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From chen...@apache.org
Subject svn commit: r1516900 - in /ctakes/trunk/ctakes-examples/data: Peds_Dysphagia_1.rtf Peds_FebrileSez_1.rtf Peds_RoutBirthNote_1.rtf VascSurg_RO-DVT.rtf
Date Fri, 23 Aug 2013 15:44:03 GMT
Author: chenpei
Date: Fri Aug 23 15:44:03 2013
New Revision: 1516900

URL: http://svn.apache.org/r1516900
Log:
CTAKES-223 - Thanks John Green for contributing the sample clinical notes.  Added additional
notes to the ctakes-examples project.

Added:
    ctakes/trunk/ctakes-examples/data/Peds_Dysphagia_1.rtf
    ctakes/trunk/ctakes-examples/data/Peds_FebrileSez_1.rtf
    ctakes/trunk/ctakes-examples/data/Peds_RoutBirthNote_1.rtf
    ctakes/trunk/ctakes-examples/data/VascSurg_RO-DVT.rtf

Added: ctakes/trunk/ctakes-examples/data/Peds_Dysphagia_1.rtf
URL: http://svn.apache.org/viewvc/ctakes/trunk/ctakes-examples/data/Peds_Dysphagia_1.rtf?rev=1516900&view=auto
==============================================================================
--- ctakes/trunk/ctakes-examples/data/Peds_Dysphagia_1.rtf (added)
+++ ctakes/trunk/ctakes-examples/data/Peds_Dysphagia_1.rtf Fri Aug 23 15:44:03 2013
@@ -0,0 +1,48 @@
+Case description for C-Takes documenting:
+Setting: Outpatient.
+Specialty: Pediatrics. 
+Note detail level (1-5): 5.
+Level of abbreviation (Low/Medium/High): Low.
+
+CC/HPI:
+Mrs X is a 13 year old female who presents to the clinic with a chief complaint of "difficulty
swallowing". The onset has been gradual and over the past year. It is intermittent and associated
with specific foods: chocolate and some meats, though her recollection is Òshoddy at bestÓ.
She has GERD, and has since she was a baby. Her mother reports she always spit up as an infant.
She knows this difficulty swallowing is different from the GERD she has experienced in the
past. She takes omeprazole 20mg daily and has for years. The sensation, she reports, is a
very different feeling. She further reports that she has not experienced GERD in years and
that attacks of GERD do noT precede dysphagic episodes. When she points to the location that
the difficulty seems to arise she indicates her midline at the level of the first intercostal
space. It has recently lead to a burning (5/10 when it happens) sensation and a need to vomit.
It is non-bilious vomit and looks exactly like what she just
  swallowed. There is no associated difficulty breathing. Sometimes taking a deep breath to
"make more room in her chest helps" the offending food to go down. She has noted some allergic
reactions that have led to lip and ÒmouthÓ swelling and have necessitated benadryl use per
her mother. These have included various foods, most notably chocolate. Her dad recalls for
her that it is most notably milk and milk chocolate. The picture is not entirely clear. She
is unable to recall any other foods at this time, though she knows there are others. So do
her parents. They cannot recall either. She denies dysphagia associated with liquids. She
denies odynophagia. She denies new medications or taking any new pills. She has no other complaints
today.
+
+ROS: 
+She denies any metallic taste or burning sensation in her throat. She denies waking nauseated
or a chronic cough. She denies fevers, chills, nausea, or vomiting. She denies unexpected
weight loss or myalgia. She denies headache. She denies chest pain, shortness of breath, or
difficulty breathing. She denies diarrhea, constipation, or changes in stool.
+
+Past Medical History:
+Mrs X has a history significant for mild intermittent asthma. She has no other past medical
history. 
+
+Past Surgical History:
+Mrs X has never had a surgery to include wisdom teeth. 
+
+Allergies:
+Mrs X has seasonal allergies. She denies any other allergies at this time to include penicillins
or foods or latex. 
+
+Medications: 
+Mrs X is on a short acting inhaler. She takes a multivitamin. She takes the aforementioned
omeprazole 20mg daily. She takes no other medications.
+
+Immunizations:
+Mrs X is up to date on all of her immunizations today.
+
+Family History:
+Her Mother and Father present with her to the clinic today. They claim to be well despite
the "normal aging issues". Mom had a endometrial polyp removed recently and is a breast cancer
survivor. Her father states that he has no health concerns but his wife says that he sometimes
has "heart problems" but the family doesn't really seem willing to talk about it.
+
+Social History:
+Mrs. X is doing well in school. She is an A student and wants to be a doctor. She lives with
both of her parents.
+
+Physical Exam:
+Vitals:
+Tcurrent 98.7 BP 115/75 HR 60 RR 20 SpO2 99% on room air.
+
+Head Eyes Ears Nose Throat: There is no conjunctivitis. Her tympanic membranes are clear
and freely mobile bilaterally, there is no rhinorrhea, nor erythema nor petechiae in the oropharynx.

+Cardiovascular: No murmors rubs or gallops. Her heart has a regular rate and rhythm. S1 and
S2 were appreciated.
+Pulmonary: Her lungs are clear to auscultation bilaterally. There is no wheezing nor rails
or rhonchi. She is not recruiting accessory muscles nor does she have a clinically apparent
prolonged expiratory phase.
+Gastrointestinal: Her abdomen is non distended without masses appreciable. Normal bowel sounds
are present in all four quadrants. Her abdomen is soft and non-tender without rebound or guarding.
There is no hepatosplenomegally appreciable on deep palpation, nor any other mass. 
+Lower Extremity: Her lower extremities are well perfused. There is no edema. Her dorsalis
pedis and posterior tibial pulses are intact bilaterally. 
+
+Labs/Ancillary:
+There are no labs at time of current encounter.
+
+Assessment and Plan:
+Mrs X is a well appearing cheerful young woman in no acute distress. Her vital signs are
stable. She has an unremarkable physical exam. Her history is significant for long standing
GERD, a risk factor for esophageal stricture/ring/web. However, she has been on omeprazole
and the dysphagia is increasing. Further, she seems to clearly differentiate the long standing
GERD from the dysphagia and is familiar with her symptoms enough to state clearly that one
does not precede the other. One would think that she would have noticed increasing GERD in
the last year. Her food related allergies that seem to localize around her lips and mouth
raise a concern for EoE (eosinophilic esophagitis). In any of the cases, the next step in
her management should be consultation with a specialist. This would likely lead to either
a pH probe, a trial of increased PPIs, or more to the point perhaps, an upper endoscopy with
biopsy.

Added: ctakes/trunk/ctakes-examples/data/Peds_FebrileSez_1.rtf
URL: http://svn.apache.org/viewvc/ctakes/trunk/ctakes-examples/data/Peds_FebrileSez_1.rtf?rev=1516900&view=auto
==============================================================================
--- ctakes/trunk/ctakes-examples/data/Peds_FebrileSez_1.rtf (added)
+++ ctakes/trunk/ctakes-examples/data/Peds_FebrileSez_1.rtf Fri Aug 23 15:44:03 2013
@@ -0,0 +1,102 @@
+Case description for C-Takes documenting:
+Setting: Inpatient.
+Specialty: Pediatrics. 
+Note detail level (1-5): 5.
+Level of abbreviation (Low/Medium/High): Low.
+
+CC/HPI:  
+X was in her regular state of good health when, at 0200 2 Feb, she awoke crying. Her mother
thought she felt hot. She performed an axillary temperature at that time. She reported the
temperature to be 104F. She then administered a "children's dose" of Tylenol. The patient
reached a temperature of around 101 to 102F. Her mother then took her to the ER. This was
around 0900. At the time of assessment in the ER her temperature was 104F. The patient was
then taken to the staff pediatrician in the clinic. After a full physical exam revealed no
other likely source of infection a urine specimen was collected by catheter. Lab results of
this specimen showed >100WBCs and moderate leukocyte esterase. X was ordered at that time
for Septra 5mL PO BID and Tylenol 4mL PO q4-6. She was then sent home with these prescriptions.
However, the patient vomited the medications. Her mother and she returned to the pediatric
clinic for refractory fevers and inability to tolerate PO antibiotics. At this time
  X had a ÒseizureÓ as described by her mother: her eyes rolled up in her head and she went
ÒrigidÓ and Òkind of vibratedÓ. This was in the waiting room of the pediatric clinic.
The pediatrician was called but the episode was over. The patient was then admitted to 5w
due to seizure, failure of outpatient medical management, and inability to tolerate PO medication.

+
+ROS: 
+Her mother reports decreased feeding. She also reports decreased wet diapers, with only a
few "barely wet" ones. Further, she denies lethargy, SOB, pulling at ears, rhinorrhea, or
cough. She also denies diarrhea and does not feel there is anything else Òout of the ordinaryÓ.
+
+Past Medical History:  
+The patient was delivered via c-section at 39+5. No infectious risk factors were identified
at birth. She showed no signs or symptoms of congenital syndromes or diseases; In other words,
the perinatal period was uncomplicated. Since her birth there was one instance of lacrimal
duct stenosis that has been resolved and a case of roseola two months ago that has also resolved.
+
+Past Surgical History:  
+No reported past surgical history.
+
+Allergies:
+No known drug or food allergies.
+
+Medications:
+Tylenol 4mL, last dose at 1540 - vomited.
+Septra 4mL, last dose at 1540 - vomited.
+
+Vaccinations:
+Reviewed and current as of 2Feb2013.
+
+Diet:  
+She is currently taking formula, mushed rice and cereal.
+
+Social History: 
+X lives at home with her two brothers, four and seven, two cats, and her mom and dad. She
is not enrolled in day-care. Mother and father are happily married. Mother works at a middle
school. Father is in the Navy.
+
+Family History: 
+No history of persistent UTI or VUR. No family history of seizure. 
+
+PE:
+Weight on admission: 6.8kg
+Vit: T 104, HR 141, RR 28, SPo2 97% on RA.
+Gen: X is a sick appearing infant female in mild distress. She is clinging to her mother
and crying.
+Neuro: There is not any ptosis or facial asymmetry. There are not signs of focal neurologic
deficit. Her pupils are equal in size and reactive to light.
+HEENT: Mucous membranes are dry. There is not deformity, swelling, nor hematoma; No venous
distention or gaping sutures. Her tympanic membranes are clear bilaterally. There is not erythema
or exudate in the pharynx, nor cough. The patientÕs nares are patent bilaterally. There is
not rhinorrhea. Her red reflexes are intact bilaterally. There is not any periauricular, occipital,
cervical, or submandibular lymphadenopathy. 
+CV: No murmurs rubs or gallops. Her heart has a regular rate and rhythm. 
+Pulm: Her chest is clear to auscultation bilaterally. There are not any wheezes, rales, nor
rhonchi. 
+GI: Her abdomen shows no distention and there are normal bowel sounds in all four quadrants.
On palpation there are no signs of hepatosplenomegaly. 
+GU: There is not any vaginal discharge. She has normal appearing female genitalia without
erythema. 
+MSK: She moves all extremities without impairment. 
+Integumentary: There are not any rashes nor lesions.
+
+Labs/Ancillary:
+
+Urinalysis Site/Specimen
+
+WBC URINE >100 (H) 
+RBC URINE 28 (H) 
+Bacteria URINE OCCASIONAL (H) 
+Mucus URINE RARE 
+Color URINE YELLOW 
+Clarity URINE SLIGHTY CLOUDY 
+pH URINE 6.0 
+Specific Gravity URINE 1.016 
+Protein URINE 50 mg/dL (1+) (H) 
+Glucose URINE NEGATIVE 
+Ketones URINE TRACE (H) 
+Bilirubin URINE NEGATIVE 
+Blood URINE SMALL (1+) (H) 
+Nitrite URINE NEGATIVE 
+Urobilinogen URINE NORMAL 
+Leukocyte Esterase URINE MODERATE (H) 
+
+Problem list:
+Inability to feed. 
+Low diaper count. 
+Labs concerning for UTI. 
+Fever.
+Vomiting. 
+Seizure. 
+
+A/P:  
+X is an 8 month old female in mild distress who appears ill. She has had a two day history
of high fever and a likely episode of febrile seizure. She also has a UA concerning for UTI
and is very volume-down. There is not any lethargy at this time nor focal neurologic deficits/signs
nor continued seizure. However, she is unable to tolerate anything PO. Her vital signs are
otherwise stable. 
+
+1. UTI w/ fevers and seizures:
+- IV access, CBC, blood cultures x1
+- Rocephin 50mg/kg IV daily. Adjust as needed by culture.
+- Tylenol 120mg PR q6.
+- Motrin 85mg PO q8 as tolerated and PRN.
+
+   * Renal Ultrasound to r/o renal scarring and hydronephrosis. 
+   * EEG to r/o seizure disorder. 
+
+2. Dehydration:
+- IVF:  mIVF D51/4NS @35cc/h.
+- I/O:  daily weights and record In/out/diapers.
+- Diet:  Formula and clears Po ad lib.
+
+3. Seizure:
+- With further seizure, spinal tap and culture CSF. 
+
+4. Further workup:
+
+   * If recurrent UTI, w/u for VUR with VCUG.

Added: ctakes/trunk/ctakes-examples/data/Peds_RoutBirthNote_1.rtf
URL: http://svn.apache.org/viewvc/ctakes/trunk/ctakes-examples/data/Peds_RoutBirthNote_1.rtf?rev=1516900&view=auto
==============================================================================
--- ctakes/trunk/ctakes-examples/data/Peds_RoutBirthNote_1.rtf (added)
+++ ctakes/trunk/ctakes-examples/data/Peds_RoutBirthNote_1.rtf Fri Aug 23 15:44:03 2013
@@ -0,0 +1,28 @@
+Case description for C-Takes documenting:
+Setting: Outpatient.
+Specialty: Pediatrics. 
+Note detail level (1-5): 3.
+Level of abbreviation (Low/Medium/High): Medium.
+
+18 hour old infant male (Baby X), AGA 3214g born at 40+1 weeks on 0 Feb 2010 at 1400 with
apgars of 8/9, routine NRP was performed. Mother is a 26 yo G3nowP3, A+, GBS+, RI, SVD w/
ROM <18 hours. PCN given x2, no other infectious risk factors. Pt requesting routine circ.
Overnight: Newborn is breast feeding well, no other issues. Hearing test pending. Pre and
post ds pending. Prob no TCB necessary. IMS pending. Wt DOL #2 pending. ABO RH+ not required.
+
+Vit: T 98.2-99.6 HR 98-136 SPO2 97 RR 26-44
+PE:
+Head circ@birth: 33.5
+Gen: Sleeping on initial exam, easily aroused, no acute distress.
+Neuro: Moro, grasp, and sucking reflexes intact. Normal tone.
+Optho: Red reflex present bilat.
+Head: Fontanelle flat, mildly overriding sutures, no evidence of low set ears, holes, tags.
+ENT: Patent nares, no flaring, no signs of cleft pallet. 
+CV: No m/r/g, rrr. S1, S2 wnl. No cyanosis, cap refill wnl. 
+Pulm: Ctab, no w/r/r. No accessory muscle recruitment. 
+Abd: Soft, nbs, non tender, no hepatosplenomegally.
+MSK: Unremarkable Otolinii/Barlow.
+Gen/Uro: Normal appearing male gen.
+Derm: No signs of jaundice, no rashes/lesions, no etn.
+
+A/P: 
+Newborn infant male in no acute distress. Unremarkable exam. Doing well.
+- Plan circumcision for this AM.
+- Counsel parents on wound care for circumcision.
+- Plan to DC this PM pending normal routine discharge w/u.

Added: ctakes/trunk/ctakes-examples/data/VascSurg_RO-DVT.rtf
URL: http://svn.apache.org/viewvc/ctakes/trunk/ctakes-examples/data/VascSurg_RO-DVT.rtf?rev=1516900&view=auto
==============================================================================
--- ctakes/trunk/ctakes-examples/data/VascSurg_RO-DVT.rtf (added)
+++ ctakes/trunk/ctakes-examples/data/VascSurg_RO-DVT.rtf Fri Aug 23 15:44:03 2013
@@ -0,0 +1,18 @@
+Case description for C-Takes documenting:
+Setting: Outpatient.
+Specialty: Vascular Surgery. 
+Note detail level (1-5): 1.
+Level of abbreviation (Low/Medium/High): High.
+
+HPI/CC: Mrs. X is a 60 yo white female with a PMH significant for HTN, CAD, AFIB, DMtype2
who presents to the clinic today for f/u to r/o a DVT after RLE edema was appreciated on PE
at a f/u apt s/p high saphenous vein ligation and stab phlebectomy of the ipsilateral leg
around Feb of 2010. Patient expresses concern over sutures remaining at the incision sites
as well as a lesion on her L arm that was noted after IV access was attempted by a tech post-op.
+
+ROS: Pt denies cp/sob. Unremarkable otherwise. 
+
+PE: Mrs X is a well appearing woman who appears her stated age. BP-R: 118/76, BP-L: 134/78.
Radial pulses 2+ bilaterally. Could not palpate pedal pulses or pop. pulses bilat., however,
pedal pulses 2 by doppler.
+
+ANC: Right LE duplex indicates no DVT.
+
+A/P: Mrs X is a 60 yo female presenting to clinic for f/u to r/o a DVT s/p a high ligation
of saphenous vein and stab phlebectomy of right leg. Some sutures remained and were removed.
Patient was counceled on hot compress therapy for superficial phlebitis and advised that it
should resolve with time. Given the exclusion of DVT, no further appointments are necessary.
+
+
+



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