Concept Mapping for file:




Input Sentence #1:
Date of services:
Section identified: date_of_service (codesystem=sectag, code=105)


Input Sentence #2:
In sections: date_of_service




Input Sentence #3: Thursday, 05/20/2010 17:13
In sections: date_of_service

C0585028:Thursday (Thursday) [Temporal Concept]




Input Sentence #4:

***END SECTION: date_of_service***


Input Sentence #5:




Input Sentence #6:
Chief Complaint:
Section identified: chief_complaint (codesystem=sectag, code=156)


Input Sentence #7:
In sections: chief_complaint




Input Sentence #8: SOB and chest pain
In sections: chief_complaint

C0392680:Sob ([D]Shortness of breath) [Sign or Symptom]

C0008031:Chest pain (Chest pain) [Sign or Symptom]




Input Sentence #9:

***END SECTION: chief_complaint***


Input Sentence #10:




Input Sentence #11:
History of present illness:
Section identified: history_present_illness (codesystem=sectag, code=158)


Input Sentence #12:
In sections: history_present_illness




Input Sentence #13: Mrs. Ztest is a 53 year old female with h/o DM2, htn, HLD, and PVD who presents with acute onset chest pain earlier today radiating to the left arm and back.
In sections: history_present_illness

C0580836:Old (Old (qualifier value)) [Temporal Concept]
C0439508:Year (/year) [Temporal Concept]
C0015780:Female (Females) [Organism Attribute]

C0455483:H O (H/O: * NOS) [Finding]

C1300562:Dm2 (dm2) [Quantitative Concept]

C0020538:Htn (Hypertensive disease NOS) [Disease or Syndrome]

C0020473:HLD (Lipidemia) [Disease or Syndrome]

C0085096:PVD (Peripheral vascular disease) [Disease or Syndrome]

C1276802:Acute onset (Sudden) [Qualitative Concept]

C0008031:Chest pain (Chest pain) [Sign or Symptom]

C0332301:Radiate (Radiating to) [Functional Concept]
C0750526:Today (Today) [Temporal Concept]
C1279919:Early (Early) [Temporal Concept]

C0230347:Left arm (Left upper arm structure) [Body Part, Organ, or Organ Component]




Input Sentence #14: She describes it as a strong pressure.
In sections: history_present_illness

C0234222:Pressure (Baresthesia) [Organ or Tissue Function]
C0442821:Strong (Strong) [Qualitative Concept]




Input Sentence #15: It began around 4am and awoke her from sleep, lasted about 15 minutes, and then resolved.
In sections: history_present_illness

C0587116:Sleep (During sleep) [Temporal Concept]

C0558291:Minute (Every minute) [Temporal Concept]




Input Sentence #16: It was also associated with dyspnea.
In sections: history_present_illness

C0013404:Dyspnea (Dyspnea) [Sign or Symptom]




Input Sentence #17: No nausea or vomiting but did have some diaphoresis.
In sections: history_present_illness

C0027497:Nausea (Nausea NOS) [Sign or Symptom] negate

C0042963:Vomit (Vomiting NOS) [Sign or Symptom] negate

C0038990:Diaphoresis (Sweating symptom NOS) [Finding]




Input Sentence #18: She also describes that she has been having similar chest pains and dyspnea with exertion over the last few months.
In sections: history_present_illness

C0008031:Chest pain (Chest pain) [Sign or Symptom]

C0231807:Dyspnea exertion (Dyspnea on exertion) [Sign or Symptom]

C0439507:Month (/month) [Temporal Concept]




Input Sentence #19: This has been getting worse in severity.
In sections: history_present_illness

C1457868:Wrong (Worse) [Qualitative Concept]
C0427004:Get (Cannot get about) [Finding]

C0439793:Severity (Severities) [Qualitative Concept]




Input Sentence #20: She says her DM has recently not been well controlled.
In sections: history_present_illness

C0011849:DM (Diabetes mellitus) [Disease or Syndrome]




Input Sentence #21: Her last hbA1c was 12 last month.
In sections: history_present_illness

C0019018:Hba1c (Glycosylated hemoglobin A) [Biologically Active Substance]

C0439507:Month (/month) [Temporal Concept]




Input Sentence #22:

***END SECTION: history_present_illness***


Input Sentence #23:




Input Sentence #24:
PAST MEDICAL HISTORY:
Section identified: past_medical_history (codesystem=sectag, code=374)


Input Sentence #25:
In sections: past_medical_history




Input Sentence #26: Hyperlipidemia
In sections: past_medical_history

C0020473:Hyperlipidemia (Lipidemia) [Disease or Syndrome]




Input Sentence #27: Peripheral Vascular Disease
In sections: past_medical_history

C0085096:Peripheral vascular disease (Peripheral vascular disease) [Disease or Syndrome]




Input Sentence #28: Depression
In sections: past_medical_history

C0011570:Depression (Mental Depression) [Mental or Behavioral Dysfunction]




Input Sentence #29: Breast and ovarian cancer
In sections: past_medical_history

C0006142:Breast cancer (Malignant tumor of breast) [Neoplastic Process]

C0029925:Ovarian cancer (OVARIAN CARCINOMA) [Neoplastic Process]




Input Sentence #30: Endometriosis (disorder)
In sections: past_medical_history

C0014175:Endometriosis (Endometriosis, site unspecified) [Disease or Syndrome]

C0012634:Disorder (Disease) [Disease or Syndrome]




Input Sentence #31: Diabetes mellitus type 2
In sections: past_medical_history

C0011860:Type 2 diabetes mellitus (Diabetes mellitus type 2) [Disease or Syndrome]




Input Sentence #32: Hypertensive disorder, systemic arterial
In sections: past_medical_history

C0020538:Systemic arterial disorder hypertensive disorder (Hypertensive disease NOS) [Disease or Syndrome]




Input Sentence #33: fe-deficiency anemia
In sections: past_medical_history

C0162316:Fe deficiency anemia (Iron deficiency anemia) [Disease or Syndrome]




Input Sentence #34:
PAST SURGICAL HISTORY:
Section identified: past_surgical_history (codesystem=sectag, code=381)


Input Sentence #35: Right Ovarian Cystectomy
In sections: past_medical_history->past_surgical_history

C0195488:Ovarian cystectomy (Removal of ovarian cyst) [Therapeutic or Preventive Procedure]
C0227873:Right ovary (Structure of right ovary) [Body Part, Organ, or Organ Component]




Input Sentence #36: EGD 06/30/2007
In sections: past_medical_history->past_surgical_history

C1322687:EGD (Endoscopes, Gastrointestinal Tract, Upper Tract) [Medical Device]




Input Sentence #37:

***END SECTION: past_surgical_history***


Input Sentence #38:
In sections: past_medical_history




Input Sentence #39:

***END SECTION: past_medical_history***


Input Sentence #40:
MEDICATIONS:
Section identified: medications (codesystem=sectag, code=430)


Input Sentence #41:
In sections: medications




Input Sentence #42: Nexium 40 milligram Cap 1 capsule by mouth dailyneeded for diarrhea
In sections: medications

C0393002:Cap 1 (CAP-1) [Immunologic Factor]
C0470232:40 (40) [Quantitative Concept]
C0439210:Milligram (mg) [Quantitative Concept]
C0939400:Nexium (Nexium) [Pharmacologic Substance]
C0006935:Capsule (capsule (pharmacologic)) [Biomedical or Dental Material]

C0419179:Mouth (Nil by mouth) [Therapeutic or Preventive Procedure]

C0011991:Diarrhea (Loose stool) [Sign or Symptom]




Input Sentence #43: Zolpidem 5 milligram Tab (Ambien) 1 tablet by mouth every evening at bedtime for five day(s)
In sections: medications

C1511466:HE 5 1 (CY51) [Cell]
C0439210:Milligram (mg) [Quantitative Concept]
C0078839:Zolpidem (zolpidem) [Pharmacologic Substance]
C0039225:Tablet (Tablet dose form (qualifier value)) [Biomedical or Dental Material]

C0487782:Ambien (Ambien) [Pharmacologic Substance]

C0419179:Mouth (Nil by mouth) [Therapeutic or Preventive Procedure]

C0587117:Evening (Evening) [Temporal Concept]

C0521112:Bedtime (Bedtime) [Temporal Concept]

C1275557:Five Day (Every five days) [Temporal Concept]




Input Sentence #44: Simvastatin 20 milligram Tab (Zocor) 1 tablet by mouth every evening for ninety day(s)
In sections: medications

C0074554:Simvastatin (Simvastatin (product)) [Pharmacologic Substance]
C0439210:Milligram (mg) [Quantitative Concept]
C0039225:Tablet (Tablet dose form (qualifier value)) [Biomedical or Dental Material]
C0673823:Endorphin 1 20 (endorphin (1-20)) [Amino Acid, Peptide, or Protein]

C0678181:Zocor (Zocor) [Pharmacologic Substance]

C0419179:Mouth (Nil by mouth) [Therapeutic or Preventive Procedure]

C0587117:Evening (Evening) [Temporal Concept]

C0439505:Day (/day) [Temporal Concept]




Input Sentence #45: Aspirin 81 milligram daily
In sections: medications

C0004057:Aspirin (Aspirin (product)) [Pharmacologic Substance]
C0332173:Daily (Daily) [Temporal Concept]
C0439210:Milligram (mg) [Quantitative Concept]




Input Sentence #46: Tamoxifen 20 milligram Tab 1 tablet by mouth daily for thirty day(s) [Please do not give more than the already prescribed 6 refills.]
In sections: medications

C0039286:Tamoxifen (Tamoxifen (product)) [Pharmacologic Substance]
C0439210:Milligram (mg) [Quantitative Concept]
C0039225:Tablet (Tablet dose form (qualifier value)) [Biomedical or Dental Material]
C0673823:Endorphin 1 20 (endorphin (1-20)) [Amino Acid, Peptide, or Protein]

C0332173:Daily (Daily) [Temporal Concept]
C0419179:Mouth (Nil by mouth) [Therapeutic or Preventive Procedure]

C0439505:Day (/day) [Temporal Concept]

C1553488:Refill (Refill) [Idea or Concept] negate
C0278329:Prescribe (Prescribed) [Functional Concept] negate




Input Sentence #47: Singulair 10 milligram Tab 1 tablet by mouth daily
In sections: medications

C0439210:Milligram (mg) [Quantitative Concept]
C0595724:Singulair (Singulair) [Pharmacologic Substance]
C0039225:Tablet (Tablet dose form (qualifier value)) [Biomedical or Dental Material]
C0426280:Apgar 1 minute 10 (Apgar at 1 minute = 10) [Finding]

C0332173:Daily (Daily) [Temporal Concept]
C0419179:Mouth (Nil by mouth) [Therapeutic or Preventive Procedure]




Input Sentence #48: Norvasc 5 milligram orally daily
In sections: medications

C0332173:Daily (Daily) [Temporal Concept]
C0439210:Milligram (mg) [Quantitative Concept]
C0162712:Norvasc (Mack Brand of Amlodipine Besilate) [Pharmacologic Substance]




Input Sentence #49: lantus 20 units qhs
In sections: medications

C0439148:Unit (Units) [Quantitative Concept]
C0876064:Lantus (Lantus) [Pharmacologic Substance]
C1275563:Qhs (Once a day, at bedtime) [Temporal Concept]




Input Sentence #50: metformin 1000 milligram bid
In sections: medications

C0585361:Bid (Twice a day) [Temporal Concept]
C0025598:Metformin (Metformin (product)) [Pharmacologic Substance]
C0439210:Milligram (mg) [Quantitative Concept]




Input Sentence #51: glyburide 5 milligram bid cc
In sections: medications

C0373595:Cc (Creatinine clearance measurement) [Laboratory Procedure]
C0585361:Bid (Twice a day) [Temporal Concept]
C0017628:Glyburide (Gyburide) [Pharmacologic Substance]
C0439210:Milligram (mg) [Quantitative Concept]




Input Sentence #52:

***END SECTION: medications***


Input Sentence #53:




Input Sentence #54:
ALLERGIES:
Section identified: allergies_and_adverse_reactions (codesystem=sectag, code=448)


Input Sentence #55:
In sections: allergies_and_adverse_reactions




Input Sentence #56: PCN - rash
In sections: allergies_and_adverse_reactions

C0030842:PCN (Penicillin -class of antibiotic-) [Antibiotic]

C0015230:Rash (Cutaneous eruption) [Disease or Syndrome]




Input Sentence #57: ACEI - angioedema
In sections: allergies_and_adverse_reactions

C0003015:ACEI (Kininase II Inhibitors) [Pharmacologic Substance]

C0002994:Angioedema (Angioedema) [Pathologic Function]




Input Sentence #58:

***END SECTION: allergies_and_adverse_reactions***


Input Sentence #59:




Input Sentence #60:
HEALTH MAINTENANCE:
Section identified: health_maintenance (codesystem=sectag, code=418)


Input Sentence #61:
In sections: health_maintenance




Input Sentence #62: Pneumovax: 11/09
In sections: health_maintenance

C0071315:Pneumovax (Pneumovax) [Immunologic Factor]




Input Sentence #63: Flu vaccine: 12/09
In sections: health_maintenance

C0021403:Flu vaccine (Influenza Virus Vaccines) [Immunologic Factor]




Input Sentence #64:

***END SECTION: health_maintenance***


Input Sentence #65:




Input Sentence #66:
Colonoscopy:
Section identified: colonoscopy (codesystem=sectag, code=903)


Input Sentence #67:
In sections: colonoscopy




Input Sentence #68: 5/08 (2 tubular adenomas)
In sections: colonoscopy

C0334292:Tubular adenoma (Tubular adenoma) [Neoplastic Process]




Input Sentence #69: Mammo: 8/09 (benign)
In sections: colonoscopy

C0205183:Benign (Benign) [Qualitative Concept]




Input Sentence #70:

***END SECTION: colonoscopy***


Input Sentence #71:




Input Sentence #72:
FAMILY MEDICAL HISTORY:
Section identified: family_medical_history (codesystem=sectag, code=315)


Input Sentence #73:
In sections: family_medical_history




Input Sentence #74: No family history of diabetes.
In sections: family_medical_history

C0260526:Family history diabetes (Family history of diabetes mellitus) [Finding] other_experiencer, negphrase




Input Sentence #75:

Section identified: mother_medical_history (codesystem=sectag, code=318)


Input Sentence #76: Mother has breast cancer.
In sections: family_medical_history->mother_medical_history

C0026591:Mother (Maternal) [Family Group] negphrase

C0006142:Breast cancer (Malignant tumor of breast) [Neoplastic Process] other_experiencer




Input Sentence #77:

***END SECTION: mother_medical_history***


Input Sentence #78:
In sections: family_medical_history




Input Sentence #79:

Section identified: father_medical_history (codesystem=sectag, code=319)


Input Sentence #80:
In sections: family_medical_history->father_medical_history




Input Sentence #81: Father has had lung CA and died of an MI at 64.
In sections: family_medical_history->father_medical_history

C0015671:Father (Father) [Family Group] negphrase

C0684249:CA lung (Cancer, Lung) [Neoplastic Process] other_experiencer

C0027051:MI (Myocardial infarction) [Disease or Syndrome] other_experiencer




Input Sentence #82:

***END SECTION: father_medical_history***


Input Sentence #83:
In sections: family_medical_history




Input Sentence #84:

***END SECTION: family_medical_history***


Input Sentence #85:
SOCIAL HISTORY:
Section identified: personal_and_social_history (codesystem=sectag, code=267)


Input Sentence #86:
In sections: personal_and_social_history




Input Sentence #87: Married.
In sections: personal_and_social_history

C0555047:Married (Married) [Finding]




Input Sentence #88: Has two children and two dogs.
In sections: personal_and_social_history

C0686744:Child (Well child) [Finding]
C0205448:Two (Two) [Quantitative Concept]

C0012984:Dog (Canis familiaris) [Mammal]




Input Sentence #89: Nonsmoker.
In sections: personal_and_social_history

C0337672:Nonsmoker (Non-smoker) [Finding]




Input Sentence #90: Rare alcohol use.
In sections: personal_and_social_history

C0001948:Alcohol use (Drinking, Alcohol) [Individual Behavior]
C0522498:Rare (Rare) [Qualitative Concept]




Input Sentence #91:

***END SECTION: personal_and_social_history***


Input Sentence #92:




Input Sentence #93:
REVIEW OF SYSTEMS:
Section identified: review_of_systems (codesystem=sectag, code=454)


Input Sentence #94:
In sections: review_of_systems




Input Sentence #95: 12 systems reviewed and negative except as mentioned in HPI.
In sections: review_of_systems

C0489633:Review system (Review of systems) [Health Care Activity]

C0205160:Negative (Negative for) [Qualitative Concept]

C0262512:HPI (History of (present illness)) [Organism Attribute]




Input Sentence #96:

***END SECTION: review_of_systems***


Input Sentence #97:




Input Sentence #98:
PHYSICAL EXAMINATION:
Section identified: physical_examination (codesystem=sectag, code=545)


Input Sentence #99:
In sections: physical_examination




Input Sentence #100:
General:
Section identified: general_exam (codesystem=sectag, code=546)


Input Sentence #101: awake and alert, well-developed, well-nourished
In sections: physical_examination->general_exam

C0239110:Alert (Consciousness clear) [Finding]

C0205170:Well (Good (qualifier value)) [Qualitative Concept]

C0424637:Nourish (Well nourished) [Finding]
C0205170:Well (Good (qualifier value)) [Qualitative Concept]




Input Sentence #102:

***END SECTION: general_exam***


Input Sentence #103:
In sections: physical_examination




Input Sentence #104:
Vital Signs:
Section identified: vital_signs (codesystem=sectag, code=547)


Input Sentence #105:
In sections: physical_examination->vital_signs




Input Sentence #106:
pulse:
Section identified: heart_rate (codesystem=sectag, code=552)


Input Sentence #107: 68
In sections: physical_examination->vital_signs->heart_rate




Input Sentence #108:

***END SECTION: heart_rate***


Input Sentence #109:
In sections: physical_examination->vital_signs




Input Sentence #110:
bp:
Section identified: blood_pressure (codesystem=sectag, code=562)


Input Sentence #111:
In sections: physical_examination->vital_signs->blood_pressure




Input Sentence #112: 180/95
In sections: physical_examination->vital_signs->blood_pressure




Input Sentence #113:

***END SECTION: blood_pressure***


Input Sentence #114:
In sections: physical_examination->vital_signs




Input Sentence #115:
temp:
Section identified: temperature (codesystem=sectag, code=548)


Input Sentence #116:
In sections: physical_examination->vital_signs->temperature




Input Sentence #117: 98.3
In sections: physical_examination->vital_signs->temperature




Input Sentence #118:

***END SECTION: temperature***


Input Sentence #119:
In sections: physical_examination->vital_signs




Input Sentence #120:

Section identified: oxygen_saturation (codesystem=sectag, code=563)


Input Sentence #121:
In sections: physical_examination->vital_signs->oxygen_saturation




Input Sentence #122: Oxygen Saturation 98? on room air
In sections: physical_examination->vital_signs->oxygen_saturation

C0523807:Oxygen saturation (Oxygen saturation measurement) [Diagnostic Procedure]

C0470250:98 (98) [Quantitative Concept]

C1547703:Room (Room) [Spatial Concept]
C1140091:Air (AIR) [Intellectual Product]




Input Sentence #123:

***END SECTION: oxygen_saturation***


Input Sentence #124:
In sections: physical_examination->vital_signs




Input Sentence #125:

***END SECTION: vital_signs***


Input Sentence #126:
Eyes:
Section identified: ophthalmologic_exam (codesystem=sectag, code=592)


Input Sentence #127:
In sections: physical_examination->ophthalmologic_exam




Input Sentence #128: PERRLA, conjunctiva clear, sclera anicteric
In sections: physical_examination->ophthalmologic_exam

C0522503:Clear (Translucent) [Qualitative Concept]
C0009758:Conjunctiva (Conjunctival structure) [Body Part, Organ, or Organ Component]

C0205180:Anicteric (Anicteric) [Finding]
C0036410:Sclera (Scleral structure) [Body Part, Organ, or Organ Component]




Input Sentence #129:

***END SECTION: ophthalmologic_exam***


Input Sentence #130:
In sections: physical_examination




Input Sentence #131:
ENT:
Section identified: ear_nose_throat_exam (codesystem=sectag, code=1124)


Input Sentence #132:
In sections: physical_examination->ear_nose_throat_exam




Input Sentence #133: no oral lesions, mucous membranes moist, not edentulous
In sections: physical_examination->ear_nose_throat_exam

C0149744:Oral lesion (Oral lesion) [Finding] negate

C0517391:Moist mucous membrane (Moist mucous membranes) [Finding] negate

C0026644:Edentulous (Mouth, Toothless) [Disease or Syndrome] negate




Input Sentence #134:

***END SECTION: ear_nose_throat_exam***


Input Sentence #135:
In sections: physical_examination




Input Sentence #136:
Neck:
Section identified: neck_exam (codesystem=sectag, code=627)


Input Sentence #137:
In sections: physical_examination->neck_exam




Input Sentence #138: no carotid bruits, no thyromegaly, no neck masses, no neck stiffness
In sections: physical_examination->neck_exam

C0007280:Carotid bruit (Carotid bruit) [Finding] negate

C0018021:Thyromegaly (Goiter) [Disease or Syndrome] negate

C0149736:Mass neck (Mass of neck) [Sign or Symptom] negate

C0151315:Neck stiffness (Stiff neck NOS) [Sign or Symptom] negate




Input Sentence #139:

***END SECTION: neck_exam***


Input Sentence #140:
In sections: physical_examination




Input Sentence #141:
Respiratory:
Section identified: pulmonary_exam (codesystem=sectag, code=656)


Input Sentence #142:
In sections: physical_examination->pulmonary_exam




Input Sentence #143: CTA bilaterally, moving air well, breath sounds symmetric, no dullness to percussion
In sections: physical_examination->pulmonary_exam

C0001868:Air movement (Air Movements) [Natural Phenomenon or Process]

C0225386:Breath (Breath) [Substance]

C0332516:Symmetric (Symmetry) [Spatial Concept]

C0541911:Dullness (Dullness) [Finding] negate
C0030987:Percussion (Percussion - action) [Diagnostic Procedure] negate




Input Sentence #144:

***END SECTION: pulmonary_exam***


Input Sentence #145:
In sections: physical_examination




Input Sentence #146:
Cardiovascular:
Section identified: cardiovascular_exam (codesystem=sectag, code=648)


Input Sentence #147:
In sections: physical_examination->cardiovascular_exam




Input Sentence #148:

Section identified: cardiac_murmurs (codesystem=sectag, code=654)


Input Sentence #149: RRR, Normal S1, Normal S2, no murmur, JVP 8 centimeter
In sections: physical_examination->cardiovascular_exam->cardiac_murmurs

C0205307:Normal (Normal (qualifier value)) [Qualitative Concept]
C1179704:S1 (S1 innervation) [Body Location or Region]

C0205307:Normal (Normal (qualifier value)) [Qualitative Concept]
C1179705:S2 (S2 innervation) [Body Location or Region]

C0018808:Murmur (Heart murmur) [Sign or Symptom] negate

C0475210:Centimeter (cm) [Quantitative Concept] negate
C0425690:JVP (Characteristic of jugular venous pulse) [Finding] negate




Input Sentence #150:

***END SECTION: cardiac_murmurs***


Input Sentence #151:
In sections: physical_examination->cardiovascular_exam




Input Sentence #152:

***END SECTION: cardiovascular_exam***


Input Sentence #153:
GI:
Section identified: gastrointestinal_exam (codesystem=sectag, code=666)


Input Sentence #154:
In sections: physical_examination->gastrointestinal_exam




Input Sentence #155: soft, non-tender, non-distended, normal active bowel sounds, no organomegaly, no bruits
In sections: physical_examination->gastrointestinal_exam

C0205358:Soft (Soft) [Qualitative Concept]

C0520960:Nontender (Non-tender) [Functional Concept]

C0205307:Normal (Normal (qualifier value)) [Qualitative Concept]
C0205177:Active (Active (qualifier value)) [Functional Concept]
C0021853:Bowel (Intestinal) [Body Part, Organ, or Organ Component]

C0006318:Bruit (Bruit) [Finding] negate




Input Sentence #156:
Rectal:
Section identified: rectal_exam (codesystem=sectag, code=676)


Input Sentence #157: Heme negative, no masses
In sections: physical_examination->gastrointestinal_exam->rectal_exam

C0205160:Negative (Negative for) [Qualitative Concept]
C0018966:Heme (Heme) [Biologically Active Substance]

C0577559:Mass (Mass of body structure) [Finding] negate




Input Sentence #158:

***END SECTION: rectal_exam***


Input Sentence #159:
In sections: physical_examination->gastrointestinal_exam




Input Sentence #160:

***END SECTION: gastrointestinal_exam***


Input Sentence #161:
Lymphatic:
Section identified: lymphatic_exam (codesystem=sectag, code=634)


Input Sentence #162:
In sections: physical_examination->lymphatic_exam




Input Sentence #163: no lymphadenopathy
In sections: physical_examination->lymphatic_exam

C0024228:Lymphadenopathy (Lymphadenopathy) [Disease or Syndrome] negate




Input Sentence #164:

***END SECTION: lymphatic_exam***


Input Sentence #165:
In sections: physical_examination




Input Sentence #166:
Musculoskeletal:
Section identified: musculoskeletal_rheumatological_exam (codesystem=sectag, code=747)


Input Sentence #167:
In sections: physical_examination->musculoskeletal_rheumatological_exam




Input Sentence #168: no swollen or inflammed joints, no joint deformities
In sections: physical_examination->musculoskeletal_rheumatological_exam

C0038999:Swollen (Swelling) [Finding] negate

C0022417:Joint (Articulation) [Body Space or Junction] negate

C0427244:Joint deformity (Joint deformity) [Finding] negate




Input Sentence #169:
Extremeties:
Section identified: extremity_exam (codesystem=sectag, code=774)


Input Sentence #170: no edema, pulses 2+ radial and 2+ dorsal pedis
In sections: physical_examination->musculoskeletal_rheumatological_exam->extremity_exam

C0013604:Edema (Edema NOS) [Pathologic Function] negate

C0442038:Radial (Radial (qualifier value)) [Conceptual Entity] negate

C0205095:Dorsal (Behind) [Spatial Concept] negate




Input Sentence #171:

***END SECTION: extremity_exam***


Input Sentence #172:
In sections: physical_examination->musculoskeletal_rheumatological_exam




Input Sentence #173:

***END SECTION: musculoskeletal_rheumatological_exam***


Input Sentence #174:
Psychiatric:
Section identified: psychiatric_exam (codesystem=sectag, code=739)


Input Sentence #175:
In sections: physical_examination->psychiatric_exam




Input Sentence #176: alert and oriented to person, place, date, idea , follows simple commands, thought content appropriate, affect appropriate
In sections: physical_examination->psychiatric_exam

C0239110:Alert (Consciousness clear) [Finding]

C1522390:Person (Person Info) [Qualitative Concept]

C0442504:Place (Place (attribute)) [Spatial Concept]

C1031756:Idea (Idea) [Invertebrate]

C0205352:Simple (Simple) [Qualitative Concept]

C1548787:Appropriate (Appropriate) [Qualitative Concept]
C0423896:Content (Feeling content) [Mental Process]

C1548787:Appropriate (Appropriate) [Qualitative Concept]




Input Sentence #177:

***END SECTION: psychiatric_exam***


Input Sentence #178:
In sections: physical_examination




Input Sentence #179:
Neurologic:
Section identified: neurological_exam (codesystem=sectag, code=707)


Input Sentence #180:
In sections: physical_examination->neurological_exam




Input Sentence #181:
CN
Section identified: cranial_nerve_exam (codesystem=sectag, code=709)


Input Sentence #182: 2-12 intact, muscle strength 5/5 in all extremities, deep tendon reflexes 2+ symmetric, no deficits to light touch
In sections: physical_examination->neurological_exam->cranial_nerve_exam

C0205266:Intact (Intact (qualifier value)) [Qualitative Concept]

C0517349:Muscle strength (Muscle Strength) [Organ or Tissue Function]

C0450380:5/5 (5/5) [Quantitative Concept]

C0015385:Extremity (Limb structure) [Body Part, Organ, or Organ Component]

C0489815:Deep tendon reflex (DEEP TENDON REFLEX) [Physiologic Function]

C0332516:Symmetric (Symmetry) [Spatial Concept]

C0162429:Deficit (Malnutrition NOS) [Disease or Syndrome] negate

C0439815:Touch (Touching) [Functional Concept] negate




Input Sentence #183:

***END SECTION: cranial_nerve_exam***


Input Sentence #184:
In sections: physical_examination->neurological_exam




Input Sentence #185:

***END SECTION: neurological_exam***


Input Sentence #186:
Skin:
Section identified: derm_exam (codesystem=sectag, code=578)


Input Sentence #187:
In sections: physical_examination->derm_exam




Input Sentence #188:

Section identified: rash_exam (codesystem=sectag, code=579)


Input Sentence #189: no rash, no skin growths
In sections: physical_examination->derm_exam->rash_exam

C0015230:Rash (Cutaneous eruption) [Disease or Syndrome] negate

C0423785:Skin growth (Skin growth) [Finding] negate




Input Sentence #190:

***END SECTION: rash_exam***


Input Sentence #191:
In sections: physical_examination->derm_exam




Input Sentence #192:

***END SECTION: derm_exam***


Input Sentence #193:

***END SECTION: physical_examination***


Input Sentence #194:
Available lab and x-ray results:
Section identified: laboratory_and_radiology_data (codesystem=sectag, code=788)


Input Sentence #195:
In sections: laboratory_and_radiology_data




Input Sentence #196:
EKG
Section identified: electrocardiogram (codesystem=sectag, code=821)


Input Sentence #197: inferior q waves suspicious for remote IMI
In sections: laboratory_and_radiology_data->electrocardiogram

C0743429:ECG Q wave inferior (EKG Q WAVE INFERIOR) [Finding]
C0750493:Suspicious (SUSPICIOUS) [Idea or Concept]

C0340305:IMI (Inferior myocardial infarction NOS) [Disease or Syndrome]
C0205157:Remote (Remote (qualifier value)) [Spatial Concept]




Input Sentence #198:

***END SECTION: electrocardiogram***


Input Sentence #199:
In sections: laboratory_and_radiology_data




Input Sentence #200:

***END SECTION: laboratory_and_radiology_data***


Input Sentence #201:
Analysis of Admitting Problems:
Section identified: analysis (codesystem=sectag, code=976)


Input Sentence #202:
In sections: analysis




Input Sentence #203: This is a 53 yo female admitted with progessive angina.
In sections: analysis

C0015780:Female (Females) [Organism Attribute]

C0002962:Angina (Angina pectoris NOS) [Sign or Symptom]




Input Sentence #204: She has significant history of cardiac risk factors, including htn, dm2, and peripheral vascular disease.
In sections: analysis

C0262926:History (History of) [Finding]
C1299394:Significant (Most significant) [Qualitative Concept]

C0035648:Risk factor (Risk factor) [Quantitative Concept]
C1522601:Cardiac (Cardiac) [Spatial Concept]

C0020538:Htn (Hypertensive disease NOS) [Disease or Syndrome]

C1300562:Dm2 (dm2) [Quantitative Concept]

C0085096:Peripheral vascular disease (Peripheral vascular disease) [Disease or Syndrome]




Input Sentence #205:

***END SECTION: analysis***


Input Sentence #206:




Input Sentence #207:
Assessment and Plan:
Section identified: assessment_and_plan (codesystem=sectag, code=973)


Input Sentence #208:
In sections: assessment_and_plan




Input Sentence #209: Will admit with to cardiology service for evaluation of angina.
In sections: assessment_and_plan

C0043177:Will (Wills) [Intellectual Product]

C0587571:Cardiology service (Cardiology service) [Therapeutic or Preventive Procedure]

C0002962:Angina (Angina pectoris NOS) [Sign or Symptom]
C0220825:Evaluation (Evaluating) [Functional Concept]




Input Sentence #210: Given her strong personal history and suspicious EKG changes, she should undergo cardiac catherization instead of more risk stratifying tests such as a nuclear stress test.
In sections: assessment_and_plan

C0424945:Personal history (Social/personal history NOS) [Clinical Attribute]
C0442821:Strong (Strong) [Qualitative Concept]

C0855329:Change ECG (Electrocardiogram change) [Finding]
C0750493:Suspicious (SUSPICIOUS) [Idea or Concept]

C1522601:Cardiac (Cardiac) [Spatial Concept]

C0456984:Test (Test finding) [Finding]
C0035647:Risk (Risk of) [Qualitative Concept]
C0205363:Stratify (Stratified) [Qualitative Concept]

C0015260:Stress test (Exercise Test) [Diagnostic Procedure]
C0521447:Nuclear (Nuclear) [Spatial Concept]




Input Sentence #211: She does not appear to need emergent cath tonight, however.
In sections: assessment_and_plan

C0750573:Emergent (EMERGENT) [Idea or Concept] negate




Input Sentence #212: DMII: hb A1c is elevated.
In sections: assessment_and_plan

C0019018:Hb a1c (Glycosylated hemoglobin A) [Biologically Active Substance]

C0205250:Elevate (High (qualifier value)) [Qualitative Concept]




Input Sentence #213: Will hold metformin and change to SSI.
In sections: assessment_and_plan

C0025598:Metformin (Metformin (product)) [Pharmacologic Substance]
C0042950:Will (Volition) [Mental Process]
C1553387:Hold (Hold - dosing instruction fragment (qualifier value)) [Idea or Concept]

C0392747:Change (Changing) [Functional Concept]

C0451512:SSI (Stuttering severity instrument) [Intellectual Product]




Input Sentence #214: HTN: increase BP control.
In sections: assessment_and_plan

C0020538:HTN (Hypertensive disease NOS) [Disease or Syndrome]

C0497247:Increase BP (Increase in blood pressure) [Finding]

C0308718:Control (CONTROL veterinary product) [Pharmacologic Substance]




Input Sentence #215: Will add beta blocker and ARB (since allergic to ACEI) .
In sections: assessment_and_plan

C0043177:Will (Wills) [Intellectual Product]

C0001645:Beta blocker (beta-Adrenergic Receptor Blockaders) [Pharmacologic Substance]

C0815017:ARB (angiotensin receptor antagonist) [Pharmacologic Substance]

C0700624:Allergic (Allergic) [Functional Concept]

C0003015:ACEI (Kininase II Inhibitors) [Pharmacologic Substance]




Input Sentence #216: Continue ASA. 4. breast
In sections: assessment_and_plan

C0004057:ASA (Aspirin (product)) [Pharmacologic Substance]

C0222605:Breast (Both breasts) [Body Part, Organ, or Organ Component]
C0038951:4 (4) [Research Activity]




Input Sentence #217:

***END SECTION: assessment_and_plan***


Input Sentence #218:




Input Sentence #219:
cancer:
Section identified: oncology_family_history (codesystem=sectag, code=372)


Input Sentence #220:
In sections: oncology_family_history




Input Sentence #221: continue tamoxifen.
In sections: oncology_family_history

C0039286:Tamoxifen (Tamoxifen (product)) [Pharmacologic Substance]




Input Sentence #222:

***END SECTION: oncology_family_history***