {Tolerating oral fluid}, diarrhea {Diarrhea}, weight loss {Weight loss}, cancer {Malignant neoplasm}, biopsy {Biopsy}, lymph node {Structure of lymph node}, tenderness {Tenderness}, bladder {Urinary bladder structure}, difficulty 
initiating urination {Delay when starting to pass urine}, biopsy {Biopsy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: PLASTIC
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Compazine
 
Attending: ___.
 
Chief Complaint:
abdominal wound 
 
Major Surgical or Invasive Procedure:
Abdominal wound exploration and removal of infected mesh.

 

###RESPONSE: Compazine {Allergy to prochlorperazine}, abdominal wound {Wound of abdomen}, Abdominal wound exploration {Exploration of penetrating wound of abdomen}, removal of infected mesh {Removal of mesh 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: History of Present Illness:
___ is a ___ year old female with history of lower 
abdominal desmoid tumor removal and reconstruction with mesh 
with subsequent infection and resection of mesh and replacement, 
eventually wound which required delayed primary closure. She 
presented to clinic with a small wound in the middle ofher lower 
abdominal incision site.  She is here today for abdominal wound 
exploration.

 

###RESPONSE: abdominal desmoid tumor removal {Excision of subfascial abdominal wall tumor}, reconstruction {Reconstruction procedure}, infection {Postoperative wound infection}, resection of mesh {Removal of mesh from wound}, replacement {Replacement procedure}, wound {Surgical incision wound}, closure {Reparative closure}, wound {Surgical incision wound}, abdominal incision {Abdomen incision}, abdominal wound 
exploration {Exploration of penetrating wound of abdomen}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
depression, chronic headaches, presyncope, type 2 diabetes
mellitus, hyperlipidemia, obesity, chronic urinary tract 
infections, and chronic back pain.  She has a longstanding
microcytosis with a negative workup in the past.
.
PSH
D&C, right first metatarsal bunion, cesarean section 
with placenta previa, bilateral breast reduction, bilateral ORIF 

of the hips for congenital dysplasia. 

 

###RESPONSE: depression {Depressive disorder}, chronic headaches {Chronic headache disorder}, presyncope {Near syncope}, type 2 diabetes
mellitus {Diabetes mellitus type 2}, hyperlipidemia {Hyperlipidemia}, obesity {Obesity}, chronic urinary tract 
infections {Chronic urinary tract infection}, chronic back pain {Chronic back pain}, microcytosis {Microcytosis, red cells}, negative {No pathologic diagnosis}, workup {Evaluation procedure}, D&C {Dilation and curettage}, right first metatarsal {Structure of first metatarsal bone of right foot}, bunion {Swelling of first metatarsophalangeal joint of hallux}, cesarean section {Cesarean section}, placenta previa {Placenta previa}, bilateral breast reduction {Reduction plasty of bilateral breasts}, congenital dysplasia {Congenital hip dysplasia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Non-contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Physical exam per PRS post operative note ___ 1844 Temp: 97.5 PO BP: 111/63 L Lying HR: 106 RR: 20 O2
sat: 100% O2 delivery: RA 
Gen: NAD, A&Ox3, lying on stretcher.
HEENT: Normocephalic. 
CV: RRR
R: Breathing comfortably on room air. No wheezing.
Abd: Lower abd with VAC in place, holding suction, trace SS
output. No surrounding erythema. 
Ext: WWP. 

 

###RESPONSE: Temp {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2
sat {Oxygen saturation measurement}, RA {Breathing room air}, Gen {General examination of patient}, NAD {No abnormality detected}, Ox3 {Oriented to person, time and place}, lying {Lying in bed}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, Breathing comfortably on room air {Breathing room air}, wheezing {Wheezing}, Abd {Examination of abdomen}, erythema {Erythema}, Ext {Examination of limb}, WWP {Normal tissue perfusion}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 10:20PM   GLUCOSE-210* UREA N-11 CREAT-0.7 SODIUM-139 
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-25 ANION GAP-13
___ 10:20PM   estGFR-Using this
___ 10:02PM URINE  HOURS-RANDOM
___ 10:02PM URINE  UCG-NEGATIVE
.
IMAGING:
Radiology Report CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS 
Study Date of ___ 12:08 AM 
IMPRESSION: 
1. Interval decrease in size of the prior anterior abdominal 
wall collections. 
2. No fistula.  No hernia. 
3. Cholelithiasis, but no features of cholecystitis. 
4. Rest of the findings as described above. 

 

###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}, CT ABD & PELVIS W {Computed tomography of abdomen and pelvis with contrast}, W/O CONTRAST {Computed tomography of abdomen and pelvis without contrast}, decrease in size {Decreased size}, anterior abdominal 
wall {Anterior abdominal wall structure}, fistula {Fistula}, hernia {Hernia of abdominal cavity}, Cholelithiasis {Calculus in biliary tract}, cholecystitis {Cholecystitis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
The patient was admitted to the plastic surgery service on 
___ and had a abdominal wound exploration and removal of 
mesh.  The patient tolerated the procedure well. 
 .
 Neuro: Post-operatively, the patient received IV pain 
medications with good effect and adequate pain control. When 
tolerating oral intake, the patient was transitioned to oral 
pain medications. 
 .
 CV: The patient was stable from a cardiovascular standpoint; 
vital signs were routinely monitored.
 .
 Pulmonary: The patient was stable from a pulmonary standpoint; 
vital signs were routinely monitored.
 .
 GI/GU: Post-operatively, the patient was given IV fluids until 
tolerating oral intake.  Her diet was advanced when appropriate, 
which was tolerated well. She was also started on a bowel 
regimen to encourage bowel movement. Intake and output were 
closely monitored. 
 .
 ID: Post-operatively, the patient was started on IV cefazolin, 
then switched to PO cefadroxil for discharge home. The patient's 
temperature was closely watched for signs of infection. 
 .
 Prophylaxis: The patient received subcutaneous heparin during 
this stay, and was encouraged to get up and ambulate as early as 
possible. 
 .
 At the time of discharge on POD#2, the patient was doing well, 
afebrile with stable vital signs, tolerating a regular diet, 
ambulating, voiding without assistance, and pain was well 
controlled.  She was discharged with wound vac in place.
 

###RESPONSE: abdominal wound exploration {Exploration of penetrating wound of abdomen}, removal of 
mesh {Removal of mesh from wound}, Neuro {Neurological assessment}, Post-operatively {Postoperative state}, IV {Intravenous therapy}, pain 
medications {Administration of analgesic}, good effect {Good therapeutic response}, adequate pain control {Demonstrates adequate pain control}, tolerating oral intake {Tolerating diet}, oral {Administration of drug or medicament via oral route}, pain medications {Administration of analgesic}, stable {Patient's condition stable}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, Pulmonary {Examination of respiratory system}, stable {Patient's condition stable}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, Post-operatively {Postoperative state}, given IV fluids {Administration of intravenous fluids}, tolerating oral intake {Tolerating diet}, diet was advanced {Advance diet as tolerated}, bowel 
regimen {Bowel care}, Intake and output {Measuring intake and output}, Post-operatively {Postoperative state}, temperature {Temperature taking}, watched for signs of infection {Monitoring for signs and symptoms of infection}, Prophylaxis {Preventive procedure}, subcutaneous heparin {Subcutaneous injection of heparin}, ambulate {Ambulation training}, afebrile {Temperature normal}, stable vital signs {Normal vital signs}, tolerating a regular diet {Tolerating normal diet}, ambulating {Fully mobile}, voiding without assistance {Normal micturition}, pain was well 
controlled {Demonstrates adequate pain control}, wound vac {Vacuum assisted skin closure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 
2. Carbamazepine (Extended-Release) 100 mg PO QAM 
3. Carbamazepine (Extended-Release) 200 mg PO QHS 
4. cefaDROXil 500 mg oral BID 
5. FLUoxetine 60 mg PO DAILY 
6. Gabapentin 300 mg PO QHS 
7. Gabapentin 100 mg PO BID 
8. MetFORMIN (Glucophage) 850 mg PO BID 
9. Omeprazole 20 mg PO DAILY 
10. Ondansetron 8 mg PO DAILY:PRN nausea 
11. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - 
Moderate 
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second 
Line 
13. RisperiDONE 0.5 mg PO DAILY 
14. Simvastatin 40 mg PO QPM 
15. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 
16. Aspirin 81 mg PO DAILY 
17. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 
18. Senna 8.6 mg PO BID:PRN Constipation - Second Line 

 
Discharge Medications:
1.  cefaDROXil 500 mg oral BID 
RX *cefadroxil 500 mg 1 capsule(s) by mouth twice a day Disp 
#*56 Capsule Refills:*2 
2.  Ibuprofen 600 mg PO Q6H:PRN Pain - Mild 
  Reason for PRN duplicate override: Alternating agents for 
similar severity 
3.  Simethicone 40-80 mg PO QID:PRN abdominal gas  
4.  OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - 
Moderate 
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours 
Disp #*50 Tablet Refills:*0 
5.  Acetaminophen 650 mg PO Q6H:PRN Pain - Mild  
6.  Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB  
7.  Aspirin 81 mg PO DAILY  
8.  Carbamazepine (Extended-Release) 100 mg PO QAM  
9.  Carbamazepine (Extended-Release) 200 mg PO QHS  
10.  Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 
 
11.  FLUoxetine 60 mg PO DAILY  
12.  Gabapentin 300 mg PO QHS  
13.  Gabapentin 100 mg PO BID  
14.  MetFORMIN (Glucophage) 850 mg PO BID  
15.  Omeprazole 20 mg PO DAILY  
16.  Ondansetron 8 mg PO DAILY:PRN nausea  
17.  Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second 
Line  
18.  RisperiDONE 0.5 mg PO DAILY  
19.  Senna 8.6 mg PO BID:PRN Constipation - Second Line  
20.  Simvastatin 40 mg PO QPM  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___ 
 
Discharge Diagnosis:
1) Infected mesh
2) Poor coping skills in setting of depression

 
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}, depression {Depressive disorder}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Personal Care:
 1. You will have a wound VAC dressing with a wound vac machine 
in place for discharge home.  This will remain in place until 
you come back on ___ for the OR.
 2. While VAC is in place, please clean around the VAC site and 
monitor for air leaks of the VAC
 3. A written record of the daily output from the VAC drain 
should be brought to every follow-up appointment. 
 4. You may shower daily with assistance as needed.  You should 
do this with wound vac apparatus disconnected from you.  Once 
you have showered you will need to reconnect your dressing to 
the wound vac apparatus and make sure it is functioning 
properly.
 5. No baths until after directed by your surgeon.
 .
 Activity:
 1. Avoid strenuous activity with wound vac in place.
 .
 Medications:
 1. Resume your regular medications unless instructed otherwise 
and take any new meds as ordered .
 2. You may take your prescribed pain medication for moderate to 
severe pain. You may switch to Tylenol or Extra Strength Tylenol 
for mild pain as directed on the packaging. Please note that 
Percocet and Vicodin have Tylenol as an active ingredient so do 
not take these meds with additional Tylenol.
 3. Take prescription pain medications for pain not relieved by 
tylenol.
 4. Take your antibiotic as prescribed if you are discharged on 
one.
 5. Take Colace, 100 mg by mouth 2 times per day, while taking 
the prescription pain medication. You may use a different 
over-the-counter stool softener if you wish.
 6. Do not drive or operate heavy machinery while taking any 
narcotic pain medication. You may have constipation when taking 
narcotic pain medications (oxycodone, percocet, vicodin, 
hydrocodone, dilaudid, etc.); you should continue drinking 
fluids, you may take stool softeners, and should eat foods that 
are high in fiber.
 .
 Call the office IMMEDIATELY if you have any of the following:
 1. Signs of infection: fever with chills, increased redness, 
swelling, warmth or tenderness at the surgical site, or unusual 
drainage from the incision(s).
 2. A large amount of bleeding from the incision(s) or drain(s).
 3. Fever greater than 101.5 oF
 4. Severe pain NOT relieved by your medication.
 .
 Return to the ER if: 
 * If you are vomiting and cannot keep in fluids or your 
medications. 
 * If you have shaking chills, fever greater than 101.5 (F) 
degrees or 38 (C) degrees, increased redness, swelling or 
discharge from incision, chest pain, shortness of breath, or 
anything else that is troubling you.
 * Any serious change in your symptoms, or any new symptoms that 
concern you.
 

###RESPONSE: wound VAC {Vacuum assisted skin closure}, dressing {Application of dressing}, in place {Device in situ}, output from the VAC drain {Monitoring of fluid output from drain}, Signs of infection {Monitoring for signs and symptoms of infection}, fever with chills {Fever with chills}, redness {Redness of skin over lesion}, swelling {Swelling}, warmth {Warm skin}, tenderness {Tenderness}, surgical site {Operative site}, drainage {Wound discharge}, incision {Surgical incision wound}, bleeding {Bleeding}, incision {Surgical incision wound}, drain {Wound discharge}, Fever {Fever}, Severe pain {Severe pain}, vomiting {Vomiting}, cannot keep in fluids {Unable to drink}, shaking {Tremor}, chills {Chill}, fever {Fever}, redness {Redness of skin over lesion}, swelling {Swelling}, incision {Surgical incision wound}, chest pain {Chest pain}, shortness of breath {Dyspnea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___               Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   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: 
morphine
 
Attending: ___.
 
Chief Complaint:
Dyspnea, cough
 
Major Surgical or Invasive Procedure:
Intubation ___
Extubation ___

 

###RESPONSE: morphine {Allergy to morphine}, Dyspnea {Dyspnea}, cough {Cough}, Intubation {Insertion of endotracheal tube}, Extubation {Removal of endotracheal tube}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms ___ is a ___ woman with a history of CHF (LVEF 70% in 
___, on Bumex), Afib (on Abixiban), and HTN who presents with 
worsening shortness of breath over the past week. Dyspnea has 
been on exertion and at rest. Associated with PND and orthopnea. 
Also associated with 1 month of increased bilateral lower 
extremity swelling, R>L. Not associated with chest pain or 
palpitations. During this time, she has had a non-productive 
cough, as well as intermittent dysuria and increased urinary 
frequency. She notes an odor to urine, but denies fevers, 
chills, chest pain, abdominal pain, or pain in legs. No recent 
sick contacts, no recent travel. No nasal congestion, cough, or 
other URI symptoms preceding dyspnea. 
  
In the ED, initial vitals were: T 98.3 HR 110 BP 142/74 RR 24 
SaO2 94% on nc  
Exam: Rales at both lung bases. RLE edema > LLE (stable from 
previous PCP ___ 
Labs:  proBNP 7388, K 3.0, Cr 1.7, Mg 1.3, WBC 12.3, Hgb 11.2, 
Plt 286, INR 1.4, lacate 1.7
Imaging:  EKG: HR 130, AFib w RVR, Left axis, Normal QRS and 
QTc, no STE. CXR: Mild pulmonary edema, worse in the interval. 
Bedside U/S: mild pericardial effusion
Consults:  Cardiology, Respiratory therapy
Patient was given Nitro gtt for control of shortness of breath. 
She developed AF + RVR, so was started on Esmolol gtt. She 
became hypotensive to ___, so Esmolol gtt was stopped, and her 
HR improved without further intervention. She also received 
Aspirin, Lasix 80mg IVx1 & 40mg IVx2, K 40mg POx1, Mg 2gm IV.
Decision was made to admit to CCU for CHF exacerbation with 
pulmonary edema requiring BiPAP
Vitals on transfer were:  HR 100 BP 113/56 RR 25 SaO2 98% ra

On the floor, patient reports feeling well. She continues to be 
a little short of breath, but the facemask is bothering her. She 
denies current chest pain. Has been coughing and short of breath 
for the past week. Cough is nonproductive. No current abdominal 
pain or dysuria.  
 
REVIEW OF SYSTEMS:  
(+) per HPI  
Cardiac review of systems is notable for absence of chest pain, 
palpitations, syncope or presyncope.  
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. 
Denies recent fevers, chills or rigors. Denies exertional 
buttock or calf pain. All of the other review of systems were 
negative.  

 

###RESPONSE: CHF {Congestive heart failure}, Afib {Atrial fibrillation}, HTN {Hypertensive disorder, systemic arterial}, worsening {Patient's condition worsened}, shortness of breath {Dyspnea}, Dyspnea {Dyspnea}, exertion {Dyspnea on exertion}, at rest {Dyspnea at rest}, PND {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, bilateral lower 
extremity swelling {Swelling of bilateral lower limbs}, chest pain {Chest pain}, palpitations {Palpitations}, non-productive 
cough {Dry cough}, dysuria {Dysuria}, urinary 
frequency {Increased frequency of urination}, odor to urine {Abnormal urine odor}, fevers {Fever}, chills {Chill}, chest pain {Chest pain}, abdominal pain {Abdominal pain}, pain in legs {Pain in lower limb}, travel {Travel abroad}, nasal congestion {Nasal congestion}, cough {Cough}, URI {Upper respiratory infection}, dyspnea {Dyspnea}, vitals {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, SaO2 {Finding of oxygen saturation}, on nc {Oxygen administration by nasal cannula}, Exam {Physical examination procedure}, Rales {Respiratory crackles}, lung bases {Structure of base of lung}, RLE edema > LLE {Edema of bilateral lower limbs}, stable {Patient's condition stable}, PCP {Primary care management}, Labs {Laboratory test}, WBC {White blood cell count}, INR {Calculation of international normalized ratio}, Imaging {Imaging}, EKG {Electrocardiographic procedure}, HR {Finding of heart rate}, AFib w RVR {Atrial fibrillation with rapid ventricular response}, Left {Structure of left side of heart}, axis {Electrocardiographic axis finding}, Normal {No abnormality detected}, QRS {Finding of electrocardiogram QRS complex}, QTc {Finding of electrocardiogram QT interval}, STE {ST segment elevation}, CXR {Plain chest X-ray}, Mild {Symptom mild}, pulmonary edema {Pulmonary edema}, worse {Patient's condition worsened}, U/S {Ultrasonography}, mild {Symptom mild}, pericardial effusion {Pericardial effusion}, Cardiology {Cardiology service}, Respiratory therapy {Respiratory therapy}, shortness of breath {Dyspnea}, AF + RVR {Atrial fibrillation with rapid ventricular response}, hypotensive {Low blood pressure}, Esmolol gtt was stopped {Recommendation to stop drug treatment}, HR {Finding of heart rate}, improved {Patient's condition improved}, Aspirin {Administration of aspirin}, Lasix {Diuretic therapy}, IV {Intravenous therapy}, CHF exacerbation {Exacerbation of congestive heart failure}, pulmonary edema {Pulmonary edema}, BiPAP {Bilevel positive airway pressure titration}, Vitals {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, SaO2 {Finding of oxygen saturation}, ra {Breathing room air}, feeling well {Well in self}, short of breath {Dyspnea}, facemask {Oxygen administration by mask}, chest pain {Chest pain}, coughing {Cough}, short of breath {Dyspnea}, Cough is nonproductive {Dry cough}, abdominal 
pain {Abdominal pain}, dysuria {Dysuria}, REVIEW OF SYSTEMS {Review of systems}, Cardiac {Cardiovascular physical examination}, review of systems {Review of systems}, chest pain {Chest pain}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope}, 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}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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
peripheral vascular disease
venous insufficiency
peripheral neuropathy
history of colon CA (no rad/chem)
rosacea
intertrigo
L5-S1 radiculopathy

PSH: 
partial colectomy 93'
R ___ angio; 
PTA R SFA c stent x 2 at mid/distal SFA ___ (Zilver 
stent)
 

###RESPONSE: Hypertension {Hypertensive disorder, systemic arterial}, hyperlipidemia {Hyperlipidemia}, peripheral vascular disease {Peripheral vascular disease}, venous insufficiency {Vascular insufficiency}, peripheral neuropathy {Peripheral nerve disease}, colon CA {Malignant neoplasm of colon}, rad {Radiation oncology AND/OR radiotherapy}, chem {Chemotherapy}, rosacea {Rosacea}, intertrigo {Intertrigo}, L5-S1 {Structure of intervertebral disc of L5 and S1}, radiculopathy {Nerve root disorder}, partial colectomy {Partial resection of colon}, angio {Angiography}, PTA {Percutaneous transluminal angioplasty}, SFA {Structure of superficial femoral artery}, stent {Insertion of arterial stent}, SFA {Structure of superficial femoral artery}, stent {Insertion of arterial stent}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
CAD in brother
 
Physical ___:
ADMISSION PHYSICAL EXAMINATION:  
VS:  T 97.1 HR 113 BP 121/76 RR 25 SaO2 100% on facemask
Gen:  elderly woman, labored breathing, nontoxic, NAD
HEENT:  no scleral icterus, erythema and ecchymosis over nose 
and mouth, mmm
NECK:  +JVD (JVP 12cm)
CV:  tachycardic, irregular rhythm, no m/r/g
LUNGS:  on facemask, coughing, junky breath sounds with 
bilateral wheezing and rhonchi; wheezing 
ABD:  soft, NT/ND, +bs, no suprapubic tenderness
EXT:  warm, 2+ edema in bilateral ___ to knees, venous stasis 
changes R>L
SKIN: erythema and ecchymosis over nose and mouth
NEURO:  alert, moving all 4 extremities, no gross deficits

DISCHARGE PHYSICAL EXAM:
Discharge Weight: 72.9 kg
VS: 97-98.6 90-110s/50-60s ___ RA
Weight: 74.4 <--75.4 <--75.1 kg <-- 75.8 kg
Tele: short asymptomatic sinus pauses while sleeping
Gen:  elderly woman, NAD
HEENT:  no scleral icterus, erythema and ecchymosis over nose 
and mouth, mmm
NECK:  no JVD
CV:  regular rate, irregularly irregular rhythm, no m/r/g
LUNGS:  wheezing and rhonchi have resolved 
ABD:  soft, NT/ND, +bs, no ttp
EXT:  warm, no edema, venous stasis changes R>L
SKIN: erythema and ecchymosis over nose and mouth mostly 
resolved
NEURO:  alert, moving all 4 extremities, no gross deficits, 
oriented to person, time, and place
 

###RESPONSE: CAD {Coronary arteriosclerosis}, PHYSICAL EXAMINATION {Physical examination procedure}, VS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, SaO2 {Finding of oxygen saturation}, facemask {Oxygen administration by mask}, Gen {General examination of patient}, labored breathing {Labored breathing}, HEENT {Physical examination procedure}, scleral icterus {Scleral icterus}, erythema {Erythema}, ecchymosis {Ecchymosis}, nose {Nasal structure}, mouth {Mouth region structure}, mmm {Moist oral mucosa}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, JVP {Finding of jugular venous pressure}, CV {Cardiovascular physical examination}, tachycardic {Tachycardia}, irregular rhythm {Irregular heart beat}, no m/r/g {Heart sounds normal}, LUNGS {Examination of respiratory system}, facemask {Oxygen administration by mask}, coughing {Cough}, breath sounds {Finding of breath sounds}, wheezing {Wheezing}, rhonchi {Wheeze - rhonchi}, wheezing {Wheezing}, ABD {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, +bs {Normal bowel sounds}, EXT {Examination of limb}, warm {Warm skin}, edema in bilateral ___ to knees {Edema of bilateral lower legs}, venous stasis {Venous stasis}, SKIN {Examination of skin}, erythema {Erythema}, ecchymosis {Ecchymosis}, nose {Nasal structure}, mouth {Mouth region structure}, NEURO {Neurological examination}, alert {Mentally alert}, moving all 4 extremities {Does move all four limbs}, deficits {Neurological deficit}, Weight {Weight finding}, VS {Vital signs finding}, RA {Breathing room air}, Weight {Weight finding}, Tele {Cardiac telemetry}, asymptomatic {Asymptomatic}, sinus pauses {Sinus arrest}, sleeping {Asleep}, Gen {General examination of patient}, HEENT {Physical examination procedure}, scleral icterus {Scleral icterus}, erythema {Erythema}, ecchymosis {Ecchymosis}, nose {Nasal structure}, mouth {Mouth region structure}, mmm {Moist oral mucosa}, NECK {Physical examination procedure}, JVD {Jugular venous engorgement}, CV {Cardiovascular physical examination}, regular rate {Normal heart rate}, irregularly irregular {Heart irregularly irregular}, rhythm {Irregular heart beat}, no m/r/g {Heart sounds normal}, LUNGS {Examination of respiratory system}, wheezing {Wheezing}, rhonchi {Wheeze - rhonchi}, ABD {Examination of abdomen}, soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, +bs {Normal bowel sounds}, EXT {Examination of limb}, warm {Warm skin}, edema {Edema}, venous stasis {Venous stasis}, SKIN {Examination of skin}, erythema {Erythema}, ecchymosis {Ecchymosis}, nose {Nasal structure}, mouth {Mouth region structure}, NEURO {Neurological examination}, alert {Mentally alert}, moving all 4 extremities {Does move all four limbs}, deficits {Neurological deficit}, oriented to person, time, and place {Oriented to person, time and place}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
======================
___ 01:40PM BLOOD WBC-12.3*# RBC-4.03 Hgb-11.2 Hct-35.9 
MCV-89 MCH-27.8 MCHC-31.2* RDW-16.2* RDWSD-52.7* Plt ___
___ 01:40PM BLOOD ___ PTT-33.7 ___
___ 01:40PM BLOOD Glucose-132* UreaN-35* Creat-1.7* Na-140 
K-3.0* Cl-93* HCO3-26 AnGap-24*
___ 01:40PM BLOOD ALT-16 AST-22 AlkPhos-131* TotBili-1.0
___ 01:40PM BLOOD proBNP-___*
___ 01:40PM BLOOD cTropnT-<0.01
___ 01:40PM BLOOD Albumin-4.1 Calcium-7.2* Phos-4.0 Mg-1.3*
___ 03:29AM BLOOD Type-ART Temp-36.3 Rates-/29 pO2-152* 
pCO2-120* pH-7.07* calTCO2-37* Base XS-0 Intubat-NOT INTUBA
___ 02:14PM BLOOD Lactate-1.7
___ 03:29AM BLOOD freeCa-0.93*

OTHER PERTINENT LABS:
======================
___ 08:53PM BLOOD cTropnT-<0.01
___ 01:40PM BLOOD cTropnT-<0.01
___ 06:55AM BLOOD TSH-7.9*
___ 06:55AM BLOOD Free T4-1.2

MICRO:
======================
___ Blood culture: negative
___ MRSA screen: negative
___ Urine culture: KLEBSIELLA PNEUMONIAE.    >100,000 
ORGANISMS/ML..
___ Sputum culture: MORAXELLA CATARRHALIS.    MODERATE GROWTH. 


IMAGING/STUDIES:
======================
CXR ___: Comparison to ___.  Decrease in extent 
of a pre-existing left pleural effusion.  Unchanged appearance 
of the right lung.  Moderate cardiomegaly.  Mild retrocardiac 
atelectasis.  Unchanged fibrotic right upper lobe changes.  
Right PICC line is constant. 

ECHO ___: 
The left atrium is moderately dilated. The estimated right 
atrial pressure is at least 15 mmHg. There is mild symmetric 
left ventricular hypertrophy with normal cavity size and 
regional/global systolic function (LVEF>55%). There is mild 
symmetric left ventricular hypertrophy. The left ventricular 
cavity size is normal. Overall left ventricular systolic 
function is normal (LVEF>55%). Doppler parameters are 
indeterminate for left ventricular diastolic function. Right 
ventricular chamber size and free wall motion are normal. The 
aortic valve leaflets (3) appear structurally normal with good 
leaflet excursion and no aortic stenosis or aortic 
regurgitation. The mitral valve leaflets are moderately 
thickened. Mild (1+) mitral regurgitation is seen. [Due to 
acoustic shadowing, the severity of mitral regurgitation may be 
significantly UNDERestimated.] There is moderate pulmonary 
artery systolic hypertension. There is no pericardial effusion. 
There is an anterior space which most likely represents a 
prominent fat pad. 

 Compared with the prior study (images reviewed) of ___, 
pulmonary artery systolic pressure is higher and mild mitral 
regurgitation is now appreciated. Other findings are similar.  

DISCHARGE LABS:
======================
___ 07:14AM BLOOD WBC-6.4 RBC-3.48* Hgb-9.6* Hct-31.4* 
MCV-90 MCH-27.6 MCHC-30.6* RDW-16.8* RDWSD-53.8* Plt ___
___ 07:14AM BLOOD Glucose-107* UreaN-27* Creat-1.7* Na-144 
K-3.7 Cl-104 HCO3-34* AnGap-10
___ 07:14AM BLOOD Calcium-7.4* Phos-3.3 Mg-2.___RIEF SUMMARY STATEMENT:
=========================
___ woman with a history of CHF (LVEF 70% in ___, on Bumex), 
Afib (on Apixiban), and HTN who presented with worsening 
shortness of breath over the past week and cough found to have R 
sided pneumonia and acute on chronic diastolic heart failure 
exacerbation requiring BiPAP, complicated by hypercarbic 
respiratory failure requiring intubation. Sputum culture grew 
Moraxella and was treated with ceftriaxone (___) and 
azithromycin (___). Patient was given steroids, d/c'ed 
after 3 days due to worsening delirium. Delirium improved after 
steroids were d/c'ed and with Seroquel.  Pt. with afib with RVR 
during hospitalization.  Started on metoprolol and amiodarone 
with improvement in rates.

ACTIVE ISSUES: 
=========================
#) ACUTE DECOMPENSATED DIASTOLIC HEART FAILURE: LVEF 70% in 
___. On admission, her exam was consistent with fluid overload, 
with elevated JVP and 2+ pitting edema in both legs. LVEF 55-60% 
on this admission. She was diuresed with 120 mg IV Lasix boluses 
and Lasix gtt. Patient was transitioned to her home Bumex prior 
to discharge. Of note, her Bumex had recently been increased as 
an outpatient but she was not aware of this increase and had 
continued at her previous dose, possibly leading to the present 
admission.

#) HYPOXIA/CAP: Patient presented with hypoxia, was likely due 
to CHF exacerbation and community acquired pneumonia. Although 
patient stated she had no history of asthma or COPD, she had 
episodes of wheezing and was given standing ipratropium nebs 
which improved wheezing and hypoxia. Patient was found to have R 
lobe pneumonia on CXR and sputum culture grew Moraxella. She was 
treated with 7 day course of Ceftriaxone. Due to worsening 
hypercarbia and wheezing, she was treated with prednisone for 
CAP, however prednisone was stopped after 3 days due to 
worsening delirium. Patient had aggressive pulmonary toilet for 
copious secretions and productive cough. Hypoxia had resolved 
prior to discharge.

#) ACUTE HYPERCARBIC RESPIRATORY FAILURE: Patient had episode of 
agitation and altered mental status on first night of admission, 
was found to have pCO2 120 and pH 7.07. She was intubated for 
hypercarbic respiratory failure and treated with diuretics and 
antibiotics for pneumonia. She was extubated the next day 
(___). She had subsequent episodes of respiratory distress 
that resolved with BiPAP.

#) AFIB with RVR: At home patient took Apixiban 2.5mg BID and 
Diltiazem 180mg BID.  On this admission, pt. with RVR.  HRs were 
140s-150s during admission which was controlled with a diltiazem 
gtt.  She was started back on her PO diltiazem and started on 
metoprolol 100 XL.  She still had difficult to control rates.  
As such, patient was started on amiodarone with improvement.  
She eventually was transitioned back to PO medications and was 
discharged on Metoprolol succinate 100 XL daily, Diltiazem 120 
mg daily, and amiodarone. She was discharged on her home 
apixaban for anticoagulation.

#) ALTERED MENTAL STATUS: Patient had worsening delirium after 
extubation most likely due to steroids, scopolamine, and ICU 
hospitalization. The scopolamine patch and steroids were d/c'ed 
and patient improved slowly. She was started on 50 mg Seroquel 
at 4 pm and 10 pm daily for continued agitation and sundowning. 
Mental status improved prior to discharge and she was AAOX3.  
She was discontinued off of Seroquel with stable mental status 
for over 72 hours.

CHRONIC ISSUES:  
=========================
#) GERD: 
- Continued home omeprazole 20 mg daily

#) CHRONIC PAIN
- Continued home Gabapentin 300mg qhs 

TRANSITIONAL ISSUES:
======================
# Discharge Weight: 72.9kg (standing, day of discharge)
# s/p CAP Course: Completed Ceftriaxone 7 days, Prednisone 3 
days
# Afib Outpatient Management:  Patient needs to follow up with 
Dr. ___ Dr. ___ from cardiology.
# Afib with RVR: Pt. with difficult to control ventricular rates 
in the setting of her illness.  She was started on metoprolol 
and amiodarone. Continued on dilt and apixaban.
# Amio:  Would consider discontinuing amiodarone now that 
patient is stable with rate-controlled Afib.  Otherwise, patient 
needs safety monitoring if she remains on Amiodarone long term. 
Please check PFTs and TFTs as an outpatient. On ___, 
TSH:7.9 Free-T4:1.2.
# Amiodarone Dosing: Given 400 BID for 1 week (to ___, 200 
BID for 3 weeks (to ___, then 200 daily (Starting 
___ 
# Consider cardioversion as outpatient
# Patient noticed to have painless lump underneath R mandible. 
Please evaluate as outpatient.
# Code: DNR/DNI
# HCP:  ___ (pt's niece): ___

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, cTropnT {Troponin T cardiac measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, pH {pH measurement}, Lactate {Lactic acid measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, TSH {Thyroid stimulating hormone measurement}, Free T4 {T4 free measurement}, Blood culture {Blood culture}, negative {No abnormality detected}, MRSA {Methicillin resistant Staphylococcus aureus infection}, negative {No abnormality detected}, Urine culture {Urine culture}, Sputum culture {Microbial culture of sputum}, CXR {Plain chest X-ray}, left {Left lung structure}, pleural effusion {Pleural effusion}, right lung {Right lung structure}, cardiomegaly {Cardiomegaly}, Mild {Symptom mild}, atelectasis {Atelectasis}, right upper lobe {Structure of upper lobe of right lung}, PICC line {Peripherally inserted central venous catheter in situ}, ECHO {Echocardiography}, left atrium is moderately dilated {Left atrial dilatation}, right 
atrial {Right atrial structure}, pressure {Pressure}, mild symmetric 
left ventricular hypertrophy {Mild left ventricular hypertrophy}, normal cavity {Normal size cardiac chamber}, regional/global systolic function {Normal left ventricular systolic function and wall motion}, mild 
symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, left ventricular 
cavity {Structure of cavity of left cardiac ventricle}, size is normal {Normal size}, left ventricular systolic 
function is normal {Normal left ventricular systolic function and wall motion}, left ventricular {Structure of myocardium of left ventricle}, Right 
ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Finding of right ventricular wall motion}, aortic valve leaflets {Structure of cardiac valve leaflet}, structurally normal {Aortic valve normal}, good {No abnormality detected}, leaflet {Structure of cardiac valve leaflet}, aortic stenosis {Aortic valve stenosis}, aortic 
regurgitation {Aortic valve regurgitation}, mitral valve leaflets {Structure of leaflet of mitral valve}, thickened {Increased thickness}, Mild (1+) mitral regurgitation {Mild mitral valve regurgitation}, mitral regurgitation {Mitral valve regurgitation}, pulmonary 
artery systolic hypertension {Pulmonary hypertensive arterial disease}, pericardial effusion {Pericardial effusion}, fat pad {Structure of normal fat pad}, study {Evaluation procedure}, systolic pressure {Increased systolic arterial pressure}, mild mitral 
regurgitation {Mild mitral valve regurgitation}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, CHF {Congestive heart failure}, Afib {Atrial fibrillation}, HTN {Hypertensive disorder, systemic arterial}, worsening {Patient's condition worsened}, shortness of breath {Dyspnea}, cough {Cough}, R 
sided {Right lung structure}, pneumonia {Pneumonia}, acute on chronic diastolic heart failure {Acute on chronic diastolic heart failure}, BiPAP {Bilevel positive airway pressure titration}, hypercarbic 
respiratory failure {Hypercapnic respiratory failure}, intubation {Insertion of endotracheal tube}, Sputum culture {Microbial culture of sputum}, steroids {Steroid therapy}, worsening {Patient's condition worsened}, delirium {Delirium}, Delirium {Delirium}, improved {Patient's condition improved}, steroids {Steroid therapy}, afib with RVR {Atrial fibrillation with rapid ventricular response}, improvement {Patient's condition improved}, rates {Finding of heart rate}, DECOMPENSATED DIASTOLIC HEART FAILURE {Decompensated cardiac failure}, exam {Physical examination procedure}, fluid overload {Hypervolemia}, JVP {Finding of jugular venous pressure}, 2+ pitting edema {2+ pitting edema}, both legs {Both lower legs}, diuresed {Diuretic therapy}, IV {Intravenous therapy}, Lasix {Diuretic therapy}, Lasix {Diuretic therapy}, increased {Increasing dosage of medication}, HYPOXIA {Hypoxia}, CAP {Community acquired pneumonia}, hypoxia {Hypoxia}, CHF exacerbation {Exacerbation of congestive heart failure}, community acquired pneumonia {Community acquired pneumonia}, asthma {Asthma}, COPD {Chronic obstructive lung disease}, wheezing {Wheezing}, standing {Orthostatic body position}, improved {Patient's condition improved}, wheezing {Wheezing}, hypoxia {Hypoxia}, pneumonia {Pneumonia}, CXR {Plain chest X-ray}, sputum culture {Microbial culture of sputum}, worsening {Patient's condition worsened}, hypercarbia {Hypercapnia}, wheezing {Wheezing}, CAP {Community acquired pneumonia}, worsening {Patient's condition worsened}, delirium {Delirium}, pulmonary toilet {Airway toilet}, copious secretions {Copious sputum}, productive cough {Productive cough}, Hypoxia {Hypoxia}, resolved {Problem resolved}, HYPERCARBIC RESPIRATORY FAILURE {Hypercapnic respiratory failure}, agitation {Feeling agitated}, altered mental status {Altered mental status}, intubated {Insertion of endotracheal tube}, hypercarbic respiratory failure {Hypercapnic respiratory failure}, diuretics {Diuretic therapy}, antibiotics {Antibiotic therapy}, pneumonia {Pneumonia}, extubated {Removal of endotracheal tube}, respiratory distress {Respiratory distress}, resolved {Problem resolved}, BiPAP {Bilevel positive airway pressure titration}, AFIB with RVR {Atrial fibrillation with rapid ventricular response}, RVR {Atrial fibrillation with rapid ventricular response}, HRs {Finding of heart rate}, rates {Finding of heart rate}, improvement {Patient's condition improved}, PO medications {Administration of drug or medicament via oral route}, apixaban {Anticoagulant therapy}, anticoagulation {Anticoagulant therapy}, ALTERED MENTAL STATUS {Altered mental status}, worsening {Patient's condition worsened}, delirium {Delirium}, extubation {Removal of endotracheal tube}, steroids {Steroid therapy}, ICU {Admission to intensive care unit}, steroids {Steroid therapy}, improved {Patient's condition improved}, agitation {Feeling agitated}, sundowning {Sundowning}, Mental status {Altered mental status}, improved {Patient's condition improved}, OX3 {Oriented to person, time and place}, discontinued {Recommendation to stop drug treatment}, stable {Patient's condition stable}, mental status {Mental state finding}, GERD {Gastroesophageal reflux disease}, CHRONIC PAIN {Chronic pain}, Weight {Weight finding}, standing {Orthostatic body position}, CAP {Community acquired pneumonia}, Afib {Atrial fibrillation}, Outpatient {Outpatient care management}, follow up {Follow-up arranged}, cardiology {Cardiology service}, Afib with RVR {Atrial fibrillation with rapid ventricular response}, ventricular {Cardiac ventricular structure}, rates {Finding of heart rate}, stable {Patient's condition stable}, rate {Finding of heart rate}, Afib {Atrial fibrillation}, monitoring {Monitoring procedure}, PFTs {Measurement of respiratory function}, TFTs {Thyroid panel}, TSH {Thyroid stimulating hormone measurement}, Free-T4 {T4 free measurement}, cardioversion {Cardioversion}, lump {Mass}, mandible {Bone structure of mandible}, evaluate {Evaluation procedure}, DNR {Not for resuscitation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Bumetanide 2 mg PO QAM 
2. bumetanide 1 mg oral QPM 
3. Diltiazem Extended-Release 180 mg PO BID 
4. Apixaban 2.5 mg PO BID 
5. Gabapentin 300 mg PO QHS 
6. Omeprazole 20 mg PO DAILY 
7. Aspirin 81 mg PO DAILY 
8. Cyanocobalamin 1000 mcg PO DAILY 
9. miconazole nitrate unknown strength topical apply underneath 
breasts and groin as needed for rash 

 
Discharge Medications:
1. Apixaban 2.5 mg PO BID 
2. Aspirin 81 mg PO DAILY 
3. Bumetanide 2 mg PO QAM 
4. Bumetanide 1 mg ORAL QPM 
5. Diltiazem Extended-Release 120 mg PO DAILY 
6. Gabapentin 300 mg PO DAILY 
7. Omeprazole 20 mg PO DAILY 
8. Amiodarone 400 mg PO BID 
9. Metoprolol Succinate XL 100 mg PO DAILY 
10. Cyanocobalamin 1000 mcg PO DAILY 
11. miconazole nitrate unknown  TOPICAL APPLY UNDERNEATH BREASTS 
AND GROIN AS NEEDED FOR RASH 
12. Docusate Sodium 100 mg PO BID 
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation 
14. Senna 8.6 mg PO BID:PRN constipation 

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
PRIMARY DIAGNOSES
===================
Acute on chronic diastolic heart failure
Community Acquired Pneumonia
Hypercarbic respiratory failure
Delirium

SECONDARY DIAGNOSES
=====================
Hypertension
Hyperlipidemia
Intertrigo

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: Acute on chronic diastolic heart failure {Acute on chronic diastolic heart failure}, Community Acquired Pneumonia {Community acquired pneumonia}, Hypercarbic respiratory failure {Hypercapnic respiratory failure}, Delirium {Delirium}, Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, Intertrigo {Intertrigo}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Ambulatory - requires assistance or aid {Finding of walking aid use}, walker {Uses zimmer frame}, cane {Uses single walking stick}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,

You were admitted to ___ 
because you had shortness of breath and cough. You were having 
trouble breathing so you were placed on BiPAP machine and sent 
to the cardiac ICU. You were found to have a pneumonia and heart 
failure exacerbation causing fluid to accumulate in your lungs. 
You required a breathing tube and breathing machine for a short 
time to help you breathe during the beginning of your 
hospitalization. You were given medications to treat your 
pneumonia and medications to help remove fluid from your lungs. 
You were given steroids to help decrease inflammation in your 
lungs, but this caused you to be agitated and confused in the 
ICU. Your confusion improved off of the steroids. Your exercise 
tolerance decreased from your baseline, so you are being 
discharged to rehab before you go home.

Sincerely,

Your ___ Team
 

###RESPONSE: shortness of breath {Dyspnea}, cough {Cough}, trouble breathing {Difficulty breathing}, BiPAP {Bilevel positive airway pressure titration}, cardiac ICU {Admission to cardiac intensive care unit}, pneumonia {Pneumonia}, heart 
failure {Heart failure}, lungs {Lung structure}, breathing tube {Insertion of endotracheal tube}, breathing {Dual pressure spontaneous ventilation support}, medications {Prescription of drug}, pneumonia {Pneumonia}, medications {Prescription of drug}, lungs {Lung structure}, steroids {Steroid therapy}, inflammation {Inflammatory disorder}, lungs {Lung structure}, agitated {Feeling agitated}, confused {Clouded consciousness}, ICU {Admission to intensive care unit}, confusion {Clouded consciousness}, improved {Patient's condition improved}, steroids {Steroid therapy}, exercise 
tolerance {Exercise tolerance finding}, baseline {Baseline state}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: 
Demerol / Zestril / adhesive tape / ondansetron / ondansetron 
HCl
 
Attending: ___.
 
Chief Complaint:
Vomiting
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: adhesive tape {Allergy to adhesive agent}, Vomiting {Vomiting}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ yo M with metastatic esophageal cancer presents with 
refractory nausea and vomiting. History was obtained from the 
patient's wife as the patient was too confused. According to his 
wife, Mr. ___ has had mild nausea periodically until ___ 
night, when he started vomiting coffee grounds every 2 hrs. On 
___ morning the vomiting stopped, but he was still not able 
to tolerate any solid foods. On ___ and ___ mornings he 
vomited yellow, frothy emesis between ___, but had no further 
vomiting. On ___ he was able to eat half an egg and some 
chicken noodle soup, but that was it. Of note, mid last week he 
also had some diarrhea, but that has resolved. Confusion began 
today, previously he was not confused. His wife does note that 
he has been very weak, with occasional tremors/""spasms"" in the 
legs. He has not complained of a headache. He has been urinating 
normally, and had a BM today or yesterday. His wife notes that 
she is a ___, and would have been able to manage taking care 
of him at home, but she was concerned that he might have an 
aspiration pneumonia.

His wife also reports that his pain (in neck, shoulders, right 
hip/pelvis) has been well-controlled on methadone 20mg tid. He 
has not required oxycodone for breakthrough in over a week. His 
oncologist did increase his methadone to 25mg tid two weeks ago, 
but he opted to return to the lower dose as he felt that the 
higher dose was causing worsening nausea.

Review of Systems:  
(+) Per HPI  
(-) Denies chills, night sweats. Denies blurry vision, diplopia, 
loss of vision, photophobia. Denies headache, sinus tenderness, 
rhinorrhea or congestion. Denies palpitations, lower extremity 
edema. Denies shortness of breath. Denies melena, hematemesis, 
hematochezia. Denies dysuria, stool or urine incontinence. 
Denies arthralgias or myalgias. Denies rashes. All other systems 
negative.  

 

###RESPONSE: metastatic {Metastatic malignant neoplasm}, esophageal cancer {Malignant tumor of esophagus}, refractory nausea and vomiting {Intractable nausea and vomiting}, confused {Clouded consciousness}, nausea {Nausea}, vomiting coffee grounds {Coffee ground vomiting}, vomiting {Vomiting}, vomited {Vomiting}, emesis {Vomiting}, vomiting {Vomiting}, able to eat {Able to eat}, diarrhea {Diarrhea}, Confusion {Clouded consciousness}, not confused {Not confused}, weak {Asthenia}, tremors {Tremor}, spasms {Spasm}, legs {Lower limb structure}, headache {Headache}, aspiration pneumonia {Aspiration pneumonia}, pain {Pain}, neck {Cervical region back structure}, shoulders {Shoulder region structure}, right 
hip {Right hip region structure}, pelvis {Structure of right half of pelvis}, nausea {Nausea}, chills {Chill}, night sweats {Night sweats}, blurry vision {Blurring of visual image}, diplopia {Diplopia}, loss of vision {Blindness AND/OR vision impairment level}, photophobia {Photophobia}, headache {Headache}, sinus {Nasal sinus structure}, tenderness {Tenderness}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, palpitations {Palpitations}, lower extremity 
edema {Edema of lower extremity}, shortness of breath {Dyspnea}, melena {Melena}, hematemesis {Hematemesis}, hematochezia {Hematochezia}, dysuria {Dysuria}, stool or urine incontinence {Double incontinence}, arthralgias {Joint pain}, myalgias {Muscle pain}, rashes {Eruption of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
PAST ONCOLOGIC HISTORY:  
- Stage IV metastatic poorly differentiated esophageal 
adenocarcinoma diagnosed in ___  
 
PAST MEDICAL HISTORY:  
- dCHF  
- CABG: ___ (LIMA to LAD) due to CCATH showing total occlusion  

of the RCA and circumflex arteries and an 80% left main  
stenosis.  
- CAD: CCATH/PCI: ___ - PTCA and DES x2 of the LMCA 
bifurcation (LAD and ramus), ___ - ___ 
___, ___ - ___, ___ - ___ anastomotic site 
of LIMA to LAD, ___, ___  
- s/p St. ___ Aortic Valve Replacement ___ - on coumadin in 
past 
- ""Intractable angina"" on methadone  
- Hypertension  
- Dyslipidemia  
- h/o defibrillation in ___  
- Nephrolithiasis  
- s/p lap cholecystectomy in ___  
- Horner's syndrome - mild  

 

###RESPONSE: Stage IV {Clinical stage IV}, metastatic {Metastatic malignant neoplasm}, esophageal 
adenocarcinoma {Adenocarcinoma in situ of esophagus}, dCHF {Diastolic heart failure}, CABG {Coronary artery bypass grafting}, LIMA {Structure of left internal thoracic artery}, LAD {Structure of anterior descending branch of left coronary artery}, CCATH {Cardiac catheterization}, total occlusion {Complete obstruction}, RCA {Right coronary artery structure}, circumflex arteries {Structure of circumflex branch of left coronary artery}, left main {Left coronary artery structure}, stenosis {Stenosis}, CAD {Coronary arteriosclerosis}, CCATH {Cardiac catheterization}, PCI {Percutaneous coronary intervention}, PTCA {Percutaneous transluminal coronary angioplasty}, DES {Endovascular insertion of drug eluting stent}, LMCA {Left coronary artery structure}, bifurcation {Bifurcation}, LAD {Structure of anterior descending branch of left coronary artery}, LIMA {Structure of left internal thoracic artery}, LAD {Structure of anterior descending branch of left coronary artery}, Aortic Valve Replacement {Replacement of aortic valve}, Intractable angina {Refractory angina}, Hypertension {Hypertensive disorder, systemic arterial}, Dyslipidemia {Dyslipidemia}, Nephrolithiasis {Kidney stone}, 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: 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:
Many family members with CAD.
 

###RESPONSE: CAD {Disorder of coronary artery}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION
VITALS: Afebrile, T 97.9, 140/90, ___, RR 20, 95% on room air 
GENERAL: Middle aged man laying in bed, in NAD
HEENT: NCAT, EOMI, PERRL, anicteric sclera, poor dentition, MMM  

NECK: supple, no LAD  
CARDIAC: RRR, S1 normal, mechanical S2, ___ systolic murmur hear 
throughout precordium. 
LUNG: Bilateral rales half-way up, no rhonchi, diminished breath 
sounds at bases bilaterally
ABDOMEN: Soft, generalized ttp, normoactive bowel sounds 
throughout, no rebound/guarding, no hepatosplenomegaly  
EXTREMITIES: WWP, no c/c/e, 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in bilateral triceps, 
biceps, deltoid, handgrip, and bilateral quads, ankle 
flexion/extension, sensation intact. Oriented to ___ and ___, 
not oriented to date. Having difficulty answering questions, not 
sure how many days he has been vomiting 

 

###RESPONSE: VITALS {Vital signs finding}, Afebrile {Temperature normal}, RR {Finding of rate of respiration}, on room air {Breathing room air}, GENERAL {General examination of patient}, laying in bed {Lying in bed}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclera {White sclera}, dentition {Finding of dentition}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, S1 normal {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmur {Murmur}, precordium {Structure of precordium}, LUNG {Examination of respiratory system}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, diminished breath 
sounds {Decreased breath sounds}, bases {Structure of base of lung}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, generalized ttp {Generalized abdominal tenderness}, normoactive bowel sounds {Normal bowel sounds}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, hepatosplenomegaly {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, WWP {Normal tissue perfusion}, 2+ DP pulses {All pulses present in bilateral lower limbs}, NEURO {Neurological examination}, CN II-XII intact {Normal central nervous system}, triceps {Triceps brachii muscle structure}, biceps {Biceps brachii muscle structure}, deltoid {Structure of deltoid muscle}, quads {Structure of quadriceps femoris muscle}, ankle {Ankle region structure}, sensation intact {Normal sensation}, Oriented {Orientated}, oriented {Orientated}, vomiting {Vomiting}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ 12:25PM BLOOD WBC-15.7*# RBC-4.55*# Hgb-11.7*# 
Hct-35.7*# MCV-78* MCH-25.6* MCHC-32.7 RDW-22.0* Plt ___
___ 12:25PM BLOOD UreaN-21* Creat-1.3*
 

###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}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine 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:
___ yo M with h/o metastatic esophageal cancer presented with 
nausea, vomiting, dehydration, hypercalcemia (14), and failure 
to thrive, and also with significant multifactorial 
encephalopathy (likely toxic-metabolic encephalopathy).

#Hypercalcemia: numerous ___, elev alk phos, malignancy 
related (Not working up with PTH levels, etc). Likely 
precipitated by dehydration. Provided IVF with NS and K 
repletion >200cc/hr (despite sig CAD history has preserved EF on 
last echo). Pt developed mild SOB with diffuse rales, so IVF 
subsequently d/c'd. Calcium improved. No reaction to test dose 
calcitonin and started calcitonin 250units SC (4mg/kg) q12h. 
Received IV pamidronate 90mg on ___.

# Acute multifactorial encephalopathy; likely multifactorial 
toxic metabolic due to hypercalcemia, pain and progression of 
malignancy. Treated with olanzapine.

#Metastatic Esophageal Cancer with bone and lung ___: disease 
progessing, he did not tolerate first round of chemo and does 
not want further chemo or treatment. On admission focus was 
sympom control and hospice care with plan to discharge to 
nursing home. However on ___ pt became intolerant of all po 
including fluids and medications. I had a conversation with his 
wife on ___ regarding this change in condition and thus 
prognosis. The decision was made to make the patient CMO. His 
PCP, oncologist and cardiologist were made aware of this change. 
He was made comfortable with morphine, olanzapine, scopolomine, 
and glycopyroate and died peacefully with his wife at the 
bedside on the morning of ___.

 

###RESPONSE: metastatic {Metastatic malignant neoplasm}, esophageal cancer {Malignant tumor of esophagus}, nausea, vomiting {Nausea and vomiting}, dehydration {Dehydration}, hypercalcemia {Hypercalcemia}, failure 
to thrive {Failure to thrive}, multifactorial 
encephalopathy {Multifactorial encephalopathy}, toxic-metabolic encephalopathy {Toxic metabolic encephalopathy}, Hypercalcemia {Hypercalcemia}, elev alk phos {Alkaline phosphatase above reference range}, malignancy {Malignant neoplasm}, dehydration {Dehydration}, CAD {Disorder of coronary artery}, echo {Echocardiography}, SOB {Dyspnea}, rales {Respiratory crackles}, improved {Patient's condition improved}, IV {Intravenous therapy}, multifactorial encephalopathy {Multifactorial encephalopathy}, toxic metabolic {Toxic metabolic encephalopathy}, hypercalcemia {Hypercalcemia}, pain {Pain}, malignancy {Malignant neoplasm}, Metastatic {Metastatic malignant neoplasm}, Esophageal Cancer {Malignant tumor of esophagus}, bone {Bone structure}, lung {Metastatic malignant neoplasm to lung}, disease {Disease}, chemo {Chemotherapy}, chemo {Chemotherapy}, hospice care {Hospice care}, discharge to 
nursing home {Discharge to nursing home}, prognosis {Determination of prognosis}, make the patient CMO {Comfort care only status}, 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: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prochlorperazine 10 mg PO Q6H:PRN nausea 
2. Lorazepam 1 mg PO Q6H:PRN nausea 
3. Metoprolol Succinate XL 50 mg PO DAILY 
4. Polyethylene Glycol 17 g PO DAILY 
5. Atorvastatin 80 mg PO DAILY 
6. Torsemide 40 mg PO DAILY 
7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 
8. Methadone 20 mg PO TID 
9. OxycoDONE (Immediate Release)  5 mg PO Q6H:PRN pain 
10. Pantoprazole 40 mg PO Q12H 
11. Citalopram 30 mg PO DAILY 
12. FoLIC Acid 1 mg PO DAILY 
13. Vitamin D Dose is Unknown  PO DAILY 

 
Discharge Medications:
none, pt deceased
 

###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
 
Discharge Diagnosis:
metastatic esophageal cancer
hypercalcemia of malignancy
failure to thrive
malnutrition, moderate
cancer related pain
bone metastasis

 
Discharge Condition:
deceased
 
                             ___ MD ___
 
Completed by: ___

###RESPONSE: metastatic {Metastatic malignant neoplasm}, esophageal cancer {Malignant tumor of esophagus}, hypercalcemia of malignancy {Humoral hypercalcemia of malignancy}, failure to thrive {Failure to thrive}, malnutrition {Nutritional disorder}, cancer related pain {Chronic pain due to malignant neoplastic disease}, bone {Bone structure}, metastasis {Metastatic malignant neoplasm}, 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:  
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: 
Spice Flavor / Children's Tylenol Plus / Bactrim
 
Attending: ___.
 
Chief Complaint:
Abscess
 
Major Surgical or Invasive Procedure:
Incision and drainage of abscess
 

###RESPONSE: Abscess {Abscess}, Incision and drainage of abscess {Incision and drainage of abscess}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Patient is a ___ yo man with PMHx sig. for developmental delay 
and history of MRSA abscesses who presents with an axillary 
abscess.  The patient reports itchy rash under his arms 
bilaterally for the past 2 weeks.  He was seen in the office on 
___, given antifungal creams and antihistamines, which have not 
helped.  A painful lump under his L arm worsened and several 
small R pustules under the right arm.  He reports that the 
redness and itching is spreading to his chest.  The patient 
reports that he has felt febrile for one night, did not take 
temperature.  No chills, nightsweats. 

The patient is a ___ and has been outside recently, has 
sunburn on left arm, but has redness on his chest which patient 
reports is not sunburn. 

In the ED, initial VS were: 98.2 86 134/88 15 98% RA. Exam was 
notable for L axilla with single large abscess 2.5x3.5cm and 
surrounding erythema. This was I&D'ed and packed.  Labs were 
unremarkable. The patient received vancomycin, percocet. 
 
Review of Systems:  
(+) Per HPI  
(-) Denies headache, sinus tenderness, rhinorrhea or congestion. 
Denies chest pain or tightness, palpitations. Denies cough, 
shortness of breath. Denies nausea, vomiting, diarrhea, 
constipation, or abdominal pain. No dysuria, urinary frequency. 
Denies arthralgias or myalgias. All other review of systems 
negative. 
 

###RESPONSE: developmental delay {Developmental delay}, MRSA {Methicillin resistant Staphylococcus aureus infection}, abscesses {Abscess}, axillary 
abscess {Abscess of axilla}, itchy {Itching}, rash {Eruption of skin}, arms {Upper limb structure}, painful {Pain}, lump {Mass}, L arm {Left upper arm structure}, pustules {Pustule}, right arm {Right upper arm structure}, redness {Redness of skin over lesion}, itching {Itching}, chest {Thoracic structure}, febrile {Fever}, chills {Chill}, nightsweats {Night sweats}, sunburn {Solar erythema}, left arm {Left upper arm structure}, redness {Redness of skin over lesion}, chest {Thoracic structure}, sunburn {Solar erythema}, VS {Vital signs finding}, RA {Breathing room air}, Exam {Physical examination procedure}, L axilla {Structure of left axillary region}, abscess {Abscess}, erythema {Erythema}, I&D {Incision AND drainage}, unremarkable {No abnormality detected}, headache {Headache}, sinus {Nasal sinus structure}, tenderness {Tenderness}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, Denies cough {Does not cough}, shortness of breath {Dyspnea}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, dysuria {Dysuria}, urinary frequency {Increased frequency of urination}, arthralgias {Joint pain}, myalgias {Muscle pain}, review of systems {Review of systems}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
ANEMIA (ICD-285.9)      
CONSTIPATION (ICD-564.0)      
CALCULUS, KIDNEY (ICD-592.0)      
CELLULITIS/ABSCESS - MRSA (ICD-682.9)      
RETARDATION, MENTAL NOS (ICD-319)      
CARPAL TUNNEL SYNDROME, BILATERAL (ICD-354.0)      

 

###RESPONSE: ANEMIA {Anemia}, CONSTIPATION {Constipation}, CALCULUS {Calculus}, KIDNEY {Kidney structure}, CELLULITIS {Cellulitis}, ABSCESS {Abscess}, MRSA {Methicillin resistant Staphylococcus aureus infection}, RETARDATION, MENTAL {Intellectual disability}, CARPAL TUNNEL SYNDROME {Carpal tunnel syndrome}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother with diabetes.
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Vitals:  98.1, 121/66, 58, 14. 97RA, ___ pain in L axilla
Gen: NAD, AOX3  
HEENT: PER, EOMI, MMM, sclera anicteric, not injected  
Neck: no LAD, no JVD  
Cardiovascular: RRR normal s1, s2, no murmurs appreciated  
Respiratory: Clear to auscultation bilaterally, no wheezes, 
rales or rhonchi  
Abd: normoactive bowel sounds, soft, non-tender, non distended  
Extremities: No edema, 2+ DP pulses, R axilla erythematous with 
scattered pustules, L axilla erythematous with I&D site  
NEURO: PERRL, EOMI, face symmetric, no tongue deviation  
Integument: Warm, moist; erythematous macular rash across chest
Psychiatric: appropriate, pleasant, not anxious  

 

###RESPONSE: Vitals {Vital signs finding}, RA {Breathing room air}, pain {Pain}, L axilla {Structure of left axillary region}, Gen {General examination of patient}, NAD {No abnormality detected}, AOX3 {Oriented to person, time and place}, HEENT {Physical examination procedure}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, sclera anicteric {White sclera}, Neck {Physical examination procedure}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, Cardiovascular {Cardiovascular physical examination}, RRR {Normal heart rate}, normal s1, s2 {Heart sounds normal}, murmurs {Murmur}, Respiratory {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Abd {Examination of abdomen}, normoactive bowel sounds {Normal bowel sounds}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, distended {Swollen abdomen}, Extremities {Examination of limb}, edema {Edema}, 2+ DP pulses {Dorsalis pulse present}, R axilla {Structure of right axillary region}, erythema {Erythema}, pustules {Pustule}, L axilla {Structure of left axillary region}, erythema {Erythema}, I&D {Incision AND drainage}, NEURO {Neurological examination}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, face symmetric {Facial symmetry}, tongue {Tongue structure}, deviation {Displacement}, Integument {Structure of integumentary system}, Warm {Warm skin}, moist {Moist skin}, erythema {Erythema}, rash {Eruption of skin}, chest {Thoracic structure}, Psychiatric {Psychiatric symptom}, anxious {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: Pertinent Results:
Admission labs:
___ 06:45PM   WBC-8.4 RBC-4.84 HGB-14.2 HCT-41.5 MCV-86 
MCH-29.2 MCHC-34.2 RDW-13.6
___ 06:45PM   NEUTS-55.7 ___ MONOS-4.0 EOS-4.1* 
BASOS-1.8
___ 06:45PM   PLT COUNT-368
___ 06:45PM   GLUCOSE-111* UREA N-17 CREAT-0.9 SODIUM-140 
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-29 ANION GAP-12
___ 06:45PM   ___ PTT-26.1 ___
___ 06:52PM   LACTATE-1.___. Abscess, left axilla:  Patient has a history of MRSA skin 
abscesses. This episode was treated with incision and drainage 
followed by IV vancomycin then oral clindamicin. He has an 
appointment with his PCP's office for the day after discharge.
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, MONOS {Monocyte count}, EOS {Eosinophil count}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, PTT {Partial thromboplastin time, activated}, Abscess {Abscess}, left axilla {Structure of left axillary region}, MRSA {Methicillin resistant Staphylococcus aureus infection}, skin 
abscesses {Abscess of skin and/or subcutaneous tissue}, incision and drainage {Incision AND drainage}, IV {Administration of drug or medicament via intravenous route}, oral {Administration of drug or medicament via oral route}, PCP {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: Medications on Admission:
OMEPRAZOLE 20 MG CPDR (OMEPRAZOLE) 1 tab po every day      
VYTONE CRE 1% (IODOQUINOL-HC) APPLY BID TO AFFECTED AREAS      
CLOTRIM ANTIFUNGAL CREA 1 % (CLOTRIMAZOLE) apply to affected 
area bid      
DIPHENHYDRAMINE HCL 25 MG CAPS (DIPHENHYDRAMINE HCL) ___ tabs PO 
Q4-6H PRN      
LORATADINE 10 MG TABS (LORATADINE) 1 tab po every day as needed 
for itch
 
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO once a day.  
2. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as 
needed for itching.  
3. iodoquinol-HC ___ % Cream Sig: One (1)  Topical twice a day.  

4. clotrimazole 1 % Cream Sig: One (1)  Topical twice a day.  
5. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every 
eight (8) hours for 6 days.
Disp:*18 Capsule(s)* Refills:*0*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
1. Abscess
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 

###RESPONSE: Abscess {Abscess}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted with an abscess in your left axilla (armpit). 
Please continue taking the prescribed antibiotics and follow-up 
with the ___ on tomorrow (___).
 

###RESPONSE: abscess {Abscess}, left axilla {Structure of left axillary region}, armpit {Structure of axillary fossa}, antibiotics {Antibiotic therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                     Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
low BP
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: low BP {Low blood pressure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ h/o Lupus, embolic strokes s/p recent stroke on coumadin, 
metastatic colon cancer on chemotherapy s/p renal transplant on 
PD admitted from clinic with hypotension. Patient presented to 
___ today for INR check, but went to ___ clinic. She 
noted that she was slightly dizzy with some blurred vision while 
walking through the parking lot. In ___ clinic, they 
checked her INR, and then decided to start her on cycle 1 of 
erbitux. She was given benadryl as premedication.  
.  
Her blood pressure was then found to be low 70/40. The patient's 
typically BP runs in SBP ___ and there is always difficulty 
obtaining accurate BP's. Because of this the patient was kept in 
clinic for gentle fluids with the goal of returning her SBP to 
mid 80's. She was also given decadron in the chance that she was 
having a reaction to erbitux. As her blood pressure did not 
increase adequately, it was decided to admit her. In addition, 
she was drowsy in clinic - ___ to Benadryl?, but was becoming 
increasingly alert as the benadryl wore off.  
.  
The patient now states that her mental status is greatly 
improved, at baseline, ""feels normal"". She also reports that she 
has increased the amount of fluid she removes in PD in order to 
dec peripheral edema. In addition, she missed her midodrine 
doses today. She also notes that yesterday she had poor PO 
intake secondary to the heat and mild nausea. Denies any 
vomting, no chills, no fever, minimal diarrhea.  
.  
In ___, the patient was admitted with fever and hypotension. 
She was found to have CDiff colitis in early ___, discharged 
on vancomycin PO - which she has finished. Several days ago, she 
was admitted to the neurology service for acute/subacute embolic 
stroke. In the work up, she was found to have a filamentous 
structure on the right atrial catheter c/w thrombus and was 
started on anticoagulation.  
.
 
Clinic course:  
# VS: 4:45pm BP 76/58 P ___  
# Meds/IVF: 1.5L NS slowly, benadryl as premedication with 
erbitux  
.  
ROS:  
(+) mild nausea, mild diarrhea, DOE but at baseline, + 
peripheral edema but dec over the past week, + leg weakness when 
climbing stairs (at baseline)  
(-) no abominal pain, no lupus symptoms, no rash, no worsening 
joint swelling, no hematochezia, no melena 

 

###RESPONSE: Lupus {Lupus erythematosus}, embolic strokes {Embolic stroke}, stroke {Cerebrovascular accident}, metastatic colon cancer {Metastatic carcinoma to colon}, chemotherapy {Chemotherapy}, renal transplant {Transplant of kidney}, PD {Peritoneal dialysis}, hypotension {Low blood pressure}, dizzy {Dizziness}, blurred vision {Blurring of visual image}, blood pressure {Blood pressure finding}, low {Low blood pressure}, BP {Blood pressure finding}, fluids {Administration of intravenous fluids}, drowsy {Drowsy}, alert {Mentally alert}, improved {Patient's condition improved}, baseline {Baseline state}, PD {Peritoneal dialysis}, peripheral edema {Peripheral edema}, poor PO 
intake {Inadequate oral intake}, nausea {Nausea}, vomting {Vomiting}, chills {Chill}, fever {Fever}, diarrhea {Diarrhea}, fever {Fever}, hypotension {Low blood pressure}, CDiff colitis {Clostridium difficile colitis}, embolic 
stroke {Embolic stroke}, right atrial {Right atrial structure}, thrombus {Thrombus}, anticoagulation {Anticoagulant therapy}, VS {Vital signs finding}, BP {Blood pressure finding}, nausea {Nausea}, diarrhea {Diarrhea}, DOE {Dyspnea on exertion}, peripheral edema {Peripheral edema}, leg weakness {Monoparesis of lower limb}, abominal pain {Abdominal pain}, lupus {Lupus erythematosus}, rash {Eruption of skin}, joint swelling {Joint swelling}, hematochezia {Hematochezia}, melena {Melena}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
.  
POncH  
# Stage III metstatic colon adenocarcinoma (dx ___: LVI, 
venous, perineural invasion; FDG-avid RUL, L adrenal gland mass 
(___), brain mets  
--s/p resection  
--s/p irinotecan X2 doses dc'd ___ intractable diarrhea  
--s/p capecitabine, oxaliplatin x3 cycles  
--s/p fluorouracil, leucovorin, oxaliplatin (Folfox) ___  
.  
PMH  
# ESRD s/p failed renal transplants x2 (___), on PD x3 
daily, immunosuppressants d/c'd on ___ given increasing 
creatinine and in setting of chemo treatment  
# SLE on prednisone 5mg daily  
# Hyperlipidemia  
# Osteoporosis  
# Mitral regurgitation  
# Dyspepsia  
# Seizure disorder s/p stroke (___)  

 

###RESPONSE: Stage III {Carcinoma of colon, stage III}, metstatic colon {Metastatic carcinoma to colon}, adenocarcinoma {Adenocarcinoma}, LVI {Blood/lymphatic vessel invasion by tumor present (breast)}, venous {Venous (large vessel) invasion by tumor present}, perineural invasion {Perineural invasion by tumor present}, FDG-avid {Positron emission tomography with computed tomography using fluorodeoxyglucose (18-F)}, RUL {Structure of upper lobe of right lung}, L adrenal gland {Structure of left adrenal gland}, mass {Mass of adrenal gland}, brain mets {Metastatic malignant neoplasm to brain}, resection {Excision}, diarrhea {Diarrhea}, ESRD {End-stage renal disease}, failed renal transplants {Failed renal transplant}, PD {Peritoneal dialysis}, chemo {Chemotherapy}, SLE {Systemic lupus erythematosus}, Hyperlipidemia {Hyperlipidemia}, Osteoporosis {Osteoporosis}, Mitral regurgitation {Mitral valve regurgitation}, Dyspepsia {Indigestion}, Seizure disorder {Seizure disorder}, 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: 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:
This is largely unknown to the patient. There are multiple 
cancers in the family.

 

###RESPONSE: multiple 
cancers {Multiple malignancy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: T 97.3, BP 95/78, HR 100, RR 20, O2sat 97 on RA  
Gen: NAD  
HEENT: NCAT, MMM, OP clear, neck supple, mildly dysarthric 
speech, mild ___ flattening on the left  
CV: RRR, S1S2, ___ murmur  
Chest: coughing with deep inspiration, crackles ___ up on right 
side posteriorly, no labored breathing  
Abd: Soft, NT, distended, no rebound, no guarding; no TTP, NABS  

Ext: 2+ pitting edema B  
Neuro: AOx3, attention intact, strength ___ bilaterally, CN II- 
XII intact  

 

###RESPONSE: VS {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2sat {Oxygen saturation measurement}, RA {Breathing room air}, Gen {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, supple {Normal movement of neck}, dysarthric 
speech {Dysarthria}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmur {Murmur}, Chest {Examination of respiratory system}, coughing {Cough}, crackles {Respiratory crackles}, right 
side {Right lung structure}, labored breathing {Labored breathing}, Abd {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, distended {Swollen abdomen}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, TTP {Tenderness}, NABS {Normal bowel sounds}, Ext {Examination of limb}, edema {Edema}, Neuro {Neurological examination}, AOx3 {Oriented to person, time and place}, attention {Finding related to attentiveness}, CN II- 
XII 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:
___ 06:08PM BLOOD WBC-9.6 RBC-3.29* Hgb-10.6* Hct-32.4* 
MCV-98 MCH-32.1* MCHC-32.7 RDW-17.7* Plt ___
___ 05:15AM BLOOD WBC-9.7 RBC-3.23* Hgb-10.4* Hct-32.1* 
MCV-99* MCH-32.1* MCHC-32.3 RDW-17.7* Plt ___

___ 12:23PM BLOOD ___
___ 11:56AM BLOOD ___
___ 06:08PM BLOOD Glucose-145* UreaN-33* Creat-8.4* Na-134 
K-4.1 Cl-100 HCO3-27 AnGap-11
___ 05:15AM BLOOD Glucose-141* UreaN-36* Creat-8.3* Na-134 
K-3.7 Cl-100 HCO3-28 AnGap-10
___ 06:08PM BLOOD Calcium-7.4* Phos-3.4 Mg-2.0
___ 05:15AM BLOOD Calcium-7.3* Phos-3.2 Mg-2.___y the time the patient reached the floor, her BP had returned 
to normal and she was feeling well. She was observed overnight, 
restarted on Midodrine and seen by the renal team. The renal 
team recomended reducing the amount of fluid removed at each 
session. She had no further episodes of low BP. In addition, her 
INR was monitored. On the day of discharge, it was 3.6 and she 
was instructed to hold her evening dose. These instructions were 
also communicated to the ___ anti-coagulation nurses; they will 
call her with further instructions.
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, 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}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, low BP {Low blood pressure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily) for ___ days.  
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) 
Tablet PO MWF (___).  
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) 
Tablet, Chewable PO QID (4 times a day).  
5. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a 

day).  
6. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO DAILY 

(Daily).  
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY 
(Daily).  
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
 
Discharge Medications:
1. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a 
day).  
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily).  
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) 
Tablet PO MWF (___).  
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) 
Tablet, Chewable PO QID (4 times a day).  
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY 
(Daily).  
8. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day: 
take at 4pm at night.
Disp:*30 Tablet(s)* Refills:*2*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Low Blood Pressure
End Stage Renal Disease

 
Discharge Condition:
improved

 

###RESPONSE: Low Blood Pressure {Low blood pressure}, End Stage Renal Disease {End-stage renal disease}, 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: Discharge Instructions:
You were admitted for low blood pressure. You were given fluids 
and restarted on Midodrine. Your blood pressure improved. The 
renal team also recomended taking off less fluid with dialysis 
to avoid low blood pressures.
.
You should continued taking coumadin. Your INR was elevated 
today. You should NOT take any warfarin (coumadin) tonight. The 
___ clinic will call you to adjust the dose. You 
will need to have your INR checked on ___.
.
If you have dizziness, light-headedness, fevers or chills, you 
should return to the emergency room.
 

###RESPONSE: low blood pressure {Low blood pressure}, fluids {Administration of intravenous fluids}, blood pressure {Blood pressure finding}, improved {Patient's condition improved}, dialysis {Dialysis procedure}, low blood pressures {Low blood pressure}, dizziness {Dizziness}, light-headedness {Lightheadedness}, fevers {Fever}, chills {Chill}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___              Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Dizziness, Left arm weakness 
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Dizziness {Dizziness}, Left arm {Structure of left upper 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: History of Present Illness:
___ year old left handed woman presenting with dizziness and left 
arm weakness. The patient reports starting a new medication, 
donepezil, about 1 week ago. Following this period in time she 
noted the onset of vertigo while standing up, which would 
resolve upon sitting down. She also noted, though not 
concurrently, that her left arm ""felt weak."" Onset of this 
sensation was slow over days. She reports difficulty reaching up 
to touch her forehead. There was no associated pain. She reports 
difficulty with handwriting because the pen jerks around the 
page. She does not have any hand weakness however, in that she 
has no difficulty in opening doorknobs or jars. The pt denied 
headache, loss of vision, blurred vision, diplopia, dysarthria, 
dysphagia. tinnitus or hearing difficulty. Denied difficulties 
producing or comprehending speech. No parasthesias. No bowel or 
bladder incontinence or retention. Denied difficulty with gait.  

  
In the emergency department, initial vitals: 13:54 0 97.9 72 
128/95 18 98. Not orthostatic. No gait abnormality. EKG- new TWI 
I, otherwise nonspecific change. CXR-atelectasis at RL base, no 
pna or effusion, large dilated air filled viscous in upper 
abdomen correlate clinically- no abd pain on exam. KUB given 
findings on CXR- non specific bowel gas pattern, need f/u final 
read. Cardiac enzymes- neg. WBC inc but U/A-neg and it appears 
to be chronically elevated. CT Head-neg. Neuro consult- no acute 
issue, no objective signs of weakness, symptoms may be related 
to Aricept, can d/c medicatoin and then get in touch with PCP to 
discuss--->per neuro added on Lithium level (mildly elevated). 
200 cc NS and 8 mg of IV Zofran given. Admitted for syncope w/u. 
 
  
On arrival to the floor, she states she is feeling somewhat 
depressed with suicidal ideation but no intent/plan. She feels 
safe now that she is hospitalized. She states that occasionally 
when she walks, she feels worried that she is going to fall but 
has not fallen as of yet. She has a mildly productive cough that 
has developed in the past 10 minutes.  
  
Review of systems:  
(+) Per HPI  
(-) Denies fever, chills, night sweats, recent weight loss or 
gain. Denies headache, sinus tenderness, rhinorrhea or 
congestion. Denied shortness of breath. Denied chest pain or 
tightness, palpitations. Denied nausea, vomiting, diarrhea, 
constipation or abdominal pain. No recent change in bowel or 
bladder habits. No dysuria. Denied arthralgias or myalgias.  

 

###RESPONSE: left handed {Left handed}, dizziness {Dizziness}, left 
arm {Structure of left upper limb}, vertigo {Vertigo}, standing {Orthostatic body position}, resolve {Problem resolved}, sitting {Sitting position}, left arm {Structure of left upper limb}, weak {Asthenia}, difficulty reaching {Difficulty reaching}, forehead {Forehead structure}, pain {Pain}, hand {Hand structure}, weakness {Asthenia}, headache {Headache}, loss of vision {Functional visual loss}, blurred vision {Blurring of visual image}, diplopia {Diplopia}, dysarthria {Dysarthria}, dysphagia {Dysphagia}, tinnitus {Tinnitus}, hearing difficulty {Hearing difficulty}, difficulties 
producing or comprehending speech {Difficulty comprehending speech}, parasthesias {Paresthesia}, bowel {Incontinence of feces}, bladder incontinence {Urinary incontinence}, retention {Retention of urine}, difficulty with gait {Abnormal gait}, vitals {Vital signs finding}, orthostatic {Orthostatic body position}, gait abnormality {Abnormal gait}, EKG {Electrocardiographic procedure}, TWI {Inverted T wave}, CXR {Plain chest X-ray}, atelectasis {Atelectasis}, RL base {Structure of base of right lung}, pna {Pneumonia}, effusion {Pleural effusion}, dilated {Dilatation}, upper 
abdomen {Upper abdomen structure}, abd pain {Abdominal pain}, exam {Physical examination procedure}, KUB {Radiography of kidney-ureter-bladder}, CXR {Plain chest X-ray}, bowel gas pattern {Finding of gastrointestinal tract gas}, Cardiac enzymes {Finding of cardiac enzyme levels}, WBC {White blood cell count}, U/A-neg {Urinalysis = no abnormality}, CT Head {Computed tomography of head}, Neuro {Neurology service}, signs {Sign}, weakness {Asthenia}, Lithium level {Finding of lithium level}, syncope {Syncope}, depressed {Depressed mood}, suicidal ideation {Suicidal thoughts}, intent {Suicidal intent}, walks {Difficulty walking}, worried {Worried}, fall {Falls}, fallen {Falls}, productive cough {Productive cough}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, headache {Headache}, sinus tenderness {Tenderness over frontal sinus}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, shortness of breath {Dyspnea}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, change in bowel {Altered bowel function}, bladder habits {Alteration in patterns of urinary elimination}, dysuria {Dysuria}, arthralgias {Joint pain}, myalgias {Muscle pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
COPD--Pt does not use 02 at home  
Hypothryoid  
Hyperlipidemia 
RLS 

PSYCHIATRIC HISTORY:  Per OMR, and patient interview:
Diagnosedwith schizoaffective disorder ___ years ago after having
her son. First hospitalization in ___ ___ after 
SA
by cutting wrists.  Several other SA, including OD, and
self-stabbing.  Reports associated ___ with some of these SA, 
but
reports no auditory hallucinations in ___ years. Pt relates that
last suicide attempt was ___ years ago, and that last psychiatric
hospitalization was ___ years ago prior to recent ___ 
admission
in ___ (5 days). Has had over 10 psychiatric
hospitalizations.  Has gone to day program at ___ over
past ___ years.
Psychiatrist: ___, MD at ___  ___
Therapist: ___ at ___ 
___

 

###RESPONSE: COPD {Chronic obstructive lung disease}, Hypothryoid {Hypothyroidism}, Hyperlipidemia {Hyperlipidemia}, schizoaffective disorder {Schizoaffective disorder}, cutting wrists {Cutting own wrists}, self-stabbing {Stabbing self}, auditory hallucinations {Auditory hallucinations}, suicide attempt {Suicidal intent}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
None known. 
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VITAL SIGNS: T 96.7 BP 110/62 HR 61 RR 18 O2 94% on RA  
GENERAL: Pleasant, depressed appearing.  
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No 
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No 
LAD, No thyromegaly.  
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, 
rubs or ___. JVP not elevated.  
LUNGS: Occasional rhonchi that clear w/ coughing, good air 
movement biaterally.  
ABDOMEN: Distended but NABS. Soft, NT, ND. No HSM  
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior 
tibial pulses.  
SKIN: No rashes/lesions, ecchymoses.  
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved 
sensation throughout. ___ strength throughout. Babinski 
equivocal. Normal coordination. Gait assessment deferred  
PSYCH: Endorses suicidal ideation but no plan, + more depressed 
recently about concern that her memory is failing her  

 

###RESPONSE: VITAL SIGNS {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 {Finding of oxygen saturation}, RA {Breathing room air}, GENERAL {General examination of patient}, depressed {Depressed mood}, HEENT {Physical examination procedure}, Normocephalic {Normal head}, atraumatic {No injuries apparent}, conjunctival pallor {Pale conjunctiva}, scleral icterus {Scleral icterus}, PERRLA {Pupils equal, react to light and accommodation}, EOMI {Normal ocular motility}, MMM {Moist oral mucosa}, OP clear {Pharynx normal}, Supple {Normal movement of neck}, LAD {Lymphadenopathy}, thyromegaly {Goiter}, CARDIAC {Cardiovascular physical examination}, Regular rhythm {Normal sinus rhythm}, normal rate {Normal heart rate}, Normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, JVP not elevated {Normal jugular venous pressure}, LUNGS {Examination of respiratory system}, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, Distended {Swollen abdomen}, NABS {Normal bowel sounds}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, edema {Edema}, pain {Pain}, 2+ dorsalis pedis {Dorsalis pulse present}, posterior 
tibial pulses {Posterior tibial pulse present}, SKIN {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, ecchymoses {Ecchymosis}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, Appropriate {Appropriate affect}, CN {Cranial nerve structure}, grossly intact {Normal nervous system function}, Preserved 
sensation {Normal sensation}, Babinski {Flexor plantar response finding}, Normal coordination {Normal coordination}, Gait assessment {Gait evaluation}, PSYCH {Initial psychiatric evaluation}, suicidal ideation {Suicidal thoughts}, depressed {Depressed mood}, memory {Memory 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:
___ 03:00PM   PLT COUNT-386
___ 03:00PM   NEUTS-83.1* LYMPHS-11.6* MONOS-3.6 EOS-1.4 
BASOS-0.2
___ 03:00PM   WBC-16.9* RBC-4.82 HGB-14.3 HCT-43.0 MCV-89 
MCH-29.8 MCHC-33.3 RDW-13.4
___ 03:00PM   LITHIUM-1.6*
___ 03:00PM   CALCIUM-11.4* PHOSPHATE-3.0 MAGNESIUM-2.1
___ 03:00PM   CK-MB-NotDone
___ 03:00PM   cTropnT-<0.01
___ 03:00PM   CK(CPK)-67
___ 03:00PM   estGFR-Using this
___ 03:00PM   GLUCOSE-98 UREA N-15 CREAT-1.0 SODIUM-136 
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13
___ 03:31PM   ___ PTT-24.6 ___
___ 06:00PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0 
LEUK-NEG
___ 06:00PM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 09:18PM   CK-MB-NotDone
___ 09:18PM   cTropnT-<0.01
___ 09:18PM   CK(CPK)-45
.
CT Head (___):
There is no hemorrhage, edema, mass effect, or acute 
large vascular territory infarction. The gray-white matter 
differentiation is preserved. There is mild asymmetric frontal 
atrophy, but the ventricles and sulci are otherwise normal in 
caliber and configuration. Basal cisterns are preserved. There 
is no shift of normally midline structures. Calcifications are 
seen involving the cavernous and supraclinoid internal carotid 
arteries. The osseous structures demonstrate no fracture. There 
are no suspicious lytic 
or sclerotic lesions. The visualized paranasal sinuses and 
mastoid air cells are normally pneumatized and clear. 
.  
IMPRESSION: No acute intracranial process. 

 

###RESPONSE: PLT COUNT {Platelet count}, 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}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, LITHIUM {Finding of lithium level}, CALCIUM {Blood calcium measurement}, PHOSPHATE {Phosphate, total measurement}, MAGNESIUM {Blood magnesium measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK(CPK {Creatine kinase measurement}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, PTT {Partial thromboplastin time, activated}, URINE {Urinalysis}, PROTEIN {Measurement of protein in urine}, GLUCOSE {Glucose measurement, urine}, KETONE {Urinalysis, acetone or ketone bodies measurement}, BILIRUBIN {Bilirubin measurement, urine}, PH {pH measurement}, COLOR {Color finding}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK(CPK {Creatine kinase measurement}, hemorrhage {Hemorrhage}, edema {Edema}, mass {Mass}, vascular {Blood vessel structure}, infarction {Infarct}, white matter {Cerebral white matter structure}, frontal {Structure of cortex of frontal lobe}, atrophy {Atrophy}, ventricles {Brain ventricle structure}, sulci {Structure of sulcus of brain}, cisterns {Structure of subarachnoid cistern}, shift of normally midline structures {Midline shift of brain}, Calcifications {Pathologic calcification, calcified structure}, internal carotid 
arteries {Internal carotid artery structure}, osseous structures {Bone structure}, fracture {Fracture}, lytic {Lysis}, sclerotic {Sclerosis}, lesions {Lesion}, paranasal sinuses {Nasal sinus structure}, mastoid air cells {Structure of mastoid cell}, intracranial {Intracranial structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ y/o female with a h/o schizoaffective disorder and 
hypothyroidism who presented with dizziness and was found to be 
hypercalcemic. The following issues were investigated during 
this hospitalization:
  
1. Dizziness: Onset of symptoms correlates with initiation of 
Aricept for short-term memory loss and this medication has been 
associated with dizziness. Patient received IVF upon arrival for 
hypercalcemia but was never found to be orthostatic. Aricept was 
held while in house with improvement in symptoms. Head CT 
unremarkable as was neuro exam. Patient was discharged with home 
___. She will not continue on Aricept. 
  
2.  Hypercalcemia: Patient with history of elevated PTH since 
___ with intermittently elevated calcium values. Calcium > 11 
on admission, but responsive to IVF. Calcium and vitamin D 
supplements discontinued but bisphosphonate continued. Endocrine 
consulted given concern for Lithium-induced hyperparathyroidism. 
24 hour urine calcium was low and consistent with 
Lithium-induced disease and not likely necessitating surgical 
intervention. Still, further work-up was deferred to the 
outpatient setting. Lithium was decreased, but maintained as the 
endocrinopathies are generally not reversed with stopping 
Lithium and mood-stabilization remains of concern. She will f/u 
her lithium levels with her outpatient psychiatrist Dr. ___. 
She will also f/u as an outpatient with endocrinology.

3. Diabetes Insipidus: Suggested by mildly elevated Na and 
chloride, in the setting of endocrinopathies in a patient on 
long-term Lithium. Patient was started on Amiloride at the 
recommendation of the endocrinology consult, with improvement in 
electrolyte derrangements. Patient was otherwise encouraged to 
remain hydrated. She will be discharged on amiloride. 
  
4. Schizoaffective d/o: Psychiatry was consulted given concern 
for suicidal ideations and depression as well as for guidance 
for Lithium. Patient was initially on a ___, requiring 
that she remain hospitalized with intention to be transferred to 
a psychiatric facility. However, as her hospitalization 
continued and her metabolic derrangements were corrected, her 
mood improved. The section was eventually lifted and the patient 
was restarted on Lithium at a lower dose with outpatient 
follow-up with her psychiatrist. 
  
5. Dementia: Per patient's outpatient psychologist, 
neuropsychological testing showed significant memory impairment 
and MRI showed vascular disease, suggesting a possible etiology 
of dementia. Patient had been started on Aricept as an 
outpatient, but this was held given the complaint of 
lightheadedness that started after initiation of medication. 

6. Hypothyroidism: Patient was maintained on outpatient 
Levothyroxine.

7. Osteoporosis: Calcium and Vitamin D were held given elevated 
calcium and PTh on presentation, though Alendronate was 
continued. 

8. Hyperlipidemia: Patient was maintained on outpatient statin. 

9. Leukocytosis: Chronic problem of unclear etiology. No obvious 
source of infection. ___ trended down during this 
hospitalization and thus work-up was not pursued. 

Full code

She was discharged with outpatient endocrine and psychiatry 
follow up.
 

###RESPONSE: schizoaffective disorder {Schizoaffective disorder}, hypothyroidism {Hypothyroidism}, dizziness {Dizziness}, hypercalcemic {Hypercalcemia}, Dizziness {Dizziness}, short-term memory loss {Poor short-term memory}, dizziness {Dizziness}, IVF {Administration of intravenous fluids}, hypercalcemia {Hypercalcemia}, orthostatic {Orthostatic hypotension}, Head CT {Computed tomography of head}, unremarkable {No abnormality detected}, neuro exam {Normal nervous system function}, Hypercalcemia {Hypercalcemia}, calcium {Blood calcium measurement}, Calcium {Blood calcium measurement}, IVF {Administration of intravenous fluids}, Lithium-induced hyperparathyroidism {Hyperparathyroidism caused by lithium therapy}, urine calcium {Calcium measurement, urine}, surgical 
intervention {Surgical procedure}, work-up {Evaluation procedure}, lithium levels {Finding of lithium level}, psychiatrist {Psychiatric follow-up}, Diabetes Insipidus {Diabetes insipidus}, Schizoaffective {Schizoaffective disorder}, suicidal ideations {Suicidal thoughts}, depression {Depressive disorder}, mood improved {Improved mood}, on Lithium {On lithium}, outpatient 
follow-up {Outpatient care management}, psychiatrist {Psychiatric follow-up}, Dementia {Dementia}, neuropsychological testing {Neuropsychological testing}, memory impairment {Memory impairment}, MRI {Magnetic resonance imaging}, vascular disease {Disorder of blood vessel}, dementia {Dementia}, lightheadedness {Lightheadedness}, Hypothyroidism {Hypothyroidism}, Osteoporosis {Osteoporosis}, elevated 
calcium {Hypercalcemia}, PTh {Hyperparathyroidism}, Hyperlipidemia {Hyperlipidemia}, Leukocytosis {Leukocytosis}, infection {Infectious disease}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
Aricept 5mg QHS (started 1 week ago)  
Simvastatin 40 mg daily  
levothyroxine 0.125 mg daily  
aspirin 81 mg daily  
iron daily  
alendronate 70 mg every week  
vitamin D 400 units b.i.d.  
calcium 400 mg b.i.d.  
lithium 300 mg ___ mg once qhs  
Risperdal 4 mg b.i.d.  
Seroquel 50 mg daily  
lorazepam 1 mg daily  
cilostazol 100 mg b.i.d.  
citalopram daily (dose unknown)  

 
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
4. Risperidone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a 
day).  
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).  
6. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times 
a day).  
7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every 
___.  
8. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a 
day (at bedtime)).  
9. Amiloride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO QHS 
(once a day (at bedtime)).
Disp:*30 Capsule(s)* Refills:*2*
11. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary:
Lightheadedness
Hyperparathyroidism
Nephrogenic Diabetes Inspidus

Secondary: 
Schizoaffective disorder

 
Discharge Condition:
Stable

 

###RESPONSE: Home With Service {Home health aide service management}, Lightheadedness {Lightheadedness}, Hyperparathyroidism {Hyperparathyroidism}, Nephrogenic Diabetes Inspidus {Nephrogenic diabetes insipidus}, Schizoaffective disorder {Schizoaffective disorder}, Stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were seen and evaluated for left hand weakness and 
lightheadedness, which was felt to be due to a new medication 
you started - Aricept. This medication has been stopped. 
Additionally, you were noted to have an elevated calcium, which 
was due to a hormone problem called hyperparathyroidism. This 
hormone problem is likely due to Lithium, which you take and 
NEED to continue to take to control your mood. However, your 
Lithium dose has been decreased. Since your walking was unsteady 
but improved when you were discharged, you will have home ___ 
care. 

Take all of your medications as directed. Your Aricept, calcium 
and vitamin D have been stopped and your Lithium has been 
decreased. You were also started on a new medication, Amiloride, 
to help control your sodium level. It is important to stay very 
well hydrated.

Keep all of your follow-up appointments. They are listed below. 
Once you are discharged, you have an appointment with endocrine 
at 3PM today. It is very important that you keep this 
appointment. You will also need to follow up with your 
psychiatrist, Dr. ___, for management of your 
Lithium. The psychiatry team here will contact him and will make 
an appointment for you. 

Call your doctor or go to the ER for any of the following: chest 
pain, shortness of breath, fevers/chills, 
nausea/vomiting/diarrhea, worsened lightheadedness or falls, 
sudden slurred speech or weakness, headaches, vision changes, 
extreme fatigue, confusion or any other concerning symptoms. 
 

###RESPONSE: left hand weakness {Weakness of left hand}, lightheadedness {Lightheadedness}, elevated calcium {Hypercalcemia}, hyperparathyroidism {Hyperparathyroidism}, mood {Mood swings}, r walking was unsteady {Unsteady when walking}, improved {Patient's condition improved}, sodium level {Finding of sodium level}, psychiatrist {Psychiatric follow-up}, chest 
pain {Chest pain}, shortness of breath {Dyspnea}, fevers {Fever}, chills {Chill}, nausea/vomiting/diarrhea {Nausea, vomiting and diarrhea}, lightheadedness {Lightheadedness}, falls {Falls}, slurred speech {Slurred speech}, weakness {Asthenia}, headaches {Headache}, vision changes {Visual disturbance}, fatigue {Fatigue}, confusion {Clouded consciousness}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
vancomycin / Zosyn
 
Attending: ___.
 
Chief Complaint:
fevers, lethargy
 
Reason for MICU transfer:  concern for septic shock

 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: vancomycin {Allergy to vancomycin}, fevers {Fever}, lethargy {Lethargy}, MICU transfer {Patient transfer to intensive care unit}, septic shock {Septic shock}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 recent diagnosis of Graves' disease and longtime 
diagnosis of Kawasaki's disease on warfarin, presenting to ED 
with intermittent fevers and lethargy x 1 week and RLQ abdominal 
pain x ___ days.  Initially developed fever up to 102 and mild 
sore throat 1 week ago, was found to have normal WBC with left 
shift and mildly elevated TSH at ___, and was discharged 
home with presumptive diagnosis of viral infection.  However, 
his fevers persisted as high as 102 with night sweats and 
headaches, and was told by his endocrinologist Dr. ___ to 
discontinue his methimazole (MMI). He then developed RLQ pain 
and right groin pain especially on ambulation, and was sent to 
ED following appointment with Dr. ___.

In the ED, his initial vitals were 98.3 77 58/34 18 98%.  He was 
given 4L fluids.  Bedside ultrasound showed no free fluid or 
tamponade with normal IVC and mildly diminished cardiac 
contractility.  Labs notable for WBC 12.8 with left shift, UA 
with 93 WBC, CXR showed no pneumonia, two CT A/P were performed 
that showed no appendicitis or bowel wall thickening but did 
show right retroperitoneal stranding.  Surgery was consulted and 
recommended admission to medicine.  Endocrinology was consulted 
for concern of thyrotoxicosis or adrenal insufficiency, and 
recommended discontinuation of steroids but further thyroid 
studies.  He had a R IJ placed, was started on levophed, 
vanc/zosyn, and hydrocortisone.

In the MICU, his initial vitals were 101.4 117 108/70 35 93% 2L. 
 He reported feeling more energy.

 

###RESPONSE: Graves' disease {Graves' disease}, Kawasaki's disease {Acute febrile mucocutaneous lymph node syndrome}, intermittent fevers {Intermittent fever}, lethargy {Lethargy}, RLQ abdominal 
pain {Right lower quadrant pain}, fever {Fever}, sore throat {Sore throat}, normal WBC {White blood cell count within reference range}, left 
shift {Left shifted white blood cells}, elevated TSH {Thyroid stimulating hormone level above reference range}, viral infection {Viral disease}, fevers {Fever}, night sweats {Night sweats}, headaches {Headache}, RLQ pain {Right lower quadrant pain}, right groin pain {Right inguinal pain}, vitals {Vital signs finding}, fluids {Administration of fluid therapy}, ultrasound {Ultrasonography}, free fluid {Effusion}, tamponade {Cardiac tamponade}, IVC {Inferior vena cava structure}, cardiac {Heart structure}, left shift {Left shifted white blood cells}, UA {Urinalysis}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, CT A/P {Computed tomography of abdomen and pelvis}, appendicitis {Appendicitis}, bowel wall {Intestinal wall structure}, thickening {Increased thickness}, right {Structure of right half of body}, retroperitoneal {Retroperitoneal compartment structure}, Surgery was consulted {Medical consultation on hospital inpatient}, thyrotoxicosis {Thyrotoxicosis}, adrenal insufficiency {Adrenal cortical hypofunction}, steroids {Steroid therapy}, thyroid 
studies {Examination of thyroid gland}, vitals {Vital signs finding}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- ___' disease based on clinical presentation (duration of
symptoms, mild orbitopathy, lid lag, non tender mildly enlarged
thyroid gland). No RAIU. No TSI or TBII testing. Had elevated 
TPO
ab 266 (reference range ___
- Kawasaki disease s/p MI (suggestive though not completely 
diagnosed on cardiac cath in ___ now on coumadin
- asthma
- hyperlipidemia
- gout

 

###RESPONSE: disease {Disease}, mild {Symptom mild}, orbitopathy {Thyroid eye disease}, lid lag {Lid lag}, tender {Tenderness of thyroid}, enlarged
thyroid gland {Goiter}, RAIU {Radionuclide imaging of thyroid using iodine radioisotope}, TSI {Thyroid stimulating immunoglobulins measurement}, TBII {Thyrotropin binding inhibitory immunoglobulins measurement}, Kawasaki disease {Acute febrile mucocutaneous lymph node syndrome}, MI {Myocardial infarction}, cardiac cath {Cardiac catheterization}, asthma {Asthma}, hyperlipidemia {Hyperlipidemia}, gout {Inflammatory disorder due to increased blood urate level}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
His father died at age ___ with asbestosis.  His mother is ___ and
is in assisted living.  He has two brothers and a sister who are
healthy.  His son age ___ was diagnosed as hypothyroid and his
daughter, age ___, is healthy.

 

###RESPONSE: died {Dead}, asbestosis {Asbestosis}, hypothyroid {Hypothyroidism}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:  101.4 117 108/70 35 93% 2L
General: Alert, oriented, mild blanching erythema throughout 
chest/trunk/extremities, no acute distress  
HEENT: dry MM, OC/OP clear
Neck: supple, no LAD, no JVP 
CV: Tachycardic, regular rhythm, normal S1/S2, no m/r/g
Lungs: Tachypneic, clear to auscultation bilaterally, no w/r/r
Abdomen: soft, non-tender, mildly distended, hypoactive bowel 
sounds, no organomegaly, no rebound or guarding  
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no c/c/e  
Neuro: CN II-XII intact, ___ strength upper/lower extremities 
 
DISCHARGE PHYSICAL EXAM:
AVSS
Lungs clear with very scant coarse sounds at right base
Very Mild RLQ tenderness

 

###RESPONSE: Physical Exam {Physical examination procedure}, PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, erythema {Erythema}, chest {Thoracic structure}, trunk {Trunk structure}, extremities {Examination of limb}, distress {Distress}, HEENT {Physical examination procedure}, dry MM {Mucous membrane dryness}, OP clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, JVP {Finding of jugular venous pressure}, CV {Cardiovascular physical examination}, Tachycardic {Tachycardia}, regular rhythm {Normal sinus rhythm}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, no m/r/g {Heart sounds normal}, Lungs {Examination of respiratory system}, Tachypneic {Tachypnea}, clear to auscultation bilaterally {Normal breath sounds}, no w/r/r {Normal breath sounds}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, distended {Swollen abdomen}, hypoactive bowel 
sounds {Decreased bowel sounds}, organomegaly {Abdominal organomegaly}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, GU {Examination of genitourinary system}, foley in place {Urinary catheter in situ}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, Neuro {Neurological examination}, CN II-XII intact {Normal central nervous system}, upper {Upper limb structure}, lower extremities {Lower limb structure}, PHYSICAL EXAM {Physical examination procedure}, AVSS {Vital signs finding}, Lungs {Examination of respiratory system}, clear {Chest clear}, right base {Structure of base of right lung}, RLQ tenderness {Tenderness of right lower quadrant of abdomen}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 09:37AM BLOOD WBC-12.8*# RBC-3.78* Hgb-10.2*# 
Hct-32.5*# MCV-86 MCH-26.9*# MCHC-31.4 RDW-16.4* Plt ___
___ 09:37AM BLOOD Neuts-91* Bands-3 Lymphs-2* Monos-3 Eos-0 
Baso-0 ___ Metas-1* Myelos-0
___ 09:37AM BLOOD ___ PTT-35.4 ___
___ 09:37AM BLOOD Glucose-105* UreaN-23* Creat-1.9*# Na-133 
K-5.0 Cl-99 HCO3-22 AnGap-17
___ 09:37AM BLOOD ALT-19 AST-20 AlkPhos-101 TotBili-0.8
___ 09:37AM BLOOD Albumin-3.4* Calcium-8.8 Phos-2.1* Mg-2.2
___ 02:42PM BLOOD T4-5.9 T3-84 calcTBG-0.75* TUptake-1.33* 
T4Index-7.8
___ 09:37AM BLOOD TSH-0.71
___ 09:37AM BLOOD Cortsol-51.8*
___ 09:53AM BLOOD Lactate-2.0
___ 03:19AM BLOOD Lactate-1.3
___ 02:34PM BLOOD O2 Sat-62
___ 03:19AM BLOOD O2 Sat-87

DISCHARGE LABS:
___ 07:10AM BLOOD WBC-5.7 RBC-3.37* Hgb-9.0* Hct-28.6* 
MCV-85 MCH-26.8* MCHC-31.6 RDW-17.6* Plt ___
___ 07:10AM BLOOD ___
___ 07:10AM BLOOD Glucose-84 UreaN-17 Creat-0.7 Na-141 
K-3.9 Cl-105 HCO3-30 AnGap-10
___ 08:20AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.5

___ ___ M  ___  ___BD & PELVIS W/O CONTRAST Study Date of 
___ 4:12 ___ 
 
  
___   ___ 4:___BD & PELVIS W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN   ___ 
# ___   
Reason: Eval retroperitoneal process as seen on previous CT 
scan. PO 
 

 
UNDERLYING MEDICAL CONDITION: 
   History: ___ with fevers and RLQ tenderness  
REASON FOR THIS EXAMINATION: 
   Eval retroperitoneal process as seen on previous CT scan. PO 
contrast already  
   given 
CONTRAINDICATIONS FOR IV CONTRAST: 
    

 
 
Wet Read: ___ ___ 7:03 ___ 
  
1. Minimal asymmetric right perinephric stranding. Please 
correlate with 
urinalysis.  
  
2. Normal appendix.  
  
3. Unchanged nonspecific right retroperitoneal stranding 
extending along the 
right iliac vessels.  
  
4. 5 mm left lower lobe pulmonary nodule should be followed in 
___ months if 
the patient is at high risk for lung malignancy.  
  

 
Final Report 
HISTORY:  ___ male with fevers and right lower quadrant 
tenderness.   
  
COMPARISON:  Same day CT of in ___.   
  
TECHNIQUE:  MDCT images were obtained from the lung bases to the 
pubic 
symphysis after administration of oral contrast.  IV contrast 
was not 
administered.  This examination was repeated since a CT 
performed at 12:00 in 
order to better visualize the appendix.  Axial images were 
interpreted in 
conjunction with coronal and sagittal reformats.   
  
FINDINGS: 
  
Coronary artery calcifications are similar to prior.  Bibasilar 
atelectasis is 
unchanged.  5 mm left lower lobe nodule should be followed as 
previously 
recommended.  No pleural or pericardial effusion.   
  
ABDOMEN:   
  
Evaluation of the intra-abdominal organs is limited by lack of 
IV contrast 
administration.  The unenhanced appearance of the liver, 
gallbladder, intra 
and extrahepatic bile ducts, pancreas, spleen, and adrenal 
glands is normal.  
There is minimal asymmetric right perinephric stranding and 
thickening of 
Gerota's fascia.  The ureters have a normal course and caliber. 
No calculi are 
seen within the kidneys or ureters, and no hydronephrosis is 
present. 
  
The stomach is normal.  The small and large bowel have a normal 
course and 
calibur.  The appendix is not dilated and the base of the 
appendix contains 
oral contrast, though the remainder of the appendix does not 
fill with oral 
contrast. No stranding is noted about the appendiceal tip. 
  
Right retroperitoneal stranding extending from the right lateral 
conal fascia 
along the right iliac vessels is unchanged and nonspecific. No 
focal fluid 
collection is present.  No retroperitoneal or mesenteric 
lymphadenopathy.  The 
unenhanced appearance of the portal and intra-abdominal systemic 
vasculature 
is unremarkable.  No abdominal wall hernia, pneumoperitoneum, or 
free 
intraperitoneal fluid. 
  
PELVIS:  The bladder contains a Foley catheter.  The terminal 
ureters are 
normal.  The prostate gland is unremarkable.  No pelvic 
side-wall or inguinal 
lymphadenopathy. No free pelvic fluid or inguinal hernia. 
  
OSSEOUS STRUCTURES:  No focal lytic or sclerotic lesion 
concerning for 
malignancy.  Retrolisthesis of L5 on S1.  Mild multilevel 
thoracolumbar spine 
degenerative changes.   
  
CT Abd and Pelvis
IMPRESSION: 
  
1.  Minimal asymmetric right perinephric stranding and 
thickening of Gerota's 
fascia, which can be seen with pyelonephritis. Clinical 
correlation with 
urinalysis recommended. 
  
2.  Unchanged right retroperitoneal stranding extending along 
the right iliac 
vessels, non-specific. Findings could relate to urinary tract 
infection.   
  
3.  Normal appendix.   
   
4.  5 mm left lower lobe pulmonary nodule should be re-assessed 
in 12 months 
if there is low risk of lung malignancy or in ___ months there 
is high risk. 
 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Eos {Eosinophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, TSH {Thyroid stimulating hormone measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, PELVIS W/O CONTRAST {Computed tomography of pelvis without contrast}, PELVIS W/O CONTRAST {Computed tomography of pelvis without contrast}, CT 
scan {Computed tomography of abdomen}, fevers {Fever}, RLQ tenderness {Tenderness of right lower quadrant of abdomen}, CT scan {Computed tomography of abdomen}, IV {Intravenous therapy}, right {Structure of right half of body}, perinephric {Structure of perirenal region}, urinalysis {Urinalysis}, appendix {Appendix structure}, right {Structure of right half of body}, retroperitoneal {Retroperitoneal compartment structure}, right iliac vessels {Structure of right iliac vessel}, left lower lobe {Structure of lower lobe of left lung}, pulmonary nodule {Nodule of lung}, lung malignancy {Metastatic malignant neoplasm to lung}, fevers {Fever}, right lower quadrant 
tenderness {Tenderness of right lower quadrant of abdomen}, lung bases {Structure of base of lung}, pubic 
symphysis {Structure of epiphysis of pubis}, oral {Administration of drug or medicament via oral route}, IV {Intravenous therapy}, appendix {Appendix structure}, Coronary artery calcifications {Calcification of coronary artery}, Bibasilar {Structure of base of lung}, atelectasis {Atelectasis}, left lower lobe {Structure of lower lobe of left lung}, nodule {Nodule of lung}, pleural {Pleural effusion}, pericardial effusion {Pericardial effusion}, ABDOMEN {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, Evaluation {Evaluation procedure}, abdominal {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, IV {Intravenous therapy}, liver {Liver structure}, gallbladder {Gallbladder structure}, intra {Intrahepatic biliary tract structure}, extrahepatic bile ducts {Extrahepatic duct structure}, pancreas {Pancreatic structure}, spleen {Splenic structure}, adrenal 
glands {Bilateral adrenal glands}, perinephric {Structure of perirenal region}, thickening {Increased thickness}, fascia {Structure of fascia}, ureters {Ureteric structure}, calculi {Calculus}, kidneys {Kidney structure}, ureters {Ureteric structure}, hydronephrosis {Hydronephrosis}, stomach {Stomach structure}, small {Structure of small intestine}, large bowel {Structure of large intestine}, appendix {Appendix structure}, dilated {Dilatation}, appendix {Appendix structure}, oral {Administration of drug or medicament via oral route}, appendix {Appendix structure}, oral {Administration of drug or medicament via oral route}, Right {Structure of right half of body}, retroperitoneal {Retroperitoneal compartment structure}, fascia {Structure of fascia}, right iliac vessels {Structure of right iliac vessel}, retroperitoneal {Retroperitoneal lymphadenopathy}, mesenteric 
lymphadenopathy {Mesenteric lymphadenopathy}, abdominal {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, unremarkable {No abnormality detected}, abdominal wall {Structure of wall of abdominal proper segment of trunk}, hernia {Herniated structure}, pneumoperitoneum {Pneumoperitoneum}, PELVIS {Structure of pelvis}, bladder {Urinary bladder structure}, Foley catheter {Urinary catheter in situ}, ureters {Ureteric structure}, prostate gland {Prostatic structure}, unremarkable {No abnormality detected}, pelvic 
side-wall {Pelvic lymphadenopathy}, inguinal 
lymphadenopathy {Inguinal lymphadenopathy}, pelvic {Structure of pelvis}, inguinal hernia {Inguinal hernia}, OSSEOUS STRUCTURES {Bone structure}, lytic {Lysis}, sclerotic {Sclerosis}, lesion {Lesion}, malignancy {Malignant neoplasm}, Retrolisthesis {Retrolisthesis}, thoracolumbar {Structure of thoracic and/or lumbar region of back}, spine {Structure of vertebral column}, degenerative changes {Degeneration of spine}, CT Abd and Pelvis {Computed tomography of abdomen and pelvis}, right {Structure of right half of body}, perinephric {Structure of perirenal region}, thickening {Increased thickness}, fascia {Structure of fascia}, pyelonephritis {Pyelonephritis}, urinalysis {Urinalysis}, right {Structure of right half of body}, retroperitoneal {Retroperitoneal compartment structure}, right iliac 
vessels {Structure of right iliac vessel}, urinary tract 
infection {Urinary tract infectious disease}, appendix {Appendix structure}, left lower lobe {Structure of lower lobe of left lung}, pulmonary nodule {Nodule of lung}, lung malignancy {Metastatic malignant neoplasm to lung}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 hyperthyroidism on methimazole, Kawasaki's on warfarin, 
presenting with one week of intermittent fevers, lethargy, and 
RLQ pain, found to be in septic shock of unclear etiology:

# Septic shock ___ pyelonephritis: The patient meet SIRS 
criteria with fever, leukocytosis, tachycardia, tachypnea, also 
hypotensive with likely source urinary given concerning UA 
(RBC-4, WBC-93, no epi's) and perinephric/retroperitoneal 
stranding on CT.  The patient was bolus 6L of NS and started a 
levophed gtt in the ED.  A central line was placed in the ED.  
The CVP was resusitated to >12, and MAP remained >65 on 
levophed.  His BP quickly improved and he was weaned from the 
levophed gtt.  He was initially given vancomycin and zosyn in 
the ED, which was narrowed to cefepime on arrival to the FICU.  
He developed a morbilliform rash after recieving vancomycin and 
zosyn in the ED.  He remained off pressors for over 48 hour and 
was admitted to a medical floor bed.  After 3 days, his 
antibiotics were narrowed to levofloxacin.  Blood and Urine 
cultures had no growth to date at that time. The patient was 
discharged on 7 day additional days of Levofloxacin for a full 
14d treatment for pylenonephritis due to septic shock.

# ___: Cr 1.9 in ED secondary to shock, which resolved to 
baseline after fluid resusitation.

# Hyperthyroidism: The patient was followed by endocrinology 
will inpatient after a recent diagnosis of Grave's Disease.  He 
was continued on his home propranolol, but the home dose of 
methimazole was held.  The patient will need to follow up with 
endocrinology with 1 week of discharge.

# Kawasaki's disease: He was continued on his home coumadin and 
quinapril.  An Echo was obtained that revealed a normal EF with 
mild aortic valve stenosis. The patients INR on d/c was 3.7 
given interaction with Coumadin. The patient will hold his 
Coumadin for 2 nights and have his INR checked on ___ at 
the ___. 

# Alcohol use: He denies a history of withdrawal, DTs, or 
seizures in previous hospitalizations.  e was initially started  
on a CIWA, but was discontinued after not scoring for the 
duration of his hospitalization.

# HLD: continued ezetimibe, held lipitor per endocrinology.

# Gout: well controlled, continued home allopurinol

# Pulmonary Nodule: Please see above.
 

###RESPONSE: hyperthyroidism {Hyperthyroidism}, Kawasaki's {Acute febrile mucocutaneous lymph node syndrome}, intermittent fevers {Intermittent fever}, lethargy {Lethargy}, septic shock {Septic shock}, Septic shock {Septic shock}, pyelonephritis {Pyelonephritis}, SIRS {Systemic inflammatory response syndrome}, fever {Fever}, leukocytosis {Leukocytosis}, tachycardia {Tachycardia}, tachypnea {Tachypnea}, hypotensive {Low blood pressure}, urinary {Urinary system structure}, UA {Urinalysis}, perinephric {Structure of perirenal region}, retroperitoneal {Retroperitoneal compartment structure}, CT {Computed tomography}, resusitated {Resuscitation}, BP {Blood pressure finding}, improved {Patient's condition improved}, vancomycin {Antibiotic therapy}, morbilliform rash {Morbilliform rash}, vancomycin {Antibiotic therapy}, pressors {Hypotensive therapy}, antibiotics {Antibiotic therapy}, Urine 
cultures {Urine culture}, pylenonephritis {Pyelonephritis}, septic shock {Septic shock}, shock {Septic shock}, baseline {Baseline state}, fluid resusitation {Administration of fluid therapy}, Hyperthyroidism {Hyperthyroidism}, Grave's Disease {Graves' disease}, Kawasaki's disease {Acute febrile mucocutaneous lymph node syndrome}, Echo {Echocardiography}, mild aortic valve stenosis {Mild stenosis of aortic valve}, Alcohol use {Current drinker of alcohol}, withdrawal {Alcohol withdrawal syndrome}, DT {Alcohol withdrawal delirium}, seizures {Seizure}, HLD {Hyperlipidemia}, Gout {Inflammatory disorder due to increased blood urate level}, Pulmonary Nodule {Nodule of lung}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Ezetimibe 10 mg PO DAILY 
2. Propranolol 10 mg PO BID 
3. Quinapril 10 mg PO DAILY 
4. Allopurinol ___ mg PO DAILY 
5. Warfarin 2.5 mg PO 4X/WEEK (___) 
6. Warfarin 2 mg PO 3X/WEEK (___) 

 
Discharge Medications:
1. Ezetimibe 10 mg PO DAILY 
2. Propranolol 10 mg PO BID 
3. Quinapril 10 mg PO DAILY 
4. Warfarin 2.5 mg PO 4X/WEEK (___) 
Do not take until instructed

5. Warfarin 2 mg PO 3X/WEEK (___) 
6. Levofloxacin 750 mg PO DAILY 
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth Daily 
Disp #*7 Tablet Refills:*0
7. PredniSONE 40 mg PO DAILY 
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*8 Tablet 
Refills:*0
8. Pulmicort Flexhaler *NF* (budesonide) 90 mcg/actuation 
Inhalation BID 
9. Allopurinol ___ mg PO DAILY 
10. Methimazole 10 mg PO TID 
Do not take this medication until instructed to do so by Dr. 
___
 
11. Simvastatin 40 mg PO DAILY 
Please do not take this medication until instructed to do so by 
your PCP. 

 

###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
- Septic Shock secondary to pyelnonephritis
- Graves Disease
- Kawasaki Disease
- Gerd
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 

###RESPONSE: Septic Shock {Septic shock}, pyelnonephritis {Pyelonephritis}, Graves Disease {Graves' disease}, Kawasaki Disease {Acute febrile mucocutaneous lymph node syndrome}, Gerd {Gastroesophageal reflux disease}, Mental Status {Mental state finding}, 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 ___ with low blood pressure and were 
found to have sepsis. While the source of the infection is not 
entirely clear, this was most likely due to a kidney infection. 
You were also treated for an asthma exacerbation. Please note 
the changes to your medications below.
 

###RESPONSE: low blood pressure {Low blood pressure}, sepsis {Sepsis}, infection {Infectious disease}, kidney infection {Infectious disorder of kidney}, asthma exacerbation {Exacerbation of asthma}, changes to your medications {Medication education}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Abdominal pain 
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Abdominal pain {Abdominal pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ w/LURT (___) with CKD stage IV
of renal allograft, RAS s/p stenting, CAD s/p DES x4 ___, 
___
on aspirin/Plavix, HFpEF, atrial fibrillation s/p DVVC (___)
on Eliquis, HTN, HLD, T2DM, aorto-iliac occlusive disease,
bilateral carotid disease c/b recent CVA, OSA, and prostate
cancer, with recent hospitalization for HF exacerbation and
pericarditis, who presents with abdominal pain. 

He states that he has had poor appetite and epigastric pain 
since
discharge on ___. He feels progressively weaker as a result. 
The
epigastric pain does not radiate. He denies fevers, nausea,
vomiting, chest pain, diarrhea, difficulty breathing, hematuria,
dysuria, lower extremity edema, back pain. 

 

###RESPONSE: LURT {Transplant of kidney}, CKD stage IV {Chronic kidney disease stage 4}, renal allograft {Live donor renal transplant}, RAS {Renal artery stenosis}, stenting {Insertion of arterial stent}, CAD {Coronary arteriosclerosis}, DES {Endovascular insertion of drug eluting stent}, HFpEF {Heart failure with normal ejection fraction}, atrial fibrillation {Atrial fibrillation}, DVVC {Direct current cardioversion}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, T2DM {Diabetes mellitus type 2}, aorto-iliac occlusive disease {Occlusion of aortoiliac artery}, l carotid disease {Disorder of carotid artery}, CVA {Cerebrovascular accident}, OSA {Obstructive sleep apnea syndrome}, prostate
cancer {Carcinoma of prostate}, HF exacerbation {Exacerbation of congestive heart failure}, pericarditis {Pericarditis}, abdominal pain {Abdominal pain}, poor appetite {Decrease in appetite}, epigastric pain {Epigastric pain}, epigastric pain {Epigastric pain}, radiate {Radiating pain}, fevers {Fever}, nausea,
vomiting {Nausea and vomiting}, chest pain {Chest pain}, diarrhea {Diarrhea}, difficulty breathing {Difficulty breathing}, hematuria {Blood in urine}, dysuria {Dysuria}, lower extremity edema {Edema of lower extremity}, 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: Past Medical 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: Past Medical History: 
Cardiovascular Issues:
1.  Coronary artery disease (s/p ___ 2 to proximal-LAD ___,
s/p ___ 2 to mid-LAD ___.
2.  Diastolic congestive heart failure.
3.  Hypertension.
4.  Dyslipidemia.
5.  Claudication/Aorto iliac occlusive disease (ABI 0.88/0.76).
6.  Morbid obesity.
7. diabetes
8 Obstructive sleep apnea
9. C diff enterocolitis
10 renal artery stenosis
11. s/p kidney transplant with CKD stage IV transplanted kidney
12. Klepbsiella UTI
13. Prostate cancer
14. Hyperparathyroidism
 

###RESPONSE: Coronary artery disease {Coronary arteriosclerosis}, proximal-LAD {Structure of proximal portion of anterior descending branch of left coronary artery}, mid-LAD {Structure of mid portion of anterior descending branch of left coronary artery}, congestive heart failure {Congestive heart failure}, Hypertension {Hypertensive disorder, systemic arterial}, Dyslipidemia {Dyslipidemia}, Claudication {Intermittent claudication}, Aorto iliac occlusive disease {Occlusion of aortoiliac artery}, Morbid obesity {Morbid obesity}, diabetes {Diabetes mellitus}, Obstructive sleep apnea {Obstructive sleep apnea syndrome}, enterocolitis {Inflammation of small intestine and colon}, renal artery stenosis {Renal artery stenosis}, kidney transplant {Transplant of kidney}, CKD stage IV {Chronic kidney disease stage 4}, transplanted kidney {Structure of transplanted kidney}, UTI {Urinary tract infectious disease}, Prostate cancer {Carcinoma of prostate}, Hyperparathyroidism {Hyperparathyroidism}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father: ___, gout  
Mother: ___, ESRD on hemodialysis
Brothers: Lung cancer and CAD 
His father died at age ___ of dementia.  His mother died at age 
___
of heart failure.  She also had a history of stroke and
hypertension.  He has two brothers, two sisters, and no 
children.
One of his brothers had an MI in his late ___. There is no 
family
history notable for hyperlipidemia, diabetes,or sudden cardiac
death.
 

###RESPONSE: gout {Inflammatory disorder due to increased blood urate level}, ESRD on hemodialysis {End stage renal failure on dialysis}, Lung cancer {Malignant tumor of lung}, CAD {Coronary arteriosclerosis}, died {Dead}, dementia {Dementia}, died {Dead}, heart failure {Heart failure}, stroke {Cerebrovascular accident}, hypertension {Hypertensive disorder, systemic arterial}, MI {Myocardial infarction}, hyperlipidemia {Hyperlipidemia}, diabetes {Diabetes mellitus}, sudden cardiac
death {Sudden cardiac death}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Admission Exam:
===============
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without 
injection.
MMM.
NECK: No cervical lymphadenopathy. 
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Soft, non distended, non-tender to deep palpation in 
all
four quadrants. 
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 
2+
bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: ___ strength throughout. Normal sensation. AOx3.

Discharge Exam:
GENERAL: NAD 
CARDIAC: Regular rhythm, normal rate. 
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing..
ABDOMEN: Soft, non distended, non-tender to deep palpation in 
all
four quadrants. 
EXTREMITIES: no edema bilateral lower extremity

 

###RESPONSE: GENERAL {General examination of patient}, Alert {Mentally alert}, interactive {Does communicate}, distress {Distress}, HEENT {Physical examination procedure}, NC {Normal head}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Sclera anicteric {White sclera}, injection {Scleral injection}, MMM {Moist oral mucosa}, NECK {Physical examination procedure}, cervical lymphadenopathy {Cervical lymphadenopathy}, CARDIAC {Cardiovascular physical examination}, Regular rhythm {Normal sinus rhythm}, normal rate {Normal heart rate}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, LUNGS {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, rales {Respiratory crackles}, increased work of breathing {Difficulty breathing}, BACK {Physical examination procedure}, spinous process {Structure of spinous process of vertebra}, tenderness {Tenderness}, CV {Cardiovascular physical examination}, tenderness {Tenderness}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, distended {Swollen abdomen}, non-tender {Abdominal tenderness}, palpation {Palpation}, EXTREMITIES {Examination of limb}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}, Pulses DP/Radial 
2+ {Peripheral pulses normal}, SKIN {Examination of skin}, Warm {Warm skin}, rash {Eruption of skin}, NEURO {Neurological examination}, GI {Examination of digestive system}, Normal sensation {Normal sensation}, AOx3 {Oriented to person, time and place}, GENERAL {General examination of patient}, NAD {No abnormality detected}, CARDIAC {Cardiovascular physical examination}, Regular rhythm {Normal sinus rhythm}, normal rate {Normal heart rate}, LUNGS {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes, rhonchi {Wheeze - rhonchi}, rales {Respiratory crackles}, increased work of breathing {Difficulty breathing}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, non distended {Swollen abdomen}, non-tender {Abdominal tenderness}, deep palpation {Deep palpation}, EXTREMITIES {Examination of limb}, edema bilateral lower extremity {Edema of bilateral lower limbs}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Labs:

___ 08:20PM BLOOD WBC-16.8* RBC-4.34* Hgb-12.3* Hct-37.8* 
MCV-87 MCH-28.3 MCHC-32.5 RDW-14.6 RDWSD-46.5* Plt ___
___ 08:20PM BLOOD ___ PTT-27.1 ___
___ 08:20PM BLOOD Glucose-167* UreaN-61* Creat-2.6* Na-138 
K-3.4* Cl-95* HCO3-24 AnGap-19*
___ 07:34AM BLOOD Glucose-147* UreaN-57* Creat-2.6* Na-144 
K-4.1 Cl-104 HCO3-23 AnGap-17
___ 02:58AM BLOOD CMV VL-NOT DETECT
___ 08:29PM BLOOD Lactate-1.1

Imaging:
CT Abdomen/Peliv
IMPRESSION: 
1. Focal wall thickening with pericolonic stranding at the 
hepatic flexure,  most consistent with focal 
colits(infectious/inflammatory/ischemic) versus  diverticulitis. 
 Recommend follow-up colonoscopy after acute symptoms subside. 
2. Sigmoid colon diverticulosis with equivocal haziness of the 
fat adjacent to  the proximal sigmoid colon could represent 
additional site of 
diverticulitis/focal colitis. 
3. Small to moderate right and small left bilateral pleural 
effusions with 
overlying atelectasis.  Small pericardial effusion again seen. 
4. Right lower quadrant transplant kidney with mild dilatation 
of the renal  pelvis, increased compared to the prior CT from ___. 

Renal Transplant US:
Interval increase in intrarenal arterial resistive indices now 
ranging from  0.89-1.0 with lack of diastolic flow seen in the 
mid and lower pole intrarenal  arteries as well as main renal 
artery. This is new compared to ___, however loss 
of diastolic flow was also seen on a prior renal ultrasound  
performed ___. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, 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}, CT Abdomen/Peliv {Computed tomography of abdomen and pelvis}, thickening {Increased thickness}, pericolonic {Structure of paracolic region}, hepatic flexure {Structure of right colic flexure}, colits {Colitis}, infectious {Infectious disease}, inflammatory {Inflammatory disorder}, ischemic {Ischemia}, diverticulitis {Diverticulitis}, colonoscopy {Colonoscopy}, Sigmoid colon diverticulosis {Diverticulosis of sigmoid colon}, sigmoid colon {Sigmoid colon structure}, diverticulitis {Diverticulitis}, colitis {Colitis}, bilateral pleural 
effusions {Bilateral pleural effusion}, atelectasis {Atelectasis}, pericardial effusion {Pericardial effusion}, Right lower quadrant {Structure of right lower quadrant of abdomen}, transplant kidney {Structure of transplanted kidney}, dilatation 
of the renal  pelvis {Dilatation of renal pelvis}, arteries {Arterial structure}, renal 
artery {Structure of renal artery}, 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:
___ w/LURT (___) with CKD stage IV of renal allograft, RAS 
s/p stenting, CAD s/p DES x4 (___) on aspirin/Plavix, 
HFpEF, atrial fibrillation s/p DVVC (___) on Eliquis, HTN, 
HLD, T2DM, aorto-iliac occlusive disease, bilateral carotid 
disease c/b recent CVA, OSA, and prostate cancer, with recent
hospitalization for CHF exacerbation and pericarditis, who 
presents with abdominal pain with CT A/P concerning for 
diverticulitis. 

#Diverticulitis.
#Abdominal pain. 
Patient presented with new onset abdominal pain.  CT A/P 
obtained in ED consistent with diverticulitis. The patient was 
started on Unasyn while inpatient and had good response. He was 
able to tolerate PO and was having normal non bloody BM at the 
time of discharge. At time of discharge, abdominal pain had 
resolved.
He was discharged with Augmentin per renal dosing 500mg BID to 
compete a 10 day course (___) In addition, given his history 
of recurrent C diff, he was started on oral vancomycin for C 
diff prophylaxis. He will continue oral vancomycin for a total 
of 15 day course (___). The patient should have a colonoscopy 
to evaluate for bowel pathology in the setting of 
diverticulitis. 

CHRONIC AND STABLE ISSUES
=========================
#ESRD s/p renal transplant
#Immunosuppression. ESRD s/p living unrelated transplantation in
___ c/b transplant glomerulopathy (biopsy proven in ___, 
now
with CKD IV. Per Renal Transplant notes, he has a had a gradual
increase in SCr over the past year. Cr is currently at baseline
2.3-2.6.
- continue mycophenolate mofetil 250 mg PO BID
- continue tacrolimus 1.5 mg PO Q12H, goal ___

#Pericarditis
#Pericardial effusion. Etiology of the effusion was thought to 
be
viral pericarditis likely due to recent upper respiratory
infection given elevated CRP. A second TTE showed small to
moderate (small ammount apically and more moderate at base)
pericardial effusion with no overt evidence of tamponade. It was
felt that the effusion was predominantly posterior and unlikely
to be amenable to 
pericardiocentesis, which was deferred.
- continue ASA 325 TID (last ___ for 2 week course
- continue colchicine 3 months (last ___

#HFpEF, Stage C, NYHA class II. Recent hospitalization for HFpEF
exacerbation due to withholding diuretic and possible bacterial
pneumonia. Currently euvolemic on exam
- continue torsemide 
- continue coreg
- continue amlodipine, hydralazine 

#CAD
#Troponinemia
- continue high dose ASA as above, then will return to ASA 81 mg
on ___
- continue pravastatin 

#HTN
- continue hydralazine, amlodipine
- continue coreg

#Atrial Fibrillation: s/p DCCV
- continue home carvedilol 
- continue home apixaban 

#T2DM
- continue home glargine 24U QAM
- continue ISS

#Dyslipidemia
#Claudication/aortoiliac occlusive disease.
#Bilateral carotid artery disease (80-99% ___, 60-69% LICA)
#Multiple CVA/embolic strokes. Strokes attributed to
subtherapeutic 
INR, switched to NOAC during inpatient admission ___. 
- continue ASA, apixaban as above
- continue Pravastatin as above

#Gout
- continue allopurinol 

#BPH
- continue tamsulosin

#GERD
- continue pantoprazole especially as he is on high dose ASA

Transitional issues:

Transitional Issues:
====================
Recommend follow-up colonoscopy after acute symptoms subside.

 

###RESPONSE: LURT {Transplant of kidney}, CKD stage IV {Chronic kidney disease stage 4}, renal allograft {Live donor renal transplant}, RAS {Renal artery stenosis}, stenting {Insertion of arterial stent}, CAD {Coronary arteriosclerosis}, DES {Endovascular insertion of drug eluting stent}, HFpEF {Heart failure with normal ejection fraction}, atrial fibrillation {Atrial fibrillation}, DVVC {Direct current cardioversion}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, T2DM {Diabetes mellitus type 2}, aorto-iliac occlusive disease {Occlusion of aortoiliac artery}, carotid 
disease {Disorder of carotid artery}, CVA {Cerebrovascular accident}, OSA {Obstructive sleep apnea syndrome}, prostate cancer {Carcinoma of prostate}, CHF exacerbation {Exacerbation of congestive heart failure}, pericarditis {Pericarditis}, abdominal pain {Abdominal pain}, CT A/P {Computed tomography of abdomen and pelvis}, diverticulitis {Diverticulitis}, Diverticulitis {Diverticulitis}, Abdominal pain {Abdominal pain}, abdominal pain {Abdominal pain}, CT A/P {Computed tomography of abdomen and pelvis}, diverticulitis {Diverticulitis}, bloody BM {Hematochezia}, abdominal pain {Abdominal pain}, oral {Administration of drug or medicament via oral route}, prophylaxis {Preventive procedure}, oral {Administration of drug or medicament via oral route}, colonoscopy {Colonoscopy}, bowel {Intestinal structure}, diverticulitis {Diverticulitis}, ESRD {End-stage renal disease}, renal transplant {Transplant of kidney}, ESRD {End-stage renal disease}, transplantation {Transplantation}, transplant glomerulopathy {Transplant glomerulopathy}, biopsy {Biopsy}, CKD IV {Chronic kidney disease stage 4}, baseline {Baseline state}, Pericarditis {Pericarditis}, Pericardial effusion {Pericardial effusion}, effusion {Pericardial effusion}, viral pericarditis {Viral pericarditis}, upper respiratory
infection {Upper respiratory infection}, elevated CRP {C-reactive protein above reference range}, TTE {Transthoracic echocardiography}, pericardial effusion {Pericardial effusion}, tamponade {Cardiac tamponade}, effusion {Pericardial effusion}, pericardiocentesis {Pericardiocentesis}, HFpEF {Heart failure with normal ejection fraction}, HFpEF {Heart failure with normal ejection fraction}, diuretic {Diuretic therapy}, bacterial
pneumonia {Bacterial pneumonia}, euvolemic {Normal blood volume}, CAD {Coronary arteriosclerosis}, HTN {Hypertensive disorder, systemic arterial}, Atrial Fibrillation {Atrial fibrillation}, DCCV {Direct current cardioversion}, T2DM {Diabetes mellitus type 2}, ISS {Sliding scale insulin regime}, Dyslipidemia {Dyslipidemia}, Claudication {Intermittent claudication}, aortoiliac occlusive disease {Aortoiliac atherosclerosis}, carotid artery disease {Disorder of carotid artery}, CVA {Cerebrovascular accident}, embolic strokes {Embolic stroke}, Strokes {Cerebrovascular accident}, Gout {Inflammatory disorder due to increased blood urate level}, BPH {Benign prostatic hyperplasia}, GERD {Gastroesophageal reflux disease}, colonoscopy {Colonoscopy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acidophilus Probiotic (acidophilus-pectin, citrus) 100 
million cell-10 mg oral DAILY 
2. DICYCLOMine 10 mg PO DAILY:PRN abdominal pain 
3. melatonin 10 mg oral QHS 
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 
5. Allopurinol ___ mg PO DAILY 
6. amLODIPine 10 mg PO DAILY 
7. Apixaban 2.5 mg PO BID 
8. Aspirin 325 mg PO TID 
9. Calcitriol 0.25 mcg PO DAILY 
10. Carvedilol 25 mg PO BID 
11. Multivitamins 1 TAB PO DAILY 
12. Mycophenolate Mofetil 250 mg PO BID 
13. Pantoprazole 40 mg PO Q24H 
14. Pravastatin 40 mg PO QPM 
15. Tacrolimus 1.5 mg PO Q12H 
16. Torsemide 80 mg PO BID 
17. Tamsulosin 0.4 mg PO QHS 
18. Colchicine 0.3 mg PO DAILY Pericarditis  
19. HydrALAZINE 25 mg PO TID 
20. Calcium Carbonate 500 mg PO QID:PRN gas 
21. Glargine 24 Units Breakfast

 
Discharge Medications:
1.  Amoxicillin-Clavulanic Acid ___ mg PO Q12H 
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by 
mouth every twelve (12) hours Disp #*16 Tablet Refills:*0 
2.  Vancomycin Oral Liquid ___ mg PO/NG BID 
RX *vancomycin [Firvanq] 25 mg/mL 5 ml by mouth twice a day Disp 
#*3900 Milliliter Milliliter Refills:*0 
3.  Glargine 24 Units Breakfast 
4.  Acidophilus Probiotic (acidophilus-pectin, citrus) 100 
million cell-10 mg oral DAILY  
5.  Allopurinol ___ mg PO DAILY  
6.  amLODIPine 10 mg PO DAILY  
7.  Apixaban 2.5 mg PO BID  
8.  Aspirin 325 mg PO TID  
9.  Calcitriol 0.25 mcg PO DAILY  
10.  Calcium Carbonate 500 mg PO QID:PRN gas  
11.  Carvedilol 25 mg PO BID  
12.  Colchicine 0.3 mg PO DAILY Pericarditis   
13.  DICYCLOMine 10 mg PO DAILY:PRN abdominal pain  
14.  HydrALAZINE 25 mg PO TID  
15.  melatonin 10 mg oral QHS  
16.  Multivitamins 1 TAB PO DAILY  
17.  Mycophenolate Mofetil 250 mg PO BID  
18.  Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain  
19.  Pantoprazole 40 mg PO Q24H  
20.  Pravastatin 40 mg PO QPM  
21.  Tacrolimus 1.5 mg PO Q12H  
22.  Tamsulosin 0.4 mg PO QHS  
23.  Torsemide 80 mg PO BID  

 

###RESPONSE: mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Diverticulitis

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Diverticulitis {Diverticulitis}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr ___,  
It was a pleasure caring for you at ___ 
___.

WHY WAS I IN THE HOSPITAL?  
- You had abdominal pain from diverticulitis 

WHAT HAPPENED TO ME IN THE HOSPITAL?  
- We gave you antibiotics and you got better
- We transitioned you to oral antibiotics

WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take all of the antibiotics as described below:
- Augmentin 500mg BID until (___)
- Vancomycin 125mg BID until (___)

We wish you the ___!

Sincerely,  
Your ___ Team  

 

###RESPONSE: abdominal pain {Abdominal pain}, diverticulitis {Diverticulitis}, antibiotics {Antibiotic therapy}, oral antibiotics {Oral antibiotic therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                       Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Penicillins / aspirin / seafood / Percocet / cats
 
Attending: ___.
 
Chief Complaint:
Syncope
 
Major Surgical or Invasive Procedure:
tPA via EKOS catheter x 2 (___)

 

###RESPONSE: Penicillins {Allergy to penicillin}, aspirin {Allergy to aspirin}, seafood {Allergy to seafood}, cats {Allergy to Felis catus protein}, Syncope {Syncope}, tPA {Intravenous injection of tissue plasminogen activator}, catheter {Insertion of central venous catheter}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ is a ___ year-old patient with a history of 
retroperitoneal lipoma and abnormal uterine bleeding who is 
transferred from an OSH due to massive pulmonary embolism. 

Of note, Ms. ___ has been having prolonged and profuse uterine 
bleeding for which she was started on norethindrone by her 
gynecologist. One day prior to admission she developed left leg 
swelling and pain which she did not make of too much. The day of 
admission she developed sudden-onset dyspnea, palpitations and 
she later lost consciousness only to regain it when EMS arrived. 


She was taken to ___ where she had a CTA 
Chest showing bilateral PEs and was started on a heparin gtt. In 
the ED she underwent a second syncopal event after going to the 
bathroom. On the day of transfer an echocardiogram was done 
showing severe RV dilation and hypokinesis sparing the apex 
leading to transfer to ___ for higher level of care. 

On arrival to the MICU,  she had no additional complaints.

 

###RESPONSE: retroperitoneal {Retroperitoneal compartment structure}, lipoma {Lipoma morphology}, abnormal uterine bleeding {Abnormal uterine bleeding}, pulmonary embolism {Pulmonary embolism}, uterine 
bleeding {Abnormal uterine bleeding}, left leg 
swelling {Localized swelling of left lower limb}, pain {Pain in left lower limb}, dyspnea {Dyspnea}, palpitations {Palpitations}, lost consciousness {Loss of consciousness}, CTA 
Chest {Computed tomography angiography of chest with contrast}, PEs {Pulmonary embolism}, heparin {Heparin therapy}, syncopal {Syncope}, echocardiogram {Echocardiography}, RV dilation {Dilatation of right cardiac ventricle}, hypokinesis {Hyperkinetic right ventricular wall}, apex {Structure of apex of heart}, MICU {Patient transfer to intensive care unit}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Seasonal allergies                                              
Retroperitoneal fatty mass                                      
H/o anemia 
C-section                                                       
Umbilical hernia s/p repair 
 

###RESPONSE: Seasonal allergies {Seasonal allergy}, Retroperitoneal fatty mass {Mass of retroperitoneal structure}, anemia {Anemia}, C-section {Cesarean section}, Umbilical hernia {Umbilical hernia}, repair {Repair of umbilical hernia}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: ___   
Father: ___ cancer   
MGM: Hypertension 
 

###RESPONSE: cancer {Malignant neoplasm}, Hypertension {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Admission Physical Exam
=======================
Vitals: Please see Metavision
GENERAL: Alert, oriented, no acute distress  
HEENT: Sclera anicteric, MMM, oropharynx clear  
NECK: supple, JVP 2cm above clavicle at 45 degrees, no LAD  
LUNGS: Clear to auscultation bilaterally, no wheezes, rales, 
rhonchi  
CV: Regular rate and rhythm, loud S2, no murmurs, rubs, gallops  

ABD: soft, non-tender, non-distended, bowel sounds present, no 
rebound tenderness or guarding, no organomegaly  
EXT: Warm, well perfused. L>R diameter of calves. Non-tender 
calves.
NEURO: AOx3, grossly non-focal

Discharge Physical Exam
=======================
Vitals: T 98.6, BP 115/65, HR 81, RR 18, SpO2 100/RA
General: Alert, oriented, no acute distress, lying comfortably. 
Tearful talking about her kids and wanting to get home to them.
HEENT: Sclera anicteric, MMM, oropharynx clear. Bandage over R 
lower neck is clean and dry.
Lungs: Faint bibasilar crackles  
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, 
gallops  
Abdomen: soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding, no organomegaly  
Ext: Warm, well perfused, 2+ pulses, trace edema in L leg up 
into shin. No edema on R side. No erythema or increased warmth.  

Skin: Without rashes or lesions - R neck bandaged from IJ line 
as above 
Neuro: moving all extremities  
 

###RESPONSE: Physical Exam {Physical examination procedure}, Vitals {Vital signs finding}, GENERAL {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, NECK {Physical examination procedure}, supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, clavicle {Bone structure of clavicle}, LAD {Lymphadenopathy}, LUNGS {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, loud {Heart sounds exaggerated}, 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}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, EXT {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, calves {Structure of calf of leg}, tender {Abdominal tenderness}, calves {Structure of calf of leg}, NEURO {Neurological examination}, AOx3 {Oriented to person, time and place}, grossly non-focal {No abnormality detected}, Physical Exam {Physical examination procedure}, Vitals {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, SpO2 {Finding of oxygen saturation}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, no acute {No abnormality detected}, distress {Distress}, lying {Lying in bed}, Tearful {Crying associated with mood}, talking {Does speak}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, MMM {Moist oral mucosa}, oropharynx clear {Pharynx normal}, Bandage {Application of bandage}, neck {Structure of right half of neck}, Lungs {Examination of respiratory system}, bibasilar {Structure of base of lung}, 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}, Abdomen {Examination of abdomen}, soft {Abdomen soft}, non-tender {Abdominal tenderness}, non-distended {Normal abdominal contour}, bowel sounds present {Normal bowel sounds}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, edema {Edema}, L leg {Structure of left lower limb}, shin {Shin structure}, edema {Edema}, R side {Structure of right lower leg}, erythema {Erythema}, warm {Warm skin}, Skin {Examination of skin}, rashes {Eruption of skin}, lesions {Lesion}, R neck {Structure of right half of neck}, bandaged {Application of bandage}, IJ line {Catheterization of internal jugular vein}, Neuro {Neurological examination}, all extremities {All extremities}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Admission labs
==============
___ 02:37PM BLOOD WBC-8.2# RBC-3.94 Hgb-9.3* Hct-31.1* 
MCV-79*# MCH-23.6*# MCHC-29.9* RDW-17.8* RDWSD-50.8* Plt ___
___ 02:37PM BLOOD Neuts-62.9 ___ Monos-10.3 
Eos-0.2* Baso-0.4 Im ___ AbsNeut-5.13 AbsLymp-2.12 
AbsMono-0.84* AbsEos-0.02* AbsBaso-0.03
___ 05:34PM BLOOD ___ PTT-49.9* ___
___ 02:37PM BLOOD Glucose-82 UreaN-8 Creat-0.6 Na-140 K-3.4 
Cl-114* HCO3-16* AnGap-13
___ 02:37PM BLOOD ALT-9 AST-18 LD(LDH)-285* AlkPhos-61 
TotBili-0.6
___ 02:37PM BLOOD cTropnT-0.03* proBNP-1552*
___ 02:37PM BLOOD Albumin-3.0* Calcium-6.8* Phos-2.2* 
Mg-1.7
___ 02:49PM BLOOD Lactate-1.6

Discharge labs
==============
___ 08:55AM BLOOD WBC-6.2 RBC-3.81* Hgb-9.1* Hct-29.2* 
MCV-77* MCH-23.9* MCHC-31.2* RDW-19.8* RDWSD-51.6* Plt ___
___ 08:55AM BLOOD Plt ___
___ 11:25AM BLOOD PTT-60.5*
___ 08:55AM BLOOD ___ PTT-66.9* ___
___ 08:55AM BLOOD Glucose-83 UreaN-8 Creat-0.7 Na-141 K-3.7 
Cl-106 HCO3-24 AnGap-15
___ 08:55AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1

Imaging
___ Pelvic US  
1. Fibroid uterus, distorting the endometrium. 
2. Blood in the endocervical canal. 
3. Normal ovaries.  No free fluid. 

___ EKOS placement
RECOMMENDATION(S):  1. Infusion of 1.0 mg tPA through each the 
EKOS 
catheter. 
2. Monitor fibrinogen and H&H at least Q6 
3. Reassessment of patient in  12  hours status post catheter 
directed 
chemical thrombectomy with EKOS 

___ TTE
The left atrium is normal in size. Left ventricular wall 
thickness, cavity size, and global systolic function are normal 
(LVEF>55%). The right ventricular cavity is mildly dilated with 
mild global free wall hypokinesis. The aortic valve leaflets (3) 
appear structurally normal with good leaflet excursion and no 
aortic stenosis. The mitral valve leaflets are structurally 
normal. There is borderline pulmonary artery systolic 
hypertension. There is no pericardial effusion. 
IMPRESSION: Suboptimal image quality. Mild right ventricular 
cavity dilation with free wall hypokinesis. Borderline pulmonary 
artery systolic hypertension. Normal left ventricular cavity 
size and global systolic function.  

___ Pulmonary arteriogram
Significant decrease in pulmonary embolic volume with 
significant improvement 
of peripheral pulmonary arterial flow 
RECOMMENDATION(S):  Continue anticoagulation. 
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Lactate dehydrogenase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, cTropnT {Troponin T cardiac measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Lactate {Lactic acid measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, 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}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Imaging {Imaging}, Pelvic US {Pelvic echography}, Fibroid uterus {Uterine leiomyoma}, endometrium {Endometrial structure}, endocervical canal {Structure of cervical canal of uterus}, Normal ovaries {Normal ovary}, free fluid {Effusion}, placement {Insertion of central venous catheter}, Infusion {Infusion}, tPA {Intravenous injection of tissue plasminogen activator}, catheter {Insertion of central venous catheter}, fibrinogen {Fibrinogen measurement}, H&H {Measurement of total hemoglobin concentration and hematocrit}, status post {Postoperative state}, catheter {Insertion of central venous catheter}, thrombectomy {Removal of thrombus}, TTE {Transthoracic echocardiography}, left atrium {Left atrial structure}, normal in size {Normal size}, Left ventricular wall {Left cardiac ventricular structure}, thickness {Normal thickness}, cavity {Structure of cavity of left cardiac ventricle}, systolic function are normal {Normal left ventricular systolic function and wall motion}, right ventricular cavity {Structure of cavity of right cardiac ventricle}, free wall hypokinesis {Hypokinesis of cardiac wall}, aortic valve leaflets {Structure of cardiac valve leaflet}, structurally normal {Aortic valve normal}, good {No abnormality detected}, leaflet {Structure of cardiac valve leaflet}, aortic stenosis {Aortic valve stenosis}, mitral valve leaflets {Structure of leaflet of mitral valve}, structurally 
normal {Mitral valve normal}, pulmonary artery systolic 
hypertension {Pulmonary hypertensive arterial disease}, pericardial effusion {Pericardial effusion}, right ventricular 
cavity {Structure of cavity of right cardiac ventricle}, free wall hypokinesis {Hypokinesis of cardiac wall}, pulmonary 
artery systolic hypertension {Pulmonary hypertensive arterial disease}, left ventricular cavity {Structure of cavity of left cardiac ventricle}, systolic function {Normal left ventricular systolic function and wall motion}, Pulmonary arteriogram {Angiography of pulmonary arteries}, decrease {Decreased size}, pulmonary embolic {Pulmonary embolism}, improvement {Patient's condition improved}, l pulmonary arterial flow {Structure of artery of pulmonary circulation}, anticoagulation {Anticoagulant 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: Brief Hospital Course:
Ms. ___ is a ___ year-old patient with a history of 
retroperitoneal lipoma and abnormal uterine bleeding who is 
transferred from an OSH due to massive pulmonary embolism. 

#Massive Pulmonary Embolism: Pt was transferred from outside 
hospital, where a CTA chest showed pulmonary embolism. Given 
syncope x2 prior to admission, echocardiographic signs of RV 
failure, elevated proBNP (1552) and troponin T (0.03), this PE 
is classified as massive. Initially, patient was hemodynamically 
stable at rest with labile hemodynamics on minimal exertion. Pt 
received tPA via EKOS catheter x 2 on ___ for directed lysis 
of clot. Pt is now hemodynamically stable. Pt on heparin gtt 
during admission; warfarin initiated on ___ (received 5mg). 
NOACs were considered, but due to insurance issues and patient 
preference, warfarin was chosen. INR on discharge of 1.1; pt 
will go home with lovenox for bridging until therapeutic on 
warfarin.

#Abnormal uterine bleeding: Has been ongoing for year but 
slightly worse recently, for which she was started on 
norethindrone. Pelvic ultrasound showed fibroid uterus with 
blood in endocervical canal, normal ovaries, no free air. Gyn 
saw patient, recommended hysterectomy. Pt not interested in 
hysterectomy at this time, will f/u with gyn as an outpatient. 
Bleeding is minimal at this time, and remained stable on heparin 
gtt and with tPA.

#Anemia: stable throughout admission. H/H of 9.1 and 29.2 on 
discharge.

TRANSITIONAL ISSUES:
#ABNORMAL UTERINE BLEEDING: will follow-up at ___ resident 
___ for gynecology 
#HYPERCOAGULABILITY: should get hypercoagulability work-up as 
outpatient. Mother also has history of PE.
#ANTICOAGULATION: initiated on warfarin on ___ will be on 
lovenox at home to bridge onto warfarin therapy. Will need close 
follow-up of coagulation studies. INR should be checked on 
___. Dr ___ manage her 
Coumadin.bility work up as outpatient
 

###RESPONSE: retroperitoneal {Retroperitoneal compartment structure}, lipoma {Lipoma}, abnormal uterine bleeding {Abnormal uterine bleeding}, pulmonary embolism {Pulmonary embolism}, Pulmonary Embolism {Pulmonary embolism}, CTA chest {Computed tomography angiography of chest with contrast}, pulmonary embolism {Pulmonary embolism}, syncope {Syncope}, echocardiographic {Echocardiography}, signs {Sign}, RV {Right cardiac ventricular structure}, elevated {Complement level above reference range}, troponin T {Troponin T measurement}, PE {Pulmonary embolism}, hemodynamically 
stable {Hemodynamically stable}, hemodynamics {Hemodynamic monitoring}, tPA {Intravenous injection of tissue plasminogen activator}, catheter {Insertion of central venous catheter}, lysis {Lysis}, clot {Blood clot}, hemodynamically stable {Hemodynamically stable}, heparin {Heparin therapy}, INR {Calculation of international normalized ratio}, on 
warfarin {Warfarin therapy}, Abnormal uterine bleeding {Abnormal uterine bleeding}, worse {Patient's condition worsened}, Pelvic ultrasound {Pelvic echography}, fibroid uterus with 
blood {Abnormal uterine bleeding due to uterine fibroid}, endocervical canal {Structure of cervical canal of uterus}, normal ovaries {Normal ovary}, free air {Pneumoperitoneum}, hysterectomy {Hysterectomy}, not interested {Lack of interest}, hysterectomy {Hysterectomy}, Bleeding {Abnormal uterine bleeding}, minimal {Symptom mild}, stable {Patient's condition stable}, heparin {Heparin therapy}, tPA {Intravenous injection of tissue plasminogen activator}, Anemia {Anemia}, stable {Patient's condition stable}, ABNORMAL UTERINE BLEEDING {Abnormal uterine bleeding}, follow-up {Follow-up arranged}, HYPERCOAGULABILITY {Hypercoagulability state}, hypercoagulability {Hypercoagulability state}, work-up {Evaluation procedure}, ANTICOAGULATION {Anticoagulant therapy}, on warfarin {Warfarin therapy}, warfarin therapy {Warfarin therapy}, follow-up {Follow-up consultation}, coagulation {Coagulation}, studies {Monitoring procedure}, INR {Calculation of international normalized ratio}, checked {Monitoring procedure}, Coumadin {Anticoagulant therapy}, work up {Evaluation procedure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. norethindrone acetate 5 mg oral BID 

 
Discharge Medications:
1.  Enoxaparin Sodium 80 mg SC BID 
Start: ___, First Dose: Next Routine Administration Time 
RX *enoxaparin 80 mg/0.8 mL 80 mg SQ twice a day Disp #*60 
Syringe Refills:*0 
2.  Warfarin 5 mg PO DAILY16 
RX *warfarin [Coumadin] 2.5 mg Two tablet(s) by mouth Once a day 
Disp #*30 Tablet Refills:*0 
3.  norethindrone acetate 5 mg oral BID  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
PRIMARY DIAGNOSES:
 - Massive pulmonary embolism
 - Abnormal uterine bleeding

SECONDARY DIAGNOSES:
 - Anemia

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: pulmonary embolism {Pulmonary embolism}, Abnormal uterine bleeding {Abnormal uterine bleeding}, Anemia {Anemia}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms ___,

You were admitted to ___ from 
___ to ___ for a massive pulmonary embolism (blood clot 
in your lungs).

WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
=============================================
 - You had an ultrasound of your heart, which showed that your 
heart was being affected by the pulmonary embolism.
 - You were seen by our gynecologists, who thought your uterine 
bleeding was stable and that you were okay to receive blood 
thinners for your blood clot.
 - You had a pelvic ultrasound, which showed fibroids in your 
uterus, which is likely the cause of your bleeding.
 - You had catheters put into your neck that reached the spot in 
your lungs where the blood clot was. A medicine called tPA was 
put into the catheters that helped to break up the clot.
 - You were on an IV drip of heparin (blood thinner).
 - You were started on warfarin (Coumadin), which is a blood 
thinner pill that you will continue to take once you leave the 
hospital.

WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
=============================================
 - You will continue to take warfarin as prescribed. It is very 
important that you take this every day to prevent your blood 
clot from getting worse.
 - You will have to inject yourself with enoxaparin (Lovenox) at 
home until you determine with your primary care doctor that your 
warfarin dose is appropriate. It is VERY important that you take 
this every day to prevent your blood clot from getting worse, 
until your primary care doctor tells you it is okay to stop.
 - You should got to Dr. ___ office on ___ to get your 
INR level drawn. 
 - You will see Dr ___ care doctor) for routine 
follow-up once you leave the hospital.
 - You will see one of our cardiologists (who helped to take 
care of your blood clot in the hospital) in the office for 
follow-up of your blood clot.
 - You will see a gynecologist in our clinic here for follow-up 
of your bleeding and fibroids.

If you have any further questions regarding your care here, 
please do not hesitate to contact us. We wish you the ___ with 
your health going forward.

Your ___ Care Team
 

###RESPONSE: pulmonary embolism {Pulmonary embolism}, blood clot {Blood clot}, lungs {Lung structure}, ultrasound of your heart {Echocardiography}, heart {Heart structure}, pulmonary embolism {Pulmonary embolism}, uterine 
bleeding {Abnormal uterine bleeding}, stable {Patient's condition stable}, receive blood 
thinners {Anticoagulant therapy}, blood clot {Blood clot}, pelvic ultrasound {Pelvic echography}, fibroids {Uterine leiomyoma}, uterus {Uterine structure}, bleeding {Abnormal uterine bleeding}, catheters {Insertion of central venous catheter}, neck {Neck structure}, lungs {Lung structure}, blood clot {Blood clot}, tPA {Intravenous injection of tissue plasminogen activator}, catheters {Insertion of central venous catheter}, clot {Blood clot}, IV {Intravenous therapy}, heparin {Heparin therapy}, blood thinner {Anticoagulant therapy}, on warfarin {Warfarin therapy}, Coumadin {Anticoagulant therapy}, blood 
thinner {Anticoagulant therapy}, warfarin {Warfarin therapy}, blood 
clot {Blood clot}, primary care {Primary care management}, blood clot {Blood clot}, primary care {Primary care management}, INR {Calculation of international normalized ratio}, follow-up {Follow-up consultation}, blood clot {Blood clot}, follow-up {Follow-up consultation}, blood clot {Blood clot}, clinic {Outpatient care management}, follow-up {Follow-up consultation}, bleeding {Abnormal uterine bleeding}, fibroids {Uterine leiomyoma}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: OBSTETRICS/GYNECOLOGY
 

###RESPONSE: OBSTETRICS {Obstetric procedure}, GYNECOLOGY {Operation on female genital organs}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
lisinopril
 
Attending: ___.
 
Chief Complaint:
endometrial cancer
 
Major Surgical or Invasive Procedure:
total laparoscopic hysterectomy, bilateral 
salpingo-oophorectomy, pelvic lymph node dissection, cystoscopy

 

###RESPONSE: endometrial cancer {Endometrial carcinoma}, laparoscopic hysterectomy {Laparoscopic hysterectomy}, bilateral 
salpingo-oophorectomy {Excision of bilateral fallopian tubes and ovaries}, pelvic lymph node dissection {Pelvic lymphadenectomy}, cystoscopy {Transurethral cystoscopy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
___ with a past medical
history notable for chronic kidney disease, hypertension, and a
history of PE and DVT in ___ who reports the onset of vaginal
bleeding on ___.  She presented to the emergency room and
underwent a CT of the abdomen and pelvis.  This showed
diverticular disease without inflammation as well as uterine
fibroids but no lymphadenopathy.   She was referred to Dr. 
___ attempted an endometrial biopsy which was nondiagnostic.  
She
also had what appeared to be a cervical biopsy and ECC on
___ which were both negative.  She then proceeded to the
operating room on ___ for a hysteroscopy with ___ curettage.  Findings were notable for a lush endometrium
with a polypoid lesion with abnormal vessels on the right 
uterine
sidewall and a larger lesion on the posterior uterine wall with
abnormal vessels, both which were biopsied and removed.  Final
pathology from this procedure showed an endometrial
adenocarcinoma, endometrioid type, FIGO grade 1.  The specimen
has been received here at ___ but has not yet been
interpreted for second opinion.  The patient was referred to GYN
oncology for further evaluation and treatment recommendations. 
She presents today for consultation along with her 2 daughters.

Since then she continues to have light vaginal bleeding.  She
otherwise feels
well and denies any pain or discomfort. She denies any
early satiety, unintentional weight changes, nausea/vomiting,
SOB/CP, increased abdominal girth, abdominal or pelvic pain,
vaginal discharge, or change in her bowel or bladder habits.

10 system Review of Systems negative except as noted above.
 

###RESPONSE: chronic kidney disease {Chronic kidney disease}, hypertension {Hypertensive disorder, systemic arterial}, PE {Pulmonary embolism}, DVT {Deep venous thrombosis}, vaginal
bleeding {Bleeding from vagina}, CT {Computed tomography}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, pelvis {Structure of pelvis}, diverticular disease {Diverticular disease}, inflammation {Inflammatory disorder}, uterine
fibroids {Uterine leiomyoma}, lymphadenopathy {Lymphadenopathy}, endometrial biopsy {Endometrial biopsy}, cervical biopsy {Cervical biopsy}, ECC {Endocervical curettage}, hysteroscopy {Hysteroscopy}, curettage {Curettage}, endometrium {Endometrial structure}, lesion {Lesion}, vessels {Blood vessel finding}, right {Right hip region structure}, uterine {Uterine structure}, lesion {Lesion}, posterior uterine wall {Structure of posterior wall of uterus}, vessels {Blood vessel finding}, biopsied {Biopsy}, removed {Removal}, endometrial
adenocarcinoma, endometrioid type {Endometrioid carcinoma of endometrium}, grade 1 {G1 grade}, GYN {Gynecologic examination}, vaginal bleeding {Bleeding from vagina}, feels
well {Well in self}, pain {Abdominal pain}, discomfort {Discomfort}, early satiety {Early satiety}, weight changes {Weight change finding}, nausea {Nausea}, vomiting {Vomiting}, SOB {Dyspnea}, CP {Chest pain}, increased abdominal girth {Swollen abdomen}, abdominal {Abdominal pain}, pelvic {Pain in pelvis}, pain {Abdominal pain}, vaginal discharge {Vaginal discharge}, bowel {Intestinal structure}, bladder {Urinary bladder structure}, habits {Habit}, Review of Systems {Review of systems}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Health Maintenance:
-Mammogram: ___ years ago
-Colonoscopy: Never
-Bone Mineral Density: Unsure 


###RESPONSE: Mammogram {Mammography}, Colonoscopy {Colonoscopy}, Density {Abnormally opaque structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History: obesity, pernicious anemia, asthma,
hypertension, anxiety disorder, hypothyroidism, personal history
of a DVT and PE, chronic kidney disease, chronic venous stasis
and lower extremity edema

Past Surgical History: Open cholecystectomy, ___
                                 
Past OB History:  G7 P5
7 vaginal deliveries without complications

Past GYN History:
Menopausal.  This is her first episode of postmenopausal
bleeding.  She has never taken any hormone replacement therapy. 
She denies any significant gynecologic problems in the past.

 

###RESPONSE: obesity {Obesity}, pernicious anemia {Pernicious anemia}, asthma {Asthma}, hypertension {Hypertensive disorder, systemic arterial}, anxiety disorder {Anxiety disorder}, hypothyroidism {Hypothyroidism}, DVT {Deep venous thrombosis}, PE {Pulmonary embolism}, chronic kidney disease {Chronic kidney disease}, chronic {Chronic edema}, venous stasis {Venous stasis}, lower extremity edema {Edema of lower extremity}, cholecystectomy {Cholecystectomy}, vaginal deliveries {Vaginal delivery}, Menopausal {Menopause finding}, postmenopausal
bleeding {Postmenopausal bleeding}, hormone replacement therapy {Hormone replacement therapy}, gynecologic problems {Female genital tract problem}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Denies family history of GYN cancer, breast cancer, colon cancer 
                                            

 

###RESPONSE: GYN {Female genital organ structure}, cancer {Malignant neoplasm}, breast cancer {Malignant neoplasm of breast}, colon cancer {Malignant neoplasm of colon}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, appropriately tender, nondistended, incision 
clean/dry/intact, no rebound/guarding
___: nontender, nonedematous

 

###RESPONSE: Afebrile {Fever}, vitals {Vital signs finding}, stable {Stable blood pressure}, distress {Distress}, CV {Cardiovascular physical examination}, regular rate and rhythm {Normal heart rate}, Pulm {Examination of respiratory system}, clear to auscultation bilaterally {Normal breath sounds}, Abd {Examination of abdomen}, soft {Abdomen soft}, tender {Abdominal tenderness}, nondistended {Normal abdominal contour}, incision {Abdomen incision}, clean/dry/intact {Wound healing well}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, nontender {Abdominal tenderness}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:25AM BLOOD WBC-7.1 RBC-3.81* Hgb-10.7* Hct-32.5* 
MCV-85 MCH-28.1 MCHC-32.9 RDW-14.5 RDWSD-44.9 Plt ___
___ 06:25AM BLOOD Glucose-114* UreaN-13 Creat-0.9 Na-139 
K-3.7 Cl-102 HCO3-27 AnGap-14
___ 06:25AM BLOOD Calcium-8.4 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}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Ms. ___ was admitted to the gynecologic oncology service 
after undergoing total laparoscopic hysterectomy, bilateral 
slapping-oophorectomy, pelvic lymph node dissection, and 
cystoscopy for endometrial cancer. Please see the operative 
report for full details.  

Her post-operative course is detailed as follows. Immediately 
postoperatively, her pain was controlled with IV morphine and IV 
toradol. Her diet was advanced without difficulty and she was 
transitioned to PO ibuprofen, liquid Tylenol, and liquid 
oxycodone. On post-operative day #1, her urine output was 
adequate so her Foley catheter was removed and she voided 
spontaneously. 

She was continued on her home medications for hypothyroidism, 
hypertension (hydrochlorothiazide restarted on post operative 
day 1), and asthma.

By post-operative day 1, she was tolerating a regular diet, 
voiding spontaneously, ambulating independently, and pain was 
controlled with oral medications. She was then discharged home 
in stable condition with outpatient follow-up scheduled.  She 
was also discharged on 28 days of Lovenox for a personal history 
of deep venous thrombosis and pulmonary embolism.
 

###RESPONSE: laparoscopic hysterectomy {Laparoscopic hysterectomy}, bilateral 
slapping-oophorectomy {Excision of bilateral fallopian tubes and ovaries}, pelvic lymph node dissection {Pelvic lymphadenectomy}, cystoscopy {Transurethral cystoscopy}, endometrial cancer {Endometrial carcinoma}, post-operative course {Postoperative state}, pain {Pain}, IV {Intravenous therapy}, IV {Intravenous therapy}, diet {Dietary finding}, urine {Urine culture}, Foley cathete {Catheterization of urinary bladder}, medications {Administration of drug or medicament}, hypothyroidism {Hypothyroidism}, hypertension {Hypertensive disorder, systemic arterial}, asthma {Asthma}, regular diet {Normal diet}, voiding spontaneously {Normal micturition}, ambulating independently {Independent walking}, pain {Pain}, oral medications {Administration of drug or medicament via oral route}, stable condition {Patient's condition stable}, outpatient follow-up {Outpatient care management}, deep venous thrombosis {Deep venous thrombosis}, pulmonary embolism {Pulmonary embolism}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
albuterol, brinzolamide-brimonidine (eye drops), clobetasol, 
fluticasone-salmeterol, hydrochlorothiazide 12.5 daily, 
latenoprost, levothyroxine 75 mcg daily, ativan, timolol, 
tramadol, baby aspirin, vitamin D3, vitamin B12
 
Discharge Medications:
1.  Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 
RX *acetaminophen 650 mg/20.3 mL 650 mg by mouth every 6 hours 
Refills:*1 
2.  Docusate Sodium 100 mg PO BID:PRN constipation 
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice 
per day Disp #*60 Capsule Refills:*1 
3.  Enoxaparin Sodium 40 mg SC Q24H 
Start: ___, First Dose: Next Routine Administration Time 
RX *enoxaparin 40 mg/0.4 mL 40 mg IM daily Disp #*28 Syringe 
Refills:*0 
4.  Ibuprofen Suspension 400 mg PO Q8H:PRN Pain - Mild 
RX *ibuprofen 100 mg/5 mL 20 ml by mouth every four (4) hours 
Refills:*0 
5.  OxycoDONE Liquid 2.5 mg PO Q4H:PRN Pain - Moderate 
RX *oxycodone 5 mg/5 mL 2.5 mg by mouth every 4 hours Refills:*0 

6.  Senna 8.6 mg PO BID:PRN constipation 
RX *sennosides [senna] 8.8 mg/5 mL 5 ml by mouth twice a day 
Refills:*0 
7.  Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing  
8.  Hydrochlorothiazide 12.5 mg PO DAILY  
9.  Levothyroxine Sodium 75 mcg 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:
endometrial cancer

 
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}, endometrial cancer {Endometrial carcinoma}, Mental Status {Neurological mental status determination}, Clear {Normal breath sounds}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Ms. ___,
.
You were admitted to the gynecologic oncology service after 
undergoing the procedures listed below. You have recovered well 
after your operation, and the team feels that you are safe to be 
discharged home. Please follow these instructions: 
. 
Laparoscopic instructions:  
* Take your medications as prescribed. We recommend you take 
non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first 
few days post-operatively, and use the narcotic as needed. As 
you start to feel better and need less medication, you should 
decrease/stop the narcotic first.
* Do not drive while taking narcotics.  
* Do not combine narcotic and sedative medications or alcohol.  
* Do not take more than 4000mg acetaminophen (tylenol) in 24 
hrs.  
* No strenuous activity until your post-op appointment.  
* Nothing in the vagina (no tampons, no douching, no sex) for 8 
weeks.
* No heavy lifting of objects >10 lbs for 4 weeks.  
* You may eat a regular diet.
* It is safe to walk up stairs.  
.
Incision care:  
* You may shower and allow soapy water to run over incision; no 
scrubbing of incision. No bath tubs for 6 weeks.  
* You should remove your port site dressings ___ days after your 
surgery, if they have not already been removed in the hospital. 
Leave your steri-strips on.  If they are still on after ___ 
days from surgery, you may remove them.  
* If you have staples, they will be removed at your follow-up 
visit.  
.
To reach medical records to get the records from this 
hospitalization sent to your doctor at home, call ___.  

.
Call your doctor at ___ for:  
* fever > 100.4  
* severe abdominal pain  
* difficulty urinating  
* vaginal bleeding requiring >1 pad/hr  
* abnormal vaginal discharge  
* redness or drainage from incision  
* nausea/vomiting where you are unable to keep down fluids/food 
or your medication  
* chest pain or difficulty breathing 
* onset of any concerning symptoms 

 

###RESPONSE: medications {Administration of drug or medicament}, medication {Administration of drug or medicament}, decrease {Decreased size}, while taking narcotics {Narcotics education}, medications {Administration of drug or medicament}, vagina {Vaginal structure}, lifting {Does lift}, regular diet {Normal diet}, walk {Does walk}, Incision care {Incision care}, incision {Surgical incision wound}, incision {Surgical incision wound}, fever {Fever}, abdominal pain {Abdominal pain}, difficulty urinating {Difficulty passing urine}, vaginal bleeding {Bleeding from vagina}, pad {Pad}, abnormal vaginal discharge {Vaginal discharge problem}, redness {Redness of skin over lesion}, drainage {Discharge}, incision {Incision}, nausea {Nausea}, vomiting {Vomiting}, fluids {Tolerating oral fluid}, medication {Administration of drug or medicament}, chest pain {Chest pain}, difficulty breathing {Difficulty breathing}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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: 
Codeine / Iodine / Morphine / Percocet / Percodan
 
Attending: ___.
 
Chief Complaint:
Left Facial Pain, Skin Infection and Fever
 
Major Surgical or Invasive Procedure:
none
 

###RESPONSE: Codeine {Allergy to codeine}, Iodine {Allergy to iodine compound}, Morphine {Allergy to morphine}, Left Facial {Structure of left half of face}, Pain {Pain in face}, Skin Infection {Infection of skin and/or subcutaneous tissue}, Fever {Fever}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 ___ year-old man with a history of squamous cell 
carcinoma s/p Mohs to the L temporal area on ___. Since the 
surgery, he has been having headaches, gradually worsening. He 
has not been able to eat much since ___ due to the pain. It now 
extends from his forehead down to his mandible on the L. He 
initially took acetaminophen, which did not change his pain. He 
then took 400 mg ibuprofen which seemed to help. On ___ he 
developed fevers and chills. He came to the hospital.
 

###RESPONSE: squamous cell 
carcinoma {Squamous cell carcinoma}, Mohs {Mohs surgery}, L temporal {Left temporal lobe structure}, surgery {Surgical procedure}, headaches {Headache}, worsening {Increased pain}, has not been able to eat {Unable to eat}, pain {Pain}, forehead {Forehead structure}, mandible {Bone structure of mandible}, pain {Pain}, fevers {Fever}, chills {Chill}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
-dyslipidemia  
-BPH  
-numerous non-melanoma skin cancers  
-actinic keratoses  
-s/p splenectomy following MVA in ___ (? vaccinations)
 

###RESPONSE: dyslipidemia {Dyslipidemia}, BPH {Benign prostatic hyperplasia}, melanoma {Malignant melanoma of skin}, skin cancers {Malignant neoplasm of skin}, actinic keratoses  {Actinic keratosis}, splenectomy {Splenectomy}, MVA {Motor vehicle accident victim}, vaccinations {Administration of vaccine to produce active immunity}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father was a ___ and family had prolonged sun exposure. 
There is a strong family history of actinic keratoses,  and skin 
cancer. 
 

###RESPONSE: actinic keratoses {Actinic keratosis}, skin 
cancer {Malignant neoplasm of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VS: T 97, BP 118/70, RR 16, O2 98% on RA  
Gen: appears comfortable, talkative and pleasant  
HEENT: L temporal surgical wound healing, slight purulence when 
pressed most pronounced at hairline, erythema is most pronounced 
around the wound but extends down to his mandible. He is very 
tender around the suture and mildly tender down the L lateral 
aspect of his face.  
Neck: supple  
Cardiovascular: regular, no murmur  
Respiratory: Clear to auscultation bilaterally, no wheezes, 
rales or rhonchi  
Abd: Soft, non-tender, non distended, no heptosplenomegally, 
bowel sounds present, abdominal scar from splenectomy  
Extremities: warm, no edema  
Neurological: grossly intact  
Skin: L temporal area described above. Otherwise, he has diffuse 
actinic keratoses, most pronounced on his back and scalp.
 

###RESPONSE: VS {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, O2 {Oxygen saturation measurement}, RA {Breathing room air}, Gen {General examination of patient}, HEENT {Physical examination procedure}, L temporal {Structure of left temporal bone}, surgical wound {Surgical wound}, healing {Wound healed}, purulence {Purulent discharge from wound}, erythema {Erythema}, wound {Wound}, mandible {Bone structure of mandible}, tender {Abdominal tenderness}, tender {Abdominal tenderness}, L lateral 
aspect of his face {Structure of left half of face}, Neck {Physical examination procedure}, supple {Normal movement of neck}, Cardiovascular {Cardiovascular physical examination}, regular {Normal heart rate}, murmur {Murmur}, Respiratory {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, Abd {Examination of abdomen}, Soft {Abdomen soft}, non-tender {Abdominal tenderness}, distended {Swollen abdomen}, heptosplenomegally {Hepatosplenomegaly}, bowel sounds present {Normal bowel sounds}, abdominal scar {Abdominal skin scar}, splenectomy {Splenectomy}, Extremities {Examination of limb}, warm {Warm skin}, edema {Edema}, Neurologic {Neurological examination}, grossly intact {Normal nervous system function}, Skin {Examination of skin}, temporal {Structure of left temporal bone}, actinic keratoses {Actinic keratosis}, back {Structure of back of trunk}, scalp {Scalp structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:30PM   WBC-24.4*# RBC-4.59* HGB-14.2 HCT-41.9 MCV-91 
MCH-31.0 MCHC-33.9 RDW-13.5

___ 07:27AM BLOOD WBC-17.5* RBC-4.22* Hgb-13.3* Hct-39.1* 
MCV-93 MCH-31.4 MCHC-33.9 RDW-13.4 Plt ___ year-old man with a history of squamous cell carcinoma s/p 
Mohs to the L temporal area on ___. Since the surgery, he has 
been having headaches, gradually worsening. He has not been able 
to eat much since ___ due to the pain. It now extends from his 
forehead down to his mandible on the L.
.
In the ED, initial VS T 99.9, BP 144/87, HR 93, RR 16, O2 96% 
RA. Exam was notable for infected-appearing wound on L temporal 
area. Labs notable for leukocytosis. Dermatology saw him and 
recommended IV MRSA coverage and observation overnight. He was 
given 1g vancomycin and admitted.  
.
His elevated temperature resolved with administration of 2 doses 
of IV vancomycin. WBC count on ED presentation was 24.4 and on 
day of discharge was 17.5. Pain was also subjectively much 
improved. Gram stain of wound revealed gram positive cocci in 
pairs. Wound and blood culture and sensitity remain pending. 
Dermatology was consulted and recommended follow-up appointment 
in their surgery clinic on ___ at 2PM and 
outpatient oral antibiotic therapy. Patient was prescribed 
Bactrim DS PO x 14 days. 
.
His other medical problems were stable and no changes were made 
to the medications other than adding Bactrim DS for his current 
skin infection.

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, 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}, squamous cell carcinoma {Squamous cell carcinoma}, Mohs {Mohs surgery}, L temporal {Left temporal lobe structure}, surgery {Surgical procedure}, headaches {Headache}, worsening {Increased pain}, has not been able 
to eat {Unable to eat}, pain {Pain}, forehead {Forehead structure}, mandible {Bone structure of mandible}, VS {Vital signs finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 {Oxygen saturation measurement}, infected-appearing wound {Local infection of wound}, L temporal {Left temporal lobe structure}, leukocytosis {Leukocytosis}, elevated temperature {Body temperature above reference range}, resolved {Problem resolved}, WBC {White blood cell count}, Pain {Pain}, improved {Patient's condition improved}, Gram stain {Gram stain method}, wound {Wound}, Wound {Wound}, blood culture {Blood culture}, oral antibiotic therapy {Oral antibiotic therapy}, stable {Patient's condition stable}, infection {Infectious disease}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
simvastatin 5 mg daily  
finasteride 5 mg dialy  
 
Discharge Medications:
1. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Bactrim DS 800-160 mg Tablet Sig: Two (2) Tablet PO twice a 
day for 14 days.
Disp:*56 Tablet(s)* Refills:*0*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
L Facial cellulitis

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: L Facial {Structure of left half of face}, cellulitis {Cellulitis}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted to ___ for 
fever and a skin infection. You were started on IV vancomycin in 
the ED and continued on admission. Your fever resolved and your 
pain improved. In addition, your white blood cell count is 
appropriately responding to the antibiotic therapy. Your 
infection treatment with antibiotics will be continued as oral 
Bactrim DS 2 pills twice daily for 14 days. You should continue 
your home medications as written in this discharge document.
.
The Following CHANGES have been made:
You were STARTED on BACTRIM DS 2 pills twice per day for 14 days 
for the infection.
.
Please follow up with your dermatologist on ___ on ___ 
at 2pm ___ ___ Center Dermatologic Surgery clinic .

 

###RESPONSE: fever {Fever}, skin infection {Infection of skin and/or subcutaneous tissue}, fever {Fever}, resolved {Problem resolved}, pain improved {Sensation of pain reduced}, white blood cell count {White blood cell count}, antibiotic therapy {Antibiotic therapy}, infection {Infectious disease}, antibiotics {Antibiotic therapy}, infection {Infectious disease}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: 
Chocolate Flavor / Atenolol
 
Attending: ___.
 
Chief Complaint:
Lethargy, speech difficulties, word-finding difficulties
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: Atenolol {Allergy to atenolol}, Lethargy {Lethargy}, speech difficulties {Has difficulty with speech}, word-finding difficulties {Word finding difficulty}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 ___ year old gentleman seen recently in the ED 
for a fall returning with lethargy, slurred & repeated speech, 
difficult with word finding. 4 days prior to admission, the 
patient was out at the ___, was pushed from a standing 
position and fell on his knees. Since that time he has had 
considerable pain, and decreased mobility. The morning prior to 
admission, he awoke with decreased appetite, had lethargy and 
then later developed difficulty with word finding, right leg 
weakness and slurred speech. He called into ___ and he was 
referred to the ED for possible stroke work up.  
.  
In the ED, Initial VS: 102 67 140/67 18 96%RA. Patient received 
Tylenol CTX, Azithro for CAP/retrocardiac opacity on CXR. Neuro 
recommended infectious work up and will follow in consult. 
Transfer VS: 98.0 63 116/40 16 98%RA.  
.  
On arrival to the floor, the patient is comfortable, and per 
niece, back to baseline. He denies any discomfort or any recent 
indications of illness: fevers, chills, cough, chest pain, 
dyspnea, sputum, abdominal pain, nausea, vomiting, dysuria.  He 
and his niece report cough and some malaise over last two days.
.  
Review of Systems:  
(+) Per HPI  
(-) Denies fever, chills, night sweats, recent weight loss or 
gain. Denies headache, sinus tenderness, rhinorrhea or 
congestion. Denies chest pain or tightness, palpitations. Denies 
cough, shortness of breath, or wheezes. Denied nausea, vomiting, 
diarrhea, constipation or abdominal pain. No recent change in 
bowel or bladder habits. No dysuria. Denies arthralgias or 
myalgias. Denies rashes or skin breakdown. No numbness/tingling 
in extremities. No feelings of depression or anxiety. All other 
review of systems negative.  

 

###RESPONSE: fall {Elderly fall}, lethargy {Lethargy}, slurred {Slurred speech}, difficult with word finding {Word finding difficulty}, standing 
position {Orthostatic body position}, fell {Elderly fall}, knees {Knee region structure}, pain {Pain}, decreased mobility {Reduced mobility}, decreased appetite {Decrease in appetite}, lethargy {Lethargy}, difficulty with word finding {Word finding difficulty}, right leg {Structure of right lower leg}, weakness {Monoparesis of lower limb}, slurred speech {Slurred speech}, stroke {Cerebrovascular accident}, RA {Breathing room air}, opacity {Abnormally opaque structure}, CXR {Plain chest X-ray}, RA {Breathing room air}, discomfort {Discomfort}, fevers {Fever}, chills {Chill}, cough {Cough}, chest pain {Chest pain}, dyspnea {Dyspnea}, sputum {No sputum}, abdominal pain {Abdominal pain}, nausea {Nausea}, vomiting {Vomiting}, dysuria {Dysuria}, cough {Cough}, malaise {Malaise}, fever {Fever}, chills {Chill}, night sweats {Night sweats}, recent weight loss {Recent weight loss}, gain {Recent weight gain}, headache {Headache}, tenderness {Tenderness}, rhinorrhea {Nasal discharge}, congestion {Nasal congestion}, chest pain {Chest pain}, tightness {Tight chest}, palpitations {Palpitations}, cough {Cough}, shortness of breath {Dyspnea}, wheezes {Wheezing}, nausea {Nausea}, vomiting {Vomiting}, diarrhea {Diarrhea}, constipation {Constipation}, abdominal pain {Abdominal pain}, change in 
bowel {Altered bowel function}, bladder {Urinary bladder structure}, dysuria {Dysuria}, arthralgias {Joint pain}, myalgias {Muscle pain}, rashes {Eruption of skin}, skin breakdown {Broken skin}, No numbness/tingling {Numbness and tingling sensation of skin}, extremities {Limb structure}, depression {Depressive disorder}, anxiety {Anxiety}, review of systems {Review of systems}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
- Atrial Fibrillation  
- Prostate cancer  
- Hypertension  
- Hyperlipidemia  
- Type two diabetes mellitus
- Osteoporosis

 

###RESPONSE: Atrial Fibrillation {Atrial fibrillation}, Prostate cancer {Carcinoma of prostate}, Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, Type two diabetes mellitus {Diabetes mellitus type 2}, Osteoporosis {Osteoporosis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Non-contributory
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
(At time of admission)
VS: 97.7 130/53 80 24 96% RA  
GEN: Elderly gentleman, well appearing and comfortable  
HEENT: No JVD, no LAD  
CV: S1 & S2 regular without murmur  
PULM: Bibasilar crackles, decreased LLL breath sounds  
ABD: NTND  
LIMBS: Bandaged knees, chronic stasis changes bilateral lower 
extremities, no edema  
NEURO: AAOx3, CN ii-xii grossly intact, gait deferred 

 

###RESPONSE: VS {Vital signs finding}, RA {Breathing room air}, GEN {General examination of patient}, HEENT {Physical examination procedure}, JVD {Jugular venous engorgement}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, S2 {Normal second heart sound, S>2<}, murmur {Murmur}, PULM {Examination of respiratory system}, Bibasilar {Structure of base of lung}, crackles {Respiratory crackles}, ABD {Examination of abdomen}, ND {Swollen abdomen}, LIMBS {Examination of limb}, Bandaged {Application of bandage}, knees {Knee region structure}, stasis {Stasis}, lower 
extremities {Lower limb structure}, edema {Edema}, NEURO {Neurological examination}, Ox3 {Oriented to person, time and place}, CN ii {Optic nerve structure}, xii {Hypoglossal nerve structure}, grossly intact {Normal nervous system function}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
Chest X-ray 
___
FRONTAL AND LATERAL VIEWS OF THE CHEST: Lung volumes are low. 
Streaky 
opacity at the lung bases likely due to atelectasis. There is 
stable 
eventration of the right hemidiaphragm. Increased density in the 
retrocardiac area and seen laterally at the left lung base are 
concerning for infectious process. There is calcification of the 
aortic knob, unchanged with a slightly tortuous aorta. Heart 
size is mildly enlarged with prominent left atrium.  There is no 
pleural effusion or pneumothorax. 
  
IMPRESSION: Increased patchy opacities at the left lung base 
concerning for pneumonia/aspiration. 

Head CT
___
FINDINGS: There is no acute intracranial hemorrhage, large areas 
of edema, 
large masses or mass effect. Periventricular white matter 
hypodensities is 
consistent with chronic small vessel ischemic changes. There is 
preservation of normal gray-white matter differentiation. The 
ventricles and sulci are normal in size and configuration given 
the patient's age. 
Soft tissues of the orbits and nasopharynx are within normal 
limits. The 
visualized paranasal sinuses and mastoid air cells are clear. No 
fractures 
are identified. 
IMPRESSION: No acute intracranial process. No acute hemorrhage. 

Laboratories on day of discharge:
WBC 6.5, Hemoglobin 11.3, Hematocrit 33.5, Platelets 196, MCV 89
INR 3.7
Na 135, K 3.3, Cl 102, HCO3 25, BUN 52, Creatinine 1.5, Glucose 
118
Ca 8.4, Mg 2.3, P 3.1
CK 308

 

###RESPONSE: Chest X-ray {Plain chest X-ray}, CHEST {Thoracic structure}, Lung {Lung structure}, opacity {Abnormally opaque structure}, lung bases {Structure of base of lung}, atelectasis {Atelectasis}, stable {Patient's condition stable}, eventration {Eventration}, right hemidiaphragm {Structure of right hemidiaphragm}, left lung {Left lung structure}, infectious process {Infectious disease}, calcification of the 
aortic knob {Aortic valve calcification}, aorta {Aortic structure}, Heart {Heart structure}, left atrium {Left atrial structure}, pleural effusion {Pleural effusion}, pneumothorax {Pneumothorax}, opacities {Abnormally opaque structure}, the left lung base {Structure of base of left lung}, pneumonia {Pneumonia}, aspiration {Aspiration pneumonia}, intracranial hemorrhage {Intracranial hemorrhage}, edema {Edema}, mass {Mass}, mass {Mass}, Periventricular white matter {Structure of periventricular white matter}, chronic {Chronic disease}, small vessel {Structure of small blood vessel (organ)}, ischemic {Ischemia}, ventricles {Brain ventricle structure}, Soft tissues of the orbits {Structure of soft tissues of orbit}, nasopharynx {Nasopharyngeal structure}, paranasal sinuses {Nasal sinus structure}, and mastoid air cells {Structure of mastoid cell}, fractures {Fracture}, intracranial {Intracranial structure}, acute hemorrhage {Acute hemorrhage}, Hematocrit {Hematocrit determination}, Platelets {Platelet}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
#) Altered mental status: Initially concerning for stroke or 
bleed given history of anticoagulation and recent fall (though 
denied hitting head), however head CT did not demonstrate any 
bleed. Neurology was consulted in the emergency room and 
evaluated the patient. Based on his fever and chest x-ray 
findings, it was felt that his symptoms represented metabolic 
encephalopathy secondary to his febrile infection.
His mental status improved during his admission, and his 
neurologic examination remained non-focal.
<br>
#) Fever: Urine analysis not consistent with urinary tract 
infection, with culture negative for 24 hours. Chest x-ray was 
concerning for pneumonia at the left base. No other localizing 
symptoms or findings on examination. Patient was given 
ceftriaxone and azithromycin in the emergency room along with 
acetaminophen. He remained afebrile after that time, without any 
leukocytosis.
- He should continue azithromycin for 2 more days, and 
cefpodoxine 200 mg Q12 hours for 4 additional days.
- Blood cultures were pending at time of discharge, but were 
negative. Final cultures should be followed up from 
rehabilitation.
<br>
#) Atrial fibrillation: Patient's INR was elevated at time of 
admission, so his warfarin was held. He is not on any 
rate-controlling agents at home and had good rate control (high 
40's to 60's) during his admission.
- His INR should be check day after discharge, and warfarin 
resumed and adjusted accordingly.
<br>
#) Hypertension: His blood pressure medications were held 
initially to monitor for any hypotension given altered mental 
status and febrile state, they were resumed day of discharge 
when his systolic pressure was 160 in the morning.
<br>
#) Hyperlipidemia: Continue pravastatin
<br>
#) Renal insufficiency: Baseline values in our system are 
varied, 1.1-1.3 or 1.4. FeUrea was 36%, which was on the cut-off 
for being consistent with pre-renal etiology. His function 
remained stable slightly above baseline at 1.4-1.5 during 
admission. He was encouarged to take PO's during his first day, 
and his home medications werer re-started on day two. Given 
small blood seen in urine analysis, CK was checked to evaluate 
for rhabdomyolysis, which was 308.
<br>
#) Anemia: Patient had mild normocytic anemia during his stay. 
Iron studies, B-12, and folate were pending at time of discharge 
and may be followed up on an outpatient basis.
<br>
#) Diabetes Mellitus: Patient's blood sugars were mildly 
elevated during his admission (100-120's), but he was not 
treated, as wished to avoid hypoglycemia.
<br>
#) Osteoporosis: Continued vitamin D, calcium, and alendronate.
<br>
#) Status-post fall earlier in week: Patient was evaluated by 
physical therapy, who felt a short stay at rehabilitation was 
appropriate.

 

###RESPONSE: Altered mental status {Altered mental status}, stroke {Cerebrovascular accident}, bleed {Bleeding}, anticoagulation {Anticoagulant therapy}, fall {Falls}, head {Head structure}, head CT {Computed tomography of head}, bleed {Hemorrhage}, fever {Fever}, chest x-ray {Plain chest X-ray}, metabolic 
encephalopathy {Metabolic encephalopathy}, febrile {Fever}, infection {Infectious disease}, mental status {Mental state finding}, improved {Patient's condition improved}, neurologic examination {Neurological examination}, Fever {Fever}, Urine analysis {Urinalysis}, urinary tract 
infection {Urinary tract infectious disease}, culture {Urine culture}, Chest x-ray {Plain chest X-ray}, pneumonia {Pneumonia}, left base {Structure of base of left lung}, leukocytosis {Leukocytosis}, Blood cultures {Blood culture}, cultures {Microbial culture}, rehabilitation {Rehabilitation therapy}, Atrial fibrillation {Atrial fibrillation}, Hypertension {Hypertensive disorder, systemic arterial}, hypotension {Low blood pressure}, altered mental 
status {Altered mental status}, febrile {Fever}, Hyperlipidemia {Hyperlipidemia}, Renal insufficiency {Renal insufficiency}, Baseline {Baseline state}, rhabdomyolysis {Rhabdomyolysis}, Anemia {Anemia}, normocytic anemia {Normocytic anemia}, Diabetes Mellitus {Diabetes mellitus}, hypoglycemia {Hypoglycemia}, Osteoporosis {Osteoporosis}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Alendronate 70mg PO Q week  
Pravastatin 20mg PO daily  
Spironolactore-HCTZ 25mg-25mg PO daily  
Warfarin 1.25mg PO Daily  
Calcium/Vitamin D  
Colace 100mg PO BID  

 
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) 
Tablet PO DAILY (Daily).  
2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
3. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
4. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve 
(12) hours for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
5. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.  

6. Calcium Carbonate-Vit D3-Min 600-400 mg-unit Tablet Sig: One 
(1) Tablet PO twice a day.  
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
8. Aldactazide ___ mg Tablet Sig: One (1) Tablet PO once a 
day.  

 

###RESPONSE: mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Primary diagnosis:
- Pneumonia
Secondary diagnoses:
- Atrial fibrillation
- Hypertension
- Hyperlipidemia
- History of prostate cancer

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 

###RESPONSE: Pneumonia {Pneumonia}, Atrial fibrillation {Atrial fibrillation}, Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, prostate cancer {Carcinoma of prostate}, Mental Status {Mental state finding}, Level of Consciousness {Finding of level of consciousness}, Alert {Mentally alert}, Ambulatory - requires assistance or aid {Finding of walking aid use}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted for concern over word-finding difficulties and 
changes in your speech. After evaluation, it was found that you 
had a pneumonia, and it was likely that the fevers were 
contributing to the changes in your mental status.

We have made the following changes to your medications:
- STARTED an antibiotic called Cefpodoxine 200 mg every 12 hours 
for 4 days
- STARTED an antibiotic called Azithromycin 250 mg daily for 2 
days

No other changes were made to your medications.
 

###RESPONSE: word-finding difficulties {Word finding difficulty}, evaluation {Evaluation procedure}, pneumonia {Pneumonia}, fevers {Fever}, mental status {Mental state finding}, antibiotic {Antibiotic therapy}, antibiotic {Antibiotic therapy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
R knee pain
 
Major Surgical or Invasive Procedure:
R patellar tendon rupture

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, knee pain {Pain of knee region}, R patellar tendon rupture {Traumatic rupture of right patellar tendon}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
He was playing softball 1 hour prior to his presentation to the
emergency department, he was jogging slowly, turning suddenly 
and
felt a pop.  He felt immediate pain in his knee and fell to the
ground but did not hit his head or lose consciousness.

He is unable to move his knee afterwards actively.
 

###RESPONSE: emergency {Emergency treatment management}, pain in his knee {Pain of knee region}, fell {Falls}, head {Head structure}, lose consciousness {Loss of consciousness}, unable to move his knee {No knee movement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
none
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
none
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Gen:NAD
RLE: dressing c/d/I
knee immobilizer in place
fires ___
foot WWP
 

###RESPONSE: Gen {General examination of patient}, NAD {No abnormality detected}, RLE {Structure of right lower limb}, dressing {Application of dressing}, knee immobilizer {Application of knee immobilizer}, in place {Device in situ}, foot {Foot structure}, WWP {Normal tissue perfusion}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 05:15AM BLOOD WBC-8.0 RBC-4.35* Hgb-13.2* Hct-39.5* 
MCV-91 MCH-30.3 MCHC-33.4 RDW-12.7 RDWSD-41.5 Plt ___
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 presented to the emergency department and was 
evaluated by the orthopedic surgery team. The patient was found 
to have a R patellar tendon rupture and was admitted to the 
orthopedic surgery service. The patient was taken to the 
operating room on ___ for R patellar tendon repair, which 
the patient tolerated well. For full details of the procedure 
please see the separately dictated operative report. The patient 
was taken from the OR to the PACU in stable condition and after 
satisfactory recovery from anesthesia was transferred to the 
floor. The patient was initially given IV fluids and IV pain 
medications, and progressed to a regular diet and oral 
medications by POD#1. The patient was given ___ 
antibiotics and anticoagulation per routine. The patient's home 
medications were continued throughout this hospitalization. The 
patient worked with ___ who determined that discharge to home was 
appropriate. The ___ hospital course was otherwise 
unremarkable.

At the time of discharge the patient's pain was well controlled 
with oral medications, incisions were clean/dry/intact, and the 
patient was voiding/moving bowels spontaneously. The patient is 
weight bearing as tolerated in the right lower extremity, and 
will be discharged on aspirin for DVT prophylaxis. The patient 
will follow up with Dr. ___ routine. A thorough 
discussion was had with the patient regarding the diagnosis and 
expected post-discharge course including reasons to call the 
office or return to the hospital, and all questions were 
answered. The patient was also given written instructions 
concerning precautionary instructions and the appropriate 
follow-up care. The patient expressed readiness for discharge.
 

###RESPONSE: emergency {Emergency treatment management}, evaluated by the orthopedic surgery team {Orthopedic assessment}, patellar tendon rupture {Rupture of patellar tendon}, admitted to the 
orthopedic surgery service {Admission by orthopedic surgeon}, patellar tendon repair {Repair of patellar tendon}, procedure {Procedure}, PACU {Postanesthesia care}, stable condition {Patient's condition stable}, anesthesia {Administration of general anesthetic}, given IV fluids {Administration of intravenous fluids}, IV {Intravenous therapy}, pain 
medications {Administration of analgesic}, regular diet {Normal diet}, oral 
medications {Administration of drug or medicament via oral route}, antibiotics {Antibiotic therapy}, anticoagulation {Anticoagulant therapy}, unremarkable {No abnormality detected}, pain was well controlled 
with oral medications {Demonstrates adequate pain control with oral analgesics}, incisions {Incision}, clean/dry/intact {Wound healing well}, voiding {Normal micturition}, moving bowels spontaneously {Normal bowel habits}, weight bearing {Weight-bearing}, right lower extremity {Structure of right lower limb}, aspirin {Administration of aspirin}, DVT prophylaxis {Prevention of deep vein thrombosis}, follow up {Follow-up arranged}, discussion {Patient education}, call the 
office {Recommendation regarding contacting someone}, instructions {Patient education}, instructions {Patient education}, follow-up care {Postoperative procedure education}, readiness for discharge {Ready for discharge}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
None. 
 
Discharge Medications:
1.  Acetaminophen 1000 mg PO Q8H  
2.  Aspirin 325 mg PO DAILY 
RX *aspirin 325 mg 1 (One) tablet(s) by mouth once a day Disp 
#*30 Tablet Refills:*0 
3.  Docusate Sodium 100 mg PO BID  
4.  OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - 
Moderate 
RX *oxycodone 5 mg ___ capsule(s) by mouth every three to six 
hours Disp #*25 Capsule Refills:*0 
5.Outpatient Physical Therapy
WBAT RLE in ___ brace locked in extension. Evaluate and 
treat. 
6.Crutches
Diagnosis: right patellar tendon rupture
Prognosis: good
Length of need: 13 months

 

###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:
R patellar tendon rupture

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: R patellar tendon rupture {Traumatic rupture of right patellar tendon}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:

###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 Instructions:

INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:

- You were in the hospital for orthopedic surgery. It is normal 
to feel tired or ""washed out"" after surgery, and this feeling 
should improve over the first few days to week. 
- Resume your regular activities as tolerated, but please follow 
your weight bearing precautions strictly at all times.

ACTIVITY AND WEIGHT BEARING:
- WBAT RLE locked in extension in ___ brace

MEDICATIONS:
  1)  Take Tylenol ___ every 6 hours around the clock. This is 
an over the counter medication.
  2)  Add  *** as needed for increased pain. Aim to wean off 
this medication in 1 week or sooner.  This is an example on how 
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days, 
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.  
Then continue with Tylenol for pain.
  3)  Do not stop the Tylenol until you are off of the narcotic 
medication.
  4)  Per state regulations, we are limited in the amount of 
narcotics we can prescribe. If you require more, you must 
contact the office to set up an appointment because we cannot 
refill this type of pain medication over the phone. 
  5)  Narcotic pain relievers can cause constipation, so you 
should drink eight 8oz glasses of water daily and continue 
following the bowel regimen as stated on your medication 
prescription list. These meds (senna, colace, miralax) are over 
the counter and may be obtained at any pharmacy.
  6)  Do not drink alcohol, drive a motor vehicle, or operate 
machinery while taking narcotic pain relievers.
  7)  Please take all medications as prescribed by your 
physicians at discharge.
  8)  Continue all home medications unless specifically 
instructed to stop by your surgeon.
      
ANTICOAGULATION:
- Please take aspirin 81 mg daily for 4 weeks

WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken 
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If 
draining, you may apply a gauze dressing secured with paper 
tape.
- Splint must be left on until follow up appointment unless 
otherwise instructed.
- Do NOT get splint wet.

DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the 
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning 
changes in your incision
- Persistent or increasing numbness, tingling, or loss of 
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid, 
medications down
- Any other medical concerns

FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___. 
You will have follow up with ___, NP in the 
Orthopaedic Trauma Clinic 14 days post-operation for evaluation. 
Call ___ to schedule appointment upon discharge.

Please follow up with your primary care doctor regarding this 
admission within ___ weeks and for any new medications/refills.

Please follow up with your primary care doctor regarding this 
admission within ___ weeks and for and any new 
medications/refills.

Physical Therapy:
WBAT locked in extension
Treatments Frequency:
Any staples or superficial sutures you have are to remain in 
place for at least 2 weeks postoperatively.  Incision may be 
left open to air unless actively draining.  If draining, you may 
apply a gauze dressing secured with paper tape.  You may shower 
and allow water to run over the wound, but please refrain from 
bathing for at least 4 weeks postoperatively.

 

###RESPONSE: orthopedic surgery {Operation on musculoskeletal system}, tired {Tired}, washed out {Exhaustion}, after surgery {Postoperative state}, activities as tolerated {Education about increasing activity tolerance}, weight bearing {Weight-bearing}, precautions {Safety precautions}, WBAT {Weight-bearing gait training}, RLE {Structure of right lower limb}, increased pain {Increased pain}, medication {Administration of drug or medicament}, Tylenol {Administration of analgesic}, for pain {Pain relief}, Do not stop the Tylenol until you are off of the narcotic 
medication {Narcotics education}, narcotics {Narcotherapy}, pain medication {Administration of analgesic}, Narcotic pain relievers can cause {Narcotics education}, constipation {Constipation}, bowel regimen {Bowel care}, medication 
prescription {Prescription of drug}, meds {Administration of drug or medicament}, senna, colace {Administration of laxative}, Do not drink alcohol {Education about alcohol consumption}, drive a motor vehicle {Unable to drive a car}, while taking narcotic pain relievers {Narcotics education}, Please take all medications as prescribed {Patient medication education}, medications {Administration of drug or medicament}, may shower {Wound treatment education}, stitches {Removal of suture}, staples that need to be removed {Removal of staples}, Incision {Surgical incision wound}, draining {Wound discharge}, draining {Wound discharge}, apply a gauze dressing {Application of dressing}, Splint {Application of splint}, PCP {Primary care management}, return to the 
emergency {Emergency treatment education}, Increasing pain {Increased pain}, pain medications {Administration of analgesic}, Increasing {Patient's condition worsened}, redness {Redness of skin over lesion}, swelling {Swelling}, drainage {Wound discharge}, incision {Surgical incision wound}, increasing {Patient's condition worsened}, numbness, tingling {Numbness and tingling sensation of skin}, loss of 
sensation {Numbness}, Fever {Fever}, Shaking {Tremor}, chills {Chill}, Chest pain {Chest pain}, Shortness of breath {Dyspnea}, Nausea {Nausea}, vomiting {Vomiting}, inability to keep food {Unable to eat}, liquid {Unable to drink}, medications {Administration of drug or medicament}, post-operation {Postoperative state}, evaluation {Evaluation procedure}, primary care {Primary care management}, new medications {New medication commenced}, primary care {Primary care management}, new 
medications {New medication commenced}, WBAT {Weight-bearing gait training}, staples {Closure by staple}, sutures {Closure by suture}, in 
place {Device in situ}, postoperatively {Postoperative state}, Incision {Surgical incision wound}, draining {Wound discharge}, draining {Wound discharge}, apply a gauze dressing {Application of dressing}, may shower {Wound treatment education}, water to run over the wound {Irrigation of wound}, postoperatively {Postoperative state}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
Dyspnea
 
Major Surgical or Invasive Procedure:
___ cardioversion - ___

 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Dyspnea {Dyspnea}, cardioversion {Cardioversion}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 AFib s/p DCCV ___ on apixaban, bicuspid aortic 
valve with mild AS, hyperlipidemia, OSA on CPAP, sarcoidosis, 
presents with dyspnea, AFib with RVR, acute CHF.  
 ___ was recently admitted in ___ for AFib with RVR. ___ was 
treated with IV diltiazem and transitioned to oral agents. ___ 
was given Lasix 20 IV for mild volume overload. ___ had sinus 
pauses on telemetry thought to be due to OSA. ___ was started on 
apixaban for anticoagulation. On ___, ___ had elective ___ 
with successful electrical cardioversion of atrial fibrillation 
to sinus rhythm.  
 ___ was seen by Dr. ___ on ___. The patient was noticed 
to be in acute heart failure but the patient strongly preferred 
outpatient treatment and so his torsemide dose was increased 
from 40mg to 120mg. ___ had some success with this and lost 14 
lbs. ___ uses 3 pillows at baseline and has recent PND. Over past 
day, ___ developed increasing dyspnea on exertion. ___ presented 
to ___ ED, BNP was ___, troponin negative, and ___ was 
transferred here.  
 In the ED, initial vital signs were: 98.3 100 ___ 95% RA  

 - Labs were notable for: WBC stable. K 3.2. Mg 1.8. BUN/Cr 
___. TnT neg. BNP 1317 (prior ___)  
 - Imaging: OSH CXR R hilar adenopathy, mild R basilar 
patchiness, no significant change from prior CXR ___  
 - The patient was given:  
 ___ 21:48 PO/NG Apixaban 5 mg  
 ___ 23:57 IV Furosemide 80 mg  
 - Consults: Atrius Cards- admit  
 Upon arrival to the floor, patient has no complaints.  
 ROS per HPI otherwise negative in 14-point review. 
 

###RESPONSE: AFib {Atrial fibrillation}, DCCV {Direct current cardioversion}, bicuspid aortic 
valve {Bicuspid aortic valve}, hyperlipidemia {Hyperlipidemia}, OSA {Obstructive sleep apnea syndrome}, sarcoidosis {Sarcoidosis}, dyspnea {Dyspnea}, AFib with RVR {Atrial fibrillation with rapid ventricular response}, AFib with RVR {Atrial fibrillation with rapid ventricular response}, IV {Intravenous therapy}, IV {Intravenous therapy}, sinus 
pauses {Sinus arrest}, telemetry {Electroencephalogram telemetry}, OSA {Obstructive sleep apnea syndrome}, anticoagulation {Anticoagulant therapy}, electrical cardioversion {Direct current cardioversion}, atrial fibrillation {Atrial fibrillation}, sinus rhythm {Sinus rhythm}, acute heart failure {Acute heart failure}, baseline {Baseline state}, dyspnea on exertion {Dyspnea on exertion}, vital signs {Vital signs finding}, RA {Breathing room air}, stable {Patient's condition stable}, Imaging {Imaging}, CXR {Plain chest X-ray}, hilar adenopathy {Hilar lymphadenopathy}, CXR {Plain chest X-ray}, IV {Intravenous therapy}, no complaints {No complaints}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Venous stasis  
A-fib s/p cardioversion in ___  
OSA (obstructive sleep apnea) on cpap  
Lymphadenopathy  
Hypertension  
Aortic stenosis, mild  
ED (erectile dysfunction)  
Hyperlipidemia  
Mediastinal adenopathy - found to have sarcoid ___ 
 

###RESPONSE: Venous stasis {Venous stasis}, A-fib {Atrial fibrillation}, cardioversion {Cardioversion}, OSA (obstructive sleep apnea {Obstructive sleep apnea syndrome}, Lymphadenopathy {Lymphadenopathy}, Hypertension {Hypertensive disorder, systemic arterial}, Aortic stenosis {Aortic valve stenosis}, erectile dysfunction {Erectile dysfunction}, Hyperlipidemia {Hyperlipidemia}, Mediastinal {Mediastinal structure}, adenopathy {Lymphadenopathy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Father died at ___ getting CABG  
Twin brothers died from alpha 1 antitrypsin
 

###RESPONSE: died {Dead}, CABG {Coronary artery bypass grafting}, 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:
VITALS: T98.1 ___ 21 96RA 153.5kg  
 GEN: Morbidly obese middle aged male in no distress  
 NECK: JVP not visible due to thick neck  
 HEART: Irreg irreg, normal S1 S2, no murmurs  
 LUNGS: Basilar crackles  
 ABD: Soft, NT, mildly distended, normal BS  
 EXT: 3+ edema to calves bilaterally, 2+ DP and ___ pulses  

DISCHARGE PHYSICAL EXAM:

VS: T97.8 103/82-128/83  ___ 98RA and CPAP
I/O: 8hr: ___ 24hr: 1320/3350
Weight: 153.5-> 150.2 -> 150-> 149.3->149.4
GEN: Morbidly obese middle aged male in no distress , sitting in 
recliner chair 
NECK: JVP difficult to assess w thick neck
 HEART: Distant heart sounds, regular, no murmurs  
 LUNGS: CTAB, no wheezes, crackles, rhonchi
 ABD: Soft, NT, mildly distended, normal BS  
 EXT: 1+ edema to knees bilaterally, 2+ DP pulses, R foot 
minimal erythema of R MTP, improved
 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, VITALS {Vital signs finding}, RA {Breathing room air}, GEN {General examination of patient}, Morbidly obese {Morbid obesity}, distress {Distress}, NECK {Physical examination procedure}, JVP {Finding of jugular venous pressure}, neck {Neck structure}, HEART {Cardiovascular physical examination}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, LUNGS {Examination of respiratory system}, crackles {Respiratory crackles}, ABD {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, distended {Swollen abdomen}, BS {Normal bowel sounds}, EXT {Examination of limb}, edema {Edema}, 2+ DP and ___ pulses {All pulses present in bilateral lower limbs}, RA {Breathing room air}, GEN {General examination of patient}, Morbidly obese {Morbid obesity}, distress {Distress}, sitting {Sitting position}, NECK {Physical examination procedure}, neck {Neck structure}, HEART {Cardiovascular physical examination}, Distant heart sounds {Heart sounds diminished}, murmurs {Murmur}, LUNGS {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, crackles {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, ABD {Examination of abdomen}, Soft {Abdomen soft}, BS {Normal bowel sounds}, EXT {Examination of limb}, edema {Edema}, knees {Knee region structure}, 2+ DP pulses {All pulses present in bilateral lower limbs}, foot {Foot structure}, erythema {Erythema}, 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: Pertinent Results:
ADMISSION LABS:
___ 09:45PM BLOOD WBC-7.3 RBC-4.48* Hgb-13.5* Hct-40.6 
MCV-91 MCH-30.1 MCHC-33.3 RDW-14.7 RDWSD-48.3* Plt ___
___ 09:45PM BLOOD Glucose-94 UreaN-15 Creat-0.8 Na-137 
K-3.2* Cl-96 HCO3-28 AnGap-16
___ 09:45PM BLOOD ___ PTT-34.1 ___
___ 06:30AM BLOOD ALT-18 AST-20 AlkPhos-56 TotBili-0.8
___ 09:45PM BLOOD proBNP-1317*
___ 09:45PM BLOOD cTropnT-<0.01
___ 06:30AM BLOOD cTropnT-<0.01
___ 09:45PM BLOOD Calcium-9.2 Phos-3.6 Mg-1.8
___ 09:51PM BLOOD Lactate-1.3

DISCHARGE LABS:

___ 01:40PM BLOOD WBC-6.8 RBC-4.50* Hgb-13.4* Hct-41.5 
MCV-92 MCH-29.8 MCHC-32.3 RDW-14.5 RDWSD-49.0* Plt ___
___ 03:04PM BLOOD ___
___ 01:40PM BLOOD Glucose-113* UreaN-22* Creat-0.9 Na-133 
K-4.1 Cl-95* HCO3-26 AnGap-16
___ 01:40PM BLOOD Calcium-9.2 Phos-3.7 Mg-2.2

MICRO

IMAGING:

___ CXR:
 
Limited exam for which repeat is suggested for more detailed 
evaluation.  
Enlarged right hilum could be due to pulmonary artery 
enlargement or 
underlying adenopathy and attention suggested on followup. 

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, 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}, PTT {Partial thromboplastin time, activated}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, cTropnT {Troponin T cardiac 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}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, evaluation {Evaluation procedure}, pulmonary artery {Pulmonary artery structure}, enlargement {Enlargement}, adenopathy {Lymphadenopathy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 AFib s/p DCCV ___ on apixaban, bicuspid aortic 
valve with mild AS, hyperlipidemia, OSA on CPAP, sarcoidosis, 
presents with dyspnea, AFib with RVR, acute CHF. 

 # Afib with RVR. Symptomatic, up to 150s day of admission, 
started on sotalol with good effect in the hospital where QTc 
prolongation was monitored. Cardioversion performed ___ with 
return to sinus rhythm. Discharged on sotalol 160mg BID and 
apixaban due to h/o ___ clot in ___. Diltiazem was stopped 
because of conversion to sinus and presence of sotalol.  

 # Acute on chronic systolic and diastolic heart failure: Cause 
of acute decompensation is likely from tachycardia-induced 
cardiomyopathy given AF with RVR. Recent outpatient TTE with 
impaired EF down to ___ with moderate global hypokinesis, 
mild AS, mild MR. ___ was found to be in acute heart failure in 
outpatient setting, and failed outpatient trial of increased 
torsemide (from 40 to 120mg daily). Good diuresis on Lasix so 
discharged on Lasix 40mg BID. Potassium levels stable at this 
dose. Weight at discharge 149.4kg, which should be approximate 
dry weight. Started on spironolactone 25mg, lisinopril 2.5mg. 
Recommended low salt diet with 2000mL fluid restriction daily 
and f/u with cardiology and PCP.
   
#acute gouty flare: Describes having gout one previously. 
Morning of ___ complaining of R ""foot"" pain. R first MTP 
joint erythematous and swollen, tender to light touch. Given 
that ___ is anti-coagulated, colchicine is preferred first line 
treatment. Given 1.8mg day one and one week of 0.6mg 
prophylaxis.

# Elevated INR: Admission INR 1.6, increased from previous 
admission in ___, where INR was 1.3-1.4.  Likely from 
apixaban (can increase INR, though not predictable increases). 
 
 # OSA on CPAP. History of some sinus pauses during last 
admission, used CPAP well during admission.  
 

 

###RESPONSE: AFib {Atrial fibrillation}, DCCV {Direct current cardioversion}, bicuspid aortic 
valve {Bicuspid aortic valve}, hyperlipidemia {Hyperlipidemia}, OSA {Obstructive sleep apnea syndrome}, sarcoidosis {Sarcoidosis}, dyspnea {Dyspnea}, AFib with RVR {Atrial fibrillation with rapid ventricular response}, Afib with RVR {Atrial fibrillation with rapid ventricular response}, Cardioversion {Cardioversion}, sinus rhythm {Sinus rhythm}, clot {Blood clot}, sinus {Sinus rhythm}, chronic systolic and diastolic heart failure {Acute on chronic combined systolic and diastolic heart failure}, decompensation {Decompensation}, tachycardia-induced 
cardiomyopathy {Tachycardia-induced cardiomyopathy}, AF with RVR {Atrial fibrillation with rapid ventricular response}, TTE {Transthoracic echocardiography}, hypokinesis {Hypokinesis of cardiac wall}, MR {Mitral valve regurgitation}, acute heart failure {Acute heart failure}, diuresis {Diuresis}, Potassium levels {Finding of potassium level}, low salt diet {Low sodium diet}, fluid restriction {Fluid restriction}, PCP {Primary care management}, gout {Inflammatory disorder due to increased blood urate level}, foot"" pain {Foot pain}, joint {Joint structure}, erythematous {Erythema}, tender {Tenderness}, first line 
treatment {First line treatment}, prophylaxis {Preventive procedure}, OSA {Obstructive sleep apnea syndrome}, sinus {Sinus arrest}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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. Apixaban 5 mg PO BID 
2. Sildenafil 20 mg PO DAILY:PRN ED 
3. Diltiazem 90 mg PO TID 
4. Torsemide 120 mg PO DAILY 

 
Discharge Medications:
1. Apixaban 5 mg PO BID 
2. Colchicine 0.6 mg PO ONCE Duration: 1 Dose 
Take for one week. 
RX *colchicine 0.6 mg 1 capsule(s) by mouth daily Disp #*10 
Capsule Refills:*0
3. Furosemide 40 mg PO BID 
Can take in the morning and mid-day. 
RX *furosemide 40 mg 1 tablet(s) by mouth twice daily Disp #*60 
Tablet Refills:*0
4. Lisinopril 2.5 mg PO DAILY 
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30 
Tablet Refills:*0
5. Sotalol 160 mg PO BID 
RX *sotalol [Betapace] 160 mg 1 tablet(s) by mouth twice daily 
Disp #*60 Tablet Refills:*0
6. Spironolactone 25 mg PO DAILY 
RX *spironolactone [Aldactone] 25 mg 1 tablet(s) by mouth daily 
Disp #*30 Tablet Refills:*0
7. Sildenafil 20 mg PO DAILY:PRN ED 

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Atrial fibrillation with RVR
Acute on chronic systolic and diastolic heart failure (rEF with 
diastolic dysfunction)
Acute gouty flare

SECONDARY DIAGNOSES:
OSA on CPAP

 
Discharge Condition:
Discharge condition stable.
AOx3
Able to ambulate safely independently.

 

###RESPONSE: Atrial fibrillation with RVR {Atrial fibrillation with rapid ventricular response}, Acute on chronic systolic and diastolic heart failure {Acute on chronic combined systolic and diastolic heart failure}, diastolic dysfunction {Diastolic dysfunction}, OSA {Obstructive sleep apnea syndrome}, stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___,

You came to the hospital because your heart was beating very 
fast and in an irregular rhythm. This is called atrial 
fibrillation (""A-fib"") with rapid ventricular response. We 
started you on a medication to help control the rhythm, called 
sotalol, and performed a procedure to stop the afib (this 
procedure is cardioversion).

You will need to keep taking the sotalol twice daily at home. 
You will stop the diltiazem you were taking, as well as the 
torsemide. You will keep taking the apixiban for blood thinner. 
You will also start Lasix twice daily, spironolactone daily and 
lisinopril daily.

New meds
==========
sotalol 160mg twice daily
Lasix 40mg twice daily
lisinopril 2.5mg daily
spironolactone 25mg daily

Stop taking these medications
=============================
diltiazem
torsemide

Keep taking these medications
================================
apixiban 

You will follow up with Dr. ___ in ___. They are making 
the appointment for you and you should be contacted.

Be Well,
your ___ team

 

###RESPONSE: heart {Heart structure}, irregular {Irregular heart beat}, atrial 
fibrillation {Atrial fibrillation}, A-fib {Atrial fibrillation}, procedure {Procedure}, afib {Atrial fibrillation}, procedure {Procedure}, cardioversion {Cardioversion}, follow up {Follow-up arranged}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   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: 
Zocor
 
Attending: ___.
 
Chief Complaint:
L leg swelling and pain
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: L leg swelling {Localized swelling of left lower leg}, pain {Pain in 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: History of Present Illness:
___ y/o M with PMHx of metastatic melanoma s/p resection of
abdominal mass, axillary LN dissection, resection of R frontal
mass with Nsurg, on immunotherapy - most recently nivolumab 
(C8D1
___, Afib not on AC, PUD with prior GI bleed x2 (___), PE
s/p IVC filter ___, gastric bypass ___, hypothyroidism,
adrenal insufficiency who presents from US appointment with new
LLE DVT. 

Pt states he has been noticing swelling, and increased pain in
the LLE for the past week. No numbness/tingling. Eventually
scheduled US appt and was told to go immediately to an ED after
they found the DVT on exam. Has been feeling weak for the past
few weeks as well and felt unsteady earlier today. 

In the ED,
- Initial vitals:  T97.2, HR 85, BP 154/100, RR 16, O2 sat 98% 
RA

- Exam notable for:  
Ext: LLE slightly larger compared to R, slight calf tenderness 
in
both legs, slight TTP in L thigh, L foot more edematous compared
to R, DP pulse intact b/l, LLE also with bandage, skin 
underneath
erythematous and edematous
Neuro: sensation intact in ___ b/l, no focal neuro deficits
appreciated
- Labs notable for: WBC 10.7 with 79% PMNs, Hgb 12, MCV 103
- Imaging notable for:  
___ US
IMPRESSION:
Deep venous thrombosis involving the distal left femoral vein 
and
extending into the left common femoral vein. There is no 
evidence
of thrombus in the right common femoral vein. The patient has an
IVC filter.

- Pt was given:  
___ IV CeFAZolin 1 g
___ PO Omeprazole 20 mg B
___ PO/NG Dexamethasone 2 mg 
___ PO/NG Levothyroxine Sodium 75 mcg  
___ PO/NG Digoxin .125 mg  
___ PO/NG Codeine Sulfate 15 mg 
___ PO/NG Torsemide 10 mg 
___ IV CeFAZolin 1 g  
___ PO/NG Codeine Sulfate 15 mg 
___ PO/NG Rivaroxaban 15 mg 

- Vitals prior to transfer: T 99.1, HR 84, BP 135/80, RR 16, O2
sat 99% RA.

Upon arrival to the floor, the patient shares that he has been
feeling weak and sustained a fall a couple weeks ago, and has
been sitting and sleeping on the couch most of the time since
then. He also recalls feeling lightheaded when getting up once 
in
the past week. He confirms that he first notice left leg 
swelling
one week ago. He recalls taking an anticoagulation pill in the
past that was not warfarin (cannot remember name), but stopped
after having GI bleeds a few years ago. He has not had any 
recent
bloody or dark stools. Denies fever/chills, N/V, CP, SOB,
pleuritic chest pain, pain with deep breathing. No dysuria or
current GI complaints. 
 

 

###RESPONSE: metastatic melanoma {Metastatic malignant melanoma}, resection {Excision}, abdominal mass {Abdominal mass}, axillary LN dissection {Excision of axillary lymph node}, resection {Excision}, R frontal {Right frontal lobe structure}, mass {Mass}, immunotherapy {Immunotherapy}, Afib {Atrial fibrillation}, PUD {Peptic ulcer}, GI bleed {Gastrointestinal hemorrhage}, PE {Pulmonary embolism}, IVC filter {Inferior vena cava filter in situ}, gastric bypass {Bypass of stomach}, hypothyroidism {Hypothyroidism}, adrenal insufficiency {Adrenal cortical hypofunction}, US {Ultrasonography}, LLE {Structure of left lower limb}, DVT {Deep venous thrombosis}, swelling {Swelling}, increased pain {Increased pain}, LLE {Structure of left lower limb}, numbness/tingling {Numbness and tingling sensation of skin}, US {Ultrasonography}, DVT {Deep venous thrombosis}, exam {Physical examination procedure}, feeling weak {Asthenia}, vitals {Vital signs finding}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, Exam {Physical examination procedure}, Ext {Examination of limb}, LLE {Structure of left lower limb}, larger {Increased size}, R {Structure of right lower limb}, calf tenderness {Pain in calf}, both legs {Both lower legs}, TTP {Tenderness}, L thigh {Structure of left thigh}, L foot {Structure of left foot}, edematous {Edema}, R {Structure of right foot}, DP pulse intact {Dorsalis pulse present}, LLE {Structure of left lower limb}, skin 
underneath
erythematous {Erythema of skin}, edematous {Edematous skin}, Neuro {Neurological examination}, sensation intact {Normal sensation}, neuro deficits {Neurological deficit}, Labs {Laboratory test}, WBC {White blood cell count}, MCV {Erythrocyte mean corpuscular volume determination}, Imaging {Imaging}, US {Ultrasonography}, Deep venous thrombosis {Deep venous thrombosis}, left femoral vein {Structure of left femoral vein}, common femoral vein {Common femoral vein structure}, no 
evidence {No abnormality detected}, thrombus {Thrombus}, right common femoral vein {Structure of right femoral vein}, IVC filter {Inferior vena cava filter in situ}, Vitals {Vital signs finding}, O2
sat {Oxygen saturation measurement}, RA {Breathing room air}, feeling weak {Asthenia}, fall {Falls}, sitting and sleeping on the couch {Semi-recumbent position}, lightheaded {Lightheadedness}, left leg 
swelling {Localized swelling of left lower limb}, anticoagulation {Anticoagulant therapy}, warfarin {Warfarin therapy}, GI bleeds {Gastrointestinal hemorrhage}, bloody {Hematochezia}, dark stools {Dark stools}, fever {Fever}, chills {Chill}, N/V {Nausea and vomiting}, CP {Chest pain}, SOB {Dyspnea}, pleuritic chest pain {Pleuritic pain}, pain with deep breathing {Chest pain on breathing}, dysuria {Dysuria}, GI complaints {Gastrointestinal symptom}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
ONCOLOGIC HISTORY:
Mr. ___ noted a ""blood blister"" on his abdomen many years 
ago
which resolved on its own.  Then, approximately a year prior to
presentation, this started to grow again and bled occasionally.
He was referred by his PCP to dermatology where he saw ___, NP, on ___ with a 2 x 2
centimeter inflamed plaque with a central ulcer on the right
abdomen noted.  Biopsy revealed nodular melanoma, present at
peripheral and deep margins, at least 7.5 mm deep, at least
___ level 4, ulcerated, 29 mitoses per millimeter squared,
absent lymphovascular and perineural invasion on the original
pathology though the specimen was reviewed in our cutaneous
oncology conference and felt to show lymphovascular invasion. 
The patient was referred here for further management.  He went 
on
to have a wide local excision and sentinel lymph node biopsy on
___.  This showed residual melanoma to 11 mm depth, 
2
of 6 recovered lymph nodes with micrometastases.

Initial staging scans on ___ revealed metastatic disease 
in
the left arm, right peritoneum, right adrenal, and left
infrahilar lymph node consistent with metastatic disease.  Brain
MRI showed no CNS metastases.  He underwent FNA of the left arm
nodule on ___ by Dr. ___ melanoma. 

Admitted to ___ with worsening SOB on ___, found 
to
have a PE, put on anticoagulation but developed abdominal wall
hematoma so, IVC filter placed. He has a history of developing 
GI
bleed while on anticoagulation in the past for atrial
fibrillation.

Was initially considered for Clinical Trial but could not be
enrolled due to elevated LFTs ( likely in the setting of acute
heavy alcohol use). 

Pembrolizumab 2 mg/kg every 3 weeks started on ___. 
Progression seen on scans on ___, therefore treatment
transitioned to ipi/nivo.

He completed 4 cycles Ipi/Nivo with good response and was
transitioned to nivolumab monotherapy. He was subsequently
hospitalized with adrenal failure and was found to have
metastatic disease to the brain. 

Neurosurgery was completed ___. Subsequent imaging revealed
ongoing abnormalities in the resection base so received CK
radiation to the site from ___.
  
PAST MEDICAL HISTORY:  
Gastric bypass
Shoulder arthritis, rotator cuff injury awaiting surgery
atrial fibrillation
diabetes
alcohol abuse
fatty liver
hypertension
osteoarthritis of the knee
radial nerve palsy
sleep apnea
GI bleed from PUD while on anticoagulation for afib
 

###RESPONSE: blood blister {Blood blister}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, resolved {Problem resolved}, bled {Bleeding}, inflamed plaque {Erythematous plaque}, ulcer {Ulcer}, right
abdomen {Structure of right side of abdomen}, Biopsy {Biopsy}, nodular melanoma {Nodular melanoma}, absent lymphovascular {Lymphatic (small vessel) invasion by tumor absent}, perineural invasion {Perineural invasion by tumor absent}, pathology {Abnormal histology findings}, wide local excision {Wide excision}, sentinel lymph node biopsy {Sentinel lymph node biopsy}, melanoma {Malignant melanoma of skin}, lymph nodes {Structure of lymph node}, metastatic disease {Metastatic malignant neoplasm to brain}, left arm {Left upper arm structure}, peritoneum {Peritoneum (serous membrane) structure}, right adrenal {Structure of right adrenal gland}, lymph node {Structure of lymph node}, metastatic disease {Metastatic malignant neoplasm to brain}, Brain
MRI {Magnetic resonance imaging of brain}, CNS metastases {Metastatic malignant neoplasm to central nervous system}, FNA {Fine needle biopsy}, left arm
nodule {Nodule of skin of left upper limb}, melanoma {Malignant melanoma of skin}, worsening {Patient's condition worsened}, SOB {Dyspnea}, PE {Pulmonary embolism}, anticoagulation {Anticoagulant therapy}, abdominal wall
hematoma {Hematoma of abdominal wall}, IVC filter {Inferior vena cava filter in situ}, placed {Implantation procedure}, GI
bleed {Gastrointestinal hemorrhage}, anticoagulation {Anticoagulant therapy}, atrial
fibrillation {Atrial fibrillation}, Clinical Trial {Clinical trial}, elevated LFTs {Liver function test above reference range}, heavy alcohol use {Alcohol intake above recommended sensible limits}, good response {Good therapeutic response}, metastatic disease to the brain {Metastatic malignant neoplasm to brain}, imaging {Imaging}, abnormalities {Imaging result abnormal}, resection {Excision}, radiation {Radiation oncology AND/OR radiotherapy}, Gastric bypass {Bypass of stomach}, Shoulder arthritis {Inflammation of joint of shoulder region}, rotator cuff injury {Injury of rotator cuff}, surgery {Surgical procedure}, atrial fibrillation {Atrial fibrillation}, diabetes {Diabetes mellitus}, alcohol abuse {Alcohol abuse}, fatty liver {Steatosis of liver}, hypertension {Hypertensive disorder, systemic arterial}, osteoarthritis of the knee {Osteoarthritis of knee}, radial nerve {Structure of radial nerve}, palsy {Paralysis}, sleep apnea {Sleep apnea}, GI bleed {Gastrointestinal hemorrhage}, PUD {Peptic ulcer}, anticoagulation {Anticoagulant therapy}, afib {Atrial fibrillation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 brother had skin cancer though he does not think it was 
melanoma.
 

###RESPONSE: skin cancer {Malignant neoplasm of skin}, melanoma {Malignant melanoma of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:  
VS: ___ 1655 Temp: 98.1 PO BP: 139/91 HR: 72 RR: 18 O2 sat:
97% O2 delivery: Ra 
GENERAL: Obese man lying in bed in NAD  
HEENT: AT/NC, Sclerae anicteric, MMM, poor dentition.
CV: Irregularly irregular rate and rhythm. No murmurs, rubs, or
gallops.
PULM: CTAB, no wheezes, rales, rhonchi.
ABD: Abdomen soft, obese, nontender to palpation, no
rebound/guarding, no hepatosplenomegaly, well-healed scar.
EXT: WWP, no cyanosis, 2+ LLE, 1+ RLE
SKIN: Warm and well perfused, numerous scatter ecchymoses over
bilateral upper extremities, mild diffuse poorly circumscribed
erythema over anterior left lower leg with scant amount of clear
fluid expressed from a 7mm thin papule
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric  
ACCESS: port

DISCHARGE PHYSICAL EXAM:
VS: ___ 1500 Temp: 98.9 PO BP: 133/96 HR: 90 RR: 18 O2 sat: 
95% O2 delivery: RA 
GENERAL: Obese man lying in bed in NAD  
HEENT: AT/NC, Sclerae anicteric, MMM, poor dentition.
CV: Irregularly irregular rate and rhythm. No murmurs, rubs, or 
gallops.
PULM: CTAB, no wheezes, rales, rhonchi.
ABD: Abdomen soft, obese, nontender to palpation, no 
rebound/guarding, no hepatosplenomegaly, well-healed scar.
EXT: WWP, no cyanosis, 2+ LLE, 1+ RLE
SKIN: Warm and well perfused, numerous scatter ecchymoses over 
bilateral upper extremities, mild diffuse poorly circumscribed 
erythema over anterior left lower leg
NEURO: Alert, moving all 4 extremities with purpose, face 
symmetric  
ACCESS: port
 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, O2 sat {Oxygen saturation measurement}, O2 delivery: Ra {Breathing room air}, GENERAL {General examination of patient}, Obese {Obese}, lying in bed {Lying in bed}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, AT/NC {Normal head}, Sclerae anicteric {White sclera}, MMM {Moist oral mucosa}, poor dentition {Impaired dentition}, CV {Cardiovascular physical examination}, Irregularly irregular {Heart irregularly irregular}, rate {Finding of heart rate}, rhythm {Irregular heart beat}, murmurs {Heart murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, ABD {Examination of abdomen}, Abdomen soft {Abdomen soft}, obese {Obese abdomen}, nontender {Abdominal tenderness}, palpation {Palpation}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, hepatosplenomegaly {Hepatosplenomegaly}, well-healed {Wound healed}, scar {Scar}, EXT {Examination of limb}, WWP {Normal tissue perfusion}, cyanosis {Cyanosis}, LLE {Structure of left lower limb}, RLE {Structure of right lower limb}, SKIN {Examination of skin}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, ecchymoses {Ecchymosis}, upper extremities {Upper limb structure}, mild {Symptom mild}, erythema {Erythema}, left lower leg {Structure of left lower leg}, papule {Papule}, NEURO {Neurological examination}, Alert {Mentally alert}, moving all 4 extremities {Does move all four limbs}, face
symmetric {Facial symmetry}, VS {Vital signs finding}, Temp {Body temperature finding}, O2 sat {Oxygen saturation measurement}, RA {Breathing room air}, RA {Breathing room air}, Obese {Obese}, lying in bed {Lying in bed}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, AT/NC {Normal head}, Sclerae anicteric {White sclera}, MMM {Moist oral mucosa}, poor dentition {Impaired dentition}, CV {Cardiovascular physical examination}, Irregularly irregular {Heart irregularly irregular}, rate {Finding of heart rate}, rhythm {Irregular heart beat}, murmurs {Heart murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, PULM {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, ABD {Examination of abdomen}, Abdomen soft {Abdomen soft}, obese {Obese abdomen}, nontender {Abdominal tenderness}, palpation {Palpation}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, hepatosplenomegaly {Hepatosplenomegaly}, well-healed {Wound healed}, scar {Scar}, EXT {Examination of limb}, WWP {Normal tissue perfusion}, cyanosis {Cyanosis}, LLE {Structure of left lower limb}, RLE {Structure of right lower limb}, SKIN {Examination of skin}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, ecchymoses {Ecchymosis}, upper extremities {Upper limb structure}, mild {Symptom mild}, erythema {Erythema}, left lower leg {Structure of left lower leg}, NEURO {Neurological examination}, Alert {Mentally alert}, moving all 4 extremities {Does move all four limbs}, face 
symmetric {Facial symmetry}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS
___ 07:56PM BLOOD WBC-10.7* RBC-3.40* Hgb-12.0* Hct-35.0* 
MCV-103* MCH-35.3* MCHC-34.3 RDW-14.7 RDWSD-55.1* Plt ___
___ 07:56PM BLOOD Neuts-79.1* Lymphs-7.6* Monos-7.7 
Eos-0.0* Baso-0.8 NRBC-0.2* Im ___ AbsNeut-8.48* 
AbsLymp-0.82* AbsMono-0.83* AbsEos-0.00* AbsBaso-0.09*
___ 07:56PM BLOOD ___ PTT-24.4* ___
___ 07:56PM BLOOD Glucose-121* UreaN-11 Creat-0.5 Na-135 
K-3.7 Cl-93* HCO3-29 AnGap-13
___ 10:29AM URINE Blood-SM* Nitrite-NEG Protein-NEG 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 10:29AM URINE RBC-6* WBC-2 Bacteri-FEW* Yeast-NONE 
Epi-<1
___ 10:29AM URINE CastHy-1*

DISCHARGE LABS
___ 05:02AM BLOOD WBC-8.7 RBC-3.42* Hgb-12.2* Hct-35.9* 
MCV-105* MCH-35.7* MCHC-34.0 RDW-15.0 RDWSD-57.4* Plt ___
___ 05:02AM BLOOD Neuts-77.0* Lymphs-10.0* Monos-8.0 
Eos-0.1* Baso-0.3 Im ___ AbsNeut-6.69* AbsLymp-0.87* 
AbsMono-0.70 AbsEos-0.01* AbsBaso-0.03
___ 05:02AM BLOOD ___ PTT-28.7 ___
___ 05:02AM BLOOD Glucose-97 UreaN-10 Creat-0.5 Na-140 
K-3.2* Cl-94* HCO3-32 AnGap-14
___ 05:02AM BLOOD Albumin-2.9* Calcium-8.3* Phos-3.4 Mg-1.7
___ 05:02AM BLOOD ALT-12 AST-37 LD(LDH)-491* AlkPhos-163* 
TotBili-0.6

MICRO
___ UCx and BCx x2 pending

IMAGING
___ ___
Focal DVT of the proximal left femoral vein measuring up to 2.3 
cm.  No other evidence of DVT in the left lower extremity veins.

 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, URINE Blood {Urine blood test}, Nitrite-NEG {Nitrite not detected in urine}, Protein-NEG {Urine protein not detected}, Glucose-NEG {Urine glucose not detected}, Ketone-NEG {Urine ketones not detected}, NEG {No abnormality detected}, Urobiln-NEG {Urine urobilinogen not detected}, pH {pH measurement}, Leuks-NEG {Urine leukocytes not detected}, URINE {Urinalysis}, RBC {Red blood cell count}, WBC {White blood cell count}, Bacteri {Bacteriuria}, URINE {Urine culture}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Lymphs {Lymphocyte count}, Monos {Monocyte count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Albumin {Albumin measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, LDH {Lactate dehydrogenase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, UCx {Urine culture}, BCx {Blood culture}, IMAGING {Imaging}, DVT {Deep venous thrombosis}, left femoral vein {Structure of left femoral vein}, DVT {Deep venous thrombosis}, left lower extremity veins {Structure of vein 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: Brief Hospital Course:
PATIENT SUMMARY
=================
Mr. ___ is a ___ man with metastatic melanoma on nivolumab 
monotherapy, atrial fibrillation not on anticoagulation, history 
of GI bleed x2 (___) and PE s/p IVC filter (___), now 
presenting with new LLE DVT.

ACTIVE ISSUES
================
#DVT
Presented with 1 week of LLE pain and swelling in the setting of 
limited mobility (pt reports recent fall, feeling weak, and 
having occasional lightheadedness when standing). Found to have 
DVT of proximal L femoral vein on Doppler ultrasound. History 
notable for PE in ___ s/p IVC filter placement. He reports 
being on a DOAC in the past, presumably for afib, which was 
discontinued in setting of 2 GI bleeds in ___. Rivaroxaban 
started in the ED on ___, transitioned to apixaban on ___ do 
to preferable bleeding risk profile. H/H stable after initiation 
of anticoagulation. 

#Concern for cellulitis
Received IV cefazolin 1g x2 in the ED for presumed cellulitis of 
LLE. Exam notable for mild erythema and ulceration of LLE with 
clear discharge, pain, and swelling which could be related to 
DVT but will continue empiric non-purulent cellulitis treatment 
for now with plan for Cephalexin 500mg QID to complete a 10 day 
course (end date ___. 

#Weakness
Pt reports weakness a fall ~2 weeks ago while on treadmill. He 
was referred for physical therapy as an outpatient at home. 

#Melanoma
Pt has stage IV BRAF WT melanoma s/p resection of abdominal mass 
and axillary LN dissection, resection of R frontal brain mass, 
progression of disease on Pembrolizumab then ipi/nivo, now with 
mixed response on nivolumab monotherapy (C8D1 ___.

#Afib
Continued home digoxin 0.125mg QD.

#Alcohol use disorder
#Cirrhosis
History of cirrhosis likely ___ alcohol use. LFTs wnl except for 
elevated alk phos and LDH. Did not score on CIWA or require 
Ativan.

CHRONIC ISSUES
================
#Adrenal insufficiency
Likely ___ immune checkpoint inhibitor therapy. Continued home 
hydrocortisone 20mg QAM, 10mg QHS.

#Hypothyroidism
Continued home levothyroxine 75mcg QD.

#HTN
Pt reports that HTN improved after gastric bypass, currently not 
on home meds. BP 110s-130s/70s-90s this admission.

#Diabetes
Pt reports that blood sugars improved after gastric bypass, 
currently not on home meds. Morning glucose 140s-150s this 
admission.

#Other home medications
Continued home omeprazole, multivitamins, iron.

TRANSITIONAL ISSUES
====================
[] F/u resolution of DVT on apixaban. Could consider 
transitioning to lovenox, deferred this admission given 
significantly higher co-pay.
[] F/u H/H, melena/hematochezia in 2 weeks on apixaban. 
[] F/u blood glucose, consider checking A1c.
[] F/u weakness, falls. Arrangements made for home ___.
 

###RESPONSE: metastatic melanoma {Metastatic malignant melanoma}, atrial fibrillation {Atrial fibrillation}, anticoagulation {Anticoagulant therapy}, GI bleed {Gastrointestinal hemorrhage}, PE {Pulmonary embolism}, IVC filter {Inferior vena cava filter in situ}, LLE {Structure of left lower limb}, DVT {Deep venous thrombosis}, DVT {Deep venous thrombosis}, LLE {Structure of left lower limb}, pain {Pain}, swelling {Swelling}, limited mobility {Impaired mobility}, fall {Falls}, feeling weak {Asthenia}, lightheadedness {Lightheadedness}, standing {Orthostatic body position}, DVT {Deep venous thrombosis}, L femoral vein {Structure of left femoral vein}, Doppler ultrasound {Doppler ultrasound}, PE {Pulmonary embolism}, IVC filter placement {Insertion of inferior vena caval filter}, afib {Atrial fibrillation}, GI bleeds {Gastrointestinal hemorrhage}, bleeding risk {At increased risk of hemorrhage}, stable {Patient's condition stable}, anticoagulation {Anticoagulant therapy}, cellulitis {Cellulitis}, cellulitis {Cellulitis}, LLE {Structure of left lower limb}, Exam {Physical examination procedure}, mild {Symptom mild}, erythema {Erythema}, ulceration {Ulcer}, LLE {Structure of left lower limb}, discharge {Discharge from skin ulcer}, pain {Pain}, swelling {Swelling}, DVT {Deep venous thrombosis}, purulent {Purulent}, cellulitis {Cellulitis}, Weakness {Asthenia}, weakness {Asthenia}, fall {Falls}, physical therapy {Physical therapy procedure}, Melanoma {Malignant melanoma of skin}, stage IV {Clinical stage IV}, melanoma {Malignant melanoma of skin}, resection {Excision}, abdominal mass {Abdominal mass}, axillary LN dissection {Excision of axillary lymph node}, resection {Excision}, R frontal {Right frontal lobe structure}, brain mass {Mass lesion of brain}, disease {Disease}, Afib {Atrial fibrillation}, Alcohol use disorder {Alcoholism}, Cirrhosis {Cirrhosis of liver}, cirrhosis likely ___ alcohol use {Alcoholic cirrhosis}, LFTs wnl {Liver function tests within reference range}, elevated alk phos {Serum alkaline phosphatase within reference range}, LDH {Serum lactate dehydrogenase level above reference range}, CHRONIC ISSUES {Chronic disease}, Adrenal insufficiency {Adrenal cortical hypofunction}, immune checkpoint inhibitor therapy {Immune checkpoint inhibitor therapy}, Hypothyroidism {Hypothyroidism}, HTN {Hypertensive disorder, systemic arterial}, HTN {Hypertensive disorder, systemic arterial}, improved {Patient's condition improved}, gastric bypass {Bypass of stomach}, Diabetes {Diabetes mellitus}, blood sugars {Blood sugar management}, improved {Patient's condition improved}, gastric bypass {Bypass of stomach}, glucose {Glucose measurement, blood}, resolution {Problem resolved}, DVT {Deep venous thrombosis}, melena {Melena}, hematochezia {Hematochezia}, blood glucose {Glucose measurement, blood}, weakness {Asthenia}, falls {Falls}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list may be inaccurate and requires 
futher investigation.
1. Colchicine 0.6 mg PO DAILY:PRN gout flare 
2. Digoxin 0.125 mg PO DAILY 
3. Hydrocortisone 10 mg PO QHS 
4. Hydrocortisone 20 mg PO QAM 
5. Levothyroxine Sodium 75 mcg PO DAILY 
6. Omeprazole 20 mg PO DAILY 
7. Cyanocobalamin 100 mcg PO DAILY 
8. Ferrous Sulfate 325 mg PO DAILY 
9. Multivitamins W/minerals 1 TAB PO DAILY 

 
Discharge Medications:
1.  Apixaban 10 mg PO BID Duration: 7 Days  
2.  Cephalexin 500 mg PO QID 
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours 
Disp #*34 Capsule Refills:*0 
3.  Colchicine 0.6 mg PO DAILY:PRN gout flare  
4.  Cyanocobalamin 100 mcg PO DAILY  
5.  Digoxin 0.125 mg PO DAILY  
6.  Ferrous Sulfate 325 mg PO DAILY  
7.  Hydrocortisone 10 mg PO QHS  
8.  Hydrocortisone 20 mg PO QAM  
9.  Levothyroxine Sodium 75 mcg PO DAILY  
10.  Multivitamins W/minerals 1 TAB PO DAILY  
11.  Omeprazole 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 With Service
 
Facility:
___
 
Discharge Diagnosis:
PRIMARY:
========
Deep vein thrombosis
Skin and soft tissue infection 

SECONDARY: 
==========
METASTATIC MELANOMA 

 
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}, Deep vein thrombosis {Deep venous thrombosis}, Skin {Infection of skin}, soft tissue infection {Soft tissue infection}, METASTATIC MELANOMA {Metastatic malignant melanoma}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - requires assistance or aid {Finding of walking aid use}, walker {Uses zimmer frame}, cane {Uses single walking stick}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___,
 
It was a pleasure caring for you at ___ 
___.  
 
WHY WAS I IN THE HOSPITAL?  
 - You were admitted for treatment of a blood clot in your leg, 
known as a deep vein thrombosis (DVT) and a skin infection.
 
WHAT HAPPENED TO ME IN THE HOSPITAL?  
 - You were started on a medication to thin your blood to treat 
your DVT
 - You were given antibiotics to treat a possible skin 
infection. 
 
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?  
 - Continue to take all your medicines and keep your 
appointments.  
 - Please call your oncologist or return to the emergency 
department if you experience any of the danger signs listed 
below. 
 
We wish you the best!  
 
Sincerely,  
Your ___ Team  

 

###RESPONSE: blood clot {Blood clot}, leg {Structure of left lower leg}, deep vein thrombosis {Deep venous thrombosis}, DVT {Deep venous thrombosis}, skin infection {Infection of skin}, started {New medication added}, medication to thin your blood {Anticoagulant therapy}, DVT {Deep venous thrombosis}, antibiotics {Antibiotic therapy}, skin 
infection {Infection of skin and/or subcutaneous tissue}, return to the emergency {Emergency treatment education}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
chest pain
 
Major Surgical or Invasive Procedure:
Cardiac cath ___ and ___
 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, chest pain {Chest pain}, Cardiac cath {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:
___ male with a past medical history significant for 
rheumatoid arthritis, chronic pain, and significant cardiac 
history including CABG in ___ and PCI 6 months ago presents 
with severe chest pain with associated arm/jaw pain since 
___. Pain initially exertional but now at rest, 
described as sharp like an ice pick with extension to left arm 
and jaw similar to pain prior to CABG. He notes SOB, 
nausea/vomiting, palpitations associated with this chest pain. 
Denies orthopnea, PND. Patient presented to OSH after having a 
possible syncopal episode when he had pain and weakness climbing 
stairs from doing laundry and thinks he may have lost 
consciousness. He had some relief with baby ASA. In ___, 
afebrile with HR ___ to ___ and systolic BP 140s, oxygen 
saturation stable on room air, troponin 0.03, EKG with no 
changes, chest x-ray negative. Patient states that he passed out 
in ___ lobby, RN reports rapid response due to severe 
chest pain which was improved with nitro SLx3, IV morphine, 
clonazepam.  
On the floor, patient complains of severe ___ chest pain and is 
tearful. Pain improved with nitro gtt.  
Review of Systems: As per HPI, otherwise negative. 
 

###RESPONSE: rheumatoid arthritis {Rheumatoid arthritis}, chronic pain {Chronic pain}, cardiac {Heart disease}, CABG {Coronary artery bypass grafting}, PCI {Percutaneous coronary intervention}, chest pain {Chest pain}, arm {Pain in upper limb}, jaw pain {Jaw pain}, Pain {Chest pain}, exertional {Chest pain}, at rest {Chest pain at rest}, sharp {Sharp pain}, extension to left arm {Pain radiating to left arm}, jaw {Pain radiating to jaw}, pain {Chest pain}, CABG {Coronary artery bypass grafting}, SOB {Dyspnea}, nausea/vomiting {Nausea and vomiting}, palpitations {Palpitations}, chest pain {Chest pain}, orthopnea {Orthopnea}, PND {Paroxysmal nocturnal dyspnea}, syncopal {Syncope}, pain {Chest pain}, weakness {Asthenia}, lost 
consciousness {Loss of consciousness}, relief {Pain relief}, ASA {Administration of aspirin}, afebrile {Temperature normal}, HR {Finding of heart rate}, BP {Blood pressure finding}, oxygen 
saturation {Finding of oxygen saturation}, on room air {Breathing room air}, troponin {Troponin measurement}, EKG {Electrocardiographic procedure}, chest x-ray {Plain chest X-ray}, negative {No abnormality detected}, chest pain {Chest pain}, improved {Patient's condition improved}, chest pain {Chest pain}, tearful {Crying}, Pain improved {Sensation of pain reduced}, Review of Systems {Review of systems}, negative {No abnormality detected}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Coronary artery disease status post 5 vessel CABG (___)  
CHF  
Hypertension  
Hypercholesterolemia  
Rheumatoid arthritis on prednisone  
Ulcerative colitis  
GERD  
Sciatica  
Appendectomy  
Knee arthroplasty  
Anxiety attacks  
Recent right knee replacement  
Recent cardiac catheterization in ___ with stent placement 
x2  
Chronic back pain  
Osteoarthritis  
Depression with recent hospitalization 
 

###RESPONSE: Coronary artery disease {Coronary arteriosclerosis}, 5 vessel CABG {Coronary artery bypass grafts x 5}, CHF {Congestive heart failure}, Hypertension {Hypertensive disorder, systemic arterial}, Hypercholesterolemia {Hypercholesterolemia}, Rheumatoid arthritis {Rheumatoid arthritis}, Ulcerative colitis {Ulcerative colitis}, GERD {Gastroesophageal reflux disease}, Sciatica {Sciatica}, Appendectomy {Excision of appendix}, Knee arthroplasty {Arthroplasty of knee}, Anxiety attacks {Anxiety attack}, nt right knee replacement {Total replacement of right knee joint}, cardiac catheterization {Cardiac catheterization}, stent placement {Placement of stent in coronary artery}, Chronic back pain {Chronic back pain}, Osteoarthritis {Osteoarthritis}, Depression {Depressive disorder}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Mother with CHF
 

###RESPONSE: CHF {Congestive heart failure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T: 98.1 BP: 141/84 HR: 67 RR: 20 02 sat: 98% on 2L wt 
204 lbs (OSH)  
GENERAL: Patient in moderate distress, tearful  
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, 
MMM. Xanthelasma present near left eye.  
NECK: nontender supple neck, no LAD, no JVD  
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs  
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably 
without use of accessory muscles  
ABDOMEN: nondistended, +BS, nontender in all quadrants, no 
rebound/guarding, no hepatosplenomegaly  
EXTREMITIES: 2+ ___ edema, moving all 4 extremities with purpose  

PULSES: 2+ DP pulses bilaterally  
NEURO: CN II-XII intact  
SKIN: warm and well perfused, no excoriations or lesions, no 
rashes  

DISCHARGE PHYSICAL EXAM:
Vitals: T 97.9 96/66 64 (58-82) 18 97% RA  
Tele: NSR 
Last 24 hours I/O: ___
Today's weight: 90.6
GENERAL: NAD, sitting up in bed  
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, 
MMM. Xanthelasma present near left eye.  
NECK: nontender supple neck, no JVD  
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs  
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably 
without use of accessory muscles, + pain with palpation over 
anterior chest, no pain with deep breath  
ABDOMEN: nondistended, +BS, nontender in all quadrants  
EXTREMITIES: no edema, moving all 4 extremities with purpose  
PULSES: 2+ DP pulses bilaterally  
NEURO: CN II-XII intact  
SKIN: warm and well perfused, no excoriations or lesions, no 
rashes  
 

 

###RESPONSE: PHYSICAL EXAM {Physical examination procedure}, Vitals {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, 02 sat {Oxygen saturation measurement}, GENERAL {General examination of patient}, distress {Distress}, tearful {Crying}, HEENT {Physical examination procedure}, NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclera {White sclera}, pink conjunctiva {Conjunctival hyperemia}, MMM {Moist oral mucosa}, Xanthelasma {Xanthelasma}, left eye {Left eye structure}, NECK {Physical examination procedure}, nontender {Abdominal tenderness}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, LUNG {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, breathing comfortably {Breathing easily}, accessory muscles {Accessory skeletal muscle}, ABDOMEN {Examination of abdomen}, nondistended {Normal abdominal contour}, +BS {Normal bowel sounds}, nontender {Abdominal tenderness}, rebound {Rebound tenderness}, guarding {Abdominal guarding}, hepatosplenomegaly {Hepatosplenomegaly}, EXTREMITIES {Examination of limb}, edema {Edema}, moving all 4 extremities {Does move all four limbs}, PULSES {Pulse finding}, 2+ DP pulses {All pulses present in bilateral lower limbs}, NEURO {Neurological examination}, CN II-XII intact {Normal central nervous system}, SKIN {Examination of skin}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Lesion}, rashes {Eruption of skin}, Vitals {Vital signs finding}, T {Body temperature finding}, RA {Breathing room air}, Tele {Cardiac telemetry}, NSR {Normal sinus rhythm}, weight {Weight finding}, RA {Breathing room air}, NAD {No abnormality detected}, sitting up in bed {Fowler's position}, HEENT {Physical examination procedure}, NC {Normal head}, EOMI {Normal ocular motility}, PERRL {Pupils equal and reacting to light}, anicteric sclera {White sclera}, pink conjunctiva {Conjunctival hyperemia}, MMM {Moist oral mucosa}, Xanthelasma {Xanthelasma}, left eye {Left eye structure}, NECK {Physical examination procedure}, supple neck {Normal movement of neck}, JVD {Jugular venous engorgement}, CARDIAC {Cardiovascular physical examination}, RRR {Normal heart rate}, S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Heart murmur}, gallops {Gallop rhythm}, rubs {Pericardial friction rub}, LUNG {Examination of respiratory system}, CTAB {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, rhonchi {Wheeze - rhonchi}, breathing comfortably {Breathing easily}, accessory muscles {Accessory skeletal muscle}, pain {Pain}, palpation {Palpation}, chest {Thoracic structure}, pain with deep breath {Pain provoked by breathing}, ABDOMEN {Examination of abdomen}, +BS {Normal bowel sounds}, EXTREMITIES {Examination of limb}, edema {Edema}, moving all 4 extremities {Does move all four limbs}, PULSES {Pulse finding}, 2+ DP pulses {All pulses present in bilateral lower limbs}, NEURO {Neurological examination}, CN II-XII {Structure of cervical spinal nerve}, intact  
SKIN {Examination of skin}, warm {Warm skin}, well perfused {Normal tissue perfusion}, excoriations {Excoriation}, lesions {Skin lesion}, rashes {Eruption of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 11:55PM BLOOD WBC-5.7 RBC-4.34* Hgb-12.9* Hct-38.1* 
MCV-88 MCH-29.8 MCHC-33.9 RDW-15.1 Plt ___
___ 11:55PM BLOOD Neuts-61.4 ___ Monos-5.2 Eos-3.7 
Baso-0.6
___ 11:55PM BLOOD ___ PTT-127.1* ___
___ 11:55PM BLOOD Glucose-104* UreaN-12 Creat-0.8 Na-142 
K-3.4 Cl-105 HCO3-28 AnGap-12
___ 11:55PM BLOOD CK-MB-1 cTropnT-<0.01
___ 09:05AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 11:55PM BLOOD Calcium-9.1 Phos-3.4 Mg-2.1

DISCHARGE LABS:
___ 06:45AM BLOOD WBC-4.2 RBC-4.43* Hgb-12.8* Hct-39.1* 
MCV-88 MCH-28.9 MCHC-32.8 RDW-15.1 Plt ___
___ 06:45AM BLOOD Glucose-118* UreaN-18 Creat-1.2 Na-140 
K-4.4 Cl-101 HCO3-31 AnGap-12
___ 07:00PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 12:31AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 06:45AM BLOOD Calcium-9.1 Phos-4.9* Mg-2.3

IMAGING:
CARDIAC CATH ___:
Hemodynamics (see above):
Coronary angiography:  right dominant
LMCA: 
LAD:  90% proximal, 100% mid
LCX:  40% proximal, 99% distal with patent stent in midvessel 
and
occluded OMs
RCA:  100% proximal
SVG-:  radial to OM patent, vein to PDA with 75% in-stent
restenosis, vein to diagonal known patent
LIMA-LAD:  not injected but known 80% in LAD beyond graft
Other: 

Assessment & Recommendations
 1. Will discuss options after review prior films with probable
PCI of restenosis of PDA graft and PCI of distal circumflex next
week.  Both supply small territories.

CARDIAC CATH ___:
Hemodynamics (see above):
Coronary angiography:  right dominant
LMCA: 
LAD:  known 80% proximal, 100% mid
LCX:  known diffuse up to 60% with patent stent in mid vessel 
and
complex ___ distal with occluded OMs
RCA:  known ___ proximal
SVG-:  diagonal patent, vein to PDA with only 30% in-stent
restenosis after IC nicardipine which is much improved compared
with angiography 3 days ago, radial to OM2 known patent
LIMA-LAD:  LAD with 70% beyond anastomosis with diffusely small
caliber distal vessel
Other:  Aortogram shows patent vein to diagonal and patent 
radial
to OM2

Interventional details
After IC nicardipine administration showed improvement in distal
PDA graft, intervention considered no longer necessary on that
area.  PCI of distal LAD beyond LIMA and PCI of distal 
circumflex
would both be difficult but could be considered if recurrent
angina or markedly positive ETT.

Assessment & Recommendations
 1. Continue med Rx.
 2. Consider PCI if recurrent angina.

CXR ___:
Normal lung volumes. Normal appearance of the mediastinum and 
the hilar
structures. Sternotomy wires of the CABG show correct alignment. 
Borderline
size of the cardiac silhouette. Mild elongation of the 
descending aorta.  No pneumonia, no pulmonary edema.  No pleural 
effusions.

EXERCISE STRESS TEST ___:
Fair exercise tolerance. Atypical/non-anginal type symptoms
with no ischemic ST segment changes at the achieved level of 
work.
Nuclear report sent separately.

CARDIAC PERFUSION STUDY ___:
1. At level of exercise achieved, no myocardial perfusion 
defects. 
2.  Normal left ventricular ejection fraction of 54%.  
3.  Mildly prominent
right ventricle.
 

###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}, 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}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, 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}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Coronary angiography {Angiography of coronary artery}, LMCA: {Structure of left coronary artery main stem}, LAD {Structure of anterior descending branch of left coronary artery}, proximal {Structure of proximal portion of anterior descending branch of left coronary artery}, mid {Structure of mid portion of anterior descending branch of left coronary artery}, LCX {Structure of circumflex branch of left coronary artery}, proximal {Structure of proximal portion of circumflex branch of left coronary artery}, distal {Structure of distal portion of circumflex branch of left coronary artery}, patent stent {Coronary stent patent}, midvessel {Structure of mid portion of circumflex branch of left coronary artery}, occluded {Complete obstruction}, OMs {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, RCA {Right coronary artery structure}, proximal {Structure of proximal portion of right coronary artery}, SVG {Aortocoronary artery bypass graft with saphenous vein graft}, radial {Structure of radial artery}, OM {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, vein {Venous structure}, PDA {Structure of posterior descending coronary artery}, stent {Placement of stent}, restenosis {Restenosis}, vein {Venous structure}, diagonal {Structure of diagonal branch of anterior descending branch of left coronary artery}, LIMA {Structure of left internal thoracic artery}, LAD {Structure of anterior descending branch of left coronary artery}, LAD {Structure of anterior descending branch of left coronary artery}, graft {Structure of transplant}, PCI {Percutaneous coronary intervention}, restenosis {Restenosis}, PDA {Structure of posterior descending coronary artery}, graft {Structure of transplant}, PCI {Percutaneous coronary intervention}, distal circumflex {Structure of distal portion of circumflex branch of left coronary artery}, CARDIAC CATH {Cardiac catheterization}, Coronary angiography {Angiography of coronary artery}, right dominant {Right dominant coronary system}, LMCA {Structure of left coronary artery main stem}, LAD {Structure of anterior descending branch of left coronary artery}, proximal {Structure of proximal portion of anterior descending branch of left coronary artery}, mid
LCX {Structure of mid portion of circumflex branch of left coronary artery}, patent stent {Coronary stent patent}, mid vessel {Structure of mid portion of circumflex branch of left coronary artery}, distal {Structure of distal portion of circumflex branch of left coronary artery}, occluded {Complete obstruction}, OMs {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, RCA {Right coronary artery structure}, proximal {Structure of proximal portion of right coronary artery}, SVG {Aortocoronary artery bypass graft with saphenous vein graft}, diagonal {Structure of diagonal branch of anterior descending branch of left coronary artery}, vein {Venous structure}, PDA {Structure of posterior descending coronary artery}, restenosis {Restenosis}, improved {Patient's condition improved}, angiography {Angiography}, radial {Coronary artery bypass grafting using radial artery graft}, OM2 {Structure of second obtuse marginal branch of circumflex branch of left coronary artery}, LIMA {Structure of left internal thoracic artery}, LAD {Structure of anterior descending branch of left coronary artery}, LAD {Structure of anterior descending branch of left coronary artery}, anastomosis {Anastomosis}, distal vessel {Structure of distal portion of anterior descending branch of left coronary artery}, patent vein {Venous access patent}, diagonal {Structure of diagonal branch of anterior descending branch of left coronary artery}, radial {Coronary artery bypass grafting using radial artery graft}, OM2 {Structure of second obtuse marginal branch of circumflex branch of left coronary artery}, PDA {Structure of posterior descending coronary artery}, graft {Structure of transplant}, PCI {Percutaneous coronary intervention}, distal LAD {Structure of distal portion of anterior descending branch of left coronary artery}, LIMA {Structure of left internal thoracic artery}, PCI {Percutaneous coronary intervention}, distal 
circumflex {Structure of distal portion of circumflex branch of left coronary artery}, recurrent {Recurrent disease}, angina {Angina}, PCI {Percutaneous coronary intervention}, recurrent {Recurrent disease}, angina {Angina}, Normal lung volumes {Lung volume test normal}, Normal appearance {Normal appearance}, mediastinum {Mediastinal structure}, hilar {Structure of hilum of lung}, Sternotomy {Sternotomy}, CABG {Coronary artery bypass grafting}, cardiac {Heart structure}, descending aorta {Descending aorta structure}, pneumonia {Pneumonia}, pulmonary edema {Pulmonary edema}, pleural 
effusions {Pleural effusion}, exercise tolerance {Exercise tolerance finding}, Atypical {Atypical angina}, anginal {Angina}, ischemic {Ischemia}, ST segment changes {Finding of electrocardiogram ST segment}, myocardial perfusion 
defects {Myocardial perfusion defect}, left ventricular {Left cardiac ventricular structure}, right ventricle {Right cardiac ventricular structure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
___ year old male with a PMHx significant for rheumatoid 
arthritis, chronic pain, and significant cardiac history 
including CABG in ___ and PCI 6 months ago presents with severe 
chest pain with associated arm/jaw pain without EKG changes or 
troponin leak.  

ACUTE ISSUES:
#Chest pain: Patient had history of CAD s/p CABG and PCIs with 
significant chest pain at rest without EKG changes and negative 
troponins. He underwent catheterization on ___ which showed 
extensive disease in the LAD, Lcx and RCA. No intervention was 
performed given that the previous films were not available for 
review and it was unknown whether the lesions were new or old. 
He underwent repeat catheterization on ___ without 
interventions given poor anatomy unchanged from prior PCI. He 
was continued on aspirin, plavix, metoprolol and atorvastatin. 
He continued to have significant chest pain at rest and with 
minimal exertion without EKG changes. He was started on imdur, 
amlodipine and ranolazine without much improvement in chest 
pain. He had a stress test and nuclear study which showed no EKG 
changes or evidence of ischemia. Chest pain was not felt to be 
due to cardiac ischemia given these findings. He was discharged 
with plans to follow-up with his PCP/cardiologist for further 
management. 
 
#Chronic pain: Patient has sciatica and multiple joint surgeries 
in addition to chronic inflammatory diseases. He is on many pain 
medications as an outpatient and had a significant requirement 
for narcotics while hospitalized. He also endorsed symptoms of 
withdrawal when he did not get his opioid medications. He 
complained mostly of back and chest pain, which was treated with 
home medications of oxycodone, oxycontin and gabapentin. He was 
seen by the chronic pain service given that patient's chest pain 
was at times reproducible who recommended increasing gabapentin, 
starting volteran gel and using a lidocaine patch. Patient's 
chest and back pain improved with these interventions. 
 
#Anxiety: Patient was continued on home clonazepam, trazodone, 
benadryl prn.   

CHRONIC ISSUES:
# ___ edema: Patient was continued on home furosemide. 

#Rheumatoid arthritis/ulcerative colitis: Patient is on 
methotrexate and prednisone at home. He had no flares of joint 
pain or diarrhea during this hospitalization. He was continued 
on home prednisone and methotrexate was held.   

TRANSITIONAL ISSUES:
- Patient was started on Imdur 30mg PO daily, amlodipine 5 mg 
daily, ranolazine 1000 mg BID
- increased gabapentin to 900 mg TID
- started acetaminophen 1000 mg q8h, voltaran cream and 
lidocaine patches
- recommend psychiatry follow-up and therapy
 
Discharge Medications:
1. Aspirin 81 mg PO DAILY 
2. ClonazePAM 1 mg PO QID 
3. DiphenhydrAMINE 25 mg PO Q6H:PRN itch 
4. FoLIC Acid 1 mg PO DAILY 
5. Furosemide 20 mg PO DAILY 
6. Gabapentin 600 mg PO BID 
7. Metoprolol Succinate XL 25 mg PO DAILY 
8. Omeprazole 20 mg PO DAILY 
9. OxycoDONE (Immediate Release)  10 mg PO Q8H:PRN pain 
10. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H 
11. PredniSONE 5 mg PO BID 
12. TraZODone 100 mg PO QHS insomnia 
13. Acetaminophen 650 mg PO Q6H:PRN pain 
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) 
hours Disp #*30 Tablet Refills:*0
14. Atorvastatin 80 mg PO QPM 
RX *atorvastatin 80 mg 1 tablet(s) by mouth every night Disp 
#*30 Tablet Refills:*0
15. Clopidogrel 75 mg PO DAILY 
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 
Tablet Refills:*0
16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp 
#*30 Tablet Refills:*0
17. Lidocaine 5% Patch 1 PTCH TD QAM 
RX *lidocaine 5 % (700 mg/patch) Place 1 patch to area of worst 
pain every morning. Please remove after 12 hours. every morning 
Disp #*30 Patch Refills:*0
18. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 
RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually q5 
minutes Disp #*20 Tablet Refills:*0
19. Methocarbamol 500 mg PO Q8H 
20. Methotrexate 15 mg PO 1X/WEEK (___) 

 

###RESPONSE: rheumatoid 
arthritis {Rheumatoid arthritis}, chronic pain {Chronic pain}, cardiac {Heart disease}, CABG {Coronary artery bypass grafting}, PCI {Percutaneous coronary intervention}, chest pain {Chest pain}, arm {Pain in upper limb}, jaw pain {Jaw pain}, EKG changes {Electrocardiogram abnormal}, Chest pain {Chest pain}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, PCIs {Percutaneous coronary intervention}, chest pain at rest {Chest pain at rest}, EKG changes {Electrocardiogram abnormal}, catheterization {Cardiac catheterization}, LAD {Structure of anterior descending branch of left coronary artery}, Lcx {Structure of circumflex branch of left coronary artery}, RCA {Right coronary artery structure}, lesions {Lesion}, catheterization {Cardiac catheterization}, PCI {Percutaneous coronary intervention}, aspirin {Administration of aspirin}, chest pain at rest {Chest pain at rest}, exertion {Chest pain on exertion}, EKG changes {Electrocardiogram abnormal}, chest 
pain {Chest pain}, stress test {Electrocardiogram with exercise test}, nuclear study {Nuclear medicine diagnostic procedure on cardiovascular system}, EKG 
changes {Electrocardiogram abnormal}, ischemia {Ischemia}, Chest pain {Chest pain}, cardiac ischemia {Myocardial ischemia}, Chronic pain {Chronic pain}, sciatica {Sciatica}, joint {Joint structure}, surgeries {Surgical procedure}, chronic inflammatory diseases {Chronic inflammatory disorder}, pain 
medications {Administration of analgesic}, narcotics {Narcotherapy}, withdrawal {Opioid withdrawal syndrome}, back {Backache}, chest pain {Chest pain}, chronic pain {Chronic pain}, chest pain {Chest pain}, chest {Thoracic structure}, pain improved {Sensation of pain reduced}, Anxiety {Anxiety}, edema {Edema of lower extremity}, Rheumatoid arthritis {Rheumatoid arthritis}, ulcerative colitis {Ulcerative colitis}, joint 
pain {Joint 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: Discharge Disposition:
Home
 
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Chest pain
Chronic pain 
Anxiety

SECONDARY DIAGNOSIS:
CAD s/p ___ 
 
___ Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 

###RESPONSE: Chest pain {Chest pain}, Chronic pain {Chronic pain}, Anxiety {Anxiety}, CAD {Coronary arteriosclerosis}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
Dear Mr. ___, 

You were admitted to ___ with chest pain. Your EKG was 
unchanged from prior. You had a cardiac cath which was unchanged 
from your prior cath about six months ago. Given that this was 
unlikely to be accounting for your chest pain, there was no 
intervention. You were continued on your home medications, but 
still had a few episodes of chest pain. A new medication was 
added to help with this pain. You should continue to take all 
your home medications as prescribed. 

It was a pleasure taking care of you, 
Your ___ Doctors

 
___ Instructions:
___

###RESPONSE: chest pain {Chest pain}, EKG {Electrocardiographic procedure}, cardiac cath {Cardiac catheterization}, cath {Cardiac catheterization}, chest pain {Chest pain}, chest pain {Chest pain}, pain {Pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
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:
Diarrhea
 
Major Surgical or Invasive Procedure:
None

 

###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, 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: History of Present Illness:
Mr. ___ is a ___ YO homeless male who presented to the ED for 2 
days of watery green diarrhea. He was in his usual state of 
health until 3 days ago when he developed greenish watery 
diarrhea. He has had > 20 BMs a day. Also has had diffuse mild 
cramping, nausea, weakness, and pre-syncope. Today he noted 
fevers and chills. He has also has HA and a cough for 2 months 
and recently was prescribed a z pack for this ___. He 
denies emesis but has had loss of appetite (last meal 2 days 
ago). Denies undercooked meat. Possible sick contacts at the 
___. There is only one bathroom for > 100 residents. He also 
recently returned from ATL on a plane.  
.  
Of note, Mr. ___ denies current blood in his stool, but he had 
BRBPR 1 month ago with anemia and states that his PCP wanted to 
refer him for colonoscopy.  
.  
In the ED vital signs were: Temp:97.1 HR:130 BP:108/76 Resp:18 
O(2)Sat:100 RA. His EKG revealed sinus tacycardia. His abdomen 
was slightly tender. Patient had a CT scan of abd/pelvis and CXR 
which were both normal. Hct, chem 7, and LFTs were WNL except 
for bicarb 21. No anion gap. Patient was given 4 liters of 
intravenous fluids but remained tachycardic with HR 110-120 and 
then he spiked a temperature of 100.8. He was given zofran, 
famotidine, tylenol, and morphine. He was admitted for fluid 
hydration. Vital signs at the time of transfer were 100.3 111 
124/76 18 100RA  
.  
On the floor, pt is still having multiple bouts of diarrhea, but 
otherwise denies complaint.  
.  
Review of systems:  
(+) Per HPI. Also + for rhinorha, HA, cough. No SOB, CP, or 
palpitations. No dysuria. Denied arthralgias or myalgias and 
rash.
 

###RESPONSE: homeless {Homeless}, watery {Liquid stool}, green {Feces color: green}, diarrhea {Diarrhea}, greenish {Feces color: green}, watery {Liquid stool}, diarrhea {Diarrhea}, diffuse {Diffuse pain}, nausea {Nausea}, weakness {Asthenia}, pre-syncope {Near syncope}, fevers {Fever}, chills {Chill}, HA {Headache}, cough {Cough}, emesis {Vomiting}, loss of appetite {Loss of appetite}, blood in his stool {Hematochezia}, BRBPR {Hematochezia}, anemia {Anemia}, colonoscopy {Colonoscopy}, RA {Breathing room air}, EKG {Electrocardiographic procedure}, sinus tacycardia {Sinus tachycardia}, abdomen 
was slightly tender {Abdominal tenderness}, CT scan of abd/pelvis {Computed tomography of abdomen and pelvis}, CXR {Plain chest X-ray}, LFTs were WNL {Liver function tests within reference range}, intravenous fluids {Intravenous infusion}, tachycardic {Tachycardia}, HR {Finding of heart rate}, Vital signs {Vital signs finding}, diarrhea {Diarrhea}, rhinorha {Nasal discharge}, HA {Headache}, cough {Cough}, SOB {Dyspnea}, CP {Chest pain}, palpitations {Palpitations}, dysuria {Dysuria}, arthralgias {Joint pain}, myalgias {Muscle pain}, rash {Eruption of skin}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
1. Homelessness: Lives in shelter by ___ for past few months 
since moved here from ___. Recently applied for ___ 
___  
2. bronchitis - presented to ED ___ with multiple complaints - 
treated with albuterol inhaler and Z pack  
3. anxiety/depression - presented to ED ___ and ___. Paranoid personality disorder  
5. nephrolithiasis - seen on CT scan  
6. Trigger finger - offerred surgery but has declined  
7. h/o head trauma at age ___ s/p being struck in head with a  
baseball. Denies LOC at that time.  
8. s/p MVA ___ years ago, pedestrian struck by utility vehicle. 
+LOC.  
9. HTN  
10. spinal stenosis  
11. PTSD 
 

###RESPONSE: Homelessness {Homeless}, bronchitis {Bronchitis}, multiple complaints {Multiple symptoms}, anxiety/depression {Mixed anxiety and depressive disorder}, Paranoid personality disorder {Paranoid personality disorder}, nephrolithiasis {Kidney stone}, CT scan {Computed tomography of abdomen}, Trigger finger {Acquired trigger finger}, head trauma {Injury of head}, head {Head structure}, LOC {Loss of consciousness}, MVA {Motor vehicle accident victim}, LOC {Loss of consciousness}, HTN {Hypertensive disorder, systemic arterial}, spinal stenosis {Spinal stenosis}, PTSD {Posttraumatic stress disorder}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
CAD- 4 brothers had MI  
mother had stent placed  
father lung cancer  
sister with depression, daughter with bipolar d/O  

 

###RESPONSE: CAD {Coronary arteriosclerosis}, MI {Myocardial infarction}, stent placed {Stented coronary artery}, lung cancer {Malignant tumor of lung}, depression {Depressive disorder}, bipolar d/O {Bipolar 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: Physical Exam:
Vitals: T: 98.3 BP: 135/90 P: 99 R: 18 O2: 100% RA  
General: Alert, oriented, no acute distress  
HEENT: Sclera anicteric, dry MM, oropharynx clear  
Neck: supple, JVP not elevated, no LAD  
Lungs: Clear to auscultation bilaterally, no wheezes, rales, 
ronchi  
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops  
Abdomen: + BS, diffusely tender to palpation in all quadrants, 
soft, mildly distended, no rebound tenderness or guarding, no 
organomegaly or ascites, rectal exam revealed no stool in vault, 
Guaiac neg.  
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema
 

###RESPONSE: Vitals {Vital signs finding}, BP {Blood pressure finding}, RA {Breathing room air}, General {General examination of patient}, Alert {Mentally alert}, oriented {Orientated}, distress {Distress}, HEENT {Physical examination procedure}, Sclera anicteric {White sclera}, dry MM {Mucous membrane dryness}, oropharynx clear {Pharynx normal}, Neck {Physical examination procedure}, supple {Normal movement of neck}, JVP not elevated {Normal jugular venous pressure}, LAD {Lymphadenopathy}, Lungs {Examination of respiratory system}, Clear to auscultation bilaterally {Normal breath sounds}, wheezes {Wheezing}, rales {Respiratory crackles}, ronchi {Wheeze - rhonchi}, CV {Cardiovascular physical examination}, tachycardic {Tachycardia}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, murmurs {Murmur}, rubs {Pericardial friction rub}, gallops {Gallop rhythm}, Abdomen {Examination of abdomen}, BS {Normal bowel sounds}, tender {Abdominal tenderness}, palpation {Palpation}, soft {Abdomen soft}, distended {Swollen abdomen}, rebound {Rebound tenderness}, tenderness {Tenderness}, guarding {Abdominal guarding}, organomegaly {Abdominal organomegaly}, ascites {Ascites}, rectal exam {Rectal examination}, Guaiac {Guaiac test for occult blood in feces specimen}, Ext {Examination of limb}, Warm {Warm skin}, well perfused {Normal tissue perfusion}, 2+ pulses {Peripheral pulses normal}, clubbing {Clubbing}, cyanosis {Cyanosis}, edema {Edema}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 09:35PM   LACTATE-1.1
___ 04:20PM   GLUCOSE-121* UREA N-16 CREAT-1.1 SODIUM-137 
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-21* ANION GAP-14
___ 04:20PM   ALT(SGPT)-15 AST(SGOT)-25 ALK PHOS-83
___ 04:20PM   LIPASE-31
___ 04:20PM   WBC-6.1 RBC-5.17 HGB-14.5 HCT-42.3 MCV-82# 
MCH-28.0 MCHC-34.2# RDW-13.7
___ 04:20PM   NEUTS-84.3* LYMPHS-10.7* MONOS-2.6 EOS-2.1 
BASOS-0.3
___ 04:20PM   PLT COUNT-265

  OVA + PARASITES (Final ___: 
      NO OVA AND PARASITES SEEN. 
      This test does not reliably detect Cryptosporidium, 
Cyclospora or
      Microsporidium. While most cases of Giardia are detected 
by routine
      O+P, the Giardia antigen test may enhance detection when 
organisms
      are rare. 

   FECAL CULTURE - R/O VIBRIO (Preliminary): 

   FECAL CULTURE - R/O YERSINIA (Preliminary): 

   FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: 
      NO E.COLI 0157:H7 FOUND. 

   Cryptosporidium/Giardia (DFA) (Preliminary): 

___ 10:16 pm STOOL     CONSISTENCY: NOT APPLICABLE
      Source: Stool. 

                            **FINAL REPORT ___

   OVA + PARASITES (Final ___: 
      NO OVA AND PARASITES SEEN. 
      This test does not reliably detect Cryptosporidium, 
Cyclospora or
      Microsporidium. While most cases of Giardia are detected 
by routine
      O+P, the Giardia antigen test may enhance detection when 
organisms
      are rare. 

___ 7:08 am STOOL     CONSISTENCY: LOOSE      Source: 
Stool. 

   FECAL CULTURE (Final ___:    NO SALMONELLA OR SHIGELLA 
FOUND. 

   CAMPYLOBACTER CULTURE (Pending): 

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___: 
      Feces negative for C.difficile toxin A & B by EIA. 
           (Reference Range-Negative). 

 

###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}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, PHOS {Phosphate, total measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, CULTURE {Microbial culture}, CULTURE {Microbial culture}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
Mr. ___ is a ___ YO homeless male who presented with acute 
diarrhea and was admitted for rehydration.  

# Diarrhea: Pt has acute onset of diarrhea, fever, nausea, and 
anorexia, most likely infectious. Given time of year and 
exposure to sick contacts in crowded shelter Viral 
gastroenteritis was felt to be the most likley etiology. Stool 
studies were sent regardless. He was placed on a bland diet and 
treated symptomatically with loperamide, IVF prn, and tylenol 
for abdominal pain. On HD2 his diarrhea had improved, he had 
remiained afebrile with stable VS and was tolerating bland diet 
with minimal abdominal pain. C diff and HIV were both negative 
as were O&P x2. There was no salmonella, shigella or Ecoli 
OH:571. Studies for yersinia, vibrio and cryptosporidum were 
pending at the time of discharge and should be followed up by 
his PCP as the results become available.
.
. 
# Sinus tachycardia: Likely from volume depletion. Pt received 
5L NS in the ED and an additional 1L of NS once on the floor. 
His tachycardia subsequently resolved and his VS remined stable 
throughout the course of his hospitalization.
 
.  
# Chronic cough: CXR no evidence of pneumonia. Pt does have post 
nasal drip which could contribute to chronic cough. He was not 
hypoxic nor was he ever in distress. This will need to be 
adressed by his PCP. 
.  
# Depression:  
COntinued home medications. He will follow up with his 
depression support group.
.  
# Homeless: SW saw and evaluated patient and have made 
arrangments for temporary housing following discharge. Please 
refer to their note for details.
.
# Hx of BRBRP: Pt denies current bleeding. But had seveal 
episodes of blood streaked toilet paper during his admission. 
His HCT remained stable. Thought secondary to hemmorhoids vs 
irritation from frequent stooling. Pt's last C-scope was ___ years 
ago in ___ and was reportedly normal. He should follow up 
with his PCP for appropriate screening/ further workup.

 

###RESPONSE: homeless {Homeless}, acute 
diarrhea {Acute diarrhea}, rehydration {Rehydration therapy}, Diarrhea {Diarrhea}, acute onset of diarrhea {Acute diarrhea}, fever {Fever}, nausea {Nausea}, anorexia {Loss of appetite}, infectious {Infectious disease}, Viral 
gastroenteritis {Viral gastroenteritis}, Stool 
studies {Stool microscopy}, bland diet {Bland diet}, abdominal pain {Abdominal pain}, diarrhea {Diarrhea}, improved {Patient's condition improved}, stable VS {Normal vital signs}, bland diet {Bland diet}, abdominal pain {Abdominal pain}, HIV {Human immunodeficiency virus infection}, Sinus tachycardia {Sinus tachycardia}, tachycardia {Tachycardia}, his VS remined stable {Normal vital signs}, Chronic cough {Chronic cough}, CXR {Plain chest X-ray}, no evidence {No abnormality detected}, pneumonia {Pneumonia}, post 
nasal drip {Posterior rhinorrhea}, chronic cough {Chronic cough}, hypoxic {Hypoxia}, distress {Distress}, Depression {Depressive disorder}, Homeless {Homeless}, BRBRP {Hematochezia}, bleeding {Bleeding}, hemmorhoids {Hemorrhoids}, frequent stooling {Frequent defecation}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
1. risperidone 2 mg Tablet Sig: One (1) Tablet PO at bedtime.  
2. citalopram Oral 

 
Discharge Medications:
1. risperidone 2 mg Tablet Sig: One (1) Tablet PO at bedtime.  
2. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times 
a day) as needed for loose stools for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
3. citalopram  Oral

 

###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:
Viral enteritis

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: Viral enteritis {Inflammation of intestine caused by virus}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted to ___ because you had diarrhea that made 
you dehydrated. The most likely cause of your diarrhea was a 
viral gastroenteritis. We gave you IV fluids and managed your 
symptoms with a medication called loperamide that helps decrease 
the frequency of bowel movements. 

While you were here we made the following changes to your 
medications:
We started you on Loperamide 2mg every 4 hours as needed for 
diarrhea.

Otherwise you should continue taking your home medications as 
prescribed
 

###RESPONSE: diarrhea {Diarrhea}, dehydrated {Dehydration}, diarrhea {Diarrhea}, viral gastroenteritis {Viral gastroenteritis}, 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: 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: 
___
 
Attending: ___.
 
Chief Complaint:
Agitation, seizure
 
Major Surgical or Invasive Procedure:
none

 

###RESPONSE: Agitation {Feeling agitated}, seizure {Seizure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Patient is a ___ y/o M with a hx of intractable seizures on 
multiple meds and with recent placement of vagal nerve 
stimulator who presents after having been found to be shaking, 
""dizzy"" and combative at his home today. He called a family 
member saying he did not feel well, and he was found shaking, 
unable to stop on his own, and was brought to the ED

Also of note, he is currently on an abx being treated for 
diverticulitis. He has been on augmentin for this for an unclear 
amount of time, likely since ___, the time of his first CT 
showing acute diverticulitis.

The patient does not remembers dates and exact sequential onset 
of symptoms. He has had diarrhea, and thinks it probably started 
after Abx use, but isnt sure.

In the ED, He was extremely agitated, thrashing and using 
profane language. he recieved 2mg Ativan IV x2. He also got 
flagyl and cipro IV in the ED.
 

###RESPONSE: seizures {Seizure}, placement of vagal nerve 
stimulator {Insertion of vagal nerve stimulator}, shaking {Tremor}, dizzy {Dizziness}, combative {Aggressive behavior}, not feel well {Malaise}, shaking {Tremor}, abx {Antibiotic therapy}, diverticulitis {Diverticulitis}, CT {Computed tomography}, diverticulitis {Diverticulitis}, diarrhea {Diarrhea}, Abx {Antibiotic therapy}, agitated {Feeling agitated}, IV {Intravenous therapy}, IV {Intravenous 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:
- intractable seizures
- s/p VNS (___)
- h/o post-op psychosis and behavioral problems post anesthesia
- Meningitis at 6 months old
- Left temporal head trauma with brief LOC at ___ yo
- h/o Arm fracture
- h/o Left orbital fracture--> required surgical repair and had
residual visual defects
- Near drowning in ___
- s/p Left leg amputation s/p prosthesis
 

###RESPONSE: seizures {Seizure}, VNS {Insertion of vagal nerve stimulator}, post-op {Postoperative state}, psychosis {Psychotic disorder}, behavioral problems {Problem behavior}, Meningitis {Meningitis}, Left temporal {Left temporal lobe structure}, brief LOC {Brief loss of consciousness}, Arm fracture {Fracture of upper limb}, orbital fracture {Fracture of orbit}, surgical repair {Repair of orbit proper}, visual defects {Visual field defect}, Near drowning {Nonfatal submersion}, Left leg {Structure of left lower limb}, amputation {Amputation of 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:
Father has pacemaker @ ___ yo; healthy mother & two sisters. No 
family history of epilepsy, vertigo, other neurologic disease.  
Born in ___, of ___ ancestry, no consanguinity.

 

###RESPONSE: epilepsy {Epilepsy}, vertigo {Vertigo}, neurologic disease {Disorder of nervous system}, consanguinity {Consanguinity}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Vitals: T: 98.1 BP: 134/88 P: 70 RR: 22 O2Sat: 98% 2L
Gen: No acute distress
HEENT: EOMI, left pupil dilated (secondary to injury), but 
reactive to light. rt reactive to light.
Neck: supple. no LAD
CV: RRR, nl s1 s2, no g/r/m
Lungs: clear to ausc, very slow inspiration and expiration 
secondary to yogic breathing.
ABd: +BS. tender to palp throughout, esp RLQ. +BS. no HSM. no 
rebounnd tenderness
Extremities: below knee amp left leg
Neuro: please see neuro note for detailed neuro exam.
 

###RESPONSE: Vitals {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, O2Sat {Oxygen saturation measurement}, Gen {General examination of patient}, distress {Distress}, HEENT {Physical examination procedure}, EOMI {Normal ocular motility}, pupil dilated {Dilated pupil}, injury {Traumatic or non-traumatic injury}, reactive to light {Finding of pupil reaction to light}, rt {Structure of pupil of right eye}, reactive to light {Finding of pupil reaction to light}, Neck {Physical examination procedure}, supple {Normal movement of neck}, LAD {Lymphadenopathy}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, nl s1 s2 {Heart sounds normal}, g {Gallop rhythm}, r {Pericardial friction rub}, m {Murmur}, Lungs {Examination of respiratory system}, clear to ausc {Chest clear}, slow inspiration and expiration {Slow respiration}, ABd {Examination of abdomen}, +BS {Normal bowel sounds}, tender {Abdominal tenderness}, palp {Palpation of abdomen}, RLQ {Structure of right lower quadrant of abdomen}, +BS {Normal bowel sounds}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, Extremities {Examination of limb}, below knee amp left leg {Amputated left lower limb below knee}, Neuro {Neurological examination}, neuro exam {Neurological examination}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ abdomen/pelvis CT with contrast
IMPRESSION:
1. Interval progression of inflammatory stranding in the left 
lower quadrant along a hyperenhancing area of sigmoid colon with 
multiple diverticula and seberal foci of extraluminal air 
consistent with diverticulitis with microperforation. No 
drainable fluid collections.
2. Prostatic enlargement.
3. Punctate focus of air within the bladder with no CT evidence 
for colonic vesicular fistula. Findings may relate to recent 
instrumentation. Clinical correlation is recommended.
.
CXR ___
FINDINGS: Single bedside AP examination labeled ""upright at 
13:51"" with patient markedly tilted to his right, is compared 
with the most recent study dated ___. A metallic 
neurostimulator device overlies the mid-left hemithorax, as 
before. Bibasilar subsegmental atelectasis and/or scarring, as 
well as multiple old healed right rib fractures with associated 
lateral pleural thickening, are redemonstrated. Allowing for 
this, no acute focal airspace process is identified. There is no 
evidence of CHF.
.
___ Head CT
IMPRESSION: No acute intracranial abnormality.
.

 

###RESPONSE: abdomen {Computed tomography of abdomen with contrast}, inflammatory {Inflammatory disorder}, left 
lower quadrant {Structure of left lower quadrant of abdomen}, sigmoid colon {Sigmoid colon structure}, multiple diverticula {Multiple diverticula}, diverticulitis {Diverticulitis}, Prostatic enlargement {Large prostate}, bladder {Urinary bladder structure}, colonic vesicular fistula {Vesicocolic fistula}, CXR {Plain chest X-ray}, left {Left lung structure}, hemithorax {Structure of half of thorax lateral to midsagittal plane}, Bibasilar {Structure of base of lung}, atelectasis {Atelectasis}, scarring {Scar}, right rib {Bone structure of right rib}, fractures {Fracture of multiple ribs}, pleural thickening {Thickening of pleura}, CHF {Congestive heart failure}, Head CT {Computed tomography of head}, intracranial {Intracranial structure}, abnormality {No abnormality detected}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Assessment: Pt is a ___ y/o M with hx intractable seizures, s/p 
VNS placed ___, who presents to the ED in likely post-ictal 
state, in setting of decreased seizure threshold with 
diverticulitis. CT showing diverticulitis with microperferation.

Hospital Course By Problem:

Diverticulitis: Pt was diagnosed with divertitulitis intially as 
an outpatient, on ___. He had a CT scan at that time. A repeat 
CT on ___ (day of admission), showed progression of disease, 
patient now with microperforation. Surgery was consulted given 
this is complicated diverticulitis. He was put on broad spectrum 
antibiotics, intially zosyn and vancomycin. Vancomycin was 
eventually discontinued given low suspicion for gram positive 
infection on bowel. Patient was on bowel rest, NPO, and on TPN. 
A PICC line was placed for the TPN and IV antibiotics since he 
has poor venous access. Patients abdominal pain improved slowly. 
Once minimal, he was started on a liquid diet, which he 
tolerated, and this was slowly advanced to regular diet. TPN was 
tapered off. Prior to discharge, the patient was switched to PO 
augmentin, which he is to continue for a total of 3 weeks of 
abx, so until ___. He was also seen by nutrition several 
times, including once with his HCP present, to go over changes 
in his diet given his new diagnosis of diverticulitis. 
.
Diarrhea: Patient had small amounts of diarrhea during 
hospitaliztion, which came back positive for clostridium 
dificile. He has a history of difficult to control seizures, so 
flagyl is avoided since it lowers seizure threshold. He was 
started on vancomycin PO 250mg q6h, which he was will continued 
until ___, 2 weeks after augmentin course is done. 
.
Agitation: Patient was agitated in the ED, likely has lower 
seizure threshold given diverticulitus. This may also be 
delerium from infection. On suggestion by epilepsy service, he 
was put on ativan standing and PRN
.
Hx of seizures: patient has significant hx of seizures, has 
vagal nerve stimulator since ___. At this time, he likely has 
lower seizure threshold secondary to infection. He was followed 
by the epilepsy service while in the hospital. Most of 
medications were switched to IV during hospitalization while he 
was NPO. He was continued on the home meds as listed. Levels of 
carbamazipine and phenytoin were checked almost daily and 
bolused and adjusted as needed. He was also placed on standing 
ativan 1mg BID while infected. Once tolerating PO, he was 
switched back to PO meds, and discharged on the medications he 
was admitted on. The Ativan was tapered off on discharge. 
.
Leukocytosis: likely secondary to diverticulitis, resolved. 
UA/UC: negative, blood cx negative, CXR normal.
.
NSVT on tele: asymptomatic, possible that it was interaction 
with vagal nerve stimulator. cardiac enzymes negative. EKG 
normal. no recurrance.
 

###RESPONSE: Assessment {Evaluation procedure}, seizures {Seizure}, VNS placed {Insertion of vagal nerve stimulator}, post-ictal 
state {Post-ictal state}, seizure {Seizure}, diverticulitis {Diverticulitis}, CT {Computed tomography}, diverticulitis {Diverticulitis}, Diverticulitis {Diverticulitis}, divertitulitis {Diverticulitis}, CT scan {Computed tomography of abdomen}, CT {Computed tomography}, disease {Disease}, Surgery was consulted {Medical consultation on hospital inpatient}, diverticulitis {Diverticulitis}, antibiotics {Antibiotic therapy}, infection on bowel {Intestinal infectious disease}, bowel {Intestinal structure}, NPO {Nil by mouth}, on TPN {Total parenteral nutrition}, PICC line {Peripherally inserted central venous catheter in situ}, TPN {Administration of total parenteral nutrition}, IV antibiotics {Intravenous antibiotic therapy}, poor venous access {Poor venous access}, abdominal pain {Abdominal pain}, improved {Patient's condition improved}, liquid diet {Liquid diet}, regular diet {Normal diet}, TPN {Total parenteral nutrition}, seen by nutrition {Seen by hospital-based dietitian}, diet {Dietary finding}, diverticulitis {Diverticulitis}, Diarrhea {Diarrhea}, diarrhea {Diarrhea}, seizures {Seizure}, seizure {Seizure}, Agitation {Feeling agitated}, agitated {Feeling agitated}, seizure {Seizure}, diverticulitus {Diverticulitis}, delerium {Delirium}, infection {Infectious disease}, suggestion by epilepsy service {Medical consultation on hospital inpatient}, seizures {Seizure}, seizures {Seizure}, vagal nerve stimulator {Insertion of vagal nerve stimulator}, seizure {Seizure}, infection {Infectious disease}, epilepsy service {Seen by neurologist}, medications {Administration of drug or medicament}, IV {Intravenous therapy}, NPO {Nil by mouth}, medications {Administration of drug or medicament}, Leukocytosis {Leukocytosis}, diverticulitis {Diverticulitis}, resolved {Problem resolved}, UA {Urinalysis}, UC {Urine culture}, blood cx {Blood culture}, CXR normal {Standard chest X-ray normal}, NSVT {Nonsustained ventricular tachycardia}, tele {Cardiac telemetry}, asymptomatic {Asymptomatic}, vagal nerve stimulator {Insertion of vagal nerve stimulator}, cardiac enzymes negative {Cardiac enzymes within reference range}, EKG 
normal {Electrocardiogram 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: Medications on Admission:
CARBAMAZEPINE 200 mg--1 tab bid and 2 tabs at bedtime
DILANTIN 160 mg QAM / 200QPM
LAMICTAL 150 mg--1 tablet(s) by mouth at 4 pm & 2 tabs @ 10pm
Multi-Vitamin W/Minerals --1 capsule(s) by mouth daily
TRILEPTAL 150 mg--1 tablet(s) by mouth daily at 10 am
AUGMENTIN 875/125 PO BID
 
Discharge Medications:
1. Dilantin Kapseal 30 mg Capsule Sig: Two (2) Capsule PO every 
morning.  
2. Dilantin Kapseal 100 mg Capsule Sig: One (1) Capsule PO every 
morning.  
3. Dilantin Kapseal 100 mg Capsule Sig: Two (2) Capsule PO every 
night.  
4. Lamotrigine 150 mg Tablet Sig: One (1) Tablet PO at 4pm 
everday.  
5. Lamotrigine 150 mg Tablet Sig: Two (2) Tablet PO at 10pm.  
6. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2 
times a day).  
7. Carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO QHS (once 
a day (at bedtime)).  
8. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO Q10AM ().  

9. Amoxicillin-Pot Clavulanate 250-125 mg Tablet Sig: Two (2) 
Tablet PO Q8H (every 8 hours) for 12 days: Until ___.
Disp:*80 Tablet(s)* Refills:*0*
10. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 
6 hours) for 26 days: until ___.
Disp:*110 Capsule(s)* Refills:*0*
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times 
a day) for 5 days: Please take 1 pill twice a day for 2 days; 
and then 1 pill once a day for 3 days after that. (total 5 
days).
Disp:*8 Tablet(s)* Refills:*0*
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*

 

###RESPONSE: mg {Blood magnesium measurement}, 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
Diverticulitis
Clostridium Dificile infection

Secondary:
Seizures

 
Discharge Condition:
stable.

 

###RESPONSE: Diverticulitis {Diverticulitis}, Clostridium Dificile infection {Infection caused by Clostridioides difficile}, Seizures {Seizure}, stable {Patient's condition stable}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You came to the hospital with abdominal pain. A CT scan was done 
of your abdomen and you were found to have diverticulitis. You 
were treated with antibiotics through your IV and bowel rest. 
Once your abdominal pain got better, you were started on a diet. 

.
You have been switched to oral antibiotics, Augmentin, which you 
should take until ___. For the Clostridium Dificile 
infection, you should continue to take the oral Vancomycin until 
___. 
.
You spoked to a nutritionist while you were here about dietary 
restrictions with Diverticulosis. She provided you with 
information sheets about diet. You were intstructed to avoid any 
food with small seeds, including strawberries. Also avoid small 
nuts and popcorn. Also try to slowly increase the fiber in your 
diet. 
.
You should continue the epilepsy regimen you were on prior to 
admission. In addition, you were taking ativan while here, and 
you should taper that off. Please take 1 pill twice a day for 2 
days, and then 1 pill once a day for 3 days after that, and then 
stop taking them. 
.
You should not go to work until after you have been cleared by 
someone in the neurology department or your PCP next week.
.
Please call your PCP or go to the hospital if you experience 
worsening abdominal pain, worsening diarrhea, or increases 
seizures. 
 

###RESPONSE: Discharge Instructions {Final inpatient visit with instructions at discharge}, abdominal pain {Abdominal pain}, CT scan was done 
of your abdomen {Computed tomography of abdomen}, diverticulitis {Diverticulitis}, treated with antibiotics {Antibiotic therapy}, IV {Intravenous therapy}, bowel rest {Nil by mouth}, abdominal pain {Abdominal pain}, diet {Dietary finding}, oral antibiotics {Oral antibiotic therapy}, Clostridium Dificile 
infection {Infection caused by Clostridioides difficile}, oral {Administration of drug or medicament via oral route}, spoked to a nutritionist {Seen by hospital-based dietitian}, Diverticulosis {Diverticulosis of large intestine}, diet {Dietary finding}, diet {Dietary finding}, epilepsy {Epilepsy}, regimen {Therapeutic regimen}, PCP {Primary care management}, PCP {Primary care management}, abdominal pain {Abdominal pain}, diarrhea {Diarrhea}, seizures {Seizure}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
gunshot wound to abdomen
 
Major Surgical or Invasive Procedure:
Exploratory laparotomy and repair of gunshot wound to the 
stomach and jejunum.

 

###RESPONSE: No Known Allergies to Drugs {Non-allergic hypersensitivity to drug or medicament}, gunshot wound {Gunshot wound}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, Exploratory laparotomy {Exploratory laparotomy}, repair {Surgical repair}, gunshot wound {Gunshot wound}, stomach {Repair of stomach}, jejunum {Repair of duodenum}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Recharge is a ___ year old male who was medflighted from scene to 
___ after sustaining a single small caliber gunshot wound to 
his LLQ.  He was taken emergently to the OR.  

He lives in ___, but along with his mother, was visiting his 
two sisters in ___.  The night of the incident, the pt was 
with his cousins, + ETOH, ___ was ___ in the ER, when his group 
was approached by several men.  He heard a shot and the next 
thing he remembers was being in the helicopter.  
 

###RESPONSE: gunshot wound {Gunshot wound}, LLQ {Structure of left lower quadrant of abdomen}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Laparoscopic appendectomy
 

###RESPONSE: Laparoscopic appendectomy {Laparoscopic appendectomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
NC
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
PE: Temp: 97.8F   HR 88  BP 108/80  RR 16  O2 Sat 97%RA
Gen: NAD
HEENT: PERRL, EOMI, sclera anicteric
CV: RRR
Pulm: Moving air well, some occas coarse breath sounds at left 
base
Abd: soft, incision clead, dry, intact. Staples in place.  
Ext: 2+pulses throughout, no c/ce

 

###RESPONSE: PE {General examination of patient}, Temp {Body temperature finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, RA {Breathing room air}, Gen {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, sclera anicteric {White sclera}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, Pulm {Examination of respiratory system}, left 
base {Structure of base of left lung}, Abd {Examination of abdomen}, soft {Abdomen soft}, incision {Surgical incision wound}, Ext {Examination of limb}, 2+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:
___ 12:48AM BLOOD WBC-13.0* RBC-4.28* Hgb-12.5* Hct-36.9* 
MCV-86 MCH-29.1 MCHC-33.8 RDW-13.7 Plt ___
___ 03:45AM BLOOD WBC-19.0* RBC-4.00* Hgb-11.6* Hct-34.9* 
MCV-87 MCH-29.1 MCHC-33.3 RDW-13.9 Plt ___
___ 08:11AM BLOOD Hct-33.1*
___ 06:02AM BLOOD WBC-15.7* RBC-4.22* Hgb-12.4* Hct-36.3* 
MCV-86 MCH-29.3 MCHC-34.2 RDW-13.4 Plt ___
___ 07:01PM BLOOD WBC-16.9* RBC-3.97* Hgb-11.9* Hct-34.5* 
MCV-87 MCH-29.8 MCHC-34.4 RDW-13.6 Plt ___
___ 06:05AM BLOOD WBC-13.6* RBC-3.76* Hgb-11.1* Hct-32.7* 
MCV-87 MCH-29.6 MCHC-34.1 RDW-13.6 Plt ___
___ 06:50AM BLOOD WBC-10.2 RBC-3.62* Hgb-10.5* Hct-31.3* 
MCV-87 MCH-29.0 MCHC-33.5 RDW-13.3 Plt ___
___ 03:45AM BLOOD ___ PTT-29.0 ___
___ 12:48AM BLOOD Glucose-117* UreaN-12 Creat-0.8 Na-146* 
K-3.0* Cl-108 HCO3-22 AnGap-19
___ 07:35PM BLOOD Glucose-128* UreaN-12 Creat-0.8 Na-137 
K-3.8 Cl-101 HCO3-27 AnGap-13
___ 03:45AM BLOOD Calcium-8.9 Phos-5.2* Mg-1.5
___ 07:35PM BLOOD Calcium-8.8 Phos-2.6* Mg-2.0
___ 12:48AM BLOOD ASA-NEG Ethanol-67* Acetmnp-NEG 
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Hct {Hematocrit determination}, 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}, 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}, 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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Brief Hospital Course:
The pt was medflighted from the scene and was taken emergently 
to the operating room, discovering a GSW through stomach and 
into jejunum, with injury to the transverse mesocolon, jejunum 
distal to ligament of treitz as well as a retroperitoneal 
hematoma

anterior and posterior gastrostomy and jejunostomy.  These were 
repaired primarily.  He was also noted to have a small 
retroperitoneal hematoma.  Postoperatively, he did well and was 
transferred to the floor from the trauma ICU on POD 1.   

On a CT scan with contrast done to locate the bullet he was 
noted to have an 8 x 10mm left renal pseudoaneurysm.  He was 
seen by vascular surgery, but no intervention was required.  

Complicating the pt's stay was the development of fevers and 
left lobe consolidation thought to be secondary to aspiration 
pneumonia.  He was started a 10 day course of levaquin.  By time 
of discharge, he was afebrile, tolerating a regular diet, pain 
was controlled with po pain medicine, and able to ambulate.  He 
was discharged home to his sister's house.  He will follow up in 
the trauma clinic but will most likely return to ___ after 
that.  

Several staples were removed prior to discharge.  The incision 
was clean, dry, and intact without signs of infection.  
 

###RESPONSE: GSW {Gunshot wound}, stomach {Stomach structure}, jejunum {Jejunal structure}, injury {Traumatic or non-traumatic injury}, transverse mesocolon {Structure of transverse mesocolon}, jejunum {Jejunal structure}, ligament of treitz {Structure of suspensory muscle of duodenum}, retroperitoneal 
hematoma {Retroperitoneal hematoma}, gastrostomy {Repair of stomach}, jejunostomy {Repair of jejunostomy}, repaired {Surgical repair}, retroperitoneal hematoma {Retroperitoneal hematoma}, CT scan {Computed tomography of abdomen}, left renal {Vascular structure of left kidney}, pseudoaneurysm {Pseudoaneurysm}, fevers {Fever}, left lobe {Left lung structure}, consolidation {Consolidation}, aspiration 
pneumonia {Aspiration pneumonia}, regular diet {Normal diet}, pain {Chest pain}, pain {Chest pain}, able to ambulate {Able to walk}, follow up {Follow-up arranged}, uma clinic {Outpatient care management}, incision {Surgical incision wound}, signs {Sign}, infection {Postoperative wound infection}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
None
 
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).
Disp:*60 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
Q4H (every 4 hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
5. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for 
6 days.
Disp:*6 Tablet(s)* Refills:*0*

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home
 
Discharge Diagnosis:
Gunshot wound to abdomen
Pneumonia

 
Discharge Condition:
Stable, afebrile, tolerating a regular diet

 

###RESPONSE: Gunshot wound {Gunshot wound}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, Pneumonia {Pneumonia}, Stable {Patient's condition stable}, regular diet {Normal diet}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Instructions:
You were admitted to the hospital after you suffered a gunshot 
wound to your abdomen and had emergency surgery.  While in the 
hospital, you developed a pneumonia and you were treated with 
antibiotics.  You will need to continue the antibiotic for 
several days after discharge.  

For pain, you can take tylenol or ibuprofen.  For severe pain, 
you can take the prescription medication, percocet.  If you take 
the percocet, please do not drive or drink alcohol.  Also, you 
should not take tylenol with percocet because percocet already 
contains tylenol.  

Several of your staples were removed.  Your incision was then 
closed with sticky tape.  You can get this wet but please do not 
soak in a tub or pool.  The tapes will fall off on their own.  

Please return call your doctor or return to the ER if you 
develop shortness of breath, chest pain, bloody cough, nausea or 
vomiting, fever, or other new or concerning symptoms.  
 

###RESPONSE: gunshot 
wound {Gunshot wound}, abdomen {Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall}, emergency surgery {Emergency operation}, pneumonia {Pneumonia}, antibiotics {Antibiotic therapy}, antibiotic {Antibiotic therapy}, pain {Pain}, severe pain {Severe pain}, incision {Surgical incision wound}, shortness of breath {Dyspnea}, chest pain {Chest pain}, bloody cough {Hemoptysis}, nausea {Nausea}, vomiting {Vomiting}, fever {Fever}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Allergies: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
back pain
 
Major Surgical or Invasive Procedure:
ALIF L4-L5
Posterior L4-L5 laminectomy and fusion and removal ___ 
rod
 

###RESPONSE: Penicillins {Allergy to penicillin}, back pain {Backache}, ALIF {Interbody fusion of lumbar spine by anterior approach}, L4-L5 laminectomy {Excision of lamina of lumbar vertebra}, fusion {Lumbar spinal fusion}, removal {Removal}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
___ presented to Dr. ___ office with complaints of 
worsening back and leg pain. After review of the patients 
history and physical examination in the office, as well as 
radiographic studies, it was determined they would be a good 
candidate for anterior and posterior L4-L5 fusion and removal of 
___ rod. The patient was in agreement with the plan and 
consent was obtained and signed.
 

###RESPONSE: back {Backache}, leg pain {Pain in lower limb}, history and physical examination {History AND physical examination}, radiographic studies {Imaging}, fusion {Lumbar spinal fusion}, removal {Removal}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
asthma, allergies
GI problems
depression
OCD/PTSD/bipolar disorder
pneumonia, migraines, chickenpox
arthritis
hemorrhoids
psoriasis

PSH: thoracic fusion in ___, three neck surgeries, 
hysterectomy, C-section, bladder sling, polyps removed
 

###RESPONSE: asthma {Asthma}, GI {Structure of digestive system}, depression {Depressive disorder}, OCD {Obsessive-compulsive disorder}, PTSD {Posttraumatic stress disorder}, bipolar disorder {Bipolar disorder}, pneumonia {Pneumonia}, migraines {Migraine}, chickenpox {Varicella}, arthritis {Arthritis}, hemorrhoids {Hemorrhoids}, psoriasis {Psoriasis}, thoracic fusion {Fusion of thoracic spine}, neck {Neck pain}, surgeries {Surgical procedure}, hysterectomy {Hysterectomy}, C-section {Cesarean section}, bladder sling {Repair of stress incontinence by suprapubic sling}, polyps removed {Resection of polyp}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
cancer, diabetes, neurologic disease, skin disease, blood 
disorders, arthritis, hypertension
 

###RESPONSE: cancer {Malignant neoplasm}, diabetes {Diabetes mellitus}, neurologic disease {Disorder of nervous system}, skin disease {Disorder of skin}, disorders {Disease}, arthritis {Arthritis}, hypertension {Hypertensive disorder, systemic arterial}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
On examination the patient is well developed, well nourished, 
A&O x3 in NAD. AVSS.
Range of motion of the lumbar spine is somewhat limited on 
flexion, extension and lateral bending due to pain.
Ambulating well with the assistance of a walker and ___, with 
brace for support.
Gross motor examination reveals good strength throughout the 
bilateral lower extremities.
There is no clonus present. 
Sensation is intact throughout all affected dermatomes.
The thoracolumbar incision is clean, dry and intact without 
erythema, edema or drainage.
The patient is voiding well without a foley catheter.

 

###RESPONSE: well nourished {Well nourished}, A {Mentally alert}, O x3 {Oriented to person, time and place}, NAD {No abnormality detected}, AVSS {Vital signs finding}, lumbar spine {Structure of lumbar vertebral column}, limited on 
flexion, extension and lateral bending {Limitation of joint movement}, pain {Pain}, support {Support}, lower extremities {Lower limb structure}, clonus {Clonus}, Sensation {Normal sensation}, affect {Mood finding}, dermatomes {Dermatome}, thoracolumbar {Structure of thoracic and/or lumbar region of back}, incision {Surgical incision wound}, erythema {Erythema}, edema {Edema}, drainage {Discharge}, voiding {Normal micturition}, foley {Catheterization of urinary bladder}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
___ 06:24AM BLOOD WBC-6.3 RBC-3.22* Hgb-9.3* Hct-29.5* 
MCV-92 MCH-28.9 MCHC-31.5* RDW-12.5 RDWSD-41.8 Plt ___
___ 06:24AM BLOOD Glucose-116* UreaN-6 Creat-0.5 Na-138 
K-4.2 Cl-96 HCO___-34* AnGap-12
___ 06:24AM BLOOD Calcium-8.4 Phos-4.7* Mg-2.___riefly, ___ was admitted to the ___ Spine Surgery 
Service on ___ and taken to the Operating Room for an 
anterior lumbar interbody fusion L4-L5 through an anterior 
approach. Please refer to the dictated operative note for 
further details. The surgery was performed without complication, 
the patient tolerated the procedure well and was transferred to 
the PACU in a stable condition. TEDs/pnemoboots were used for 
postoperative DVT prophylaxis. Intravenous antibiotics were 
given per standard protocol. Initial postop pain was controlled 
with a dilaudid PCA. The patient remained NPO. On HD#2, she 
returned to the operating room for a posterior L4-L5 laminectomy 
and fusion and ___ rod removal scheduled as part of a 
staged 2-part procedure. Please refer to the dictated operative 
note for further details. The second surgery was also without 
complication and the patient was transferred to the PACU in a 
stable condition. Postoperative labs were grossly stable. The 
patient remained NPO until bowel function returned, then diet 
was advanced as tolerated. The patient was transitioned to oral 
pain medication when tolerating PO diet. Foley was removed on 
POD#2 from the second procedure, and the patient was able to 
void. A hemovac drain that was placed at the time of surgery was 
also removed on POD#2. A brace was fitted for comfort and 
support. She received 2 units of pRBCs due to acute 
post-operative blood loss anemia. Physical therapy was consulted 
for mobilization OOB to ambulate. Hospital course was otherwise 
unremarkable. On the day of discharge the patient was afebrile 
with stable vital signs, comfortable on oral pain control and 
tolerating a regular diet.
 

###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, anterior lumbar interbody fusion {Interbody fusion of lumbar spine by anterior approach}, surgery {Surgical procedure}, procedure {Surgical procedure}, stable {Patient's condition stable}, DVT prophylaxis {Prevention of deep vein thrombosis}, Intravenous antibiotics {Intravenous antibiotic therapy}, postop pain {Postoperative pain}, PCA {Patient controlled analgesia}, remained NPO {On nothing by mouth status}, laminectomy {Excision of lamina of vertebra}, fusion {Lumbar spinal fusion}, removal {Removal}, procedure {Surgical procedure}, surgery {Surgical procedure}, stable {Patient's condition stable}, stable {Patient's condition stable}, remained NPO {On nothing by mouth status}, bowel {Intestinal structure}, oral {Administration of drug or medicament via oral route}, pain medication {Administration of analgesic}, Foley was removed {Removal of urinary bladder catheter}, able to 
void {Normal micturition}, removed {Removal of drain}, support {Support}, blood loss anemia {Anemia due to blood loss}, mobilization {Mobilization}, unremarkable {No abnormality detected}, stable {Patient's condition stable}, pain control {Pain control}, tolerating a regular diet {Tolerating normal diet}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. dextroamphetamine-amphetamine 15 mg oral QAM 
2. Amphetamine-Dextroamphetamine XR 30 mg PO DAILY 
3. Gabapentin 300 mg PO TID 
4. Diazepam 10 mg PO Q8H:PRN muscle spasm 
5. Senna 8.6 mg PO BID:PRN constipation 
6. Morphine SR (MS ___ 30 mg PO Q12H 
7. OxyCODONE (Immediate Release) 15 mg PO Q6H 
8. mometasone 220 mcg (14 doses) inhalation DAILY 
9. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild 
10. Omeprazole 20 mg PO BID 
11. Albuterol Sulfate (Extended Release) Dose is Unknown  PO 
Frequency is Unknown 
12. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze, sob 
13. Vitamin D ___ UNIT PO DAILY 

 
Discharge Medications:
1.  Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever  
2.  Docusate Sodium 100 mg PO BID 
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day 
Disp #*60 Capsule Refills:*0 
3.  Albuterol Sulfate (Extended Release) 4 mg PO Q12H  
4.  Diazepam 5 mg PO Q6H:PRN spasm 
RX *diazepam 5 mg 1 tab by mouth every six (6) hours Disp #*90 
Tablet Refills:*0 
5.  Morphine SR (MS ___ 60 mg PO Q12H 
RX *morphine [MS ___ 60 mg 1 tablet(s) by mouth every twelve 
(12) hours Disp #*60 Tablet Refills:*0 
6.  OxyCODONE (Immediate Release) 15 mg PO Q3H:PRN Pain - 
Moderate 
RX *oxycodone 15 mg 1 tablet(s) by mouth q3h Disp #*112 Tablet 
Refills:*0 
7.  Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze, sob  
8.  Amphetamine-Dextroamphetamine XR 30 mg PO DAILY  
9.  dextroamphetamine-amphetamine 15 mg oral QAM  
10.  Gabapentin 300 mg PO TID 
RX *gabapentin [Neurontin] 300 mg 1 capsule(s) by mouth three 
times a day Disp #*90 Capsule Refills:*0 
11.  mometasone 220 mcg (14 doses) inhalation DAILY  
12.  Omeprazole 20 mg PO BID  
13.  Senna 8.6 mg PO BID:PRN constipation 
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp 
#*60 Tablet Refills:*0 
14.  Vitamin D ___ 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:
Lumbar spondylosis, scoliosis, and disk degeneration.

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory.

 

###RESPONSE: Home With Service {Home health aide service management}, Lumbar spondylosis {Lumbar spondylosis}, scoliosis {Scoliosis deformity of spine}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
ACTIVITY: DO NOT lift anything greater than 10 lbs for 2 weeks. 

___ times a day you should go for a walk for ___ minutes as 
part of your recovery. You can walk as much as you can tolerate. 

You will be more comfortable if you do not sit or stand more 
than ~45 minutes without changing positions.

BRACE: You have been given a brace. This brace should be worn 
for comfort when you are walking. You may take it off when 
sitting in a chair or while lying in bed.

WOUND: Remove the external dressing in 2 days. If your incision 
is draining, cover it with a new dry sterile dressing. If it is 
dry then you may leave the incision open to air. Once the 
incision is completely dry, (usually ___ days after the 
operation) you may shower. Do not soak the incision in a bath or 
pool until fully healed. If the incision starts draining at any 
time after surgery, cover it with a sterile dressing. Please 
call the office. 
Please call the office if you have a fever>101.5 degrees 
Fahrenheit and/or drainage from your wound.

MEDICATIONS: You should resume taking your normal home 
medications. Refrain from NSAIDs immediately post operatively.

You have also been given Additional Medications to control your 
post-operative pain. Please allow our office 72 hours for refill 
of narcotic prescriptions. Please plan ahead. You can either 
have them mailed to your home or pick them up at ___ 
___, ___. We are not able 
to call or fax narcotic prescriptions to your pharmacy. In 
addition, per practice policy, we only prescribe pain 
medications for 6 months from the date of surgery.
 

###RESPONSE: walk {Does walk}, walk as much as you can tolerate {Education about increasing activity tolerance}, sit {Does sit}, stand {Does stand}, walking {Does walk}, sitting {Sitting position}, lying in bed {Lying in bed}, WOUND {Wound treatment education}, incision {Surgical incision wound}, draining {Wound discharge}, new dry sterile dressing {Change of dressing}, incision {Surgical incision wound}, incision {Surgical incision wound}, incision {Surgical incision wound}, incision {Surgical incision wound}, draining {Wound discharge}, sterile dressing {Application of dressing, sterile}, fever {Fever}, drainage from your wound {Wound discharge}, post-operative pain {Postoperative pain}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: 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: 
Sulfa (Sulfonamide Antibiotics) / Ceftin / Biaxin
 
Attending: ___.
 
Chief Complaint:
Obesity
 
Major Surgical or Invasive Procedure:
___: Laparoscopic Roux-en-Y Bypass

 

###RESPONSE: Sulfa {Allergy to sulfonamide}, Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, Ceftin {Allergy to cephalosporin}, Biaxin {Allergy to clarithromycin}, Obesity {Obesity}, Laparoscopic {Laparoscopic procedure}, Roux-en-Y Bypass {Roux-en-Y gastrojejunostomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
Per Dr. ___

___ is a ___ female referred for evaluation
of gastric restrictive surgery in the treatment and management 
of
morbid obesity by her primary care physician ___ in
___.  ___ was seen and evaluated in our ___ clinic initially ___ and
___ with follow-up sessions on ___ and ___.  

___ has class II severe obesity with weight of 233.9 pounds as
of ___.  Her initial screen weight on ___ was 232.8 
pounds
with her highest weight in this time period as 236.1 pounds on
___.  Her height is 65.5 inches and her BMI is 39.2.  Her
previous weight loss efforts have included Weight Watchers, 
___, Nutrisystem, the Grapefruit Diet, self-initiated diets 
and
exercise.  She has not taken prescription weight loss 
medications
or used over-the-counter ephedra-containing appetite
suppressants/herbal supplements.  She has been able to lose up 
to
22 pounds but her weight loss attempts have failed to produce
lasting results.  She stated that her lowest adult weight was 
150
pounds at the age of ___ and her highest weight was 236.1 pounds
on ___ and she weighed 236 pounds ___ years ago when weighed at
the ___.  She stated that she has been
struggling with weight since the birth of her daughter and cites
as factors contributing to her excess weight large portions,
convenience eating, emotional eating, inconsistent meal pattern
and lack of exercise.  Her current physical activity is walking
her dog for 15 minutes ___ times a day at a slow pace.  She
denied history of eating disorders - no anorexia, bulimia,
diuretic or laxative abuse and she denied binge eating.  She 
does
have a diagnosis of depression and has been followed by a
therapist as well as a psychopharmacologist.  She was
hospitalized for depression in ___ and she is on several
psychotropic medications (buspirone, duloxetine).
 

###RESPONSE: evaluation {Evaluation procedure}, f gastric restrictive surgery {Operation on stomach}, morbid obesity {Morbid obesity}, primary care {Primary care management}, evaluated {Evaluation procedure}, clinic {Outpatient care management}, severe obesity {Severe obesity}, weight {Weight finding}, weight {Weight finding}, weight {Weight finding}, height {Height / growth finding}, BMI {Finding of body mass index}, weight loss {Weight loss}, Weight Watchers {Weight maintenance consultation}, Nutrisystem {Weight maintenance consultation}, Grapefruit Diet {Patient-initiated diet}, self-initiated diets {Patient-initiated diet}, exercise {Exercises}, prescription {Prescription of drug}, weight loss {Weight loss}, weight loss {Weight loss}, weight {Weight finding}, weight {Weight finding}, struggling with weight {Weight maintenance regimen}, birth {Mother delivered}, excess weight {Excessive weight gain}, large portions {Excessive eating}, inconsistent meal pattern {Irregular meal times}, lack of exercise {Lack of exercise}, activity {Finding of functional performance and activity}, walking {Does walk}, eating disorders {Eating disorder}, anorexia {Loss of appetite}, bulimia {Bulimia nervosa}, diuretic {Abuse of diuretics}, laxative abuse {Abuse of laxatives}, binge eating {Binge eating behavior}, depression {Depressive disorder}, depression {Depressive disorder}, psychotropic medications {On psychotropic medication}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Past Medical History:
Her medical history is noteworthy for:

1)  hypertension
2)  type 2 diabetes with hemoglobin A1c of 8.8% on ___ at 
    ___ (previous A1c was very high at 9.2%)
3)  hyperlipidemia with elevated triglycerides
4)  gastroesophageal reflux
5)  osteoarthritis of the hand joints
6)  history of paroxysmal supraventricular tachycardia
7)  carotid artery stenosis (moderate 50% blockage)
8)  chronic sinusitis
9)  history of hiatal hernia
10) hepatic steatosis by ultrasound
11) question of thyromegaly

Her surgical history is significant for:

1)  left breast biopsy that was benign
2)  cataract surgery
3)  tubal ligation
4)  tonsillectomy

 

###RESPONSE: hypertension {Hypertensive disorder, systemic arterial}, type 2 diabetes {Diabetes mellitus type 2}, hemoglobin A1c {Hemoglobin A1c measurement}, hyperlipidemia {Hyperlipidemia}, elevated triglycerides {Serum triglycerides above reference range}, gastroesophageal reflux {Gastroesophageal reflux disease}, osteoarthritis of the hand joints {Degenerative joint disease of hand}, paroxysmal supraventricular tachycardia {Paroxysmal supraventricular tachycardia}, carotid artery stenosis {Carotid artery stenosis}, chronic sinusitis {Chronic sinusitis}, hiatal hernia {Hiatal hernia}, hepatic steatosis {Steatosis of liver}, ultrasound {Ultrasonography of liver}, thyromegaly {Goiter}, left breast {Left breast structure}, cataract surgery {Cataract surgery}, tubal ligation {Ligation of fallopian tube}, tonsillectomy {Tonsillectomy}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Social History:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Family History:
Her family history is
noted for father deceased age ___ of ___; mother living age ___ and
history of atrial fibrillation, colon cancer and arthritis;
brother deceased age ___ of ___, diabetes and obesity; another
brother living age ___ with diabetes and carotid stenosis s/p
carotid endarterectomy; sister living age ___ with history of
breast CA and thyroid disease. 
 

###RESPONSE: deceased {Dead}, atrial fibrillation {Atrial fibrillation}, colon cancer {Malignant neoplasm of colon}, arthritis {Arthritis}, deceased {Dead}, diabetes {Diabetes mellitus}, obesity {Obesity}, diabetes {Diabetes mellitus}, carotid stenosis {Carotid artery stenosis}, carotid endarterectomy {Carotid endarterectomy}, breast CA {Malignant neoplasm of breast}, thyroid disease {Disorder of thyroid gland}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
Gen: Well appearing female in no acute distress
CV: Regular rate and rhythm, No M/T/H
Lungs: CTA b/l
Abdomen: Soft NT/ND, Incisions clean dry and intact
Extremeties: No edema, peripheral pulses strong and intact
 

###RESPONSE: Gen {General examination of patient}, Well appearing {Well cared for appearance}, no acute {No abnormality detected}, distress {Distress}, CV {Cardiovascular physical examination}, Regular rate and rhythm {Normal heart rate}, Lungs {Examination of respiratory system}, CTA {Normal breath sounds}, Abdomen {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, Incisions {Surgical incision wound}, clean dry and intact {Wound healing well}, Extremeties {Examination of limb}, edema {Edema}, peripheral pulses strong and intact {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:
Labs after admission:
___ 04:15PM BLOOD Glucose-156* UreaN-16 Creat-0.9 Na-139 
K-4.8 Cl-106 HCO3-26 AnGap-12
___ 04:15PM BLOOD Calcium-8.7 Phos-4.0 Mg-2.0
___ 08:00AM BLOOD WBC-12.7* RBC-3.85* Hgb-11.8* Hct-36.2 
MCV-94 MCH-30.8 MCHC-32.7 RDW-12.9 Plt ___
___ 07:56AM BLOOD Type-ART FiO2-70 pO2-83* pCO2-57* 
pH-7.31* calTCO2-30 Base XS-0 Intubat-NOT INTUBA Comment-SIMPLE 
FAC
___ 09:02AM BLOOD ___ PTT-29.3 ___

Labs prior to discharge:
___ 07:30AM BLOOD WBC-10.1 RBC-3.63* Hgb-11.1* Hct-34.5* 
MCV-95 MCH-30.5 MCHC-32.1 RDW-13.0 Plt ___
___ 07:30AM BLOOD Glucose-194* UreaN-9 Creat-0.7 Na-139 
K-4.2 Cl-100 HCO3-27 AnGap-16
___ 07:30AM BLOOD Calcium-9.0 Phos-2.1* Mg-1.9

Imaging:
___ CTA chest, abd, pelvis: 
1. No pulmonary embolism. 
2. Ground-glass opacity in the lung apices with diffuse, 
predominantly 
central, ground-glass nodules in both lungs, concerning for 
early 
bronchopneumonia.  This patient requires a followup chest CT as 
an outpatient 
to demonstrate resolution of these nodules after treatment. 
3. Small bilateral pleural effusions and bibasilar atelectasis. 
4. No evidence of bowel obstruction or anastomotic leak. 

___  BAS/UGI AIR/SBFT:
Normal postoperative appearance of the stomach and 
gastroesophageal junction without obstruction or leak. 

 

###RESPONSE: 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}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, 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}, BLOOD Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, CTA chest, abd, pelvis {Computed tomography angiography of thorax and abdomen and pelvis with contrast}, pulmonary embolism {Pulmonary embolism}, Ground-glass opacity {Ground glass lung opacity}, lung apices {Structure of apex of lung}, ground-glass {Ground glass lung opacity}, nodules in both lungs {Nodule of lung}, bronchopneumonia {Bronchopneumonia}, followup {Follow-up consultation}, chest CT {Computed tomography of chest}, resolution {Problem resolved}, nodules {Nodule of lung}, bilateral pleural effusions {Bilateral pleural effusion}, bibasilar {Structure of base of lung}, atelectasis {Atelectasis}, No evidence {No abnormality detected}, bowel obstruction {Intestinal obstruction}, anastomotic leak {Gastrointestinal anastomotic leak}, Normal {No abnormality detected}, postoperative {Postoperative state}, stomach {Stomach structure}, gastroesophageal junction {Cardioesophageal junction structure}, obstruction {Obstruction}, leak {Anastomosis, leaking}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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 presented to pre-op on ___. Pt was 
evaluated by anaesthesia and taken to the operating room for 
laparoscopic Roux-en-Y gastric bypass. There were no adverse 
events in the operating room; please see the operative note for 
details. Pt was extubated, taken to the PACU until stable. She 
was then transferred to ___ 9. On POD #1, Patient had an acute 
desaturation requiring 70 percent o2 via face mask and was 
transferred to TSICU. A chest X-ray showed low lung vol, 
moderate cardiomegaly, signs of mild fluid overload. A CT/CTA 
was done which ruled out pulmonary embolism but showed b/l 
pleural eff, apical findings concerning for bronchopneumonia. 
The patient was managed with a combination of O2 via facemask, 
chest ___, duonebs, and encouragement of Incentive spirometry. 
She soon reduced her O2 requirements to 2L via nasal cannula and 
was stable enough to be transferred out of the TSICU. Since that 
point she resumed the ___ bariatric gastric bypass pathway. 

Neuro: The patient was alert and oriented throughout 
hospitalization; pain was initially managed with a PCA and then 
transitioned to oral Roxicet once tolerating a stage 2 diet. 
CV: The patient remained stable from a cardiovascular 
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable thereafter from a 
pulmonary standpoint; vital signs were routinely monitored. Good 
pulmonary toilet, early ambulation and incentive spirometry were 
encouraged throughout hospitalization. 
GI/GU/FEN: The patient was initially kept NPO.  An upper GI 
study (POD1) were both negative for a leak, therefore, the diet 
was advanced sequentially to a Bariatric Stage 3 diet, which was 
well tolerated. Patient's intake and output were closely 
monitored.  JP output remained serosanguinous throughout 
admission; the drain was removed prior to discharge. Her insulin 
regimen was adjusted to reflect her lower postoperative blood 
glucose levels.
ID: The patient's fever curves were closely watched for signs of 
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs 
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___ 
dyne boots were used during this stay and was encouraged to get 
up and ambulate as early as possible.

At the time of discharge, the patient was doing well, afebrile 
with stable vital signs.  The patient was tolerating a stage 3 
diet, ambulating, voiding without assistance, and pain was well 
controlled.  The patient received discharge teaching and 
follow-up instructions with understanding verbalized and 
agreement with the discharge plan.

 

###RESPONSE: anaesthesia {Anesthesia consultation}, laparoscopic {Laparoscopic procedure}, Roux-en-Y gastric bypass {Roux-en-Y gastrojejunostomy}, operative {Surgical procedure}, extubated {Removal of endotracheal tube}, PACU {Postanesthesia care}, stable {Patient's condition stable}, desaturation {Oxygen saturation below reference range}, o2 via face mask {Oxygen administration by mask}, transferred to TSICU {Patient transfer to intensive care unit}, chest X-ray {Plain chest X-ray}, lung {Lung structure}, cardiomegaly {Cardiomegaly}, signs {Sign}, fluid overload {Hypervolemia}, CT {Computed tomography of chest}, CTA {Computed tomography angiography of chest with contrast}, pulmonary embolism {Pulmonary embolism}, b/l 
pleural eff {Bilateral pleural effusion}, apical {Structure of apex of lung}, bronchopneumonia {Bronchopneumonia}, O2 via facemask {Oxygen administration by mask}, chest {Thoracic structure}, Incentive spirometry {Incentive spirometry}, nasal cannula {Oxygen administration by nasal cannula}, stable {Patient's condition stable}, bariatric {Bariatric operative procedure}, gastric bypass {Bypass of stomach}, pathway {Care regime}, Neuro {Neurological examination}, alert {Mentally alert}, oriented {Orientated}, pain {Pain}, PCA {Patient controlled analgesia}, oral {Administration of drug or medicament via oral route}, tolerating {Tolerating diet}, CV {Cardiovascular physical examination}, stable {Patient's condition stable}, cardiovascular {Cardiovascular physical examination}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, stable {Patient's condition stable}, pulmonary {Examination of respiratory system}, vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, Good {Good therapeutic response}, pulmonary toilet {Airway toilet}, ambulation {Ambulation training}, incentive spirometry {Incentive spirometry}, NPO {Nil by mouth}, upper GI {Upper gastrointestinal tract structure}, study {Evaluation procedure}, negative {No abnormality detected}, leak {Anastomosis, leaking}, diet 
was advanced {Advance diet as tolerated}, Bariatric {Bariatric operative procedure}, Stage 3 diet {Dietary regime}, well tolerated {Tolerating diet}, intake and output {Measuring intake and output}, monitored {Monitoring procedure}, JP {Insertion of tube into jejunum}, output remained serosanguinous {Serosanguineous discharge from wound}, drain was removed {Removal of drain}, insulin 
regimen {Insulin regime}, postoperative {Postoperative state}, blood 
glucose levels {Finding of blood glucose level}, ID {Infection control procedure}, fever {Fever}, watched for signs of 
infection {Monitoring for signs and symptoms of infection}, blood counts {Blood test}, signs {Sign}, bleeding {Bleeding}, Prophylaxis {Preventive procedure}, heparin {Heparin therapy}, ambulate {Ambulation training}, afebrile {Fever}, stable vital signs {Normal vital signs}, tolerating a stage 3 
diet {Tolerating diet}, ambulating {Fully mobile}, voiding {Micturition finding}, pain was well 
controlled {Demonstrates adequate pain control}, teaching {Patient education}, follow-up {Follow-up arranged}, instructions {Patient education}, 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:
The Preadmission Medication list is accurate and complete.
1. BusPIRone 15 mg PO DAILY 
2. Duloxetine 30 mg PO DAILY 
3. Fexofenadine 180 mg PO DAILY 
4. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 
5. Lisinopril 10 mg PO DAILY 
6. Metoprolol Tartrate 25 mg PO DAILY 
7. Rosuvastatin Calcium 20 mg PO DAILY 
8. TraZODone 50 mg PO HS 

 
Discharge Medications:
1. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN pain 
RX *oxycodone-acetaminophen [Roxicet] 5 mg-325 mg/5 mL ___ ml 
by mouth every four (4) hours Refills:*0
2. Docusate Sodium (Liquid) 100 mg PO BID 
RX *docusate sodium 50 mg/5 mL 100 mg by mouth twice a day 
Refills:*0
3. Ranitidine (Liquid) 150 mg PO BID 
RX *ranitidine HCl 15 mg/mL 150 mg by mouth twice a day 
Refills:*3
4. BusPIRone 15 mg PO DAILY 
5. Duloxetine 30 mg PO DAILY 
6. Fexofenadine 180 mg PO DAILY 
7. Lisinopril 10 mg PO DAILY 
8. Metoprolol Tartrate 25 mg PO DAILY 
9. Rosuvastatin Calcium 20 mg PO DAILY 
10. TraZODone 50 mg PO HS 
11. Enoxaparin Sodium 30 mg SC BID Duration: 28 Days 
Start: ___ - ___, First Dose: Next Routine Administration 
Time 
RX *enoxaparin 30 mg/0.3 mL 30 mg SC twice a day Disp #*56 
Syringe Refills:*0
12. NPH 12 Units Breakfast
NPH 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *NPH insulin human recomb [Humulin N KwikPen] 100 unit/mL (3 
mL) 12 or 8 units SC 12 Units before BKFT; 8 Units before BED; 
Disp #*60 Syringe Refills:*3

 

###RESPONSE: mg {Blood magnesium measurement}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Obesity

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 

###RESPONSE: With Service {Home health aide service management}, Obesity {Obesity}, 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 - 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:

###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 Instructions: Please call your surgeon or return to 
the emergency department if you develop a fever greater than 
101.5, chest pain, shortness of breath, severe abdominal pain, 
pain unrelieved by your pain medication, severe nausea or 
vomiting, severe abdominal bloating, inability to eat or drink, 
foul smelling or colorful drainage from your incisions, redness 
or swelling around your incisions, or any other symptoms which 
are concerning to you.

Diet: Stay on Stage III diet until your follow up appointment. 
Do not self advance
diet, do not drink out of a straw or chew gum.

Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1.  You are being discharged on medications to treat the pain 
from your operation. These medications will make you drowsy and 
impair your ability to drive a motor vehicle or operate 
machinery safely. You MUST refrain from such activities while 
taking these medications.
2. You should begin taking a chewable complete multivitamin with 
minerals. No gummy vitamins.
3. You will be taking Zantac liquid ___ mg twice daily for one 
month. This medicine prevents gastric reflux.
4. You should take a stool softener, Colace, twice daily for 
constipation as needed, or until you resume a normal bowel 
pattern.
5. You must not use NSAIDS (non-steroidal anti-inflammatory 
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and 
Naproxen. These agents will cause bleeding and ulcers in your 
digestive system.

Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may 
resume moderate
exercise at your discretion, no abdominal exercises.

Wound Care:
You may shower, no tub baths or swimming. 
If there is clear drainage from your incisions, cover with 
clean, dry gauze. 
Your steri-strips will fall off on their own. Please remove any 
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling, 
redness, or drainage from the incision sites

 

###RESPONSE: emergency {Emergency treatment}, fever {Fever}, chest pain {Chest pain}, shortness of breath {Dyspnea}, abdominal pain {Abdominal pain}, pain {Pain}, pain medication {Administration of analgesic}, nausea {Nausea}, vomiting {Vomiting}, abdominal bloating {Abdominal bloating}, inability to eat {Unable to eat}, drink {Unable to drink}, drainage {Wound discharge}, incisions {Surgical incision wound}, redness {Redness of skin over lesion}, swelling {Swelling}, incisions {Surgical incision wound}, Diet {Obesity diet education}, Stage III diet {Dietary regime}, medications {Administration of analgesic}, pain {Pain}, operation {Surgical procedure}, medications will make you {Patient medication education}, drowsy {Drowsy}, impair your ability to drive a motor vehicle or operate 
machinery safely {Patient should not drive or operate machinery}, activities {Functional activity education}, while 
taking these medications {Patient medication education}, gastric reflux {Gastric reflux}, take a stool softener {Administration of laxative}, constipation {Constipation}, a normal bowel 
pattern {Normal bowel habits}, must not use {Patient medication education}, bleeding {Gastrointestinal hemorrhage}, ulcers in your 
digestive system {Gastrointestinal ulcer}, No heavy lifting {Recommendation to avoid activity of daily living}, exercise {Exercises}, abdominal exercises {Abdominal exercises}, no tub baths {Recommendation to avoid activity of daily living}, drainage {Wound discharge}, incisions {Surgical incision wound}, cover with 
clean, dry gauze {Application of dressing}, after surgery {Postoperative state}, increased pain {Increased pain}, swelling {Swelling}, redness {Redness of skin over lesion}, drainage {Wound discharge}, incision sites {Surgical incision wound}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Followup Instructions:
___

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT:  
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   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:
n/v/d
 
Major Surgical or Invasive Procedure:
None
 

###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, n/v/d {Nausea, vomiting and diarrhea}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: History of Present Illness:
Ms. ___ is a ___ woman w/ PMH multiple myeloma s/p 
chemotherapy currently undergoing GCSF injections in preparation 
for stem cell transplant this coming ___ presenting with 1 
week of general malaise and nausea, vomiting, diarrhea x 1 day.

She has had approximately 20 episodes of nonbloody nonbilious 
emesis as well as nonbloody watery diarrhea. She has had poor 
p.o. intake and subjective fevers and chills with profuse 
diaphoresis. She is currently getting treated at ___. 
Her most recent preparation shot was earlier today. The only 
other medical problem is anxiety and depression for which she 
takes Ativan as needed. No significant cough dysuria or 
hematuria. She does have some epigastric abdominal pain.

Exam was significant for tachycardia, dry mucous membranes, 
epigastric tenderness to palpation.

VS significant for Tmax 99.7, HR 111, BP 135/69, RR 16, O2Sat 
94% on RA.

CXR shows: Scattered bilateral densities overlying ribs may in 
part relate to rib lesions, new since ___, but also raise 
concern for underlying multifocal infection. No prior for 
comparison since ___.

CT A/P showed: multiple loops of small bowel with wall edema. 
Mild wall thickening of ascending colon, transverse colon, 
rectum. Associated mesenteric edema and small amount of ascites 
concerning for entero-proctocolitis. Numerous punched out lytic 
lesions within the pelvis, imaged spine, and proximal femurs
consistent with multiple myeloma.

She received Zofran, Lorazepam, NS and LR IVF 3L total, 
Clonazepam, Tylenol 1g, diphenhydramine 25 mg. 

She reports that she started feeling malaise and nausea a week 
ago. She started taking her GCSF shots 4 days ago. She reports 
that she started to have worsening nausea with vomiting of NBNB 
emesis and diarrhea, no  melena/hematochezia. She reports that 
she is having abdominal pain but also says that she's been 
having this for awhile and thinks this is from her multiple 
myeloma. She had a fever this week that she measured at home. 
She denies chest pains, SOB, cough. She denies lower extremity 
swelling. She feels
that all of her bones are aching and she can't get comfortable. 
She hasn't had morphine or other narcotics all day today. 
Doesn't feel like the Zofran is working for nausea. Feeling very 
anxious as well.

ROS: Pertinent positives and negatives as noted in the HPI.  All 
other systems were reviewed and are negative. 

 

###RESPONSE: multiple myeloma {Multiple myeloma}, chemotherapy {Chemotherapy}, stem cell transplant {Allogeneic peripheral blood stem cell transplant}, malaise {Malaise}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, emesis {Vomiting}, watery {Liquid stool}, diarrhea {Diarrhea}, poor 
p.o. intake {Inadequate oral intake}, fevers {Fever}, chills {Chill}, diaphoresis {Excessive sweating}, anxiety {Anxiety}, depression {Depressive disorder}, cough {Cough}, dysuria {Dysuria}, hematuria {Blood in urine}, epigastric abdominal pain {Epigastric pain}, tachycardia {Tachycardia}, dry mucous membranes {Mucous membrane dryness}, epigastric tenderness {Tenderness of epigastrium}, palpation {Palpation}, RA {Breathing room air}, CXR {Plain chest X-ray}, rib {Bone structure of rib}, lesions {Lesion}, infection {Infectious disease}, CT A/P {Computed tomography of abdomen and pelvis}, small bowel {Structure of small intestine}, edema {Edema}, thickening {Increased thickness}, ascending colon {Ascending colon structure}, transverse colon {Transverse colon structure}, rectum {Rectum structure}, mesenteric {Mesentery structure}, edema {Edema}, ascites {Ascites}, proctocolitis {Proctocolitis}, lytic 
lesions {Lytic lesion of bone on X-ray}, pelvis {Structure of pelvis}, spine {Structure of vertebral column}, proximal femurs {Bone structure of proximal femur}, malaise {Malaise}, nausea {Nausea}, nausea {Nausea}, vomiting {Vomiting}, emesis {Vomiting}, diarrhea {Diarrhea}, melena {Melena}, hematochezia {Hematochezia}, abdominal pain {Abdominal pain}, multiple 
myeloma {Multiple myeloma}, fever {Fever}, chest pains {Chest pain}, SOB {Dyspnea}, cough {Cough}, lower extremity 
swelling {Swelling of lower limb}, aching {Aching pain}, nausea {Nausea}, anxious {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: Past Medical History:
Multiple Myeloma
Chronic obstructive pulmonary disease 
Gastroesophageal reflux disease 
Chiari malformation type I 
Anxiety 
PTSD (post-traumatic stress disorder) 
Hypertensive disorder 
Asthma 
Colitis 
Erosive gastritis 
Anemia 
Arthritis 
Hyperlipidemia 
Depressive disorder 
Colon polyp 
HYSTERECTOMY 
ANTERIOR CRUCIATE LIGAMENT REPAIR 

 

###RESPONSE: Multiple Myeloma {Multiple myeloma}, Chronic obstructive pulmonary disease {Chronic obstructive lung disease}, Gastroesophageal reflux disease {Gastroesophageal reflux disease}, Chiari malformation type I {Chiari malformation type I}, Anxiety {Anxiety}, PTSD (post-traumatic stress disorder {Posttraumatic stress disorder}, Hypertensive disorder {Hypertensive disorder, systemic arterial}, Asthma {Asthma}, Colitis {Colitis}, Erosive gastritis {Erosive gastritis}, Anemia {Anemia}, Arthritis {Arthritis}, Hyperlipidemia {Hyperlipidemia}, Depressive disorder {Depressive disorder}, Colon polyp {Polyp of colon}, ANTERIOR CRUCIATE LIGAMENT REPAIR {Repair of anterior cruciate ligament of knee joint}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: 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:
Reviewed and found to be not relevant to this illness/reason for 
hospitalization.
 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Physical Exam:
VITALS: 99.1 PO 150 / 84 99 16 95% Ra 
GENERAL: alert, anxious, tearful, fidgeting, moving around in 
bed
a lot
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma. 
Oropharynx without visible lesion, erythema or exudate
CV: Heart tachycardic, no murmur, no S3, no S4.  No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally.  Breathing is non-labored
GI: Abdomen soft, non-distended, tender to palpation over lower
abdomen.  Bowel sounds present.  No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with 
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: tearful, anxious

DISCHARGE EXAM: 
Vital Signs: 98.8  127/67 98 18 96% RA
glucose: 
. 
GEN: NAD, ambulating , pleasant, interactive, nervous, anxious
EYES: PERRL, EOMI, conjunctiva clear, anicteric
ENT: moist mucous membranes, no exudates 
NECK: supple 
CV: RRR s1s2 nl, no m/r/g
PULM: CTA, no r/r/w 
GI: normal BS, mild diffuse tenderness, no HSM  
EXT: warm, no c/c/e
SKIN: no rashes 
NEURO: alert, oriented x 3, answers ? appropriately, follows 
commands, non focal
PSYCH: appropriate
ACCESS: PIV
FOLEY: absent

 

###RESPONSE: GENERAL {General examination of patient}, alert {Mentally alert}, anxious {Anxiety}, tearful {Crying associated with mood}, fidgeting {Fidgeting}, EYES {Ophthalmic examination and evaluation}, Anicteric {White sclera}, pupils equally round {Pupil size and shape normal}, ENT {Abdominal tenderness}, Ears {Ear structure}, nose {Nasal structure}, erythema {Erythema}, masses {Abdominal mass}, trauma {Traumatic injury}, Oropharynx {Oropharyngeal structure}, lesion {Lesion}, erythema {Erythema}, exudate {Exudate}, CV {Cardiovascular physical examination}, Heart {Cardiovascular physical examination}, tachycardic {Tachycardia}, murmur {Murmur}, no S3 {Third heart sound, S>3<, inaudible}, no S4 {Fourth heart sound, S>4<, inaudible}, JVD {Jugular venous engorgement}, RESP {Examination of respiratory system}, Lungs {Examination of respiratory system}, labored {Labored breathing}, GI {Examination of digestive system}, soft {Abdomen soft}, non-distended {Normal abdominal contour}, tender {Abdominal tenderness}, palpation {Palpation}, lower
abdomen {Lower abdomen structure}, Bowel sounds present {Normal bowel sounds}, HSM {Hepatosplenomegaly}, GU {Examination of genitourinary system}, suprapubic {Hypogastric region structure}, tenderness {Tenderness}, palpation {Palpation}, MSK {Musculoskeletal system physical examination}, Neck {Physical examination procedure}, supple {Normal movement of neck}, all extremities {All extremities}, SKIN {Examination of skin}, rashes {Eruption of skin}, ulcerations {Ulcer}, NEURO {Neurological examination}, Alert {Mentally alert}, oriented {Orientated}, face symmetric {Facial symmetry}, EOMI {Normal ocular motility}, speech fluent {Does speak fluently}, moves all limbs {Does move all four limbs}, sensation to light touch grossly
intact {Normal light touch sensation}, PSYCH {Psychiatry procedure or service}, tearful {Crying associated with mood}, anxious {Anxiety}, Vital Signs {Vital signs finding}, RA {Breathing room air}, GEN {General examination of patient}, NAD {No abnormality detected}, ambulating {Fully mobile}, anxious {Anxiety}, EYES {Ophthalmic examination and evaluation}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, conjunctiva clear {Conjunctiva normal}, anicteric {White sclera}, ENT {Abdominal tenderness}, moist mucous membranes {Moist oral mucosa}, exudates {Exudate}, NECK {Physical examination procedure}, supple {Normal movement of neck}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, s1s2 nl {Heart sounds normal}, no m/r/g {Heart sounds normal}, PULM {Examination of respiratory system}, CTA {Normal breath sounds}, GI {Examination of digestive system}, normal BS {Normal bowel sounds}, tenderness {Tenderness}, HSM {Hepatosplenomegaly}, EXT {Examination of limb}, warm {Warm skin}, SKIN {Examination of skin}, rashes {Eruption of skin}, NEURO {Neurological examination}, alert {Mentally alert}, oriented {Orientated}, PSYCH {Psychiatry procedure or service}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Pertinent Results:
ADMIT LABS:
WBC 54.3, Hgb 13.6, Plt 301
INR 1.2, PTT 26
Cr 0.7
AlkP 173
trop neg x 1
phos 2.2
lactate 2.1
flu negative

DISCHARGE LABS: 
___ 06:25AM BLOOD WBC-4.7 RBC-3.81* Hgb-11.1* Hct-34.5 
MCV-91 MCH-29.1 MCHC-32.2 RDW-15.9* RDWSD-52.6* Plt ___
___ 06:25AM BLOOD Glucose-87 UreaN-5* Creat-0.5 Na-141 
K-3.1* Cl-101 HCO3-27 AnGap-13
___ 06:25AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.8

# CXR (___): Scattered bilateral densities overlying ribs may 
in part relate to rib lesions, new since ___, but also 
raise concern for underlying multifocal infection. No prior for 
comparison since ___.

# CT A/P (___): IMPRESSION: 1. Multiple relatively collapsed 
loops of small bowel demonstrate wall edema.  Mild wall 
thickening of the ascending colon and possibly the transverse 
colon. Mild wall thickening and hyperemia of the rectum.  
Associated mesenteric edema and small amount of ascites.  
Findings concerning for entero-proctocolitis. 2. Numerous 
punched-out lytic lesions within the pelvis, imaged spine, and 
proximal femurs, consistent with multiple myeloma. 3. Anterior 
wedge compression deformities of T12 through L2 of indeterminate 
age, but unlikely to be acute. 
.

 

###RESPONSE: WBC {White blood cell count}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, CXR {Plain chest X-ray}, rib {Bone structure of rib}, lesions {Lesion}, infection {Infectious disease}, small bowel {Structure of small intestine}, edema {Edema}, thickening {Increased thickness}, ascending colon {Ascending colon structure}, transverse 
colon {Transverse colon structure}, thickening {Increased thickness}, hyperemia {Hyperemia}, rectum {Rectum structure}, mesenteric {Mesentery structure}, edema {Edema}, ascites {Ascites}, entero {Inflammation of intestine}, proctocolitis {Proctocolitis}, lytic lesions {Lytic lesion of bone on X-ray}, pelvis {Structure of pelvis}, spine {Structure of vertebral column}, proximal femurs {Bone structure of proximal femur}, multiple myeloma {Multiple myeloma}, compression {Compression}, deformities {Deformity}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the 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:
ASSESSMENT & PLAN: ___ F h/o multiple myeloma s/p chemotherapy 
currently undergoing GCSF injections in preparation for stem 
cell transplant this coming ___ presenting with 1 week of 
general malaise and nausea, vomiting, diarrhea x 1 day.

ACUTE/ACTIVE PROBLEMS:
# Fever
# Nausea/vomiting/diarrhea: 
# Body pain/aches
   Ms. ___ presented with nausea/vomiting/diarrhea, fever. 
Although severity of these symptoms reportedly increased in the 
setting of GCSF initation (x4 days), she reports diarrhea 
occurring even beforehand. Admit WBC was elevated 54.3, lactate 
2.1 - but in the setting of GCSF.
    CT A/P showed evidence of mild enteroproctocolitis. Workup 
of her symptoms included the following: Flu: neg, Stool cdiff, 
salmonella/shigella/campylobacter were neg, CMV VL was 
undetectable.  Of note, CXR was negative. 
    To evaluate whether the G-CSF may play a role in her 
symptomology, hematology was consulted.  They felt that her 
constellation of symptoms were not attributable to the G-CSF.  
Although there are reports of anaphylaxis to G-CSF use - this 
was considered unlikely.  
    She was placed on IV Zofran, lorazepam ___, and hydrated.  On 
the Day1 of hospitalization, her nausea/vomiting and diarrhea 
resolved.  There were no further episodes of fever.  Due to low 
suspicion for bacterial infection, no antibiotics were given.  
She noted steady improvement in her symptoms with good tolerance 
of PO solids on day of discharge.  She was reassured that she 
should expect full recovery from a likely viral gastroenteritis. 
 . 
  Cause of Body pain unclear.  ? side effect of the ___ as she 
describe it as her bones that are hurting her. 

# Leukocytosis:
# MM
  Being treated at ___. S/p XRT, chemotherapy (RVD - last 
___.  Was planned for BMT on ___ per Partner's records. On 
admit, with high WBC with bands likely due to the effect of 
GCSF.  Dr. ___ staff at ___ was consulted - and it was 
felt that harvesting and port would be have to be postponed 
until she recoevers.  Transfer to ___ was felt not indicated.  
Reportedly, in the future, a more supervised approach would be 
adopted for her next Harvesting attempt.  She was continued on 
acyclovir. 

CHRONIC/STABLE PROBLEMS:
#Anxiety
#Depression:
Continued on home citalopram, venlafaxine.  Ativan above as 
needed (per ___ hasn't had a prescription since ___

#HTN: continue diltiazem

GENERAL/SUPPORTIVE CARE:
# Nutrition/Hydration: regular diet
# Functional status: ambulatory
# Bowel Function: holding
# Lines/Tubes/Drains: PIVs
# Precautions: universal
# VTE prophylaxis: SQH
# Consulting Services: none
# Contacts/HCP/Surrogate and Communication: son
# Code Status/Advance Care Planning: Full Code, presumed
# Disposition: Home without services. . 

NOTE: She reports that she has run out of oxycodone (confirmed 
on PMP).  1 day of oxycodone was provided to provide bridge for 
her visit/contact with her PCP. 

 

###RESPONSE: multiple myeloma {Multiple myeloma}, chemotherapy {Chemotherapy}, stem 
cell transplant {Allogeneic peripheral blood stem cell transplant}, malaise {Malaise}, nausea, vomiting, diarrhea {Nausea, vomiting and diarrhea}, Fever {Fever}, Nausea/vomiting/diarrhea {Nausea, vomiting and diarrhea}, pain {Pain}, nausea/vomiting/diarrhea {Nausea, vomiting and diarrhea}, fever {Fever}, diarrhea {Diarrhea}, WBC was elevated {Leukocytosis}, CT A/P {Computed tomography of abdomen and pelvis}, enteroproctocolitis {Proctocolitis}, Flu {Influenza}, CXR {Plain chest X-ray}, anaphylaxis {Anaphylaxis}, nausea/vomiting and diarrhea {Nausea, vomiting and diarrhea}, fever {Fever}, bacterial infection {Bacterial infectious disease}, viral gastroenteritis {Viral gastroenteritis}, Body pain {Generalized aches and pains}, MM {Plasma cell myeloma}, XRT {X-ray beam therapy}, chemotherapy {Chemotherapy}, Anxiety
#Depression {Mixed anxiety and depressive disorder}, HTN {Hypertensive disorder, systemic arterial}, regular diet {Normal diet}"
"###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an ""EMPTY: No SNOMED annotations found in this fragment"" if there are none. For any that you find, you will return a list of: ""text {annotation}"", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: 
###TEXT: Medications on Admission:
The Preadmission Medication list may be inaccurate and requires 
futher investigation.
1. Vitamin D ___ UNIT PO 1X/WEEK (___) 
2. Diltiazem Extended-Release 240 mg PO DAILY 
3. Venlafaxine XR 75 mg PO DAILY 
4. Citalopram 40 mg PO DAILY 
5. Dexamethasone 4 mg PO DAILY:PRN during radiation 
6. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - 
Moderate 
7. Morphine Sulfate ___ 30 mg PO DAILY 
8. Morphine Sulfate ___ 60 mg PO QHS 
9. Acyclovir 400 mg PO Q8H 
10. Senna 17.2 mg PO DAILY 
11. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 

 
Discharge Medications:
1.  Acyclovir 400 mg PO Q8H  
2.  Citalopram 40 mg PO DAILY  
3.  Dexamethasone 4 mg PO DAILY:PRN during radiation  
4.  Diltiazem Extended-Release 240 mg PO DAILY  
5.  Morphine Sulfate ___ 30 mg PO DAILY  
6.  Morphine Sulfate ___ 60 mg PO QHS  
7.  Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line  
8.  OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - 
Moderate 
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours 
Disp #*6 Tablet Refills:*0 
9.  Senna 17.2 mg PO DAILY  
10.  Venlafaxine XR 75 mg PO DAILY  
11.  Vitamin D ___ UNIT PO 1X/WEEK (___)  

 

###RESPONSE: EMPTY: No SNOMED annotations found in this fragment"