Datasets:

JaimeML
/

snomed-entity-challenge

Dataset card Viewer Files Files and versions Community

Split (1)

train · 2.1k rows

text stringlengths 539 21.6k
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze: ###TEXT: 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}