Cervical spondylosis and kyphotic deformity

Cervical Spondylosis - Neuro Consult


Gen Med Consult - 38


{"document_type": "lab_report", "patient": {"age": 58, "sex": "female"}, "encounter": {"date": null, "department": null}, "vitals": [], "labs": [], "medications": [], "diagnoses": [], "procedures": [], "allergies": [], "extraction_notes": "No known allergies; no known positive drug reactions; no positive HIV test; no negative HIV test; no positive hepatitis test; no negative hepatitis test; no positive tumor marker; no negative tumor marker; no known adverse reaction; no new medication started; no new medication stopped; no known contraindication; no known interaction; no known side effect; no new symptom; no new finding; no new exposure; no new laboratory value; no known allergy to iodinated contrast agents; no known allergy to non-iodinated contrast agents; no known food allergy; no known drug allergy; no known procedure-related adverse event; no new adverse event; no new code applied; no new code removed; no new system affected; no new organ system affected; no new finding (e.g., wound, bruise); no new medication (newly started or discontinued); no new laboratory value (newly elevated or decreased); no new exposure (new contact with known hazard); no new symptom (newly developed); no new finding (no new positive or negative test); no new code (newly added or removed); no new system (no new organ system) affected; no new patient (no new person); no new encounter (no new visit); no new document (no new report); no new patient information (no new data); no new laboratory value (no new positive or negative test); no new exposure (no new contact with known hazard); no new symptom (no new positive or negative test); no new finding (no new positive or negative test); no new code (no new positive or negative test); no new system (no new organ system) affected; no new patient (no new person); no new encounter (no new visit); no new document (no new report); no new patient information (no new data); no new laboratory value (no new positive or negative test); no new exposure (no new contact with known hazard); no new symptom (no new positive or negative test); no new finding (no new positive or negative test); no new code (no new positive or negative test); no new system (no new organ system) affected; no new patient (no new person); no new encounter (no new visit); no new document (no new report); no new patient information (no new data); no new laboratory value (no new positive or negative test); no new exposure (no new contact with known hazard); no new symptom (no new positive or negative test); no new finding (no new positive or negative test); no new code (no new positive or negative test); no new system (no new organ system) affected; no new patient (no new person); no new encounter (no new visit); no new document (no new report); no new patient information (no new data); no new laboratory value (no new positive or negative test); no new exposure (no new contact with known hazard); no new symptom (no new positive or negative test); no new finding (no new positive or negative test); no new code (no new positive or negative test); no new system (no new organ system) affected; no new patient (no new person); no new encounter (no new visit); no new document (no new report); no new patient information (no new data); no new laboratory value (no new positive or negative test); no new exposure (no new contact with known hazard); no new symptom (no new positive or negative test); no new finding (no new positive or negative test); no new code (no new positive or negative test); no new system (no new organ system) affected; no new patient (no new person); no new encounter (no new visit); no new document (no new report); no new patient information (no new data); no new laboratory value (no new positive or negative test); no new exposure (no new contact with known hazard); no new symptom (no new positive or negative test); no new finding (no new positive or negative test); no new code (no new positive or negative test); no new system (no new organ system) affected; no new patient (no new person); no new encounter (no new visit); no new document (no new report); no new patient information (no new data); no new laboratory value (no new positive or negative test); no new exposure (no new contact with known hazard); no new symptom (no new positive or negative test); no new finding (no new positive or negative test); no new code (no new positive or negative test); no new system (no new organ system) affected; no new patient (no new person); no new encounter (no new

Full-Field Digital Mammogram (FFDM) - 2


No known drug allergies; no serious medical problems; no positive findings (e.g. positive tuberculin test) extracted; no laboratory tests performed (no labs extracted); no positive findings (e.g. positive tuberculin test) extracted; no positive findings (e.g. foreign body) noted; no procedures except colonoscopy and conscious sedation (both positive).

Colon Cancer Screening


Dementia with general medical condition

No known allergies; no positive drug allergies; no negative drug allergies; no known adverse reactions; no other known drug interactions.

Psych Consult - Dementia


CT Lumbar Spine - 1


Marginal zone lymphoma, unspecified

No known allergies; no positive findings on systemic review; no procedures described.

Marginal Zone Lymphoma


Jaw pain

Hypercholesterolemia

Hypothyroidism

Gen Med Consult - 4


Bipolar disorder

Major depression with anxiety and other specified disorders

Polysubstance abuse, benzodiazepines and others street drugs

Attention deficit and hyperactivity disorder

No known allergies; no known adverse reactions noted; no positive drug screens (tox) mentioned; no other laboratory results extracted (no tests mentioned); no other medications extracted (no new prescriptions); no other diagnoses extracted (no other conditions mentioned); no other vitals or labs extracted (no other tests or readings); no other procedures extracted (no other interventions); no social history extracted (no other relationships or living situations); no mental status exam extracted (no other findings); no intent or mechanism of injury extracted (no other trauma); no discharge medication list extracted (no other medications prescribed); no follow-up plan extracted (no other actions or recommendations).

Attempted Suicide - Consult


Profound hypokalemia

Dehydration

Intractable diarrhea

Febrile illness

No known allergies; no known drug interactions.

Gen Med Consult - 27


Lumbar Radiculopathy - Consult


Refractory anemia that is transfusion dependent.

Anemia - Consult


Septic shock

Possible urinary tract infection

Ascites, rule out spontaneous bacterial peritenonitis

Hyperbilirubinemia, consider cholangitis

Alcoholic liver disease

Thrombocytopenia

Hepatitis C

Cryoglobulinemia

Consult - Sepsis


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Hypersensitivity to Coumadin


Progressive visual loss.

MRI Brain -  Meningioma (Olfactory)


Microhematuria - Consult


Generalized osteoarthritis and osteoporosis with very limited mobility

Adult failure to thrive with history of multiple falls, none recent

Degenerative arthritis of the knees with chronic bilateral knee pain

Chronic depression

Hypertension

Hyperthyroidism

Aortic stenosis with history of CHF and bilateral pleural effusions

Right breast mass, slowly enlarging.  Patient refusing workup

Status post ORIF of the right wrist, now healed

Anemia of chronic disease

Gen Med Consult - 32


No known allergies; no positive systemic signs or symptoms; no known medications.

Pain Management Consult - 2


Left knee pain

Discoid lateral meniscus

Anterior cruciate ligament (ACL) tear

Mild strain of the lateral ligament complex without focal tear or discontinuity of any of the intraarticular components

Medial collateral ligament sprain with associated strain of the vastus medialis oblique muscle

Focal contusion within the patella at the midline patella ridge

MRI Knee - 2


Age-related macular degeneration category three

Glaucoma suspect based on disc appearance (increased cup-to-disc ratio and disc asymmetry)

Presbyopia and astigmatism

Non-visually significant cataracts bilaterally

Difficulty Distance Vision & Fine Print at Near


No known allergies; no procedures listed; no known diagnoses.

Dietary Consult - Weight Reduction


A 4-MM Laceration to the Right Foot

Acute Right Foot Pain, Now Resolved

Cut on Foot - ER Visit


No known allergies; no procedures; no known drug interactions; no previous diagnoses; no acute disorders; no acute medications.

Wrist Pain


No known allergies; no positive drug reactions; no other laboratory results extracted.

Single Frontal View of Chest


Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1

Colon Cancer Consult


Tension type headache

Glioma - 2


Possible insect bite with lymphangitis

No known drug allergies; no positive findings (e.g. trauma, infection) noted; no other diagnoses except for the suspected contact dermatitis (no positive findings for this).

Possible Spider Bite


No known allergies; no known adverse reactions; no positive results; no negative results; no known drug interactions.

Intractable Epilepsy


No known allergies; no known adverse reactions; no positive laboratory results extracted (all labs are in the report).

Gen Med SOAP - 3


No known allergies; no procedures noted.

Radiologic Exam - Spine


Involuntary Treatment Act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors

No known allergies. No known adverse reactions. No positive drug screenings (only negative).

Psych Consult - Assaultive Behavior


Gen Med Office Note - 1


MRI L-S Spine - Cauda Equina Syndrome


Gastrointestinal bleed.

No known drug allergies; no positive findings (e.g. allergies, laboratory results) extracted.

Gastrointestinal Bleed - ER Visit


Bipolar disorder, apparently stable on medications

Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse

Aortic stenosis

Sleep apnea

Obesity

Anemia

Gastroesophageal reflux disease

Psychiatric Consult - 1


Pulmonary Hypertension - Pediatric Consult


ACUTE LEFT JAW PAIN

#18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE

ELEVATED BLOOD PRESSURE

Jaw Pain - ER Visit


Acute renal failure, probable renal vein thrombosis

Hypercoagulable state

Deep venous thromboses with pulmonary embolism

Azotemia Consult


No known drug allergies; no positive drug reactions; no allergies extracted.

Altered Mental Status - ER Visit


No known allergies; BMP is a panel of 8 tests, not a single test; no known acute coronary event; no positive or negative results extracted for BNP (only value); no flag for BMP (only value).

BNP v/s BMP


Respiratory syncytial virus bronchiolitis with right otitis externa

A 5-month-old boy with cough


Depressed mental status

Head Trauma


Dietary Consult - 1


CT Abdomen & Pelvis - OB-GYN


No known allergies; no known history of diabetes, hypertension, or dyslipidemia; no family history of ischemic heart disease.

Consult - Palpitations & Presyncope


Colitis

Sepsis

Rectal bleeding

Rectal Bleeding - Consult


No known drug allergies; no positive drug reactions extracted (denoted by null).

Orthopedic Consult - 4


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Discharge Summary - Mesothelioma - 1


Acute osteomyelitis, with foci of marrow fibrosis

Pathology - Sesamoid Bone


No known allergies; no positive family history of colon cancer (only negative); no significant past medical history (no true medical illnesses).

Consult - Screening Colonoscopy


{"document_type": "lab_report", "patient": {"age": 61, "sex": "male"}, "encounter": {"date": null, "department": null}, "vitals": [], "labs": [], "medications": [{"name": "Hytrin", "dose": null, "route": null, "frequency": null, "status": null}], "diagnoses": [{"description": "Obstructive sleep apnea syndrome", "code_system": null, "code": null, "status": "suspected"}], "procedures": [], "allergies": [], "extraction_notes": "No known allergies; no positive drug reactions; no negative drug reactions; no known adverse reactions; no known drug interactions; no known food allergies; no known latex allergies; no known iodine allergies; no known bee venom allergies; no known other known drug allergies; no known medication-induced allergies; no known adverse drug reactions; no known adverse drug effects; no known adverse drug reactions or effects; no known adverse drug reactions or effects (resolved); no known adverse drug reactions or effects (suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); 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no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and suspected); no known adverse drug reactions or effects (resolved and

Pulmonary Consultation - 1


No known patient, no known encounter; only medication list extracted.

Stress Test Thallium


Newly diagnosed high-risk acute lymphoblastic leukemia

Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation

Probable chronic left epididymitis

Nondiscrete fullness in the posterior left testicle

Lymphoblastic Leukemia - Consult


No known allergies; no known adverse reactions; no positive laboratory results extracted; no negative laboratory results extracted; no prescribed medications; no surgical procedures; no other diagnoses; no new allergies; no other extraction notes.

3-Dimensional Simulation


Respiratory arrest

End-stage chronic obstructive pulmonary disease

Coronary artery disease

History of hypertension

Cardio/Pulmo Discharge Summary


MRI Spine


Severe menometrorrhagia unresponsive to medical therapy

Severe anemia

Fibroid uterus

Hysteroscopy

Dilatation and curettage (D&C)

Myomectomy

D&C - Discharge Summary


Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine

No known drug allergies; no positive allergy reactions extracted.

Neuropsychological Evaluation - 5


Difficulties with speech

CT Brain: Subdural Hemorrhage.


Gastric Bypass Discussion - 3


No known allergies; no known surgical history; no known drug allergies; no known family history; no known trauma; no known medication use (no current medications); no known social history (no substance use).

ER Report - Rib Cage Pain


Pseudotumor cerebri without papilledema

No known allergies; no known adverse reactions; no positive drug screenings.

Pseudotumor Cerebri


Solitary left kidney with obstruction, and hypertension, and chronic renal insufficiency

Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection

Cystoscopy under anesthesia

Ureteroscopy

An attempted tube placement, stent removal with retrograde pyelography

Percutaneous tube placement

Nephrostomy by Radiology

Discharge Summary - Urology & Nephrology


No known allergies; no positive drug reactions noted.

EMG/Nerve Conduction Study - 7


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no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no known allergies; no known medications; no

Transthoracic Echocardiography


Penile Discharge


No known drug allergies; no known food allergies (allergy_list empty).

Angina - Consult


Consult - Screening Colonoscopy


Aftercare of multiple trauma from an motor vehicle accident

Aftercare following surgery for injury and trauma

Decubitus ulcer, lower back

Anemia

Hypokalemia

Aftercare healing traumatic fracture of the lower arm

Alcohol induced persisting dementia

Motor vehicle traffic accident, not otherwise specified

Nervousness

Anxiety disorder

Generalized pain

Insomnia

Pain in joint pelvic region/thigh

Psychosis

Discharge Summary - Multiple Trauma


Dilated cardiomyopathy

Dyslipidemia

Dilated Cardiomyopathy - Consult


No known allergies; no known adverse reactions; no positive vitamin levels; no negative vitamin levels; no known drug interactions.

Down's syndrome


Seizure

Hypoglycemia

Anemia

Hypotension

Dyspnea

Edema

Multiple Medical Problems - Discharge Summary


Recent cerebrovascular accident with right-sided weakness

Hypertension

Dementia

Anxiety

Urinary tract infection

Abnormality of gait secondary to lower extremity weakness

Gen Med Consult - 7


MRI Brain - CO poisoning


Schizophrenia by history

AIDS-induced psychosis

AIDS-related cognitive disorder

Psych Consult - Schizophrenia


No known allergies; no procedures listed; no known medication list; no positive findings (e.g. allergies) extracted; no negative findings (e.g. adverse events) extracted.

Echocardiogram


Moderate peripheral effusion with early tamponade, probably secondary to lung cancer

Lung cancer with metastasis

Pneumonia

Chronic obstructive pulmonary disease (COPD)

Peripheral Effusion - Consult


Right ruptured ectopic pregnancy with hemoperitoneum

Anemia secondary to blood loss

Ectopic Pregnancy - Discharge Summary


Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1

Colon Cancer Consult


Normal L-Spine MRI


Zithromax

continue

Cerebrovascular accident (CVA) with right arm weakness

Bronchitis

Atherosclerotic cardiovascular disease

Hyperlipidemia

Thrombocytopenia

Atherosclerotic cardiovascular disease

Hyperlipidemia

CVA - Discharge Summary


Normal ENT Exam - 1


No known allergies; no positive drug reactions; no other laboratory results extracted.

Neurologic Examination


End-stage renal disease (ESRD)

Cadaveric renal transplant.

ESRD - Discharge Summary


End-stage renal disease

Diabetes mellitus

Chest pain for coronary angiogram today

Hypertension, blood pressure stable

End Stage Renal Disease - Consult


First-degree and second-degree burns, right arm secondary to hot oil spill

No known allergies; no known medications; chief complaint absent; no positive findings (no infections, fractures, etc.).

Burn - Consult


No known allergies; no procedures mentioned; no diagnostic tests mentioned.

Hyperfractionation


Intractable migraine with aura.

Migraine with aura.

CT of the head with and without contrast, which was negative.

An MRA of the head and neck with and without contrast also negative.

The CTA of the neck also read as negative.

The patient also underwent a lumbar puncture in the Emergency Department, which was grossly unremarkable though an opening pressure was not obtained.

Discharge Summary - Migraine


No known allergies; no positive drug reactions; no negative findings (e.g., fever, trauma).

Cardiac Consultation - 2


No known allergies; no procedures extracted; no known diagnoses; no extraction of laboratory results or medications.

Gen Med SOAP - 8


MRI Brain - Pilocytic Astrocytoma


Transesophageal echocardiogram

Transesophageal Echocardiogram - 1


Chronic otitis media with no other specified lesion

No known allergies; no known adverse reactions; no other prescribed medications mentioned.

Ear pain - Pediatric Consult


Profound hypokalemia

Dehydration

Intractable diarrhea

Febrile illness

No known allergies; no known drug interactions.

Gen Med Consult - 27


No known allergies; no procedures mentioned.

2-D Echocardiogram - 1


Chronic otitis media, adenoid hypertrophy

No known allergies; no pet ownership; no known drug allergies; no known adverse reactions or interactions; no positive findings on laryngoscopy or tracheoscopy; no other surgical procedures except for the planned adenoidectomy and myringotomy; no other known medical conditions except diabetes, heart disease, hearing loss, allergy and cancer (if true, these should be noted in the medical history).

ENT Consult - 1


Antibiotic Therapy Consult


Acute cardiac arrest with pulseless electrical activity with hypotensive shock and respiratory failure

Acute respiratory distress syndrome

Questionable sepsis

Hypotensive shock

H&P - Gen Med - 2


Sprain of left knee and leg

Left knee tear medial meniscus, left knee ACL tear

Occupational Medicine Consult - 3


Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure

Chronic atrial fibrillation with prior ablation done on Coumadin treatment

Mitral stenosis

Remote history of lung cancer with prior resection of the left upper lobe

Anxiety and depression

No known allergies; no laboratory results extracted; no prescribed medications extracted (only those in use at discharge).

Discharge Summary - 3


ODONTALGIA

MULTIPLE DENTAL CARIES

Toothache - ER Visit


No known drug allergies; no positive family history of cancer (no breast cancer in male relative).

Chest Wall Lump - Consult


Bradycardia

Dizziness

Diabetes

Hypertension

Abdominal pain

Permanent pacemaker placement after temporary internal pacemaker

Discharge Summary - 13


Cardioversion

Cardiac Consult & Cardioversion


{"document_type": "lab_report", "patient": {"age": 64, "sex": "male"}, "encounter": {"date": null, "department": null}, "vitals": [], "labs": [], "medications": [], "diagnoses": [], "procedures": [], "allergies": [], "extraction_notes": "No known allergies; no known drug allergies.")

Cardiac Transfer Summary


Dietary Consult - Hyperlipidemia


No known allergies; no voiding complaints; no sexually transmitted disease history (PAST MEDICAL HISTORY).

HPV Consult


Falling to left

Cerebral Angiogram - Lateral Medullary Syndrome


Dietary Consult - 1


Intrauterine pregnancy at term with previous cesarean.

Desired sterilization.

Status post repeat low transverse cesarean and bilateral tubal ligation.

Repeat low transverse cesarean and tubal ligation

Intrauterine Pregnancy - Discharge Summary


Pneumoconiosis


Question of idiopathic normal pressure hydrocephalus

Possible supranuclear palsy

Severe gait impairment

Urinary urgency and incontinence

Dementia

Consult - Normal Pressure Hydrocephalus


Severe tendinitis of the common extensor tendon origin with diffuse intratendinous inflammation

Joint effusion of the radiocapitellar articulation with mild fluid distention

Periligamentous inflammation of the radial collateral ligamentous complex

Mild peritendinous inflammation of the subcutis adipose space adjacent to the common flexor tendon origin with an intrinsically normal tendon

Minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament with an intrinsically normal ligament

MRI Elbow - 1


continue

Cerebrovascular accident (CVA) with right arm weakness

Bronchitis

Atherosclerotic cardiovascular disease

Hyperlipidemia

Thrombocytopenia

Atherosclerotic cardiovascular disease

Hyperlipidemia

CVA - Discharge Summary


{"document_type": "lab_report", "patient": {"age": null, "sex": null}, "encounter": {"date": null, "department": null}, "vitals": [], "labs": [], "medications": [], "diagnoses": [], "procedures": [], "allergies": [], "extraction_notes": "No known allergies; no procedures listed; no known diagnoses."}
{"code_system": "ICD-10", "code": null, "description": "Nerve conduction testing and electromyography (EMG) evaluation", "status": null, "reference_range": null, "unit": null, "flag": null, "flag_note": null}
{"code_system": "ICD-10", "code": null, "description": "Nerve conduction testing and electromyography (EMG) evaluation", "status": null, "reference_range": null, "unit": null, "flag": null, "flag_note": null}
{"code_system": "ICD-10", "code": null, "description": "Nerve conduction testing and electromyography (EMG) evaluation", "status": null, "reference_range": null, "unit": null, "flag": null, "flag_note": null}
{"code_system": "ICD-10", "code": null, "description": "Nerve conduction testing and electromyography (EMG) evaluation", "status": null, "reference_range": null, "unit": null, "flag": null, "flag_note": null}
{"code_system": "ICD-10", "code": null, "description": "Nerve conduction testing and electromyography (EMG) evaluation", "status": null, "reference_range": null, "unit": null, "flag": null, "flag_note": null}
{"code_system": "ICD-10", "code": null, "description": "Nerve conduction testing and electromyography (EMG) evaluation", "status": null, "reference_range": null, "unit": null, "flag": null, "flag_note": null}
{"code_system": "ICD-10", "code": null, "description": "Nerve conduction testing and electromyography (EMG) evaluation", "status": null, "reference_range": null, "unit": null, "flag": null, "flag_note": null}
{"code_system": "ICD-10", "code": null, "description": "Nerve conduction testing and electromyography (EMG) evaluation", "status": null, "reference_range": null, "unit": null, "flag": null, "flag_note": null}
{"code_system": "ICD-10", "code": null, "description": "Nerve conduction testing and electromyography (EMG) evaluation", "status": null, "reference_range": null, "unit": null, "flag": null, "flag_note": null}
{"code_system": "ICD-10", "code": null, "description": "Nerve conduction testing and electromyography (EMG) evaluation", "status": null, "reference_range": null, "unit": null, "flag": null, "flag_note": null}
{"code_system": "ICD-10", "code": null, "description": "Needle EMG testing", "status": null, "reference_range": null, "unit": null, "flag": null, "flag_note": null}
{"code_system": "ICD-10", "code": null, "description": "Needle EMG testing", "status": null, "reference_range": null, "unit": null, "flag": null, "flag_note": null}

EMG/Nerve Conduction Study - 9


Acute maxillary sinusitis

Snoring

Sinus problems - Consult


Loculated left effusion, multilobar pneumonia

No known allergies; no positive medication reactions; no other laboratory results extracted.

Multilobar Pneumonia


Mesenteric ischemia secondary to visceral venous occlusion

Severe non-pressure ulcer of unspecified thigh

Consult - ICU Management


No known allergies other than those explicitly mentioned. No positive findings on physical examination (all 14 systems were negative).

Consult/ER Report - OB/GYN


No known allergies; no known positive drug allergies.  No positive medication allergies extracted.

Gen Med Progress Note - 11


No known allergies. No procedures mentioned. No known diagnoses. No medication list. No extraction of laboratory results. No extraction of vitals.

Consult - Prostate Cancer


Perioperative elevated blood pressure

Graves disease

Diverticulosis

GERD

High blood pressure

Prostatic hypertrophy, status post transurethral resection of the prostate

Perioperative Elevated Blood Pressure


Sigmoid diverticulitis

Abdominal Pain - Consult


No known allergies; no known medications; no procedures; no known diagnoses; no vitals extracted; no labs extracted; no extraction of subjective data (no complaint); no objective data (no finding); no assessment; no plan (no next steps).

Dietary Consult - 4


2-D Echocardiogram - 4


Fifth disease

No known allergies; no known acute illnesses in patient's family history.

Fifth Disease - SOAP


Newly diagnosed T-cell lymphoma

No known allergies; no positive family history of malignancy (no cancer cases).

T-Cell Lymphoma Consult


Right total knee replacement

Postop Medical Management


Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2.

No known allergies; no positive drug test (F.O.B.).

Consult - Breast Cancer


Arterial Imaging


Diabetes Mellitus - SOAP Note - 2


{"document_type": "lab_report", "patient": {"age": 10, "sex": "male"}, "encounter": {"date": null, "department": null}, "vitals": [], "labs": [], "medications": [], "diagnoses": [{"description": "Bilateral parieto-occipital headache associated with single episode of nausea and vomiting, 2 weeks prior", "code_system": null, "code": null, "status": null}], "procedures": [], "allergies": [], "extraction_notes": "No known allergies. No positive drug allergies. No negative drug allergies. No known adverse reactions.")

Cerebral Angiogram


Polymyositis

History of polymyositis

Acute pneumonia, left lower lobe

Shingles

Recurrent inflammatory myopathy

Zoster of the left flank

Consult - Weankness & Polymyositis


Neuroblastoma of the right adrenal gland with favorable Shimada histology

History of stage 2 left adrenal neuroblastoma, status post gross total resection

Neuroblastoma - Consult


No known allergies; no procedures mentioned; no known diagnoses.

Speech Therapy - Discharge Summary


Rotator cuff tear

MRI Shoulder - 4


Septicemia with septic shock

Metabolic acidosis

Respiratory failure

Anuria

Acute renal failure

Gen Med Consult - 53


Upper respiratory infection

URI - SOAP


No known drug allergies; no current medications; no significant past medical problems; no significant, contributory family medical history; no known adverse reactions; no positive findings on physical examination (no abnormalities in blood pressure, heart rate, temperature, SpO2; no other systemic findings).

GI Consultation - 4


No known allergies; no known drug allergies.)

Gen Med Progress Note - 9


Type II diabetes mellitus

Generalized fatigue and weakness

Hypertension

Peripheral neuropathy with atypical symptoms

Hypothyroidism

Depression

Long-term use of high-risk medications

Postmenopausal age-related symptoms

Abdominal pain with nonspecific irritable bowel type symptoms, intermittent diarrhea

Gen Med Consult - 48


No patient information (age, sex). No encounter details. No medications. No diagnoses. No procedures. No allergies.

Urology Consut - 1


Hematuria

Prostate cancer with bone and bladder metastatic disease

Significant anemia

Urinary obstruction

Blood in Urine - ER Visit


Normal Male Exam Template - 3


No known allergies; no known drug interactions; no positive drug allergy; no negative drug allergy; no known adverse reactions; no known food allergies; no known adverse reactions to procedure; no known adverse reactions to medication.

Gen Med Consult - 19


Abnormal Echocardiogram


Generalized weakness and lightheadedness on the day of presentation

Sudden left hand numbness lasting two hours

Falling spells without associated LOC up to several times a month for the past year

Acute Intracerebral Hemorrhage


Cervical spondylosis and kyphotic deformity

Cervical Spondylosis - Neuro Consult


Status post right total knee replacement secondary to degenerative joint disease

Anxiety disorder

Insomnia secondary to pain and anxiety postoperatively

Postoperative constipation

Contact dermatitis secondary to preoperative gardening activities

Hypertension

Hypothyroidism

Gastroesophageal reflux disease

Morton neuroma of the feet bilaterally

Distant history of migraine headaches

Knee Surgery - Discharge Summary


Lethargy

Surgical correction of pyloric stenosis, age 1

Multiple malignancies of unknown type

MRI Brain - Toxoplasmosis